Paeds Flashcards
Indication for serial casting in MTA?
Rigid deformity with medial crease
How do you reduce a nursemaid’s elbow?
Supinate forearm and flex elbow to 90 deg
2 options for tendon transfers of HMSN?
tib post to dorsum of foot
peroneus longus to brevis
4 signs of AVN of femoral head following treatment for DDH (radiographic)?
- failure of appearance or growth of the ossific nucleus 1 year after reduction
- broadening of femoral neck
- increased density and fragmentation of ossified femoral head
- residual deformity of proximal femur after ossification
Diagnosis and most common site/cause
Congenital pseudoarthrosis of the clavicle
Caused by extrinsic compression by the subclavian
Right middle 1/3 of clavicle 90%
Left only if situs inversus
How do you differentiate CVT and oblique talus on x-ray
oblique talus:
navicular will reduce on plantarflexion latearl
Meary’s angle <35 degrees
WHen i say Olecranon apophysis avulsion fracture, you say:
osteogenesis imperfecta
What is Nail-Patella syndrome?
Hypoplastic Nails and Petallae
AD inheritance
Also includes:
Laxity
scoliosis
scapular hypoplasia
presence of cervical ribs
amongst other things
Reduction Maneuver for displaced medial epicondyle fracture into joint?
Robert’s Technique
- Supination of the forearm - stretches flexor/pronator mass
- Valgus stress on the elbow - opens up ulnohumeral joint medially and stretch FP mass
- Extending the wrist and fingers - causes a pull on FP mass
- Early motion within 3-5 days minimizes risk of stiffness
Most common cause of revision following early spica casting of a femur fracture in paeds?
Loss of reduction
Although rare
Classification of Sprengel’s:
see chart
What fracture type has the highest rate of growth arrest in the body?
SH4 of medial malleolus
Describe the spectrum of myelodysplasia
Spina bifida oculta:
- Defect in vertebral arch with confined cord and meninges
Meningocoele:
- Protruding sac without neural elements
Myelomeningocoele:
- Protruding sac with neural elements
Rachischisis
- Neural elements exposed with no covering
What zone of the growth plate does Little Leaguer’s shoulder occur?
Hypertrohpic zone
4 factors predictive of physeal arrest in distal femur physeal fracture
SH classification
Presence of displacement
open fracture
Hardware penetration into physis from surgical management
Valproic acid has what detrimental effect on surgery?
Increases bleeding time
Complications of clubfoot correction (non op: 2, op: 6)
Nonop complications
- deformit relapse
- dynamic supination
Operative complications
- Residual cavus
- pes planus (due to overcorrection)
- undercorrection
- intoeing gait
- Osteonecrosis of talus
- dorsal bunion
Should kids with MRSA attend school?
Play sports?
Yes, only if their wound/abscess/draining pus can be adequately covered up
They should not use pools or treatment pools
What is normal thigh foot angle?
0-20 of ER
Contraindications to Pavlik harness (4)?
- Abnormal muscle function (i.e. spina bifida, spasticity)
- Age over 6 months
- Teratologic hip dislocation
- Failure of Pavlik treatment for 3 weeks.
Preferred surgical option for a large talocalcaneal coalition?
Triple fusion
in osteo with community acquired MRSA, what should you consider doing?
Screen for DVT
Rapid CT-PE if any suggestive signs
Why do you need a pre-op MRI in sprengels?
To identify omovertebral bar
Three technical factors that can increase risk of compartment syndrome when using hip spica for femur fracture?
- Rough cast edge at popliteal fossa
- Excessive traction
- Knee flexion > 90
Cause and treamtent of stiff-knee gait in CP?
Cause: rectus femoris firing out of phase
Treatment: transfer of distal rectus femoris tendon
dDx for bilateral valgus (3)
Physiologic
Renal osteodystrophy (Rickets)
Skeletal dysplasia
- Morquio
- Spondyloepiphyseal dysplasia
- Chondroctodermal dysplasia
Treatment of hallux varus
Conservative:
- most resolve with time
Can do abductor hallucis release
excsision of central epiphyseal bracket
Workup of Arthrogryposis at 3 months? (3)
Perform at 3-4 months of age
- neurologic studies
- enzyme tests
- muscle biopsies
2 methods of percutaneous reduction of radial head fracture
- K-wire joystick technique
- Metaizeau technique
involves retrograde insertion of a pin/nail across the fracture site
fracture is reduced by rotating the pin/nail
Anterolateral bowing:
what’s the chance this patient has NF?
What is the chance an NF patient has anterolateral bowing?
what’s the chance this patient has NF?
50%
What is the chance an NF patient has anterolateral bowing?
10%
Name 4 non-ortho manifestations of myelodysplasia
Neurosurgical manifestations
- Arnold-chiari manifestation (Type II); Most common associated congenital abnormality
- Hydrocephalus
- Tethered cord
Urological manifestations
- Neurologic bladder
IgE mediated latex allergy
- Results in profound anaphylaxis
- Present in 20-70% of patients with this disorder
What part of the acetabulum is deficient in a NON-neuromuscular hip dysplasia?
Anterior or anterolateral
4 indications for surgery in infantile Blount’s
Stage I and II in children > 3 years
Stage III, IV, V, VI in children <3 years
failure of brace treatment
metaphyseal-diaphyseal angles > 20 degrees
Muscle imbalance in equinovalgus foot?
Opposite of equinovarus
TA/TP weak
PB/PL strong
What is the Safe zone in DDH reduction?
how do you increase it?
ROM at which hip stays reduced
typically:
90-100 degrees flexion
mild abduction of 20-45 degrees
increase it with adductor tenotomy
Paediatric trigger finger - waht must you release?
A1 pulley + 1 slip of FDS
What is a reason why intra-thecal baclofen is preferred over PO for CP?
PO associated with cognitive impairment.
What is contraindicated in the treatment of DMD scoliosis?
Bracing
may interfere with already compromised respiraotry function
What is angle A and how does it help evaluate DDH?
Acetabular Index
varies with age (decreases)
normal is less than 25 deg 2yo kid
(remember 2yo is ~20deg)
Name 5 reduction techniques of radial head reduction:
Elastic bandage
Patterson
Israeli
Metaezeau (retrograde pin)
K-wire joystock
Indications for hemivertebrectomy in congenital scoli
Progressive curve >40 degrees
Patient <5
lumbosacral vertebra best (but can be done in thoracic)
(JAAOS 2004)
BLocks to reduction in DDH
Labrum
Inverted limbus
capsule
transverse acetabular ligament
ligamentum teres
pulvinar
Give general principles of operative treatment for PFFD
Limb Lengthening
- if predicted LLD <20cm
- If femoral length >50% of opposite side
Amputation ±prosthesis
- If femoral length <50% contralateral side or LLD >20cm
- If foot is proximal to level of contralateral knee
- If prosthetic knee will not be below the level of the contralateral knee
*based on level of knee - must have it normal to walk normal
Hip Fusion
- If absent acetabulum (Aitken D), fuse residual limb to pelvis and make knee into a hip
5 Risks for CP
Prematurity (most common)
Anoxic injury
Prenatal intrauterine factors
Perinatal infections (ToRCH, toxoplasmosis, rubella, CMV, Herpes)
Meningitis
Brain malformations
Best predictor of success with tendon transfers in CP?
Patients with good voluntary control had the greatest improvement in functional use scores.
Name this implant, procedure, and what its done for:
telescopic rod for Schofield-Miller realignment procedure for OI
Can use telescoping or non-telescoping rods
Pin configuration post CRPP of distal femoral physeal injury
antegrade
avoids going intra-articular and avoids pin-tract infection into joint
Kid with MPS comes in with burning in radial 3 digits, worse at night, some clumsiness of the hands. Top 2 dDx
Carpal tunnel syndrome: MPS is one of the most common causes of CTS in kids
cervical myelopathy (unless its San Fillipo - no C-spine issues)
What part of the physis does a SCFE occur in?
Hypertrophic
4 non-orthopedic manifestations of Downs?
- mental retardation
- heart disease (50%)
- endocrine disorders (hypothyroidism)
- premature aging
How do you screen for and diagnose MPS?
Screen: urine
Diagnose: enzyme assay for activity in skin fibroblasts or WBC
Orthopaedic Manifestations of Charcot Marie Tooth (HMSN)? (4)
pes cavus
hammer toes
hip dysplasia
scoliosis
Good prognostic signs of anterolateral bowing? (2)
Duplicated hallux
Delta-shaped osseous segment in concavity of bow
Indications for anterior approach in addition to posterior approach in scolisis
Large curve (>75 degrees)
Stiff curves
Skeletally immature (Risser grade 0, boys
Most common complication of lateral condyle fracture?
Lateral overgrowth/spurring
Indications for contralateral pinning in SCFE
High risk patients:
Endocrinopathy
Obese
Young age, indicated by:
- Boys
- Girls
- Open Triradiate cartilage
Genetic transmission of DMD
X linked recessive
Important to counsel patients of risk of subsequent kids with the disease
Non-ortho manifestations of Down (3)
Cardiac abnormaltieis (50%)
Endocrine (hypothryoidism)
mental retardation
premature aging
3 complications of radial head/neck fractures
AVN
synostosis
loss of ROM (pronation > supination)
radial head overgrowth
What is the most common manifestation of child abuse?
Skin manifestations (bruises, burns)
Fractures are the second most common
When do you IMN a femur in paediatrics (age & weight)
> 11 years
>49 kg
Remember to use lateral start point
Pediatric elbow dislocation - most common nerve injury
Ulnar nerve
Kid with hemihypertrophy. What must you do?
serial ultrasounds q3 months until age 7,
then physical exam q6 until skeletal maturity
TO RULE OUT WILM’S TUMOUR
Complications seen with too much flexion in Pavlik?
Femoral nerve palsy.
2 complications of transphyseal distal humerus fracture?
Cubitus varus
Medial condyle AVN
Name 3 differences in the upper airway of a paediatric patient vs. adult
floppy epiglottis
large tongue
small larynx
NIH Consensus Development Conference Statement diagnosis criteria for NF1?
Two or more of the following:
- six or more café-au-lait macules over 5 mm in greatest diameter in prepubertal individuals and over 15 mm in postpubertal individuals.
- two or more neurofibromas of any type or one plexiform neurofibroma.
- freckling in the axillary or inguinal region.
- optic glioma.
- two or more Lisch nodules (iris hamartomas).
- a distinctive osseous lesion such as sphenoid dysplasia or thinning of long bone cortex with or without pseudarthrosis.
- a first-degree relative (parent, sibling, or offspring) with NF-1 by the above criteria.is based on presence of both
What are three ways to assess coronal deformity of the L/E on AP xrays?
1) mechanical axis
2) mLDFA 88 (range 85°-90°) and mMPTA (range 85°-90°)
3) Tibial Femoral Angle
6 signs of preganglionic brachial plexus injury
Winged scapulae (long thoracic)
Absent rhomboid function (dorsal scapular nerve)
Absent RTC (suprascapular nerve)
Absent Latissimus dorsi (thoracodorsal nerve)
Horner’s syndrome (sympathetic chain)
Elevated hemidiaphragm (phrenic nerve)
CP hip management based on Reimer’s Migration Index
Soft tissue release
Children 40%
VDRO + ST release
Kids >4 OR Reimer’s index >60%
Abduction osteotomy or girdlestone procedure
Chronic painful dislocation
3 orthopaedic associations with tibial deficiency.
Ectrodactyly (cleft hand)
preaxial polydactyly
ulnar aplasia
high rate of MSK anomalies (75%)
How do you decide what size of nancy nail?
- nail size determined by multiplying width of narrowest portion of femoral canal by 0.4
- the goal is 80% canal fill
Spinal manifestations of achondroplasia vs. pseudoachondroplasia
Achondroplasia
- foramen magnum stenosis
- kyphosis
- lumbar stenosis/decreased interpedicular distance
Pseudoachondroplasia
- cervical instability
Complications seen with too much abduction in Pavlik?
AVN
What are two options to treat AVN
following proximal femur fracture?
● Vascularised free fibula graft
● Core decompression
By the time you transition from casting to boots and bars for Ponsetti, how much abduction should the foot be in?
70 degrees
MPS with least spinal abnormalities?
San Filippo
only has scoliosis, and even that is rare
JAAS 2013
2 factors prognostic of long term neurologic sequelae from paediatric trauma:
O2 sat at presentation
GCS 72 hours post injury
In surgical correction of blounts, what do you have to include in Langenskiold V, VI?
Epiphysiolysis (bar resection)
First line treamtent in tarsal coalition?
trial of non-op with immobilization or orthotics - always
2 indications for exploring the artery in a supercondylar fracture
Pulse is lost after reduction
Persistance of pulseless hand after reduction
3 nonorthopaedic conditions of marfans?
- cardiac abnormalities
- aortic root dilatation
- possible aortic dissection in future
- mitral valve prolapse
- superior lens dislocations (60%)
- spontaneous pneumonthoraces
AAOS guidelines for paediatric femoral shaft fractures
6 months - 5 years: spica
5 years - 11 years: TENS, IMN or submuscular plating
>11 years: submuscular plating or TENS
They make NO reommendations on weight in the official criteria
JAAOS 2011 states:
We believe that regardless whether a patient has an unstable comminuted or oblique fracture, rigid nails are appropriate for patients aged >11 years who weigh >49 kg.
We recommend the lateral trochanteric approach to avoid the risks associated with starting at or near the piriformis and near the tip of the trochanter
Who gets Gower’s sign? Describe it
Rises by walking hands up legs to compenate for gluteus maximum and quadriceps weakness
2 life-threatening intra-operative complications in DMD:
intraoperative cardiac event
malignant hyperthermia
Consult anesthesia & cardio preop
tarsal coalition
Chance of it being bilateral?
Patient with 1 coalition has what percentage of having another?
50% chance of being bilateral
20% chance of a second coalition if they have 1
Complication with too mcuh abduction in DDH treatment?
AVN of femoral head
via impingement of the posterior-superior retinacular artery
What is the risk of AVN for Delbet Type 1B?
Nearly 100%
(transphyseal proximal femur fecture with displacement of epiphysis out of acetabulum)
MRSA infected kids have higher levels of what on admission?
ESR, CRP, WBC
Indications for selective thoracic fusion:
Non-structural lumbar curve (Lenke 3 or above)
Lower end vertebra touches CSVL
Lenke 1C, 2C, 3C, 4C
No significant sagittal imbalance
Major Thoracic Curve
Double thoracic Curve
Risk factors for AVN post pinning of a SCFE. (5)
- unstable SCFE
- over-reduction of an acute slip
- attempted reduction of a chronic slip
- pins in the superolateral quadrant
- femoral neck osteotomy
7 options for interpositional graft after resection of physeal bar:
Fat
PMMA
Cranioplast (like PMMA: takes longer to set, less exothermic reaction, less chance of heat necrosis)
Bone wax
Cartilage
Muscle
Silicone
Who gets Duchenne muscular dystrophy?
Males only
X-linked recessive
How does TA compare to PL in:
a) Clubfoot
b) Cavo - varus foot
a) TA stronger
b) TA weaker
BBFF: malrotation at what level has what effect?
Midshaft malrotations lead to decreased supination
(vs distal malrotation)
3 ways that Beckers differes from Duchennes?
- dystrophin protein is decreased instead of absent
- later onset with slower progression and longer life expectancy (average diagnosis occurs at age 8 compared to 2 years of age with Duchenne’s)
- more prone to cardiomyopathy
4 radiographic signs of osteopetrosis?
“erlenmeyer flask” proximal humerus and distal femur
“rugger jersey spine” with very dense bone
loss of medullary canal “bone within a bone” appearance
block femoral metaphysis
Name 3 syndromes with abnormal ossification of secondary growth centers
Spondyloepiphyseal dysplasia
Multiple epiphyseal dysplasia
diastrophic dysplasia
5 Orthopedic (non-spine) manifestations of Achondroplasia?
- facial features
- frontal bossing
- button noses
- small nasal bridges
- trident hands (inability to approximate extended middle and ring finger)
- bowed legs
- radial head subluxation
- muscular hypotonia
What percentage of LCP patients will eventually need THA?
50%
What part of the growth plate does SCFE secondary to renal osteodystrophy occur?
Secondary spongiosa
Torticollis: head tilt and rotation which direction?
Tilt: towards side of pathology
Rotation: chin rotates away from pathology
2 optioins for treating elbow flexion contractures
Clarke’s pectoral transfer
Steindler’s flexorplasty
What condition can be confirmed using fibroblast culturing to analyze type I collagen in equivocal cases?
OI
(best for type 4)
You plan a femoral derotational osteotomy on a child with femoral anteversion.
Where do you make your osteotomy?
How much correction do you need?
intertrochanteric osteotomy
amount of correction = (IR-ER) / 2
What is von Recklinghaussen disease?
NF1
3 positive effects of bisphosphonates in OI (not the side effects)
Improves mobility
decreases fracture rate
improves vertebral bone density
Improves vertebral height (not overall height)
What is the Sofield-Miller procedure?
Realignment osteotomy with rod fixation for OI
Fassier-Duval rods can be used.
Age range for open reduction and hip spica +/- femoral osteotomy?
18 months - 4 years
Describe the GMFCS scale.
Most important thing to look for when examining tibal hemimelia?
Is the extensor mechanism intact and is there a flexion contracture of the knee.
5 conditions associated with Cavovarus foot?
- Charcot-Marie-Tooth
- Freidreich’s ataxia
- Cerebral palsy
- Polio
- spinal cord lesions
Never do what when ORIFing a lateral condyle fracture?
Never dissect posteriorly
Blood supply comes from there and will cause AVN if you disrupt it
You cant reduce a galleazzi fracture. What is most likely blocking reduction and which approach do you take to remove it?
ECU
Dorsal
Should Down syndrome kids avoid contact sports? If yes, what indication?
Avoid sports if progressive radiographic instability or signs of myelopathy
INdications for hemiepiphysiodesis in congenital scoli
Failure of formation (hemivertebra)
patient <4
Curve < 40 deg
(only get about 15 degrees of correction. Contraindicated in failure of segmentation)
How many ossification centers in the proximal humerus?
3: HH, GT, LT
What 2 actions may help reduce AVN rates in femoral head/neck fractures in paediatric patients?
early reduction
Joint decompression (hematoma aspiration or core decompression)
Second most common nerve palsy in SCHF?
radial
AIN most common
Post tibial spine fracture, what is the factor most highly linked to arthrofibrosis?
Prolonged immobilization > 4 weeks
So start mobilizing before then
Surgical treatment of hip dislocation in myelodysplasia is controversial b/c of high failure rates. What is the anatomic cause of failure? Be specific
Paralytic hip dislocation (not teratologic)
B/c of paralysis of the hip abductors and extensors and unopposed pull of the hip adductors and flexors
This leads to high relapse rates
Foot muscular Imbalances in Hereditary Motor Sensory Neuropathy?
- plantar flexed 1st ray is initial deformity
- cavus caused by peroneus longus (normal) overpower weak tibialis anterior
- varus caused by tibialis posterior (normal) overpowering weak peroneus brevis
When do you mobilize a medical epicondyle fracture in paediatric patients?
Early - after about a week if nondisplaced/displaced
Phase 1 or 2 rib at an increased risk of progression?
Phase 2: rib overlap with apical vertebra
Characteristic lesion in Fredrich’s ataxia
Spinocerebellar degenerative disease, therefore, lesions in:
- Dorsal root ganglia (peripheral)
- Corticospinal tracts (central)
- Dentate nuclei in the cerebellum
- Sensory peripheral nerves
Describe the Beighton-Horan scale.
5 or more on 9-point Beighton-Horan scale defines joint hypermobility
- passive hyperextension of each small finger >90° (1 point each)
- passive abduction of each thumb to the surface of forearm (1 point each)
- hyperextension of each knee >10° (1 point each)
- hyperextension of each elbow >10° (1 point each)
- forward flexion of trunk with palms on floor and knees fully extended (1 point)
In LCP, when do you want to perform surgery (if indicated)
initial or fragmentation phase
no positive effect has been found for containment surgery performed after initial or early fragmentation stage
What is the best indicator of peak growth?
Risser 0 or closure of triradiate (occurs at same time)
How does MRSA get its virulence and resistance?
Virulence:
- panton-valentine leukocidase (PVL)
- It is released and kills WBC
Resistance:
- mecA gene
- Makes an altered penicillin-binding protein with less affinity for penicillin, giving it resistance. Normally, PBP binds penicillin into cell wall, inhibiting cell wall synthesis
WHat joints are most commonly invovlved in JIA?
knee > hand/wrist > ankle > hip > C-spine
Most common nerve palsy in SCHF?
AIN
4 risk factors for DVt in pediatric psteomyelitis?
CRP > 6
surgical treatment
age > 8-years-old
MRSA
7 donor options for nerve transfer in Brachial plexopathy?
sural
intercostal
spinal accessory
phrenic
cervical plexus
contralateral C7
hypoglossal
Name a contraindication to hemiepiphysiodesis in congenital scoliosis:
Segmentation defects (ie bars)
b/c there is no chance for the concave side to catch-up i growth
Therefore, part of the indication for hemiepeiphysiodesis is a failure of formation (hemi-vertebra - b/c when you epiphysiodese the wedged side, the concave side has the ability for catchup growth)
Classification of tibial spine/eminence fractures
Meyers & McKeevers
I: undisplaced
II: displaced with posterior hinge
III: completely displaced with no bony contact
IV: comminuted
Treatment of hip abduction contracture in myelodysplasia
Ober-Yount Procedure:
proximal division of fascia lata and IT band release
4 options for elbow release in arthrogryposis
Triceps to biceps
Steindler flexorplasty
Pec Major to biceps
Triceps V-Y lengthening and posterior capsulectomy
dDx of toe walking (4)
CP
DMD
Tethered Cord/spinal dysraphism
Diastematomyelia
CMT
Unilateral Short limb causing unilateral toe walking
Non-ortho
Autism
Schizophrenia
DDH U/S:
What is beta angle and what is normal?
- angle created by lines along the labrum and the ilium
- normal is less than 55°
Order of correction in ponsetti method
Cavus first (midfoot)
Then adduction & Varus (hindfoot)
Equinus last
(CAVE)
Indication for surgery in LCP?
Lateral pillar B, B/C, C in kids >8 (bone age >6)
They do better with pelvic/femoral osteotomy
Diagnosis?
CVT
Clues:
talus is vertical
navicular dorsal dislocation
You do an iliac crest biopsy to confirm diagnosis of OI.
3 positive findings?
decrease in cortical widths
decreased cancellous bone volume
increased bone remodeling
In neuromsucular scoliosis that affects lungs, at what FVC can you safely perform surgery
30% and above
You reduce a dislocated DDH hip. Development of what radiologic landmark in the next few months is considered a positive prognosticator?
Teardrop - not usually present in a dislocated hip.
What is the most common type of child abuse?
Neglect
Followed by physical > sexual > emotional maltreatment
3 conditions that are commonly found with tibial hemimelia?
- ectrodactyly
- preaxial polydactyly
- ulnar aplasia
Risk factors for SMA syndrome in AIS surgery (7)
shorter (by a mean of 7.1 cm, p = 0.03)
weighed less (by a mean of 11.5 kg, p = 0.001)
had a lower body mass index (p = 0.003)
had a greater minimal thoracic curve magnitude achieved by bending (a mean of 12 degrees greater [45 degrees for subjects with superior mesenteric artery syndrome and 33 degrees for controls], p = 0.015)
had a lower percent correction of the thoracic curve on bending (a mean of 11% lower, p = 0.025)
and had more lumbar lateralization (88%, compared with 61% in the control group, had a Lenke lumbar modifier of B or C instead of A, p = 0.008)
Multivariate logistic regression analysis identified:
A staged procedure (odds ratio, 31.0)
the lumbar modifier (odds ratio, 9.06)
body mass index (odds ratio, 7.75)
thoracic stiffness (odds ratio, 6.67)
as the most predictive of the development of superior mesenteric artery syndrome
(Braun et al. 2006 JBJS)
How do you tell the difference between posteromedial bowing and calcaneovalgus foot?
Posteromedial bowing: apex is in distal tibia
Calcaneovalgus foot: apex is at ankle joint
Describe, in detail, the Ponseti method
- Corrects in order CAVE
- All casts are LLC
- weekly cast changes
1st cast:
- Supinate the foot
- elevate 1st ray (MT)
- This will maintian all the MT heads in a row
2nd cast:
- corrects MT adductus and hindfoot varus
- abduct forefoot against counterpressure on the head of the talus (not CC joint or fibula)
- This will correct MT adductus by reduction of the MT and navicular on head of talus and cuboid on calc
- With further casting, the calc will evert and move under talus
- Must perform abduction with the forefoot in supination and the foot in equinus so that the calc an evert and abunct under talus
- Keep performing serial casts until full correction of “A” and “V”
TAL
- In the office
- Then cast for 2 more weeks
- Then Denis-Brown brace (boots and bars)
- These go on 24hrs a day for 3 months, then nighttime and naptime for 2-3 years
Mainstay of treatment in duchenne muscular dystrophy? What effect does it have (3)
Corticosteroids
- prolongs ambulation
- slows scoliosis
- slows deterioration of FVC
4 indications for operative management of proximal humerus fracture (peads)?
Adolescent with severe deformity (> 45 degrees or
Vascular Injury
Open fracture
Intra-articular displacement
Define Baumans Angle
Line down axis of Humerus
Line through lateral condylar physis
Angle between them
SHould be 70-75
Define Arthrogryposis
Non-progressive congenital disorder involving multiple rigid joints (usually symmetric), leading to severe limitation in motion
What part of the growth plate does a SCFE occur in?
Hypertrophic zone
caused by weakness in the perichondral ring
What is the most common complication of proximal femur fracture?
AVN
(Coxa vara and non-union also important)
When do you brace congenital scoliosis?
To control supple compensatory curves
Non-ortho associations of hemihypertrophy (2 major types)
Malignant intra-abdominal tumours
- Wilm’s - most common
- adrenal carcinoma
- hepatoblastoma
GU abnormalities
- medullary sponge kidney
- polycystic kidney
- inguinal hernia
Best xray to ID a SCFE?
lateral
Acceptable criteria for distal radius fractures
<9 years old: 30 degrees dorsal angulation. Bayonette apposition <1cm
>9 years old: 20 degrees dorsal angulation
No rotational deformities
What disorder is Botox contraindicated in?
Spinal muscular atrophy
What is a Charnley WIlliams rod used for?
ORIF of NF tibial pseudoarthrosis
Asymptomatic Paediatric Isthmic spondy, soccer player. Do you limit sports?
No
Manage with close observation and no restrictions
3 facets of first line treatment for JIA?
- steroid injections
- DMARDs
- etanercept, rituximab, azathioprine - Opthamologic Exams
Assume growth in males and females stop at what age?
Males: 16
Females: 14
Treatment of dislocated hip in myelomeningocele?
Surgical reduction of hips in patients with spina bifida is associated with a high failure rate and therefore treatment indications are controversial.
Reduction for patients with L4 level is most controversial and may be considered if unilateral.
Dislocated hips in patients with L3 level and above are typically left alone.
3 things affecting Proliferative Zone
Achondroplasia
Multiple Hereditary Exostoses (MHE)
Gigantism
“A Giant Me”
You treat a femur fracture with hip spica:
1) Where do you mould?
2) What is dreaded complication and how to prevent it?
3) What do parents need before leaving hospital?
1) Distal femur and buttocks
2) Compartment syndrome of the thigh, prevent by smoothing cast around politeal fossa, avoiding excessive traction and knee flexion
3) Special car seat
8 risks for brachial plexus birth injury
Large of gestational age
High birth weight
Cephalopelvic disproportion
Shoulder dystocia
Forceps delivery
Difficult presentation
Breech position
Prolonged labour
DDH U/S:
What is minimal age?
4-6 weeks.
Name 3 conditions that can present with teratologic hip?
arthrogryposis
myelomeningocele
Larsen’s syndrome
3 surgical treatment options for Adolescent Blounts?
- Transient lateral hemiepiphysiodesis
- Permanent lateral hemiepiphysiodesis
- Valgus HTO with ORIF or gradual corrrection (ilizarov or TSF)
4 radiographic signs of hemophila on knee xray?
- squaring of patella and femoral condyles (Jordan’s sign)
- ballooning of distal femur
- widening of intercondylar notch
- patella appear long and thin on lateral
Indications for poor prognosis in bracing of AIS
poor in-brace correction
hypokyphosis (relative contraindication)
male
obese
noncompliant (effectiveness is dose related)
Preferred treatment of congenital vertical talus
Reverse ponsetti casting +
surgial reduction & pinning of talonavicular joint +
TAL
What are the stages of LCP?
Initial:
- infarction produces a smaller, sclerotic epiphysis with medial joint space widening
Fragmentation:
- femoral head fragmentation (result of neovascular process)
Reossification:
- Ossific nucleus undergoes reossification
Remodeling:
- Femoral head remodels until skeletal maturity
WHere does a Salter osteotomy hinge on?
Symphysis Pubis
1 cut from AIIS to sciatic notch
How much bend do you want in a nancy nail?
3x canal size
7 Physical or radiologic signs of child abuse?
- long bone fxs in infant that is not yet walking
- multiple bruises
- multiple fxs in various stages of healing
- corner fxs
- posterior rib fractures
- bucket handle fractures
- transphyseal separation of the distal humerus
- single transverse long bone fractures
- skull fractures
Manifestations of Gauchers (5)
Systemic Manifestations
- fatigue (anemia)
- prolonged bleeding (thrombocytopenia)
- fever, chills, sweats (infection)
- seizure, developmental delay (CNS involvement)
Orthopaedic Manifestations
- bone pain (fracture, osteomyelitis)
- joint pain or contracture
- bone crisis (osteonecrosis)
3 keys to surgical treatment of CVT?
- release of tight dorsal lateral structures
- pinning of talonavicular joint
- reconstruction of spring ligament
What are the weak and spastic muscles in equinovarus foot?
Spastic: TP and TA
Weak: PB, PL
Sillence Type I and IV:
a) What is the diesease?
b) What is quickest way to differentiate on exam?
c) Which has better prognosis?
d) Inheritance patterns?
a) OI
b) Type 1 has blue sclera
c) Type 1 is milder
d) Both AD
Bonus: DIvided into A and B based on tooth invovlement. Type 1 more likely to lose hearing.
3 blocks to reduction in proximal humerus reduction
long head biceps
capsule
periosteum
DDH U/S:
What is alpha angle and what is normal?
- angle created by lines along the bony acetabulum and the ilium
- normal is greater than 60°
4 ortho and 2 nonortho associations with Friedrich’s ataxia
Ortho
- cavovarus foot: often rigid
- scoliosis
- ataxia
- areflexia (but with positive plantar response)
Non-ortho
- Cardiomyopathy
- nystagmus
paeds patient with femur fracture. >100lbs. Result with flexible IM nail?
Increased risk of complications such as nonunion
Indications for MRI in scoliosis case
atypical curve pattern
- left thoracic curve
- short angular curve
- apical kyphosis
rapid progression
Any child
excessive kyphosis
structural abnormalities
neurologic symptoms or pain
foot deformities
asymmetric abdominal reflexes
a syrinx is associated with abnormal abdominal reflexes and a curve without significant rotation
Othopaedic Manifestations of CMT?
Scoliosis
Pes Cavus
Hammertoes
Hip dysplasia
Explain how the Silfverskiöld test works!
- Improved ankle dorsiflexion with knee flexed = gastrocnemius tightness
- Equivalent ankle dorsiflexion with knee flexion and extension= achilles tightness
newborn comes in with congenital dislocation of knee and DDH, which do you treat first and why?
Knee
b/c you can’t get a pavlik on with a dislocated knee
DDH U/S:
What is maximal age (for usefulness)?
4-6 months
(i.e. use xray)
Name (9) associated conditions with fibular deficiency
Anteromedial tibial bowing
Ankle instability: ball & socket ankle
Equinovalgus foot deformity
Tarsal coalition (50%)
Absent lateral rays
Femoral abnormalities
- PFFD
- Coxa Vara
Cruciate ligament deficiency
Genu valgum: Due to lateral femoral condyle hypoplasia
Significant leg shortening discrepancy
- Shortening of femur and/or tibia
How much does a leg grow in a year and where does the growth come from?
23 mm /year
- proximal femur - 3 mm / yr (1/8 in)
- distal femur - 9 mm / yr (3/8 in)
- proximal tibia - 6 mm / yr (1/4 in)
- distal tibia - 5 mm / yr (3/16 in)
Conditions that may cause SCFE?
- obesity (most important)
- hypothyroidism (labs show elevated TSH)
- osteodystrophy of chronic renal failure
- Rickets
I say absent clavicles, you say:
Cleidocranial dysplasia
failure of intramembranous ossifciation
leads to failure of formation of midline structures
ie failre of pubis to ossify
2 techniques to reduce a radial head fracture
Patterson maneuver
hold the elbow in extension and apply distal traction with the forearm supinated and pull the forearm into varus while applying direct pressure over the radial head
Israeli technique
pronate the supinated forearm while the elbow is flexed to 90° and direct pressure stabilizes the radial head
Best surgical appraoch to CP HV?
1st MTP fusion +/- Akin
Risk factors for birth fractures
Vaginal deliveries
breech presentation
prolonged labor
macrosomia (>4.5 kg)
3 types of CP gait
toe walking
crouched
stiff-knee
in SCHF with median sensory symptoms, what is the major complication that is now at increased risk/most commonly to be missed?
Compartment syndrome
They cannot give the regular symptoms (pain) of compartment syndrome so the risk goes up
Why would you do a squatting skyline xray?
To diagnose symptomatic bipartate. Compare with static and if there is separation then there may be a fracture of the fibrocartlaginous connection.
What pulleys need to be released in childresn’ trigger finger?
A2 & A3
Best x-ray view for lateral condyle fracture?
internal oblique
List the normal progression of leg angulation:
Born: max varus
1.5 years: neutral (actually just under 2 years, but 1.5 easier to remember)
3 years: max valgus
7 years: physiologic valgus
as per Selenius
(0 –> 1.5 –> 3 –> 6)
Most common inheritance pattern of hereditary motor sensory neuropathy (HMSN). Name 2 other types
AD most most common
So counsel parents and patients on risks of future generations
can be AR and X-linked
What percentage growth of the humerus comes from the proximal growth plate?
80%
Principals for bladder extrophy repair?
Multidiosciplinary
Gen surg + Urologist
stage I: primary closure of bladder (newborn)
stage II: epispadias repair in males (1-2 y/o)
stage III: bladder neck reconstructions (4 y/o)
pelvic osteotomies may be performed at any stage of process
Contraindication to treatment of paediatric femur fracture (open physes)
Piriformis start femoral nail
b/c of increased risk of AVN
superior retinacular vessels of MFCA are at risk
When evaluating function of CP kid, what are 6 areas to ask about?
- nutritional status
- respiratory function
- sitting/standing posture
- upper and lower extremities function
- communication skills
- acuity of hearing and vision
What is the strongest independent risk factor for septic arthritis in paeds?
CRP >20mg/L
(even though it’s not on the Kocher criteria)
Physiologic Classification of CP
Spastic
Athetoid
Ataxic
Mixed (Usually Spastic/Athetoid)
Hypotonic
4 technical considerations for fixation of pediatric distal femur fracture?
- avoid multiple attempts at reduction
- avoid physis with hardware if possible
- if physis must be crossed (SH I and SH II with small Thurston-Holland fragments), use smooth k-wires
- SH II fracture, if possible, should be fixed with lag screws across the metaphyseal segment avoiding the physis
- postoperatively follow closely to monitor for deformity
Bado Classification
Monteggia Fractures
Dislocation goes where the apex is (THINK the apex pushes the radial head out)
I: apex anterior proximal ulnar fracutre with anterior dislocation of radial head
II: Apex posterior ulna fracture with posterior dislocation of the radial head
III: Apex lateral ulna fracture with lateral dislocatio nof the radial head
IV: BBFF with anterior dislocation of radial head
Most common cause of septic hip in neonates?
Group B Strep
(one of the practice mcq’s says that this is only for community kids, if they are aditted to nicu with multiple lines and stuff then it is Staph. Aureus)
Two indications for endocrine workup in a SCFE?
- child is < 10 years
- weight is < 50th percentile
Stretching is a reccomendation for flexible flatfoot. If it is flexible wtf are you stretching?
Tight heel cord
How do you immobilize a Galleazzi fracture?
In supination
3 indications for CRPP of pediatric distal radius fracture.
- Failure of cast management
- SH 1 or 2 with NV compromise (reduces the need for constricting cast)
- Fractures which required reduction under anesthesia (ie. failed ER reduction)
What must you do for workup in patient with congenital scoliosis?
Echo: cardiac defects - 10%
Renal ultrasound and GU workup - genitourinary defects - 25%
MRI - spinal cord malformations
What is normal range for IR and ER of hip?
IR = 20-60
ER = 30-60
What protein is elevated in 75% of fetus in second trimester if they have spina bifida?
alpha-fetoprotein (AFP)
What is the sudden cause of death in a patient with FGFR3 mutation
FOramen magnum stenosis
4 radiographic findings in OI
thin cortices
generalized osteopenia
saber shins
skull radiographs reveal wormian bones
Metaphyseal bands (bisphosphonate use)
Surgical treatment of flexible cavovarus foot?
(4 elements)
- plantar fascia release
- Tib Post transfer
- 1st ray dorsiflexion osteotomy
- TAL (says orthobullets, but this is wrong as achilles is already loose in cavovarus - incr calc pitch - as in SPORC2016)
What part of acetabulum is deficient in neuromuscular hip dysplasia?
posterior superior
Describe an NF1 patient’s risk of cancer
Increased risk of benign and maligant tumours, including:
melanoma
leukemia
rhabdomyosarcoma
pheochromococytoma
carcinoma
pancreatic endocrine tumours
astrocytoma
LLD Principals:
a)
b) 2-5 cm
c) > 5 cm
a)
b) 2-5 cm = shorten long side
c) > 5 cm = lengthen short side +/- shorten long side
What does Hilgenreiner’s-Epipyseal angle predict?
What are the values?
Predicts natural history of coxa vara
Normal:
Will resolve spontaneously if
Will need surgery if >60
Most common long term sequelae of brachial plexus birth injuries
Glenoid retroversion
Due to IR of shoulder due to Erb’s palsy
At what level of SPina Bifida is hip dislocation most common and why?
L3 - uopposed hip flexion and adduction
8 injury patterns suspicious for child abuse
Long bone fractures in infant who is not walking
Multiple bruises
Multiple fractures in various stages of healing
Corner fractures: High specificity for child abuse
Posterior rib fractures
Bucket handle fractures (Same as corner fractures,
Avulsed bone fragment is seen en face as a bucket handle)
Transphyseal separation of the distal humerus
Skull fracture
RIsk of AVN with paediatric hip factures
Type I: 80-100%
Type II: 50%
Type III: 30%
Type IV: 10%
PFFD:
4 indications for limb lengthening with the goal of ambulation without prosthesis.
- predicated limb length discrepancy of >20cm
- stable hip and functional foot
- femoral length >50% of opposite side
- femoral head present (Aiken classifications A & B)
What is the primary treatment for Gauchers?
IV enzyme replacement therapy.
Not effective in type 2.
Medications end in -glucerase.
Also consider bone marrow transplant
4 conditions associated with CVT?
- myelodysplasia (common)
- arthrogryposis
- diastematomyelia
- chromosomal abnormalities
High association with genetic or neuromuscular disorder (50%)
Compare infantile and adolescent Blounts
Infantile
- pathologic genu varum in children 0-3 years of age
- more common
- deformity rarely from femur
- typically bilateral
Adolescent Blount’s
- pathologic genu varum in children > 10 years of age
- more likely to have femoral deformity
- less common
- less severe
- more likely to be unilateral
dDx for anterolateral bowing (2)
NF
tibial deficiency
3 associated endocrine disorders with SCFE
Hypothyroidism
Osteodystrohpy of CRF
Growth HOrmone Treatment
Where should pins be placed and why, for pediatirc femur ex-fix?
Laterally
To reduce quads scarring.
Diagnosis?
Sacral agenesis
Plantarflexion lateral of two cases with rockerbottom sole deformity.
What is the diagnosis in A and B?
A = Congenital oblique talus
B = Congenital vertical talus
(Difference is that Oblique talus corrects the talonavicular joint with stress plantarflexion lateral)
Diagnosis?
Equinovalgus
i.e. CP foot
Clues:
Inferior tilt of talus
Loss of medial arch
Diagnosis
Bisphosphonates on OI
Results in metaphyseal banding at each dosing
X-ray findings of clubfoot
Dorsiflexion lateral (Turco)
- hindfoot parallelism between talus and calcaneus (talocalcaneal angle <35 deg)
AP:
- Kite’s talocalcaneal angle <20 degrees (N = 20-40)
- Talus - 1st MT angle <5 degrees
dDx for global hypotonia (2). How do you tell the difference?
SMA:
- absent DTR
- fasciculations (including tongue)
Duchnne muscular dystrophy
- present DTRs
Also:
Emery-Dreifuss dystrophy
limb girdle dystrohpy
Guillain-Barre syndrome
Management of unilateral pars defect at L4 that has failed conservative management.
Pars Repair
Indiated at L4 and above
L5: must fuse in-situ
What x-ray is this?
What is the diagnosis?
45 degree oblique
Calcaneonavicular coalition
Kid with septic hip: what position will the hip be held in?
Flexion, abduction, ER
Diagnosis?
Give 1 dDx
Multiple Epiphyseal Dysplasia
Classic for MED to present as “bilateral” Legg-Calve-Perthes disease
In a patient with Sprengel’s, what is the most likely associated abnormality to expect?
- Scoliosis
- Klippel-Feil
(JAAOS)
see chart
What is the cuase of a fishtail deformity of the distal humerus?
lateral trochlear ossification center AVN
General order of closure of the distal tibial growth plate?
Central, then medial, then lateral
This is why you get a Tillaux fracture, b/c it is the last part of fuse
Diagnosis
What is their physical exam going to be like?
What other test do you order?
Congenital radio-ulnar synostosis
No pronation or supination on exam, with hand fixed in variable amounts of prosupination
Order a chromosomal analysis as they commonly have duplicated sex chromosomes
What level myelomeningocoele has a higher risk of hip dislcoation?
L3
+ adductors, no abductors
= higher risk of dislocation
Marginal ambulators
Describe the deformity in congenital vertical talus
Rockerbottom foot:
Hindfoot: equinovalgus (everted & lateralized)
Midfoot: rigid dorsiflexion
Forefoot: abducted & dorsiflexed
What is P and how does it help evaluate DDH?
Perkins Line
Femoral head ossification should be medial to this line
Describe the anatomy of CVT
Dorsal structures are tight (navicular dorsally dislocated)
Rocketbottom foot
- hindfoot equinovalgus
- rigid midfoot dorsiflexion
- forefoot abducted and dorsiflexed
Tib post is tight
What is H and how does it help evaluate DDH?
Hilgenreiners Line
A normal head should be below it.
What are the normal values of Staheli Rotational Profile?
femoral anteversion:
- IR = ER = 30-60 degrees
tibial torsion:
- TFA: 0 to -10 degrees ER
- Transmalleolar: 0 to -10 degrees ER
Foot
- Heel bisector between 2nd/3rd webspace
Foot Progression Angle
- -5 to 20 degrees ER
Spine changes in NF1
Vertebral scalloping
Rib penciling
TP spindling
Vertebral wedging
Paravertebral soft-tissue mass
Short curve with severe apical rotation
intervertebral foraminal enlargement
Wideened interpediculate distance
Dysplastic pedicles
What is an Evans osteotomy and what deformity does it correct?
Corrects hindfoot valgus.
(calcaneal lateral column lengthening osteotomy)
In what direction does the ankle physis close and what part closes last?
central (first)
medial
posterior
anterolateral (last)
Name 2 surgical options for treatment of Sprengel’s
Woodward’s
Green
Leibovic
Bellman’s
Mears
Delbet Classification
Paediatric femoral neck fractures
Ia: transphyseal (epiphysis) no displacement
Ib: transphyseal (epiphysis) displacement
II: femoral neck (transcervical)
III: Basicervical
IV: Intertrochanteric
Name 6 associated abnormalities with Sprengel’s
Scoliosis (most common)
Klipper-Feil
Spina bifida
omovertebral bone
rib anomalies
clavicular abnormalities
humeral shortening
foot abnormalities
Major complication of lateral closing wedge osteotomy for cubitus varus?
Lateral prominence
Foot polydactyly classification?
Venn-Watson classification
Postaxial
- Y MT
- T MT
- Wide MT head
- Complete duplication
Central:
- duplication of 2nd, 3rd, 4th toe
Pre-axial
- Short block 1st MT
- wide MT head
