Pediatrics 2016

Question 1

3. Figures 3a and 3b are the radiographs of a patient who has a painful right leg without any sign of infection. The original injury to the leg occurred 2 years ago when an external fixator was placed. Treatment should now address the tibia with
4. observation.
5. surgery and no procedure to the fibula.
6. surgery and guided growth of the fibula.
7. surgery and osteotomy of the fibula.
8. amputation and prosthetic fitting.

Answer 1

4. Surgery and osteotomy of the fibula.

Question 2

13. Figures 13a and 13b are the radiographs of a 12-year-old girl who is referred for scoliosis. (26 degree curve) What is the best treatment option?
14. Continued observation with follow-up in 4 months for repeat radiographs
15. Full-time thoracolumbosacral brace wear at least 13 hours per day
16. Full-time serial body casting for 3 months
17. Anterior thoracoscopic tethering procedure
18. Posterior spinal fusion with instrumentation

Answer 2

2. Full-time thoracolumbar brace wear iwth at least 13 hours per day

RECOMMENDED READINGS

Weinstein SL, Dolan LA, Wright JG, Dobbs MB. Effects of bracing in adolescents with idiopathic scoliosis. N Engl J Med. 2013 Oct 17;369(16):1512-21. doi: 10.1056/NEJMoa1307337. Epub 2013 Sep 19. PubMed PMID: 24047455.

Sanders JO, Khoury JG, Kishan S, Browne RH, Mooney JF 3rd, Arnold KD, McConnell SJ, Bauman JA, Finegold DN. Predicting scoliosis progression from skeletal maturity: a simplified classification during adolescence. J Bone Joint Surg Am. 2008 Mar;90(3):540-53. doi: 10.2106/JBJS.G.00004. PubMed PMID: 18310704.

Question 3

12. A cast index higher than 0.8 can help to predict which complication following closed reduction and casting of a pediatric distal radius fracture?
13. Skin breakdown under the cast
14. Neurologic injury
15. Growth arrest
16. Redisplacement of the fracture in a cast
17. Compartment syndrome

Answer 3

4. Redisplacement of the fracture in a cast.

RECOMMENDED READINGS

Kamat AS, Pierse N, Devane P, Mutimer J, Horne G. Redefining the cast index: the optimum technique to reduce redisplacement in pediatric distal forearm fractures. J Pediatr Orthop. 2012 Dec;32(8):787-91. doi: 10.1097/BPO.0b013e318272474d. PubMed PMID: 23147621.

McQuinn AG, Jaarsma RL. Risk factors for redisplacement of pediatric distal forearm and distal radius fractures. J Pediatr Orthop. 2012 Oct-Nov;32(7):687-92. doi: 10.1097/BPO.0b013e31824b7525. PubMed PMID: 22955532.

Question 4

29. Figures 29a through 29c are the pelvic and knee radiographs of an 11-year-old girl who has pain on the inner aspect of her thigh. She walks with a limp and has decreased range of motion of the right hip and knee secondary to her pain. Her right knee is stable, and there is no joint line tenderness. What is the best next step?
30. Arthroscopy of the right knee
31. Rest, ice, and elevation of the right limb
32. Injection of the right knee
33. Surgery on the right hip
34. Nerve block of the right limb

Answer 4

4. Surgery on the right hip.

RECOMMENDED READINGS

Hosseinzadeh P, Iwinski HJ, Salava J, Oeffinger D. Delay in the Diagnosis of Stable Slipped Capital Femoral Epiphysis. J Pediatr Orthop. 2015 Oct 21. [Epub ahead of print] PubMed PMID: 26491912.

Aronsson DD, Loder RT, Breur GJ, Weinstein SL. Slipped capital femoral epiphysis: current concepts. J Am Acad Orthop Surg. 2006 Nov;14(12):666-79. Review. PubMed PMID: 17077339.

Question 5

33. A 2-week-old infant has minimal use of the right upper extremity. The child was delivered after a prolonged and difficult labor. Which examination findings are associated with 90% recovery of function?
34. Flail extremity, no elbow flexion and ptosis
35. Torticollis with no shoulder, elbow, or wrist function
36. No shoulder abduction or external rotation, no elbow flexion or supination, intact wrist flexion

and extension, hand intrinsics intact

4. No shoulder abduction or external rotation, no elbow flexion or supination, no wrist flexion or

extension, hand intrinsics intact

5. No shoulder abduction or external rotation, no elbow flexion or supination, no wrist flexion or

extension, no hand intrinsic function

Answer 5

3. No shoulder abduction or external rotation, no elbow flexion or supination, in tact wrist flexion and extensio, hand intrinsics intact.

RECOMMENDED READINGS

Waters PM. Update on management of pediatric brachial plexus palsy. J Pediatr Orthop. 2005 Jan- Feb;25(1):116-26. Review. PubMed PMID: 15614072.

Ho Christine. Disorders of the upper extremity. In: Herring JA ed. Tachdjian’s Pediatric Orthopaedics. Vol 1. 5th ed. Philadelphia, PA: Elsevier-Saunders; 2014:464-471.

Question 6

38. What is the biochemical effect of an intramuscular injection of botulinum toxin A?
39. Competitively blocks postsynaptic acetylcholine receptors
40. Inhibits synaptic acetylcholinesterase activity
41. Inhibits the presynaptic release of acetylcholine
42. Decreases the number of neuromuscular junctions
43. Disassociates the action of actin and myosin in targeted muscles

Answer 6

3. Inhibits the presynaptic release of ACh.

Question 7

43. Figure 43a is a standing lower extremity anteroposterior radiograph of a 2 and a half-year-old boy who has bowed legs. An examination reveals a 6-cm distance between the medial condyles of his knees when his feet are touching and his legs are extended. A gait evaluation reveals a moderate varus thrust while walking. He is slightly overweight. What is the best next step?
44. Observation
45. Bilateral knee-ankle-foot orthoses
46. Bilateral medial tibial hemiepiphysiodesis using 2-hole plate and screws
47. Bilateral medial femoral and tibial hemiepiphysiodesis using 2-hole plate and screws
48. Bilateral valgus-producing tibial osteotomies

Answer 7

1. Observation

RECOMMENDED READINGS

Bowen RE, Dorey FJ, Moseley CF. Relative tibial and femoral varus as a predictor of progression of varus deformities of the lower limbs in young children. J Pediatr Orthop. 2002 Jan-Feb;22(1):105-11. PubMed PMID: 11744864.

Arazi M, Oğün TC, Memik R. Normal development of the tibiofemoral angle in children: a clinical study of 590 normal subjects from 3 to 17 years of age. J Pediatr Orthop. 2001 Mar-Apr;21(2):264-7. PubMed PMID: 11242264.

Question 8

49. Figures 49a through 49f are the MR images of a 12-year-old boy who has severe back and radiating right leg pain after falling from the back of a pickup truck 4 days ago. He can walk only short distances with his hips in extension and his knees flexed. Straight-leg raise and crossed straight-leg raise findings are positive; motor and sensory examination findings are otherwise within normal limits. Radiographs taken in the emergency department are negative for fracture or dislocation. What is the best next step?
50. Observation
51. Rest, activity modification, and bracing
52. L5-S1 diskectomy with foraminotomy
53. L5-S1 decompression with instrumented posterior spinal fusion
54. Direct L5 pars repair

Answer 8

2. Rest, activitiy modification and bracing

RECOMMENDED READINGS

Pizzutillo PD, Hummer CD 3rd. Nonoperative treatment for painful adolescent spondylolysis or spondylolisthesis. J Pediatr Orthop. 1989 Sep-Oct;9(5):538-40. PubMed PMID: 2529267.

Cavalier R, Herman MJ, Cheung EV, Pizzutillo PD. Spondylolysis and spondylolisthesis in children and adolescents: I. Diagnosis, natural history, and nonsurgical management. J Am Acad Orthop Surg. 2006 Jul;14(7):417-24. Review. PubMed PMID: 16822889.

Cheung EV, Herman MJ, Cavalier R, Pizzutillo PD. Spondylolysis and spondylolisthesis in children and adolescents: II. Surgical management. J Am Acad Orthop Surg. 2006 Aug;14(8):488-98. Review. PubMed PMID: 16885480.

Question 9

56. A 12-year-old girl has L3-L4–level myelomeningocele. She is a full community ambulator with ankle-foot orthoses. She has had swelling and erythema of her right proximal tibia for 1 week. Her temperature is 37.7°C. Radiographs show a mild periosteal reaction. Her erythrocyte sedimentation rate (ESR) is 40 mm/h (reference range [rr], 0-20 mm/h), and her C-reactive protein (CRP) level is 0.8 mg/L ([rr], 0.08-3.1 mg/L). What is the best next step?
57. Aspiration of the knee to rule out infection
58. Empiric antibiotic treatment
59. Open incision and drainage of osteomyelitis
60. Immobilization in a splint for 3 weeks
61. Immobilization in long-leg cast for 12 weeks

Answer 9

4. Immobilization in a splint for 3 weeks.

RECOMMENDED READINGS

Kumar SJ, Cowell HR, Townsend P. Physeal, metaphyseal, and diaphyseal injuries of the lower extremities in children with myelomeningocele. J Pediatr Orthop. 1984 Jan;4(1):25-7. PubMed PMID: 6693564.

Lock TR, Aronson DD. Fractures in patients who have myelomeningocele. J Bone Joint Surg Am. 1989 Sep;71(8):1153-7. PubMed PMID: 2777841.

Question 10

64. A patient has been prepped for surgery; while working in the operating room, a resident notices an alcohol odor while speaking to the attending surgeon. The procedure has not yet begun. What is the assisting resident’s responsibility in this scenario?
65. Assume that the odor is from the skin prep
66. Ask the surgeon to take a break for 5 minutes
67. Report the finding immediately
68. Address the issue after the procedure because the patient has been prepped and is ready
69. Be prepared to perform the procedure without guidance

Answer 10

3. Report the finding immediately

Question 11

70. An 8-year-old boy is struck by a motor vehicle. An examination in the emergency department reveals a closed-head injury, pulmonary contusion with rib fractures, hypotension, and a displaced transverse femur fracture. After initial resuscitation, he is stabilized but has persistent drops in blood pressure. Treatment should consist of
71. placement of a traction pin and balanced traction for 4 weeks followed by spica casting.
72. immediate spica casting and admission to the pediatric intensive care unit (PICU) for

additional stabilization.

3. immediate open reduction and internal fixation of the femur fracture.
4. admission to the PICU for hemodynamic resuscitation and fracture fixation within 48 hours.
5. admission to the PICU and fracture fixation within 2 weeks of injury.

Answer 11

4. Admission to the PICU for hemodynami resuscitation and fixation within 48 hours.

Question 12

74. An 8-year-old child underwent the surgical procedure on the hand as seen in Figure 74. This condition is associated with
75. Blount disease.
76. Down syndrome.
77. achondroplasia.
78. Poland syndrome.
79. pseudoachondroplasia.

Answer 12

4. Poland Syndrome

RECOMMENDED READINGS

Catena N, Divizia MT, Calevo MG, Baban A, Torre M, Ravazzolo R, Lerone M, Sénès FM. Hand and upper limb anomalies in Poland syndrome: a new proposal of classification. J Pediatr Orthop. 2012 Oct- Nov;32(7):727-31. doi: 10.1097/BPO.0b013e318269c898. PubMed PMID: 22955538.

Ireland DC, Takayama N, Flatt AE. Poland’s syndrome. J Bone Joint Surg Am. 1976 Jan;58(1):52-8. PubMed PMID: 175070.

Question 13

81. Figure 81 is the anteroposterior elbow radiograph of a 12-year-old child. What is the best treatment option?
82. Long-arm cast for 6 weeks followed by physical therapy
83. Sling with early range of motion to prevent stiffness
84. Open reduction and internal fixation with plating and immediate range of motion
85. Closed reduction and casting accepting residual angulation of 60 degrees
86. Percutaneous reduction and immobilization for 3 weeks, followed by protected

range of motion

Answer 13

5. Percutaneous reduciton and immobilization for 3 weeks, followed by protetcted range of motion.

RECOMMENDED READINGS

Radomisli TE, Rosen AL. Controversies regarding radial neck fractures in children. Clin Orthop Relat Res. 1998 Aug;(353):30-9. Review. PubMed PMID: 9728157.

D’souza S, Vaishya R, Klenerman L. Management of radial neck fractures in children: a retrospective analysis of one hundred patients. J Pediatr Orthop. 1993 Mar-Apr;13(2):232-8. PubMed PMID: 8459018.

Question 14

86. An increase in which complication(s) has been seen in children with ipsilateral forearm fractures associated with supracondylar humerus fractures?
87. Ipsilateral nerve palsy and compartment syndrome
88. Open injury and compartment syndrome
89. Pulseless extremity and ipsilateral nerve palsy
90. Associated rupture of the biceps tendon
91. Infection and iatrogenic ulnar nerve injury

Answer 14

1. Ipsilateral nerve palsy and compartment syndrome.

Question 15

92. Which femur fracture pattern is most associated with nonaccidental injury?
93. Transverse
94. Spiral
95. Oblique
96. Butterfly
97. Comminuted

Answer 15

1. Transverse

Question 16

95. Figure 95 is the radiograph of a 20-month-old girl who has a nonpainful limp on her left side. What is the best treatment option?
96. Pavlik harness full time for 3 months
97. Hip abduction bracing and physical therapy
98. Closed reduction, an arthrogram with at least a 10-mm medial dye pool, and spica casting
99. Open reduction, osteotomy as needed, and spica casting
100. Observation with a shoe lift as needed

Answer 16

4. Open reduction, osteotomy as needed, and spica casting.

Question 17

104. Figures 104a and 104b are the follow-up radiographs of a 6-year-old child who sustained a proximal tibia fracture 1 year ago. Treatment of this deformity should involve
105. observation.
106. osteotomy of the tibia alone.
107. osteotomy of the tibia and fibula.
108. guided growth of the tibia alone.
109. guided growth of the tibia and fibula.

Answer 17

1. Observation

RECOMMENDED READINGS

Zionts LE, MacEwen GD. Spontaneous improvement of post-traumatic tibia valga. J Bone Joint Surg Am 1986 June; 68(5): 680-687. PubMed PMID: 3722224.

Jackson DW, Cozen L. Genu valgum as a complication of proximal tibial metaphyseal fractures in children. J Bone and Joint Surg Am 1971 Dec; 53(8): 1571-1578. PubMed PMID: 5121797.

Question 18

113. Figures 113a and 113b are the radiographs of a 14-year-old boy who is seen in the emergency department after injuring his knee while playing basketball. He has substantial anterior knee swelling, an inability to actively extend his knee, and normal sensory examination findings of the lower leg. What is the best treatment option?
114. Closed reduction and immobilization in a cylinder cast
115. Closed reduction and percutaneous fixation with cannulated screws
116. Open reduction and internal fixation (ORIF) with multiple cannulated screws
117. Direct repair of the patella tendon
118. Spanning-knee external fixation

Answer 18

3. Open Reduction and internal fixation (ORIF) with multiple cannulated screws

RECOMMENDED READINGS

Pretell-Mazzini J, Kelly DM, Sawyer JR, Esteban EM, Spence DD, Warner WC Jr, Beaty JH. Outcomes and Complications of Tibial Tubercle Fractures in Pediatric Patients: A Systematic Review of the Literature. J Pediatr Orthop. 2015 Apr 10. [Epub ahead of print] PubMed PMID: 25887827.

Jakoi A, Freidl M, Old A, Javandel M, Tom J, Realyvasquez J. Tibial tubercle avulsion fractures in adolescent basketball players. Orthopedics. 2012 Aug 1;35(8):692-6. doi: 10.3928/01477447-20120725- 07. PubMed PMID: 22868593.

Question 19

122. Figures 122a and 122b are the radiographs of a 6-year-old child who fell from a tree. The most common neurologic injury associated with this fracture could result in which functional deficit?
123. Loss of sensation to the thumb and long finger
124. Inability to extend the wrist and fingers
125. Inability to adduct fingers
126. Inability to flex the wrist
127. Inability to flex the thumb interphalangeal joint

Answer 19

5. Inability to flex the thumb interphalangeal joint.

RECOMMENDED READINGS

Abzug JM, Herman MJ. Management of supracondylar humerus fractures in children: current concepts. J Am Acad Orthop Surg. 2012 Feb;20(2):69-77. doi: 10.5435/JAAOS-20-02-069. Review. PubMed PMID: 22302444.

Babal JC, Mehlman CT, Klein G. Nerve injuries associated with pediatric supracondylar humeral fractures: a meta-analysis. J Pediatr Orthop. 2010 Apr-May;30(3):253-63. doi: 10.1097/ BPO.0b013e3181d213a6. PubMed PMID: 20357592.

Question 20

129. Figures 129a and 129b are the radiographs of a 5-year-old boy who has a deformity of the lower leg. His parents note that the deformity has been slowly improving since he began walking. At skeletal maturity, this boy may expect to have
130. limb-length discrepancy.
131. scoliosis.
132. skin lesions.
133. an increased risk for bone tumors.
134. an increased risk for neurologic issues.

Answer 20

1. Limb-length discrepancy

RECOMMENDED READINGS

Shah HH, Doddabasappa SN, Joseph B. Congenital posteromedial bowing of the tibia: a retrospective analysis of growth abnormalities in the leg. J Pediatr Orthop B. 2009 May;18(3):120-8. doi: 10.1097/ BPB.0b013e328329dc86. PubMed PMID: 19339901.

Pappas AM. Congenital posteromedial bowing of the tibia and fibula. J Pediatr Orthop. 1984 Sep;4(5):525-31. PubMed PMID: 6490868.

Question 21

138. A 6-year-old boy underwent closed reduction and pinning of a type 3 supracondylar humerus fracture. The pins were removed at 3 weeks; his radiographs at that time showed an abundance of callus. Six weeks later, he has limited elbow motion. His current range of motion is 45 to 100 degrees. What is the best next step?
139. Recast for an additional 3 weeks because of a possible delayed union
140. Return to the operating room for manipulation and possible arthroscopic contracture release
141. Reassure and observe for the return of motion over 3 to 6 months
142. Order a dynamic elbow brace and a gradual increase in motion
143. Initiate indomethacin treatment

Answer 21

3. Reassure and observe for the return of motion over 3-6 months.

RECOMMENDED READINGS

Spencer HT, Wong M, Fong YJ, Penman A, Silva M. Prospective longitudinal evaluation of elbow motion following pediatric supracondylar humeral fractures. J Bone Joint Surg Am. 2010 Apr;92(4):904-10. doi: 10.2106/JBJS.I.00736. PubMed PMID: 20360514.

Keppler P, Salem K, Schwarting B, Kinzl L. The effectiveness of physiotherapy after operative treatment of supracondylar humeral fractures in children. J Pediatr Orthop. 2005 May-Jun;25(3):314-6. PubMed PMID: 15832145.

Question 22

143. For a patient with achondroplasia, the thoracolumbar kyphosis seen in infancy will most likely
144. resolve with independent walking.
145. increase with independent walking.
146. increase with skeletal maturity.
147. remain unchanged with independent walking.
148. remain unchanged with skeletal maturity.

Answer 22

1. Resolve with independent walking.

RECOMMENDED READINGS

Shirley ED, Ain MC. Achondroplasia: manifestations and treatment. J Am Acad Orthop Surg. 2009 Apr;17(4):231-41. Review. PubMed PMID: 19307672.

Engberts AC, Jacobs WC, Castelijns SJ, Castelein RM, Vleggeert-Lankamp CL. The prevalence of thoracolumbar kyphosis in achondroplasia: a systematic review. J Child Orthop. 2012 Mar;6(1):69-73. doi: 10.1007/s11832-011-0378-7. Epub 2011 Dec 3. PubMed PMID: 22442656.

Question 23

152. Figure 152 is the radiograph of a 3-year-old child who has a foot deformity. At this age, treatment should consist of
153. observation.
154. bracing.
155. nonsurgical treatment using the Ponseti method alone.
156. serial casting followed by surgery.
157. anterior tibial tendon transfer surgery.

Answer 23

4. Serial casting followed by surgery

RECOMMENDED READINGS

Miller M, Dobbs MB. Congenital Vertical Talus: Etiology and Management. J Am Acad Orthop Surg. 2015 Oct;23(10):604-11. doi: 10.5435/JAAOS-D-14-00034. Epub 2015 Sep 3. Review. PubMed PMID: 26337950.

Yang JS, Dobbs MB. Treatment of Congenital Vertical Talus: Comparison of Minimally Invasive and Extensive Soft-Tissue Release Procedures at Minimum Five-Year Follow-up. J Bone Joint Surg Am. 2015 Aug 19;97(16):1354-65. doi: 10.2106/JBJS.N.01002. PubMed PMID: 26290087.

Question 24

162. Figures 162a and 162b are the pelvic radiographs of a 13-year-old boy who is seen in the emergency department. He has a 1-year history of pain in his right hip with weight bearing. An examination reveals a shortened right leg that is held in external rotation and has limited flexion with obligate external rotation with maximal hip flexion. An examination of his left hip reveals full and normal motion without pain. What is the best next step?
163. Immediate in situ fixation of the right hip with a cannulated screw
164. Immediate right surgical hip dislocation, proximal femoral osteotomy, and relative lengthening

of the femoral neck

3. Immediate bilateral hip fixation with cannulated screws
4. Physical therapy for improved right hip range of motion
5. Delayed in situ fixation of the right hip with a cannulated screw after physical therapy for

improved hip range of motion

Answer 24

1. Immediate instu fixation fo the right hip with a cannulated screw

RECOMMENDED READINGS

Wensaas A, Svenningsen S, Terjesen T. Long-term outcome of slipped capital femoral epiphysis: a 38-year follow-up of 66 patients. J Child Orthop. 2011 Apr;5(2):75-82. doi: 10.1007/s11832-010-0308-0. Epub 2010 Dec 12. PubMed PMID: 21594079.

Thawrani DP, Feldman DS, Sala DA. Current Practice in the Management of Slipped Capital Femoral Epiphysis. J Pediatr Orthop. 2015 Apr 15. [Epub ahead of print] PubMed PMID: 25929770.

Question 25

169. A 4-year-old child cannot fully extend the small finger. An examination reveals a 45-degree flexion contracture at the little finger proximal interphalangeal joint with soft-tissue webbing. The extensor and flexion tendons are intact. There is no history of trauma. What is the best initial treatment?
170. Reassurance; the natural history is near-complete resolution
171. Z-plasty of the webbing with extension casting
172. Full excision of the fibrous band with intrinsic rebalancing
173. Digital stretching with progressive nighttime splinting
174. Proximal phalanx extension osteotomy with shortening

Answer 25

4. Digital stretching with progressive nighttime splinting

RECOMMENDED READINGS

Comer GC, Ladd AL. Management of complications of congenital hand disorders. Hand Clin. 2015 May;31(2):361-75. doi: 10.1016/j.hcl.2015.01.011. Review. PubMed PMID: 25934210.

Zancolli E. Congenital abnormalities of the retinacular system of the hand. In: Gupta A, Kay SPJ, Scheker LR, eds. The Growing Hand: Diagnosis and Management of the Upper Extremity in Children. London, England: Mosby; 2000:367-374.

Question 26

174. Figure 174 is a picture of a 3-year-old boy who has a foot deformity. The parents are concerned about the shape of his foot. He walked at 12 months, has no limp, and runs and plays without difficulty. An examination reveals the foot is flexible in the hindfoot, no pain is elicited with palpation or motion, and his gait is normal for a 3-year-old. What is the best next step?
175. Obtain an MRI of the foot
176. Obtain a CT scan of the foot
177. Reassure and educate the parents
178. Prescribe inserts for medial foot support
179. Prescribe reverse last shoes until the deformity improves

Answer 26

3. Reassure and educate the parents.

RECOMMENDED READINGS

Jane MacKenzie A, Rome K, Evans AM. The efficacy of nonsurgical interventions for pediatric flexible flat foot: a critical review. J Pediatr Orthop. 2012 Dec;32(8):830-4. doi: 10.1097/BPO.0b013e3182648c95. Review. PubMed PMID: 23147627.

Pfeiffer M, Kotz R, Ledl T, Hauser G, Sluga M. Prevalence of flat foot in preschool-aged children. Pediatrics. 2006 Aug;118(2):634-9. PubMed PMID: 16882817.

Question 27

183. Figures 183a and 183b are the radiographs of a 12-year-old boy who sustained an injury. After reduction, what is the most likely cause of physeal arrest?
184. The amount of initial displacement
185. The size of the metaphyseal fragment
186. A postreduction angulation exceeding 20 degrees
187. A postreduction physeal gap exceeding 3 mm
188. A concomitant fibular fracture

Answer 27

4. A postreduction physeal gap exceeding 3mm

RECOMMENDED READINGS

Barmada A, Gaynor T, Mubarak SJ. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. J Pediatr Orthop. 2003 Nov-Dec;23(6):733-9. PubMed PMID: 14581776.

Wuerz TH, Gurd DP. Pediatric physeal ankle fracture. J Am Acad Orthop Surg. 2013 Apr;21(4):234-44. doi: 10.5435/JAAOS-21-04-234. Review. PubMed PMID: 23545729.

Question 28

189. A 4-year-old girl has bilateral ankle swelling and a swollen right knee. She has a mild limp but no pain with walking or with joint range of motion. Her temperature is 37.7°C, her erythrocyte sedimentation rate is 45 mm/h (reference range [rr], 0-20 mm/h), and her C-reactive protein level is 1.5 mg/L (rr, 0.08-3.1 mg/L). After treatment initiation, what is the best next step?
190. Echocardiogram to rule out the source of multiple infection
191. Hematology consultation
192. MRI of the lower extremities
193. Ophthalmologic consultation
194. Infectious disease consultation

Answer 28

4. Opthalmologic consultation

RECOMMENDED READINGS

Punaro M. Rheumatologic conditions in children who may present to the orthopaedic surgeon. J Am Acad Orthop Surg. 2011 Mar;19(3):163-9. Review. PubMed PMID: 21368097.

Herring JA. Arthritis. In: Herring. ed. Tachdjian’s Pediatric Orthopaedics. Vol 1. 5th ed. Philadelphia, PA: Elsevier-Saunders; 2014:1007-1017.

Question 29

195. A 4-year-old boy is seen with his parents in the emergency department after an unwitnessed fall. He has pain in his right thigh and no other obvious injury. A radiograph reveals a spiral right femur fracture with no comminution and 1 cm of shortening. What is best next step?
196. Skeletal survey
197. CT scan of the head
198. Child protective services notification
199. Hip spica casting
200. Flexible intramedullary nailing

Answer 29

4. Hip Spica Casting

Question 30

210. Figures 210a and 210b are the radiographs of a 5-year-old child who sustained an injury after a fall from a monkey bar. Treatment should include reduction of the
211. ulna and ulnohumeral joint.
212. ulna and distal radioulnar joint.
213. ulna alone.
214. ulna and radiocapitellar joint.
215. ulnohumeral joint alone.

Answer 30

4. Ulna and the radiocapitellar joint

Question 31

223. Figure 223 is the anteroposterior weight-bearing radiograph of a 10-year-old boy who has had intermittent ankle pain for 6 months. What is the best treatment option?
224. An ankle brace and initiation of physical therapy with an ankle stabilization protocol.
225. Distal tibial osteotomy
226. Medial hemiepiphysiodesis with a screw or plate
227. Excision of osteochondromas and a fibular osteotomy with tenodesis tendon transfer to the

distal fibula

5. Complete epiphysiodesis and osteotomy with gradual correction with an external fixator

Answer 31

3. Medial emiephphyseiodesis with screw or plate

RECOMMENDED READINGS

Stieber JR, Dormans JP. Manifestations of hereditary multiple exostoses. J Am Acad Orthop Surg. 2005 Mar-Apr;13(2):110-20. Review. PubMed PMID: 15850368.

Rupprecht M, Spiro AS, Rueger JM, Stücker R. Temporary screw epiphyseodesis of the distal tibia: a therapeutic option for ankle valgus in patients with hereditary multiple exostosis. J Pediatr Orthop. 2011 Jan-Feb;31(1):89-94. doi: 10.1097/BPO.0b013e318202c20e. PubMed PMID: 21150737.

Question 32

229. Figure 229a is the radiograph of a 22-month-old boy who has infantile idiopathic scoliosis. What is the preferred initial treatment to minimize curve progression?
230. Observation
231. Serial casting
232. Rib-to-spine growing rods
233. Spine-to-spine growing rods
234. Posterior spinal fusion with instrumentation

Answer 32

2. Serial Casting

RECOMMENDED READINGS

Sanders JO, D’Astous J, Fitzgerald M, Khoury JG, Kishan S, Sturm PF. Derotational casting for progressive infantile scoliosis. J Pediatr Orthop. 2009 Sep;29(6):581-7. doi: 10.1097/ BPO.0b013e3181b2f8df. PubMed PMID: 19700987.

Tis JE, Karlin LI, Akbarnia BA, Blakemore LC, Thompson GH, McCarthy RE, Tello CA, Mendelow MJ, Southern EP; Growing Spine Committee of the Scoliosis Research Society. Early onset scoliosis: modern treatment and results. J Pediatr Orthop. 2012 Oct-Nov;32(7):647-57. Review. PubMed PMID: 22955526.

Waldron SR, Poe-Kochert C, Son-Hing JP, Thompson GH. Early onset scoliosis: the value of serial risser casts. J Pediatr Orthop. 2013 Dec;33(8):775-80. doi: 10.1097/BPO.0000000000000072. PubMed PMID: 23965912.

Question 33

239. Video 239 is the CT scan of an 8-year-old boy who has neck pain and torticollis. He reports waking up from sleep 4 weeks ago with neck pain and noticed his head was stuck in a position in which it was tilted to the left and turned to the right. His mother mentions a recent upper respiratory tract infection, but no other recent medical history. What is the best next step?
240. Nonsteroidal anti-inflammatory drugs (NSAIDs) and a soft cervical collar
241. Cervical traction followed by use of a soft cervical collar for 4 weeks
242. Cervical traction followed by halo-vest placement to maintain reduction
243. Posterior C1-C2 fusion using the Gallie technique
244. Observation

Answer 33

3. Cervical traction followed by halo-vest placement to maintain reduction

RECOMMENDED READINGS

Neal KM, Mohamed AS. Atlantoaxial rotatory subluxation in children. J Am Acad Orthop Surg. 2015 Jun;23(6):382-92. doi: 10.5435/JAAOS-D-14-00115. Review. PubMed PMID: 26001430.

Rahimi SY, Stevens EA, Yeh DJ, Flannery AM, Choudhri HF, Lee MR. Treatment of atlantoaxial instability in pediatric patients. Neurosurg Focus. 2003 Dec 15;15(6):ECP1. Review. PubMed PMID: 15305843.

Question 34

247. After treatment, the child seen in Figure 247 is expected to
248. walk and run with a prosthesis.
249. walk only with a prosthesis.
250. walk only.
251. run and walk.
252. not run and not walk.

Answer 34

4. Run and walk

RECOMMENDED READINGS

Ziont LE. What’s New in Idiopathic Clubfoot? J Pediatr Orthop. 2015 Sep; 35(6): 547-50. PubMed PMID: 25298569.

Lohle-Akkerskijk JJ, Rameckers EA, Adriesse H, de Reus I, van Erve RH. Walking capacity of children with clubfeet in primary school: something to worry about? J Pediatr Orthop B. 2015 Jan; 24(1): 18-23. PubMed PMID: 25350905.

Question 35

265. An 8-year-boy with hemiplegic cerebral palsy is evaluated for toe-walking gait on his right leg. An examination reveals he has no hip or knee flexion contracture and he cannot place his foot flat during the stance phase of gait. He has maximal ankle dorsiflexion of 5 degrees with his knee flexed and 10 degrees short of neutral with his knee extended. What is the best surgical treatment?
266. Open Achilles lengthening
267. Complete release of the Achilles tendon
268. Complete anterior tibial tendon transfer
269. Gastrocnemius recession
270. Split anterior tibial tendon transfer

Answer 35

4. Gastrocnemius Recession

RECOMMENDED READINGS

Barouk P, Barouk LS. Clinical diagnosis of gastrocnemius tightness. Foot Ankle Clin. 2014 Dec;19(4):659-67. doi: 10.1016/j.fcl.2014.08.004. Epub 2014 Sep 26. Review. PubMed PMID: 25456715.

Karol LA. Surgical management of the lower extremity in ambulatory children with cerebral palsy. J Am Acad Orthop Surg. 2004 May-Jun;12(3):196-203. Review. PubMed PMID: 15161173.