Paediatrics

Question 1

Rhizomelic
Mesomelic
Acromelic

Answer 1

Rhizo = "root", so more proximal than distal shortening
Meso = "middle", so middle segment shortening
Acro = "tip", so distal segment shortening

Question 2

Achondroplasia features

Answer 2

Rhizomelic shortening
Frontal bossing
Button nose
Cervical stenosis
Radial head dislocation
Trident hands
Lumbar lordosis
Short pedicles
Champagne glass pelvis
Genu varum

Question 3

Diastrophic dysplasia features

Answer 3

Short-limbed dwarfism
Cleft palate
Clubfoot
Hip dysplasia
Cauliflower ears
Hitchhiker thumb

Question 4

Multiple Epiphyseal dysplasia

Answer 4

Proportionate dwarfism (no spinal involvement)
Shortened metacarpals
Double-layer patella

Question 5

Spondyloepyphyseal dysplasia

Answer 5

Proportionate dwarfism
Spinal involvement
Barrel chest
Cervical instability (common)

Question 6

McCune-Albright syndrome triad

Answer 6

Polyostotic Fibrous dyslplasia
Cafe-au-lait spots
Endocrine dysfunction

Question 7

What investigations to order in Non-accidental Injury with:

1. Children less than 2 years old
2. Children less than 1 year old
3. Neurological findings
4. Shaking is suspected

Answer 7

1. Skeletal survey (Skull, CXR, extremities)
2. Lateral thoracolumbar x-ray
3. Head CT
4. Ophthalmologic exam

Question 8

Age at Appearance (ossification) of ossification centers of the elbow

Answer 8

CRITOE

Capitellum = 1
Radial head = 4
Inner epicondyle = 6
Trochlea = 8
Olecranon = 10
External epicondyle = 12

Question 9

Age at Fusion of ossification centers of the elbow

Answer 9

CET OR I

Capitellum, External epicondyle, Trochlea = 12
Olecranon, Radial head = 15
Inner epicondyle = 17

Question 10

Indications for fixation in Supracondylar fractures

Answer 10

Medial comminution
Type IIb
Type III
Type IV
Flexion type

Urgent:
Pulseless
Neuro deficit
Floating elbow
Brachialis sign "subcutaneous bone"
Swelling (if excessive)

Question 11

Baumann’s angle

Answer 11

Humeral shaft
Lateral condylar physis on AP

Normal = 70-75 degrees
Deviation of 5-10 degrees should not be accepted

Question 12

Indications for ORIF in medial epicondyle fractures in Paeds

Answer 12

Fracture entrapped in the joint
Extension of the fracture to the articular surface
Displaced >5 mm
Elbow dislocation
Open fracture
> 2 mm displacement in athletes

Note: 9x higher rate of radiographic union with surgery

Question 13

Indications for ORIF of radial head fractures in Paeds

Answer 13

> 30 degrees residual angulation (after reduction)
3 mm residual translation
< 45 degrees pronation / supination ROM

Question 14

Patterson maneuver for closed reduction of Paediatric radial head fracture

Answer 14

Extension
Traction
Supination
Varus
Direct pressure

Question 15

Israeli technique for closed reduction of Paediatric radial head fracture

Answer 15

Supination
Flex to 90
Direct pressure
Pronate while maintaining pressure

Question 16

Metaizeau technique for reduction of Paediatric radial head fracture

Answer 16

Sharpen end of TENs nail a bit
Insert TENs nail
Guide it into radial head
Rotate TENs nail
Check on II
Rotate the other way if no improvement

Question 17

Indications for reduction of both bone forearm fracture in Paeds

Answer 17

If less then 9 yo then:
> 15 degrees angulation

If more than 9 yo then:
> 10 degrees angulation

Bayonetting > 1cm
Don’t accept malrotation (doesn’t remodel)

Question 18

What is a Morscher osteotomy

Answer 18

Femoral neck lengthening osteotomy for residual Perthes. Take GT off, osteotomy in line with inferior neck, reattach GT more lateral and distal.

Question 19

Cast Index in Distal radius fractures

Answer 19

Lateral x-ray inner cast diameter (excluding padding)
Divided by
AP x-ray inner cast diameter (excluding padding)
(measured at the fracture site)

Ideal is 0.8 or less. This is associated with a lower chance of fracture redisplacement (5.6% vs 26%).

Question 20

Indications and treatment of Femoral Shaft fractures in Paeds

Answer 20

< 6 months old = Pavlik harness
0-5 years old + no shortening = Spica casting
0-5 years old + shortening = Traction, then delayed Spica
5-11 years old + <49kg + Length stable = TENS nails
>5 years old + >49kg = Submuscular plate
>11 years old or >49kg = Antegrade nail (trochanteric)

Question 21

Cozen’s Phenomenon

Answer 21

Late valgus deformity after proximal tibial metaphyseal fracture in Paeds (3 to 6 year old)

Occurs in 50-90% of cases
Develops 5-15 months post injury
Maximal deformity at 12-18 months
Prevent by casting in extension and Varus mold. However, deformity occurs regardless of treatment.
Valgus deformity usually resolves spontaneously.

Question 22

Blocks to open reduction of hip DDH

Answer 22

Capsule (lax, can be constricted by psoas)
Psoas (tight)
Labrum (inverted)
Ligamentum teres (thickened)
Transverse ligament (hipertrophied)
Pulvinar (thickened)

Extrinsic: adductor tightness

Question 23

Packaging conditions / disorders

Answer 23

Neck (Torticollis)
Hip (DDH)
Knee (Dislocation)
Foot (Metatarsus adductus)

Question 24

Acetabular index in DDH

Answer 24

Line between:
Hilgenreiner’s line
A line formed by: point on the lateral margin of triradiate cartilage and point on the lateral margin of the acetabulum

Should be less than 25 degrees after 6 months of age.

Question 25

Center-edge angle of Wiberg in DDH

Answer 25

Line between: Perkin's line A line formed by: Center of femoral head to a poin on the lateral margin of the acetabulum Should be more than 20 degrees after 5 years old (can't seen bone very well until then)

Question 26

Basic DDH treatment by age

Answer 26

< 6 weeks - Observe or Pavlik < 6 months - Pavlik < 18 months - Closed reduction and Spica > 2 years - Open reduction + Femoral osteotomy > 4 years - Open reduction + Acetabular osteotomy > 14 years - Periacetabular ostotomy or Shelf

Question 27

What is Pavlik Harness disease

Answer 27

Erosion of the Posterior Superior Acetabulum due to persistent dislocated position Discontinue Pavlik if fails after 3-4 weeks If hip is reducible (ortalani positive), go into a semi-rigid brace

Question 28

Conditions affecting the Hypertrophic Zone of the Physis

Answer 28

``` SCFE Rickets Multiple Epiphyseal Dyslplasia Spondyloepiphyseal dysplasia Fractures (Zone of provisional calcification) ```

Question 29

Conditions affecting the Proliferative Zone of the Physis

Answer 29

Achondroplasia | Multiple Hereditary Exostoses

Question 30

Conditions affecting the Reserve Zone of the physis

Answer 30

Gaucher's Diastrophic dysplasia Pseudoachondroplasia

Question 31

Indication for physeal bar resection

Answer 31

< 50% of physis involved | 2+ years of growth remaining

Question 32

Indication for physeal bar resection

Answer 32

< 50% of physis involved | 2+ yearsof growth remaining

Question 33

What is the angle of Drennan and what is its significance

Answer 33

Metaphyseal - Diaphyseal angle of the proximal tibia in Infantile Blount's disease < 10 = 95% chance of spontaneous recovery without bracing > 16 = 95% chance of progression

Question 34

What conditions are associated with congenital vertical talus

Answer 34

``` Spinal muscular atrophy Cerebral palsy Arthrogryposis Myelomeningocele Diastematomyelia Congenital hip dislocation ```

Question 35

At what age does the navicular bone ossify

Answer 35

Age 3 This is relevant in Congenital vertical talus, where the 1st metatarsal is used as a surrogate for the navicular on x-rays.

Question 36

What is the physiological varus / valgus ages and alignment in Paeds

Answer 36

1 year = Varus 15 deg 2 yo = Neutral 3 yo = Valgus 10 deg 6 yo = 6 degrees valgus Saleneus chart / curve 15 degree variation each way at each age

Question 37

Pathologic causes of Varus legs in paeds

Answer 37

``` Fibrous dysplasia Infection Rickets Skeletal dysplasias (OI, FGFR3) Trauma JRA AnteroLateral bowing Blount's ``` FIRST JAB from bone school

Question 38

Important steps / points in Blounts correction osteotomy

Answer 38

Osteotomy distal to TT Must correct Internal rotation as well as Varus If doing acute correction, must do an ANTERIOR COMPARTMENT FASCIOTOMY! "Rab" oblique osteotomy (banana osteotomy) vs corticotomy and frame vs closing wedge (shortening) Fibula osteotomy required in most cases

Question 39

What are the predictors of Walking in Cerebral Palsy

Answer 39

``` Hemiplegic - 100% walk Diplegic - 75% walk Quadriplegic - 25% walk Sit by 2 Stand by 4 ```

Question 40

Coxa Vara in Paeds indications for surgery

Answer 40

Epiphyseal angle (vs Hilgenreiner's line) < 45 - no operation 45-60 and stable - observe 45-60 and progressing - Valgising osteotomy > 60 - Valgising osteotomy Aim is to get angle to < 40 Use 150 degree plate Add 20 degrees anteversion (usually retroverted)

Question 41

What are the three types of Tibial Bowing

Answer 41

Antero - Lateral = Neurofibromatosis Antero - Medial = Fibular hemimelia Postero - Medial = Physiologic

Question 42

Fibular Hemimelia associated conditions

Answer 42

``` Ankle instability DDH Absent lateral rays PFFD Tibial Bowing (anteromedial) Talipes equinoVALGUS Tarsal coalition Cruciate ligament deficiency Genu VALGUM LLD ```

Question 43

Differentials for hemihypertrophy

Answer 43

Beckwith-Weidermann syndrome Neurofibromatosis Klippel-Trenaunay-Weber syndrome Proteus syndrome ``` Malignant tumors Ollier's Fibrous dysplasia Poliomyelitis Spastic hemiplegia Russell-Silver syndrome (hemiartrophy, short, cafe-au-lait, clinidactyly) Haemophilia Xray therapy Condrodysplasia punctata ```

Question 44

Perthes disease good prognostic factors

Answer 44

``` Male gender (longer remodeling time) Involvement of head low (Caterall or Herring) Containment of head good Range of Movement Age < 6 at onset ``` Herring low Stuhlberg low

Question 45

What are the three types of osteochondroses (and give an example of each)

Answer 45

Crushing Pulling Splitting ``` Crushing = Kohler's, Friedberg's, Panner's, Kienbock's Pulling = Osgood-Schlatter, Sever's, Sinding-Larsen-Johansson, Menelaus-Batten Splitting = OCD (knee, ankle, hip) ```

Question 46

What is Kohler's Disease

Answer 46

AVN of the navicular 4-6 yo boys Resolves in 18+ months

Question 47

What is Panner's Disease

Answer 47

AVN of the capitellum 4-10 yo boys Non-op mgmt if no OCD If OCD, then treat as required

Question 48

Indications for amputation in Fibular Hemimelia

Answer 48

Less than 2 rays of the foot > 16cm LLD at maturity (some texts say 20) Unstable ankle (relative) Associated severe PFFD (relative)

Question 49

4 things to examine for in a Juvenile Hallux Valgus case

Answer 49

Ligamentous laxity Achilles tightness TMTJ hypermobility Neurological exam

Question 50

Infications for contralateral SUFE pinning

Answer 50

PRE SLYPT Portly Remote Endocrine ``` Severe slip Late presentation Young age (<10 yo) Posterior sloping angle (>14 degrees) Triradiates open ```

Question 51

Physeal / Metaphyseal dysplasias

Answer 51

``` Multiple hereditary exostoses Achondroplasia Hypochondroplasia Metaphyseal chondrodysplasia Dyschomdrodysplasia (Olliers and Maffuci) ```

Question 52

Epiphyseal dysplasias

Answer 52

Multiple epiphyseal dysplasia Spondyloepiphyseal dysplasia Dysplasia epiphysealis hemimelica Chondrodysplasia punctata

Question 53

Diaphyseal (/metaphyseal) dysplasias

Answer 53

``` Metaphyseal dysplasia Craniodiaphyseal dysplasia Diaphyseal dysplasia Craniometaphyseal dysplasia Osteopetrosis Pyknodysostosis ```

Question 54

Autosomal Recessive Conditions

Answer 54

FrOGS SHODM ``` Friedrich’s ataxia Osteogenesis imperfecta 2/3 Gauchers Sickle cell Spinal Muscular atrophy Hypophosphatasia Osteopetrosis Diastrophic dysplasia Mucopolysacharidpses (except Hunter, which is X) ```

Question 55

What is the safe zone for the hip in closed reduction for DDH

Answer 55

Less than 60 abduction Less than 90 flexion "Ramsay" safe zone Maximum abduction - Position of re-dislocation If this zone is less than 20 degrees, then not safe.