114 B Day (11/29 A & B 11/30) Daily Mastery Plan

Front 1

Hx:32mo M w/ severe infantile Blounts dz txd w/full time bracing x 1 yr. f/u, the varus deformity b/l legs has worsened despite compliance w/bracing. What tx is now recommended? 1-Observation, stop bracing; 2-Observation, continuation of full-time bracing; 3-B/l prox tibial osteotomies; 4-B/l distal femur osteotomies; 5-B/l prox tibial medial hemiepiphysiodesis

Back 1

Surgery is indicated if varus secondary to Blount's dz persists at the age of 4 or if bracing fails in 2-3 year olds p/ 12 mths. Correction is achieved surgically with a proximal tibial realignment osteotomy. Answer 5 is incorrect because closing down the medial side will cause further varus. Answer 4 is wrong because the pathology is in the tibia and not the femur in infantile blount’s.Ans3

Front 2

A pedi pt has just been dx'd w/ osteomyelitis of the femur. All of the following are risk factors for the development of DVT EXCEPT? 1-Surgical tx of osteomyelitis; 2-CRP > 6; 3- MRSA; 4-Fever of > 38.5 deg 5-Pt age> 8-yo

Back 2

Risk factors 4: DVT in child w/ osteomyelitis include surgical treatment, CRP > 6, MRSA, and age > 8. A fever of > 38.5 has NOT been found to be a risk factor, Some studies suggest that S. aureus exotoxins, such as the Panton-Valentine leukocidin, can cause leukocyte lysis and additional injury to endothelial surfaces. These events can cause microthrombosis and deep venous thrombosis, the possible mechanism by which Panton-Valentine leukocidin secreted by MRSA leads to endothelial cell damage. It suggests tissue necrosis could result from release of reactive oxygen species (ROS) from lysed PMNs rather than a direct necrotic effect on epithelial cells.Ans4

Front 3

Hx:7yo B c/o worsening L knee pain x 2 wks. He has been unable to bear weight through the L LE x 24 hrs. The knee & lower leg are warm and tender to palpation. t= 100.9 deg, CRP is 11 mg/dL (nml <1). A xray Fig A. A jnt aspiration yields 2 mL's of synovial fluid demonstrating a CC= 2,500 and no organisms on gram stain. Which of the following is the next step in management? 1. Repeat aspiration of the L knee; 2-Observation with repeat xray in 1 wk; 3-(MRI); 4-Begin IV broad-spectrum abx & obtain an ID consult; 5-Exploratory surgical arthrotomy

Back 3

this patient is presenting with signs of infection, but a nl xrays & knee aspiration. Osteomyelitis should be suspected, and MRI is the most appropriate next step. pt is too ill to observ, and a dx must be made before ABX are started. MRI is also useful as it will help evaluate for malignancy which should also be on the differential.Ans3

Front 4

Hx:10-yo B c/o 2 days of worsening R knee pain, unable to ambulate on the leg since waking up this morning, denies any recent trauma to the leg. PE is notable for focal tenderness over the distal femur w/out a palpable fluid collection, ESR is 68 mm/hr (normal <15) and CRP is 14 mg/dL (normal <1). T=101.2 deg xray Fig A&B. An aspiration of the knee reveals 1700 nucleated cells per mL, and no organisms on gram stain. Which is the most appropriate management? 1-MRI; 2-Obser w/ f/u ESR, CRP, & repeat aspiration in 2 days; 3-PO cephalosporin & f/u in 10 days; 4-Surgical arthrotomy, I & D proced; 5-Chest, abdomen, and pelvis CT

Back 4

child's clinical presentation is consistent w/ an acute infection. xrays do not show osseous changes for 7-10 days, but soft tissue swelling may be noticeable. The knee aspiration is NOT consistent with septic arthritis of the knee. The child most likely has acute osteo. MRI will confirm Dx & assist in planning a bone bx & cx to guide ABX management. xrays may show deep soft tissue swelling, but are unlikely to show osseous changes during an acute episode.Ans1

Front 5

Hx:14yo B presents 6 mths p/ spraining his R ankle. xrays obtained at the time of injury are shown in Fig A, returns to clinic w/ persistent R ankle pain. pt denies fevers, ESR of 35 mm/h (nl 0-20). CRP and WBC are nl. xrays, MRI Figures B, C, D. What is the next most appropriate step in management? 1- Casting of the ankle & observation; 2-CT of the tibia
3-PO ABX, w/ outpt f/u in 6 wks; 4-Bx & Cx of the tibial lesion; 5-Urgent ankle arthrotomy

Back 5

pt's presentation is consistent with subacute osteomyelitis, with the development of a Brodie's abscess, most important aspect of treating children and adolescents with subacute hematogenous osteomyelitis is R/O tumors. Therefore, in addition to cx of involved tissue, a bx is needed. They also state that IF infection is confirmed, tx consists of administration of appropriate ABX and, when the osteomyelitis is chronic=sx > 1 mth), débridement and removal of any sequestrum may be required. Pts w/ this condition usually do not have any constitutional sx, and lab w/u may be nl. Subacute osteomyelitis is a distinct form of osteomyelitis, and Brodie abscess is one type of subacute osteomyelitis. Subacute osteomyelitis is difficult to diagnose because the characteristic signs and symptoms of the acute form of the disease are absent, insidious onset, mild symptoms, and lacks a systemic reaction, and supportive laboratory data are inconsistent, which may persist for years before converting to a frank osteomyelitis. Subacute osteomyelitis may mimic various benign and malignant conditions, resulting in delayed diagnosis and treatment.Ans4

Front 6

Hx:8-yo B fell while riding his bike & landed on his outstretched arm. xrays are provided in Fig A. Which of the following increases the risk of displacement following CR & casting? 1-LAC immobilization; 2-SAC immobilization; 3-Cast index > 0.85; 4-Conscious sedation during reduction
5-Plaster cast immobilization

Back 6

The cast index is defined as the sagittal width of the cast divided by the coronal width. If the fracture involves the physis, repeated closed reductions are not recommended due to potential injury of the physis. Therefore it is important to recognize acceptable alignment, know the potential for remodeling at certain ages, and the importance of a well-molded cast, cast index of patients who lost reduction was 0.79 compared to 0.70 in patients who did not lose reduction. Patients with short arm casts missed fewer school days and experienced less difficulty with activities of daily living.Ans3

Front 7

Hx: 9yo B w/Duchenne muscular dystrophy has increasing difficulty with ambulation, denies back pain, difficulty sitting in a chair, or shortness of breath. Annual screening spine xrays demonstrate a 20 deg thoracolumbar curve. Which of the following statements best describes the approp tx plan for his scoliosis? 1-Given the poor prognosis, surgical treatment is not appropriate; 2-PSF should be performed before curve progresses >30 deg; 3- PSF should be performed if the curve progresses to > 55 deg; 4-PSF should be performed if FVC drops < 60%; 5-With appropriate bracing, curve progression and surgical tx will most likely be unnecessary

Back 7

Duchenne muscular dystrophy is a X-linked recessive disease of dystrophin causing progressive proximal muscle wasting. Scoliosis of Duchenne muscular dystrophy behaves similar to neuromuscular curves. Rapid progression of the curve (up to 2 degrees per month) ultimately results in restrictive pulmonary disease. Bracing is not effective in halting or slowing progression. Surgical intervention should occur prior to rapid progression of the curve to prevent cardiac and pulmonary complications before they occur. No specific numeric criteria are agreed upon, but most authors advocate fusion for a 20-30 deg curve.Ans2