115 A Day Abos (12/2 A & B 12/3) Daily Mastery Plan

Front 1

Hx:12yo B c/o R sided anterior knee pain and an outtoeing gait that has worsened over the past few yrs, PE= external foot-progression angle of 25 deg, a thigh-foot axis of +30 degrees, and a positive apprehension test for lateral patellar subluxation on the R side. There is also noted symmetrical hip rotation on exam. What is the most likely cause of this patient's outtoeing and knee pain? 1-B/l developmentally dislocated hips; 2-Excessive external tibial torsion; 3-Excessive femoral anteversion; 4-ER contracture of the hips
5-Excessive internal tibial torsion

Back 1

Out-toeing gait in late childhood and early adolescence is most commonly caused by excessive external tibial torsion. By late childhood and early adolescence the average thigh foot axis is 10 degrees external (range -5 to +30), and the average foot progression angle is approximately 5 degrees external for late childhood/early adolescence. External rotation contracture of the hips is most common cause of out-toeing in infancy and early toddlers. Excessive external tibial torsion is mostly unilateral affecting the right side and patients will also present with complaints of patellofemoral pain and instabilit.Ans2

Front 2

Which of the following is true regarding the structure outlined in Figure A? 1-It is comprised of the iliopectineal eminence and quadrilateral surface; 2-In normal hips, all children usually have this radiographic figure by 18 months of age; 3- This figure is usually present in children with developmental dysplasia of the hip prior to reduction; 4-The structure is a result of the radiographic superimposition of the ilioischial and Iliopectineal lines; 5-It is comprised of the cotyloid fossa and iliopectineal eminence

Back 2

The structure outlined in Figure A is the acetabular teardrop and it is comprised of the quadrilateral surface and cotyloid fossa. In normal hips, all children have a teardrop figure by age 18 months of age, the structures responsible for teardrop figure by removing sections from the hemipelvis of an anatomic specimen with an electric saw. The normal and abnormal appearances of the teardrop shadow of the acetabulum of three patients were then demonstrated on both plain radiographs and CT scans.Ans2

Front 3

Which of the following concepts regarding pediatric hips is true? 1-The proximal femoral physis & greater trochanteric apophysis develop from different cartilaginous physes; 2-The proximal femoral physis grows at a rate of 9 mm/yr; 3-Nl infant femoral anteversion is b/t 10-20 deg; 4-The ossific nucleus of the proximal femur is visable on xrays by 6 mths of age in most children; 5- (SCFE) typically occurs through the zone of proliferation

Back 3

The ossific nucleus of the proximal femur is visible on radiographs by 6 months of age in most children. The proximal femoral physis and greater trochanteric apophysis develop from the same cartilage physis in the infant which undergoes apoptotic division in the child. The distal femoral physis (not proximal) grows at a rate of 9 mm per year. The normal infant femoral anteversion is between 30-40 degrees. SCFE typically occurs through the zone of hypertrophy, not the zone of proliferation. Vitale and Skaggs review the history, diagnosis, treatment, and outcome of developmental dysplasia of the hip. Wientroub and Gill review the use of ultrasonography in the diagnosis and prognosis of developmental dysplasia of the hip. They recommond detection with ultrasound because of the delayed femoral head ossification (~5 months) and discuss the cost ineffectiveness of routine screening of all newborns.Ans4

Front 4

Hx:2-wk-old infant girl is referred for a hip clunk noticed by the pediatrician. She was the product of a NSVD and is otherwise healthy. PE= R hip Ortolani sign. A coronal US fig A. What is the next step in treatment? 1-Observ w/ repeat US in 1 mth
2-Pavlik harness application; 3-CR & spica casting
4-OR & spica casting; 5-OR, acetabular osteotomy, femoral shortening, and spica casting

Back 4

This patient has a right hip dislocation (DDH), as demonstrated by the positive Ortolani sign. Pavlik harness application is indicated for treatment. If the hip does not stay reduced within a few weeks, the next option is an arthrogram under anesthesia, closed reduction, and spica casting. Open reduction and casting is reserved for when closed reduction has failed. Acetabular osteotomy and femoral shortening are procedures used for children with DDH typically older than 1.5 years.Ans2

Front 5

Hx:5 yo B w/ CP presents to the clinic w/a dislocated R hip, what quadrant of the acetabulum is most likely deficient? 1-Anterior-inferior; 2-Anterior-superior; 3-Posterior-superior; 4-Posterior-inferior; 5-Anterior-inferior and anterior-superior

Back 5

In patients with cerebral palsy, the hip is normal at birth, but a combination of muscle imbalance and bony deformity leads to progressive hip dysplasia. The review article by Flynn notes that spasticity or contracture usually involves the adductor and iliopsoas muscles. Because of the pull of these muscles, the majority of hips subluxate in the posterosuperior direction. Because physical examination is unreliable, an AP of the pelvis is required for diagnosis.Ans3

Front 6

Figure A depicts an ultrasound of a newborn infant's hip. Which of the following structures (1 through 5) represents the labrum? 1-1; 2-2; 3-3; 4-4; 5-5

Back 6

: Figure A depicts an ultrasound of a newborn infant, which is routinely used in the screening and monitoring for hip dysplasia. The structure labeled by the number 4 is the labrum.

Harke et al reviewed the management of congenital dislocation and dysplasia of the hip and the role of ultrasound (US). They concluded that US has distinct advantages over clinical and radiographic examination. As a “novel” technique for evaluation of infant hip dysplasia in 1991, they hoped US would provide a tool for screening and studying the natural history of the developmental disorders of the hip. Since that time, ultrasound has become very helpful in the evaluation of newborn and infant hips as the ossific nucleus of the femoral head is not visible on radiographs.

Hint 6

Illustration A depicts an ultrasound with structures abbreviated. Illustration B is a cartoon schematic of the hip. Il:ilium, Ac:acetabulum, L:labrum, G:gluteal muscles, C:capsule, GT:greater trochanter, H:femoral head, LT/P:ligamentum teres/pulvinar, Tr: triradiate cartilage.

Front 7

Hx: 14yo high school running back strikesL knee on an opposing players helmet during practice. He is able to continue playing for 10 more minutes before seeking medical attention. On PE= has soft tissue swelling at the anterior knee and early ecchymosis formation. His range of motion was full and no palpable crepitus over the patella was noted. His knee is stable to varus and valgus at 30 degrees. He has a grade one Lachman examination and the medial tibial plateau is anterior to the medial femoral condyle upon a posteriorly directed force on the proximal tibia. There is less than one-quartile of medial and lateral patellar translation with a negative "J" sign. Radiographs are shown in Figures A-C. What is the most appropriate next step in management. 1-(MRI) for ligament recon planning; 2- Immobilize in 120 deg of knee flexion for 24 hrs and return-to-play in 2 wks; 3-ORIF w/ interfragmentary screws w/ return-to-play in 5 months
4-Symptomatic tx w/ return-to-play as tolerated; 5-LLC x 6 wks w/ toe-touch wtbearing precautions w/ RtP x 2 mths

Back 7

pt has a benign exam and radiographs demonstrate a bipartite patella. No further evaluation is necessary and symptomatic treatment with RICE and return-to-play as tolerated is most appropriate.Ans4

Hint 7

Front 8

All of the following are findings associated with Ehlers-Danlos syndrome EXCEPT: 1. Superior lens dislocation of the eye
2. Joint hypermobility
3. Skin hyperelasticity
4. Pathologic defect of collagen
5. Poor wound healing

Back 8

Superior lens dislocation of the eye is associated with Marfan's syndrome, not Ehlers-Danlos. (Inferior lens dislocation is associated with homocystinuria). Ehlers-Danlos consists of a spectrum of collagen abnormalities resulting in findings including but not limited to: generalized ligamentous laxity, joint hypermobility, poor wound healing, pes planus, vascular defects, high palates, gastroparesis, and mitral valve prolapse. The most common subtypes result from a mutation affecting collagen type V. Raff et al review the different disorders that are associated with generalized ligamentous laxity and their underlying pathologic defects. Included are Ehlers-Danlos, osteogenesis imperfecta, Marfan syndrome, and Larsen syndrome.Ans1

Front 9

A 10-month-old child fell off of the couch and has L elbow pain & swelling. A xray Fig A. All of the following are characteristics of this injury pattern EXCEPT: 1-High risk of tardy ulnar nerve palsy; 2-Posteromedial displacement; 3-High association with child abuse; 4-High risk of cubitus varus deform; 5-High risk of subsequent AVN of the medial condyle

Back 9

distal humeral physeal separation (transphyseal fracture). This is supported by the radiograph which show posteromedial displacement of the radial and ulnar shafts relative to the distal humerus. Posteromedial displacement is most common. . In the child with a visible ossification center at the capitellum, a true elbow dislocation will have disruption of the radiocapitellar line and transphyseal separation of the distal humerus will not. This injury pattern is associated with child abuse, and may lead to cubitus varus deformity or AVN of the medial condyle. Tardy ulnar nerve palsy is not associated with transphyseal fractures, and is more commonly seen following lateral condyle fracture nonunions and cubitus valgus, Transphyseal fractures are either Salter I injuries or can be associated with a metaphyseal fragment (Salter-Harris Type II) that can range in size from a small fragment to a large Thurston-Holland fragment.Ans1