Mrc - Peds

Front 1

Types of CP

Back 1

spasticity, athetoid, ataxia, mixed

Front 2

Spasticity management

Back 2

Botox, baclofen, selective dorsal rhizotomy

Front 3

Botox

Back 3

botulinum-A toxin; competitive inhibitor at motor endplate- pre-synaptic cholinergic receptor

Front 4

Baclofen

Back 4

GABA agonist; oral vs intra-thecal

Front 5

Selective dorsal rhizotomy

Front 6

CP patient with toe walking (usually hemiplegic)

Back 6

if ankle DF > 5-10 = AFO; if ankle DF < -10 degrees = TAL vs recession/Strayer

Front 7

Diplegic with crouch gait

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do gait analysis, will require multiple level release; hamstring contracture most likely to recur

Front 8

Indications for scoliosis correction in CP

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progressive deformity, sitting imbalance, pelvic obliquity

Front 9

Hip subluxation/dislocation in CP

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goal is prevent dislocation; do early soft tissue release (adductor and flexor); later treatment: VDRO and pelvic osteotomies

Front 10

CP equinovarus foot

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Gait analysis; treatment: tib post split transfer vs rancho procedure

Front 11

Spina Bifida- general issues

Back 11

Level describes lowest functioning root; if changes in function, get an MRI (detethering); Latex allergy (IgE mediated); Fractures are common

Front 12

Most common level in Spina Bifida related to hip dislocation

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L3-L4

Front 13

Risk of scoliosis in thoracic myelodysplasia

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100%; rapid progression; bracing ineffective; if correction done, high infection risk, and need anterior and posterior fusion

Front 14

Teratologic hip dislocations in arthrogryposis

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irreducible; pseudoacetabulum at birth; Pavlik harness contraindicated

Front 15

Larsen’s Syndrome

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Multiple joint dislocations, flattened fascies, cervical kyphosis

Front 16

Duchenne’s muscular dystrophy

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Gower’s sign; markedly elevated CPK; calf pseudohypertrophy; X-linked recessive. Absent dystrophin

Front 17

Scoliosis in Duchenne’s

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progression after become wheelchair dependent; PSF for curves progressing > 20-25 degree; Respiratory function declines with curve progression

Front 18

Fascico-scapulo-humeral dystrophy

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scapular winging bilaterally

Front 19

Becker’s Muscular Dystrophy

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Abnormal (but present) dystrophin gene

Front 20

Friedreich’s Ataxia

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spinocerebellar degenerative disease; staggering wide based gait w/ cavovarus foot

Front 21

Limb development genes

Back 21

with the influence of homeobox and sonic hedgehog

Front 22

Primary centers of ossification

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present at birth (shaft); secondary centers are typically the epiphyses

Front 23

Apert’s Syndrome

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complex syndactyly of hands and feet; FGFr2

Front 24

Diastrophic Dysplasia

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Sulfate transporter protein- cauliflower ear and hitchiker thumb

Front 25

Morquio’s Syndrome

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accumulation of keratan sulfate; normal intellegence; C1-2 instability

Front 26

Rickets types

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vitamin D dependent, vit D resistent (sex linked dominant), renal rickets (renal osteodystrophy) with secondary hyperparathyroidism

Front 27

Osteopetrosis

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AR chromosome 11, osteoclast issues; rugger jersey spine; treatment with bone marrow transplant; no intra-medullary canal in long bones

Front 28

Pseudarthrosis of the tibia

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Antero-lateral bowing of the tibia in Neurofibromatosis

Front 29

Plexiform neurofibroma

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skin lesions in NF; looks like a bag of worms

Front 30

What ADI do you operate on in Downs’

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> 10 mm or neurologic decline; Tx: C1-2 fusion

Front 31

Adolescent Idiopathic Scoliosis: progression factors

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Age, skeletal maturity, peak growth velocity (just prior to menarche), Curve magnitude > 20deg, curve type (Thoracic > Lumbar; Double > Single)

Front 32

Progression after maturity predictors

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Thoracic curves > 50, Lumbar curves > 30; Typically 1-2 degrees per year

Front 33

AIS treatments based off of curve magnitude

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<20 = observation; 25-40 = brace; >50 = surgery

Front 34

Risks for crankshaft post fusion

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severe curves ( >70 deg), age less than 10 years

Front 35

Anterior and Posterior instrumentation/fusion indications

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very large curves; myelodysplasia (SB) or Neurofibromatosis

Front 36

AIS: Organism in delayed infection (9-12 months)

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P. acnes

Front 37

Infantile Idiopathic Scoliosis

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2mo-3yrs; usually L thoracic; male predominance; want to know RVAD (>20 deg = high risk progression)

Front 38

RVAD and treatment

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< 20 = observation; 20-35 = cast/brace >35 MRI and cast or surgery

Front 39

Congenital Scoliosis worst prognosis

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worst prognosis is unilateral bar with contralateral hemivertebrae; Tx: fuse hemivertebrae

Front 40

Associated anomalies in congenital scoli

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Uro is #1, also GI and Cardiac

Front 41

Congenital scoliosis types

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Failure of formation, failure of segmentation

Front 42

Indications for hemivertebrectomy

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only for lower lumbar vertebrae with oblique take-off

Front 43

VEPTR titanium rib device

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indication is thoracic insufficiency syndrome; osteotomize rib fusions and avoid early spine fusion

Front 44

Scoliosis in Neurofibromatosis

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anterior and posterior fusion b/c of high pseudarthrosis r

Front 45

Indications for surgery in peds spondylolysthesis

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Grade III on presentation; progression of Grade II, failure of non-operative management

Front 46

Scheuermann’s Kyphosis: clinical features and Tx

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Greater than 3 adjacent vertebrae with 5 degrees wedging; narrowed disk space; smorl nodes: Tx: curve > 80 degrees

Front 47

Klippel Feil Syndrome

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Abnormal cervical segmentation; classic triad is low hairline, webbed neck, limited cervical ROM; Tx: observation

Front 48

Atlanto-axial instability

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JRA; Down’s syndrome

Front 49

C1-C2 Rotatory Subluxation (Grisel’s disease)

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Head stuck in somewhat cocked position; CT scan to diagnose subtale C1-2 subluxation; Tx: traction, fusion in resistant cases

Front 50

C2-C3 Pseudosubluxation

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on backboard, in children < 8y/o; Schwischuk’s line

Front 51

Schwischuk’s line

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in children less than 8 y/o; draw line.....

Front 52

Torticollis: clinical features and Tx

Back 52

if palpable mass in SCM, then is classical torticollis; if no palpable mess, need to rule out Klippel Feil; Tx: stretching and release SCM in refractory cases

Front 53

Congenital Pseudarthrosis of Clavicle

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non-tender mass RIGHT clavicle due to failure of medial and lateral anlage; Tx: observation

Front 54

When to fit prosthesis if congenital amputation upper extrem

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about 6 months

Front 55

Radial Clubhand

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associated (VATER) and remember thrombocytopenia absent radius <absent radius but thumb present>; Must have good elbow ROM and biceps to do centralization procedure

Front 56

Preaxial polydactyly thumb

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excise least helpful thumb

Front 57

Risk factors for Congenital Dislocation Hip

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First born, female, breech, famiily history; associated with mettatarsuls adductus

Front 58

Ortolani sign

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dislocated hip reduced

Front 59

Barlow sign

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push back; relocated hip is subluxated posteriorly

Front 60

Congenital dislocation of hip: radiographic signs

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Hilgenreiner (horizontal line through tri-radiate) and Perkins line (line drawn down from edge of sourcil): epiphysis should be in inner-lower quadrant

Front 61

Pavlik harness

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Reducible hip in child younger than 6 months; Anterior straps flex to 90; posterior straps permit abduction, but do not want to pull into abduction

Front 62

Problem with Pavlik harness

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femoral nerve palsy possible

Front 63

Irreducible hip or > 6 months: what to do (DDH)

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to OR for possible closed reduction under anesthesia and SPICA

Front 64

DDH recognized at or after walking age

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open reduction usually +/- femoral shortening and varus

Front 65

Prognosis in Perthes

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age of onset > 6yrs; total head involvement with lateral extrusion, incongruent joint

Front 66

Lateral Pillar Classification (Perthes)

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A = no loss of height; B = 50 percent; C = more than 50 percent

Front 67

Slipped Capital Femoral Epiphysis: key points

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Fracture through hypertrophic zone; Stable (can walk) Unstable (cannot walk); Acute (sympoms <3wks); endocrine w/u if < 10 yrs

Front 68

Klein’s Line

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line in SCFE

Front 69

Indication for prophylactic pinning in SCFE

Back 69

child < 10 years old with proven endocrine abnormality (usually hypothyroid)

Front 70

Proximal Femoral Focal Deficiency

Back 70

Sonic Hedge Hog gene involved; 50% have fibular hemimelia; can lengthen, epiphysiodesis, Van-Ness rotationplasty, Amputation

Front 71

Congenital short femur

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often absent ACL; can be lengthened if 30% or less shortening

Front 72

Growth rates “rule of thumb” to predict LLD

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Distal femur 9mm/year, proximal physis 6mm/year; boys grow until 16 years, girls grow till 14 years

Front 73

Limb length discrepancy- classic treatment

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one inch or less = shoe lift; 2.5 - 4 cm = contra-lateral epiphysiodesis; >4cm = lengthening;

Front 74

When to fit prosthesis if congenital amputation lower extrem

Back 74

one year old

Front 75

Congenital dislocation of the knee: treatment

Back 75

often associated with hip dislocation; need to treat knee first with serial casting to 90 degrees flexion; then put in Pavlik harness

Front 76

Osgood Schlatter’s Disease

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fragmentation of tibial tubercle due to repetetive trauma; treatment is conservative

Front 77

Severs disease

Back 77

calcaneal apophyseal irritation

Front 78

Fibular Hemimelia: treatment

Back 78

if 4-5 toes, OK to do limb lengthening or contra-lateral epiphysiodesis; if 3 toes (severe foot deformity), treatment will be amputation and early prosthetic fitting

Front 79

Tibial Hemimelia: clinical features and Tx

Back 79

only longitudinal deficiency that is heritable (AD); associated clubfoot; look for knee dimple; treatment depends on quad function (BKA if quad fxn +/- tib-fib synostosis)

Front 80

Bowing of the tibia

Back 80

Antero-lateral in Neurofibromatosis = congenital pseudarthrosis of tibia <treatment is bracing>; postero-medial bowing associated calcaneovalgus foot = spontaneously corrects but with LLD at maturity

Front 81

Infantile Blounts: features and Tx

Back 81

onset prior to age 3; metaphyseal-diaphyseal angle > 13 degrees high risk of progression; Black girls;

Front 82

Adolescent Blounts: features and Tx

Back 82

femoral varus as well

Front 83

Idiopathic clubfoot: clinical features and Tx

Back 83

Calcaneus-talus parallel radiographically; CAVE (cavus, adductus, varus, equinus); serial long leg casting +/- achilles tenotomy; then bracing x 1-2 yrs

Front 84

Most common surgery for persistent clubfoot deformity

Back 84

split transfer tib ant tendon to lateral border of foot

Front 85

Congenital vertical talus

Back 85

plantar flexion lateral view the first ray does not line up with talus; can try casting; would surgically release if fails

Front 86

Congenital oblique talus

Back 86

plantar flexion lateral view the first ray does line up with the talus

Front 87

Cavus foot in child/adolescent

Back 87

usually neurologic; need to check spinal cord (diastematomyelia); if felxible can do plantar release and metatarsal osteotomy; No Triple Arthrodesis!

Front 88

Coleman block test

Back 88

asesses flexibility of cavus foot

Front 89

Flexible flat-foot

Back 89

Treatment is benign neglect

Front 90

Kohler’s disease

Back 90

AVN of tarsal navicular; resolves spontaneously; Treat symptomatically

Front 91

Peroneal Spastic Flatfoot

Back 91

calcaneo-navicular coalition most common cause; “anteater sign” on oblique x-ray; CT scan before surgery to r/o second coalition

Front 92

Calcaneonavicular flatfoot treatment

Back 92

CT scan to r/o other coalitions; may then resect bar and interpose EDB or fat

Front 93

Talocaneal coalition

Back 93

If >50% involvement, need to do subtalar fusion; if <50%, may resect and EDB/Fat interposition

Front 94

Osteomyelitis in children: location

Back 94

almost always metaphyseal; feeder vessels go to zone of provisional calcification, and this is were bacteria seed

Front 95

Osteomyelitis in children: organisms

Back 95

S. aureus (most common), Group B Strep (neonates), Gram negatives

Front 96

Septic Arthritis- capuslar attachments

Back 96

hip metaphysis is intracapsular; as is shoulder, elbow, and ankle

Front 97

Hip position in septic hip

Back 97

flexed, abducted, externally rotated hip

Front 98

Puncture wounds of foot in children

Back 98

Surgical debridement and IV Abx (no oral anti-pseudomonal drugs for children)

Front 99

Non accidental fractures in children

Back 99

infantile femur fracture (non-ambulatory child); metaphyseal corner fractures

Front 100

Nerve injury extension type sypracondylar

Back 100

AIN most common

Front 101

Most stable pin configuration

Back 101

three diverging pins from the lateral side

Front 102

Medial epicondyle fracture in children

Back 102

ORIF if entrapped in joint (often associated with elbow dislocation); may have ulnar nerve entrapped

Front 103

Radial head and neck Fx in children

Back 103

< 30 deg = splint/cast; 30-60 deg = attempted CR; >60 degrees = ORIF

Front 104

Olecranon Fx in children

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sometimes associated with osteogenesis imperfecta; neeeds ORIF id displaced

Front 105

Odontoid Fractures and Halo’s

Back 105

Usually use 8 pins, and less torque than adults

Front 106

Pediatric Femur Fracture; Tx by age

Back 106

0-2 = immediate SPICA; 2-5 years = SPICA cast, but if 2cm shortening, do traction then SPICA; 5 - skeletal maturity: ex-fix, flex nails, plate; reamed nails (troch starting point);

Front 107

Pediatric Femur Fracture “length unstable”

Back 107

cannot do flexible nails; ORIF, ex-fix

Front 108

ACL avulsion (intercondylar eminence Fx)

Back 108

attempt closed reduction with knee in extension; if fails do arthroscopic ORIF avoiding physis

Front 109

Proximal metaphyseal fractures of tibia

Back 109

often valgus deformity develops that sometimes self resolves; need to let family know this might happen

Front 110

Distal femoral physeal closure sequence

Back 110

closes medially first, then last antero-lateral (near insertion of anterior tib-fib ligaments) leading to Tillaux Fx’s

Front 111

Tillaux Fracture

Back 111

anterior tib-fib ligament avulsion; typically ORIF