Ortho Peds Review | Dr Hutaif Pediatric Orthopedics Rev -...

DISCUSSION: Osteochondrosis of the tarsal navicular is most commonly identified between the ages of 2 and 9 years. The condition is benign and self limited in nature. In patients with severe pain, a period of casting may be warranted, but otherwise management usually consists of observation or a supportive orthotic.

Scientific References

: DiGiovanni CW, Patel A, Calfee R, et al: Osteonecrosis in the foot. J Am Acad Orthop Surg 2007;15:208-217.
Williams GA, Cowell HR: Kohler’s disease of the tarsal navicular. Clin Orthop Relat Res 1981 ;158:53- 58.

**8 • American Academy of Orthopaedic Surgeons**

Figure 2

DISCUSSION: The history and laboratory studies indicate that this is not an infection. A lesion in this location and in this age group is likely a Ewing’s sarcoma. The presentation is usually a painful mass. About 20% of patients have a fever. The radiograph shows a typical mottled, permeative lesion with periosteal reaction. An MRI scan should be obtained to further evaluate the soft-tissue mass. Staging of the lesion should take place before biopsy, which should be done by the surgeon who would be performing the next stage of surgical treatment, ideally an orthopaedic oncologist.

REFERENCES: Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.
Meyer JS, Nadel HR, Marina N, et al: Imaging guidelines for children with Ewing sarcoma and osteosarcoma: A report from the Children’s Oncology Group Bone Tumor Committee. Pediatr Blood Cancer 2008;51:163-170.
T

DISCUSSION: Physiologic bowing is common and benign. Bowing is typically symmetric, involves both the femur and tibia, and is usually most prominent in toddlers. It usually resolves by 2 years of age but there is great variability. By age 36 months, almost all children will correct spontaneously. In children with physiologic bowing, the screening examination is typically normal and a family history is absent; therefore, radiographs are not necessary. If the deformity has not resolved by age 2 years, an AP radiograph of the lower limbs should be obtained. This provides documentation of the severity of the bowing, permits measurement of the metaphyseal-diaphyseal angle and/or Langenskiold grade, and allows evaluation for conditions such as rickets or bony dysplasia. No treatment is indicated for physiologic bowing.

REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 7.
Salenius P, Vankka E: The development of the tibiofemoral angle in children. J Bone Joint Surg Am
J V _:_

DISCUSSION: The most likely diagnosis is toxic synovitis, and the normal C-reactive protein supports that diagnosis. Juvenile inflammatory arthritis is extremely rare to present with hip involvement. The child most likely does not have a bacterial infection because he has improved rapidly without treatment. A normal CBC with differential precludes the diagnosis of leukemia.

REFERENCES: Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, pp 2068-2070.
Del Beccaro MA, Champoux AN, Bockers T, et al: Septic arthritis versus transient synovitis of the hip: The value of screening laboratory tests. Ann Emerg Med 1992;21:1418-1422.
Kocher MS, Mandiga R, Zurakowski D, et al: Validation of a clinical prediction rule for the differentiation between

**2010 Pediatric Orthopaedic Examination Answer Book • 11**

septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am 2004:86:1629-1635.

**12 • American Academy of Orthopaedic Surgeons**

Figure 7a Figure 7b

DISCUSSION: A limbus or apophyseal fracture caused by heavy lifting or twisting is commonly seen in older children and adolescents. Patients describe feeling a popping sensation and report radicular symptoms. Radiographs usually are not sufficient to diagnose the injury. MRI or CT should be used to determine the exact location of the fracture. Nonsurgical management is rarely successful. A wide laminectomy with surgical excision of the limbus fragment is recommended if neurologic symptoms are present.

REFERENCE: Fischgrund JS (ed): Orthopedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, p 694.

**2010 Pediatric Orthopaedic Examination Answer Book • 13**

Figure 8

DISCUSSION: Fractures in this region of the fifth metatarsal have been shown to be prone to delayed union and
nonunion and therefore are most reliably managed with internal fixation. Bone grafting is generally not required.

REFERENCES: Herrera-Soto JA, Scherb M, Duffy MF, et al: Fractures of the fifth metatarsal in children and adolescents. J Pediatr Orthop 2007;27:427-431.
Fetzer GB, Wright RW: Metatarsal shaft fractures and fractures of the proximal fifth metatarsal. Clin Sports Med 2006;25:139-150.

DISCUSSION: The patient has typical adolescent idiopathic scoliosis with a right thoracic curve. This represents a Lenke-IB curve pattern; therefore, only treatment of the thoracic curve is required. The proximal thoracic and thoracolumbar curves are very flexible. The patient is Risser 1 and has just started her menstrual cycles; therefore, she is at significant risk for further curve progression. Bracing is not appropriate for a curve of this magnitude and will not halt the progression of this curve, nor will vertebral body stapling stop this curve. Vertebral body stapling is sometimes useful in small thoracic curves of less than 35 degrees and skeletally immature patients. Anterior and

**14 • American Academy of Orthopaedic Surgeons**

posterior spinal fusion is not required because the patient has no other risk factors, such as neurofibromatosis nor is she at risk for crankshaft. Anterior fusion is an option, but it is not listed.

REFERENCES: Lenke LG, Betz RR, Harmes J, et al: Adolescent idiopathic scoliosis: Anew classification to determine extent of spinal arthrodesis. J Bone Joint Surg Am 2001;83:1169-1181.
Lenke LG, Betz RR, Haher TR, et al: Multisurgeon assessment of surgical decision making in adolescent idiopathic scoliosis: Curve classification, operative approach, and fusion levels. Spine 2001;26:2347- 2353.

DISCUSSION: The risk of neurologic compromise associated with congenital kyphosis is normally secondary to risk of progression. The classic study of the natural history of congenital spinal deformity by McMaster and Singh confirms that an anterolateral bar with contralateral quadrant vertebrae has the greatest risk.
REFERENCES: McMaster MJ, Singh H: Natural history of congenital kyphosis and kyphoscoliosis: A study of one hundred and twelve patients. J Bone Joint Surg Am 1999;81:1367-1383.
Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, p 351.

DISCUSSION: Avulsion fractures of the tibial spine are a relatively rare injury in children. Historically, the most common cause of this fracture was falls from bicycles, but with the increased participation in competitive sports, the etiology is changing. Most fractures occur in children ages 8 to 14 years, and they typically present with a painful hemarthrosis and refusal to bear weight. The Meyers and McKeever classification is based on degree of displacement, where type I is minimally displaced, type II is anteriorly displaced with an intact posterior hinge, and type III is completely displaced. The Ilia and Illb modifications have been added to account for fragment comminution and rotation, respectively. Long leg casting is advocated for type I fractures, though there is debate whether the knee should be maintained in full extension or in 10 to 20 degrees of flexion. Management of type II and III fractures is much more controversial. Type II fractures can be treated closed if adequate reduction can be achieved, but if not, surgical management is indicated. Surgery is also indicated for type III fractures, and results of open versus arthroscopic procedures are similar long term. Kocher and associates examined 80 consecutive skeletally immature patients with type II or III tibial eminence fractures that were treated surgically. They found that the anterior hom of the medial meniscus was entrapped beneath the displaced fracture fragment in 36 of 80 cases, whereas the lateral meniscus was only entrapped in 1 of 80 cases. This is not to be confused with the data

**2010 Pediatric Orthopaedic Examination Answer Book • 17**

from Lowe and associates in JBJS 2002 where they found the lateral meniscus to be involved in blocking reduction. This was not thought due to entrapment of the lateral meniscus. Rather, with the anterior cruciate
ligament and lateral meniscus still being attached to the avulsed fracture fragment, they felt the two structures were pulling in opposite directions and therefore blocking reduction of the fragment.

REFERENCES: Falstie-Jensen S, Sondergard-Petersen PE: Incarceration of the meniscus in fractures of the intercondylar eminence of the tibia in children. Injury 1984;15:236-238.
Kocher MS, Micheli LJ, Gerbino P, et al: Tibial eminence fractures in children: Prevalence of meniscal entrapment. Am J Sports Med 2003;31:404-407.
Accousti WK, Willis RB: Tibial eminence fractures. Orthop Clin North Am 2003;34:365-375.
Lowe J, Chaimsky G, Freedman A, et al: The anatomy of tibial eminence fractures: arthroscopic observations following failed closed reduction. J Bone Joint Surg Am 2002;84:1933-1938.

Figure 14a Figure 14b Figure 14c Question 14
A 14-year-old boy underwent in situ screw fixation for a left slipped capital femoral epiphysis 8 months ago. He
noted 3 months of intermittent right hip pain but is presently asymptomatic. The last episode of pain was 2 days prior to this office visit. He reports that he has pain approximately once a week over the past 3 months. Examination of the right hip is normal, and includes pain-free internal rotation. Radiographs and an MRI scan are shown in Figures 14a through 14c. Treatment should consist of which of the following?

1. ##### In situ screw fixation of the right hip
2. ##### Physical therapy
3. ##### Limitation of activities and return to the clinic if pain persists
4. ##### Biopsy of the femoral neck lesion
5. ##### Irrigation and debridement of the right hip PREFERRED RESPONSE: 1
DISCUSSION: The patient history is concerning for a pre-slip slipped capital femoral epiphysis (SCFE) of the right hip. In one study, nearly 40% of patients with SCFE had bilateral involvement, and of that 40%, half presented initially with a unilateral SCFE but had a subsequent SCFE on the contralateral limb. Radiographs are normal, but the MRI scan shows increased signal about the proximal femoral physis. Treatment should include prophylactic screw fixation of the right hip.

REFERENCES: Aronsson DD, Loder RT, Breur GJ, et al: Slipped capital femoral epiphysis: Current concepts. J Am Acad Orthop Surg 2006;14:666-679.
Loder RT, Aronson DD, Greenfield ML: The epidemiology of bilateral slipped capital femoral epiphysis: A study of children in Michigan. J Bone Joint Surg Am 1993;75:1141-1147.

**18 • American Academy of Orthopaedic Surgeons**

Loder RT: Controversies in slipped capital femoral epiphysis. Orthop Clin North Am 2006;37:211-221, vii.

Figure 15a Figure 15b

DISCUSSION: The injury is a type 3 supracondylar humerus firaacture with a radial nerve injury. Most nerve
injuries associated with fractures recover spontaneously within 6 to 12 weeks. Complete recovery is expected within 3 to 6 months. Closed reduction and percutaneous pinning is the recommended treatment for supracondylar fractures of the elbow. Cast treatment for displaced fractures carries a higher risk of associated compartment syndrome. There is no indication for exploring the radial nerve acutely. Open reduction is necessary only if the closed reduction fails.

REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 406-409.
Campbell CC, Water PM, Emans JB, et al: Neurovascular injury and displacement in type III
supracondylar humerus fractures. J Pediatr Orthop 1995;15:47-52.

**2010 Pediatric Orthopaedic Examination Answer Book • 19**

Figure 16

DISCUSSION: The growth plate in the distal femur has an undulating topography, with prominences called mammillary bodies that interdigitate with other portions of the physis to provide stability at the distal femur. A typical distal femoral physeal fracture propagates through multiple layers of the growth plate as opposed to most Salter-Harris type I physeal fractures.

REFERENCES: Smith DG, Geist RW, Cooperman DR: Microscopic examination of a naturally occurring epiphyseal plate fracture. J Pediatr Orthop 1985;5:306-308.
Jaramillo D, Kammen BF, Shapiro F: Cartilaginous path of physeal fracture separations: Evaluation with MR
imaging: An experimental study with histologic correlation in rabbits. Radiology 2000;215:504-511. Question 17
A 14-year-old boy has had a 3-month history of low back pain with no known trauma. The pain is worse with activity and relieved by rest, although he does report difficulty with prolonged sitting in school.
The patient was on the football team but stopped participating because of the back pain during football practice. He reports no history of radicular pain and denies any numbness, tingling, or weakness in the legs.

**20 • American Academy of Orthopaedic Surgeons**

Neurologic examination is normal. Back examination reveals slight tenderness over the lower back area but no swelling or skin defects. Strength testing is 5 over 5 in the lower extremities and the straight leg raise test is negative. Back range of motion is nearly full, but back extension is painful. The hamstrings are slightly tight. Initial radiographs, including AP, lateral and oblique views, are negative. What is the best test to determine the patient’s diagnosis?

1. ##### Flexion and extension lateral radiographs
2. ##### MRI
3. ##### Myelogram
4. ##### Diskogram
5. ##### Bone scan with SPECT PREFERRED RESPONSE: 5
DISCUSSION: A bone scan with SPECT is very sensitive and specific for spondylolysis not seen on initial
radiographs. MRI can sometimes visualize spondylolysis, but it is not as sensitive nor as specific as a bone scan with SPECT. Flexion and extension views have no role in the evaluation of the patient who presents with classic spondylolysis-type symptoms. The most sensitive physical examination finding is pain with back extension. Oblique radiographs can be obtained, but they are not as sensitive or specific as a bone scan with SPECT. The patient does not have any signs of a disk problem; therefore, an evaluation of the disk is not helpful.
REFERENCES: Hu SS, Tribus CB, Diab M, et al: Spondylolisthesis and spondylolysis. J Bone Joint Surg Am 2008;90:656-671.
Lawrence JP, Greene HS, Grauer JN: Back pain in athletes. J Am Acad Orthop Surg 2006;14:726-735.

Figure 18a Figure 18b

DISCUSSION: Talar neck fractures are uncommon. In children younger than age 6 years, displacement is rare and

**2010 Pediatric Orthopaedic Examination Answer Book • 21**

closed treatment is usually successful in achieving union and avoiding osteonecrosis. In adolescence, however, talar neck fractures should be treated as they are in adults. This fracture is displaced, and there is dislocation of the subtalar joint. The tibiotalar and talonavicular joints remain reduced. In the classification originally created by Hawkins and modified by Canale and Kelly, this would be a Hawkins type II, carrying a 20% to 50% risk of osteonecrosis. The rate of osteonecrosis increases with the Hawkins grade. The presence of talar neck comminution and open talar neck fractures are also risk factors for osteonecrosis after talar neck fracture.

REFERENCES: Vallier HA, Nork SE, Barei DP, et al: Talar neck fractures: Results and outcomes. J Bone Joint Surg Am 2004;86:1616-1624.
Jensen I, Wester JU, Rasmussen F, et al: Prognosis of fracture of the talus in children: 21 year follow up of 14
cases. Acta Orthop Scand 1994;65:398-400.
Bucholz RW, Heckman JD, Court-Brown C (eds): Rockwood and Green’s Fractures in Adults, ed 6. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 2249-2291.
Beaty JH, Kasser JR (eds): Rockwood and Green’s Fractures in Children, ed 6. Philadelphia, PA, Lippincott
Williams and Wilkins, 2006, pp 1129-1180.

DISCUSSION: Age at presentation and range of motion of the hip are the two most significant predictors of long- term outcome. Younger patients and patients who maintain range of motion of the hip are more likely to have a good outcome. In Herring’s study, children with a chronologic age of younger than 8 years or a bone age of less than 6 years had significantly more favorable outcomes compared with older children. Limited hip range of motion may be due to muscle spasm early on, or synovitis; but in late disease, it may reflect incongruity of the joint.
Classifications based on femoral head shape have also been correlated to prognosis. Significant shortening of the affected hip is not common.

REFERENCES: Herring JA, Kim HT, Browne R: Legg-Calve-Perthes disease. Part II: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am 2004;86:2121-2134. Herring JA, Kim HT, Browne R: Legg-Calve-Perthes disease. Part I: Classification of radiographs with use of the modified lateral pillar and Stulberg classifications. J Bone Joint Surg Am 2004;86:2103-2120. Skaggs DL, Tolo VT: Legg-Calve-Perthes disease. J Am Acad Orthop Surg 1996;4:9-16.

DISCUSSION: Pediatric flexor tendon injuries have several remarkable distinctions from those in adults. Delayed presentation is more common in children, at times requiring staged flexor tendon reconstruction. Three to four weeks of postoperative immobilization following acute repair is recommended in children as opposed to early motion protocols used in adults. Temporary paralytic agents (botulinum toxin type A) have also been shown to facilitate the rehabilitation phase of flexor tendon care in very young children.
REFERENCE: Fischgrund JS (ed): Orthopedic Knowledge Update 9. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2008, p 675.

DISCUSSION: Slip angle has been shown to be highly predictive of the risk for increased slippage in patients with spondylolisthesis. None of the other radiographic parameters listed has been shown to be predictive of the risk for increased slippage.

REFERENCES: Huang RP, Bohlman HH, Thompson GH, et al: Predictive value of pelvic incidence in progression of spondylolisthesis. Spine 2003;28:2381-2385.
Mac-Thiong JM, Wang Z, de Guise JA, et al: Postural model of sagittal spino-pelvic alignment and its relevance for lumbosacral developmental spondylolisthesis. Spine 2008;33:2316-2325.

**2010 Pediatric Orthopaedic Examination Answer Book • 23**
Figure 22a Figure 22b

DISCUSSION: There are several reasons to obtain an MRI of the entire spinal cord of this patient to evaluate for abnormalities. These include her young age and the presence of a left-sided curve. For juvenile scoliosis patients with more than a 20-degree Cobb angle, there is an approximately 20% prevalence of a neurologic abnormality. Therefore, recommendations for work-up include an MRI scan of the entire spine.

REFERENCES: Gillingham BL, Fan RA, Akbamia BA: Early onset idiopathic scoliosis. J Am Acad Orthop Surg 2006;14:101-112.
Gupta P, Lenke LG, Bridwell KH: Incidence of neural axis abnormalities in infantile and juvenile patients with spinal deformity: Is a magnetic resonance image screening necessary? Spine 1998;23:206-210.

**24 • American Academy of Orthopaedic Surgeons**

Figure 23a Figure 23b

DISCUSSION: The radiograph and clinical photograph show a growth arrest of the distal radius on the right. There is shortening and narrowing of the physis of the radius, and there is radial deviation of the hand. Greater than 2 cm of growth still remains in the distal radius of a 10-year-old girl. Epiphysiodesis of both bones bilaterally would leave the same deformity. The first step in treatment is to evaluate the extent of the growth arrest to see if the arrest is resectable. Lengthening of the radius and epiphysiodesis of the ulna could restore the proper length and alignment and would be the treatment of choice if the arrest was not resectable. Osteotomy of the radius and ulna would not address the growth disturbance.

REFERENCES: Pritchett JW: Growth and development of the distal radius and ulna. J Pediatr Orthop 1996;16:575-577.
Waters PM, Bae DS, Montgomery KD: Surgical management of posttraumatic distal radial growth arrest in adolescents. J Pediatr Orthop 2002;22:717-724.

Figure 24

DISCUSSION: Ultrasound of both the hip and the shoulder can show the presence of septic arthritis and osteomyelitis. Multiple sites of infection are common in neonates. A bone scan can be used to identify other areas of involvement.

REFERENCES: Wong M, Isaacs D, Howman-Giles R, et al: Clinical and diagnostic features of osteomyelitis occurring in the first three months of life. Pediatr Infect Dis J 1995;14:1047-1053.
Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 57-73.

DISCUSSION: Displaced physeal fractures of the distal femur are at high risk for causing premature growth arrest of the involved physis and subsequent deformity. Nonunion of these fractures is extremely rare.

REFERENCES: Arkader A, Warner WC Jr, Horn BD, et al: Predicting the outcome of physeal fractures of the distal femur. J Pediatr Orthop 2007;27:703-708.
Thomson JD, Strieker SJ, Williams MM: Fractures of the distal femoral epiphyseal plate. J Pediatr Orthop 1995;15:474-478.

**2010 Pediatric Orthopaedic Examination Answer Book • 27**

Figure 27a Figure 27b

DISCUSSION: The boy has a Seymour’s fracture of the toe. The germinal matrix of the nail bed is trapped in the fracture site; thus this should be considered an open fracture. Ideally, it should be treated with open reduction and internal fixation and use of antibiotics at the time of injury. Because this is a delayed presentation, it is even more important to do a formal open reduction and a good irrigation and debridement, followed by the use of postoperative antibiotics. Because the fracture has been displaced for several days, overall management will be easier if the fracture reduction is maintained with pin fixation.

REFERENCE: Fischgrund JS (ed): Orthopedic Knowledge Update 9. Rosemont, IL. American Academy of Orthopaedic Surgeons, 2008, p 737.

**28 • American Academy of Orthopaedic Surgeons**

DISCUSSION: For children between the ages of 1 and 6 years, closed reduction and early spica casting is recommended. In some instances, associated injuries or body habitus may preclude cast treatment. Pavlik harness treatment of femoral fractures is for infants younger than 1 year of age. Rarely is there an indication for traction. Internal fixation is reserved in general for children older than age 6 years or with confounding factors.

REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 271-280.
Flynn JM, Schwend RM: Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347- 359.

Figure 29a Figure 29b

DISCUSSION: The child has a type I hip fracture without associated dislocation. This is an acute hip fracture through the proximal femoral physis, and can occur with or without associated dislocation. He had no prodrome of hip or thigh pain and no femoral neck changes to indicate that this is an unstable slipped capital femoral epiphysis. Osteonecrosis in these transepiphyseal hip fractures is the most common and most devastating complication. The rate of osteonecrosis is most dependent on the initial displacement of the fracture. These fractures should be treated emergently, and decompression of the hip joint is recommended by many authors.
REFERENCES: Moon ES, Mehlman CT: Risk factors for avascular necrosis after femoral neck fractures in children: 25 Cincinnati cases and meta analysis of 360 cases. J Orthop Trauma 2006;20:323-329. Canale ST: Fractures of the hip in children and adolescents. Orthop Clin North Am 1990;21:341-352.

**2010 Pediatric Orthopaedic Examination Answer Book • 29**

DISCUSSION: Return of active biceps before 3 months and preservation of full passive shoulder range of motion are predictors of a good outcome. Breech delivery is usually associated with preganglionic injury. Preganglionic injury can result in a Homer’s sign, which includes ptosis, myosis, and anhydrosis. Preganglionic injuries are unlikely to recover. The Moro reflex is elicited by dropping a baby’s head a short distance and observing active elbow extension and fanning of the fingers, followed by elbow flexion and crying. Absence of the Moro reflex suggests a poor prognosis.

REFERENCES: Smith NC, Rowan P, Benson LJ, et al: Neonatal brachial plexus palsy: Outcome of absent biceps function at three months of age. J Bone Joint Surg Am 2004;86:2163-2170.
Waters PM: Obstetric brachial plexus injuries: Evaluation and management. J Am Acad Orthop Surg
1997;5:205-214.

Figure 31

**30 • American Academy of Orthopaedic Surgeons**

DISCUSSION: The occurrence of a forearm fracture in a 9-month-old child has a greater than 50% chance that the injury is due to child abuse. It is mandatory to report this to child protective services unless there is some compelling reason that it is definitely not child abuse. In addition, a skeletal survey should be requested to look for other injuries. A bone scan would show other injuries, but a skeletal survey is a more efficient way to evaluate for other fractures. A MRI of the brain is not indicated unless fimdoscopic examination reveals an abnormality.

REFERENCES: Kocher MS, Kasser JR: Orthopaedic aspects of child abuse. J Am Acad Orthop Surg 2000;8:10/- 20.
Chang DC, Knight V, Ziegfeld S, et al: The tip of the iceberg for child abuse: The critical roles of the pediatric trauma service and its registry. J Trauma 2004;57:1189-1198.

DISCUSSION: The recurrence rate of clubfoot deformity after successful correction by the Ponseti method has been shown to inversely correlate with reported brace compliance. Maternal age, walking age, and body mass index have not been correlated to recurrence. A positive family history increases the risk of a child being bom with a clubfoot but does not influence the recurrence rate.

REFERENCES: Dobbs MB, Rudzki JR, Purcell DB, et al: Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet. J Bone Joint Surg Am 2004;86:22-27.
Noonan KJ, Richards BS: Nonsurgical management of idiopathic clubfoot. J Am Acad Orthop Surg 2003;11:392-402.

■

**2010 Pediatric Orthopaedic Examination Answer Book • 31**

Figure 33

DISCUSSION: Humeral shaft fractures in infants and young children heal rapidly and have excellent remodeling potential. Appropriate treatment in this age group is immobilization with a coaptation splint and bandaging the arm to the thorax for comfort. Internal fixation is appropriate in multiple trauma, and
external fixation may be useful when soft-tissue injury is extensive.

REFERENCES: Caviglia H, Garrido CP, Palazzi FF, et al: Pediatric fractures of the humerus. Clin Orthop Relat Res 2005;432:49-56.
Husain SN, King EC, Young JL, et al: Remodeling of birth fractures of the humeral diaphysis. J Pediatr Orthop 2008;28:10-13.

Figure 34

**32 • American Academy of Orthopaedic Surgeons**

DISCUSSION: With a diagnosis of neurofibromatosis and severe kyphosis, anterior and posterior treatment is needed to achieve correction and fusion. In situ fusion has a high failure rate with the kyphotic deformity and even with traction, correction of the kyphosis is not expected. Anterior treatment alone may achieve correction, but in neurofibromatosis only circumferential treatment has been shown to provide long-term stability.

REFERENCES: Crawford AH, Schorry EK: Neurofibromatosis update. J Pediatr Orthop 2006;26:4I3- 423. MehJman CT, Al-Sayyad MJ, Crawford AH: Effectiveness of spinal release and halo-femoral traction in the management of severe spinal deformity. J Pediatr Orthop 2004;24:667-673.

Figure 35

DISCUSSION: The patient has arthrogryposis. Szoke and associates performed open reduction through a medial approach on 40 hip dislocations in 26 patients with this condition and reported good results in 80% and fair results in 12%. Due to the stiffness associated with this disorder, closed reduction with or without skin or skeletal traction is not feasible. Open reduction through an anterior approach is reserved for older children.

REFERENCES: Szoke G, Staheli LT, Jaffe K., et al: Medial-approach open reduction of hip dislocations in amyoplasia-type arthrogryposis. J Pediat Orthop 1996;16:127-130.
Staheli LT, Chew DE, Elliott JS, et al: Management of hip dislocations in children with arthrogryposis. J Pediatr
Orthop 1987;7:681-685.

**2010 Pediatric Orthopaedic Examination Answer Book • 33**

Figure 36a Figure 36b

DISCUSSION: The examination and radiographs are consistent with a sleeve fracture of the patella, which is an avulsion fracture of the distal pole of the patella with a disruption of the extensor mechanism. Treatment is open reduction and internal fixation of the patella, and repair of the extensor mechanism.
The distal fragment can be much larger than it appears on the radiographs because it consists largely of cartilage.

REFERENCES: Wu CD, Huang SC, Liu TK: Sleeve fracture of the patella in children: A report of five cases. Am J Sports Med 1991;19:525-528.
Grogan DP, Carey TP, Leffers D, et al: Avulsion fractures of the patella. J Pediatr Orthop 1990; 10:721 - 730. Question 37
When addressing a proximal intertrochanteric or subtrochanteric fracture in a juvenile with open growth plates, the arterial supply from what artery at the neck must be preserved?

1. ##### Lateral femoral circumflex
2. ##### Medial femoral circumflex
3. ##### Superior gluteal
4. ##### Inferior gluteal
5. ##### Obturator PREFERRED RESPONSE: 2
DISCUSSION: The medial femoral circumflex artery supplies blood to the femoral head. Its position along the
posterior-superior femoral neck places this structure at risk with intramedullary nailing of the femur. Therefore, lateral entry through the greater trochanter is preferred when intramedullary fixation is performed.

**34 • American Academy of Orthopaedic Surgeons**

REFERENCES: Gordon JE, Swenning TA, Burd TA, et al: Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children. J Bone Joint Surg Am 2003;85:1295- 1301.
Green NE, Swiontkowski MF: Skeletal Trauma in Children, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 419- 424.

DISCUSSION: Home factor treatment has decreased the incidence of hemophilic arthropathy. Since 1992,
recombinant factor VIII was approved in the United States and can be safely used as prophylaxis or episodic treatment of hemarthrosis. Essentially, recombinant factor VIII eliminated the risk of HIV and hepatitis virus transmission associated with plasma-derived coagulation factors.

REFERENCES: Luck JV Jr, Silva M, Rodriguez-Merchan EC, et al: Hemophilic arthropathy. J Am Acad Orthop Surg 2004;12:234-245.
Manco-Johnson MJ, Abshire TC, Shapiro AD. et al: Prophylaxis versus episodic treatment to prevent joint disease in boys with severe hemophilia. N Engl J Med 2007;357:535-544.

**2010 Pediatric Orthopaedic Examination Answer Book • 35**

DISCUSSION: The mechanism by which bisphosphonates act is by inhibiting osteoclasts. One mechanism of bisphosphonates is to cause osteoclast apoptosis. Another mechanism of bisphosphonates is to disrupt the cytoskeleton of osteoclasts, resulting in loss of the ruffled border. The uncoupling of bone resorption and bone formation with decreased bone resorption results in increased bone mineralization. This translates into fewer fractures in patients with osteogenesis imperfecta and improved quality of life.

REFERENCES: Bumei G, Vlad C, Georgescu I, et al: Osteogenesis imperfecta: Diagnosis and treatment. J Am Acad Orthop Surg 2008;16:356-366.
Lin JT, Lane JM: Bisphosphonates. J Am Acad Orthop Surg 2003; 11:1-4.
Seikaly MG, Kopanati S, Salhab N, et al: Impact of alendronate on quality of life in children with osteogenesis imperfecta. J Pediatr Orthop 2005;25:786-791.

Figure 40

DISCUSSION: Hip instability in nonambulatory children with spinal muscular atrophy has been shown to be an infrequent cause of pain or disability; therefore, aggressive treatment generally is not indicated. Observation is the most appropriate management.

**36 • American Academy of Orthopaedic Surgeons**
REFERENCES: Sporer SM, Smith BG: Hip dislocation in patients with spinal muscular atrophy. J Pediatr Orthop 2003;123:10-14.
Thompson CE, Larsen LJ: Recurrent hip dislocation in intermediate spinal atrophy. J Pediatr Orthop 1990;10:638-641.

DISCUSSION: The use of folic acid in developed countries has lead to a decrease in neural tube defects. The incidence of neural tube defects is increased in third world countries.

REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 111-122.
Lemke L, Dias L: Spina bifida, in Cramer KE, Scherl SA, Einhom TA (eds): Orthopaedic Surgery Essentials: Pediatrics. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 203-210.

Figure 42

DISCUSSION: Whereas bilateral Perthes of the hips occurs in 11% of cases, in patients with symmetric changes/stages, other diagnoses must be considered such as Meyers dysplasia. Multiple epiphyseal dysplasia is most _A_ r _L_ e _-_ a _M_ d _a_ il _d_ y _en_ d _a_ ia _C_ g _o_ n _p_ o _y_ sed by evaluation of other radiographs, in particular of the knee and, if confirmatory, of the
**2010 Pediatric Orthopaedic Examination Answer Book • 37**

spine to assess for spondyloepiphyseal dysplasia.

REFERENCES: Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, pp 806-810.
Hesse B, Kohler G: Does it always have to be Perthes’ disease? What is epiphyseal dysplasia? Clin Orthop Relat
Res 2003;414:219-227.

DISCUSSION: Fracture of the odontoid process in children is usually caused by a fall, motor vehicle accident, or minor trauma, and almost always occurs through the synchondrosis at the base of the dens. Neurologic deficits are rare in isolated odontoid fractures in children. Closed reduction by neck extension and immobilization using a cast, a brace, or halo traction for 6 to 8 weeks is usually sufficient to allow the fracture to heal.

REFERENCE: Fischgrund JS (ed): Orthopedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, p 692.

**38 • American Academy of Orthopaedic Surgeons**

DISCUSSION: Successful antibiotic treatment of acute osteomyelitis should lead to a rapid decline in the CRP. The CRP is the most sensitive study to follow the treatment of osteomyelitis. The CRP should decline after 48 to 72 hours of appropriate treatment. CBC and ESR are helpful in initial evaluation and diagnosis, but remain abnormal in the early phase of treatment regardless of response. Imaging studies are useful for surgical planning or secondarily if the CRP remains elevated.

REFERENCES: Unkila-Kallio L. Kallio MJ, Eskola J, et al: Serum C-reactive protein, erythrocyte sedimentation rate, and white blood cell count in acute hematogenous osteomyelitis of children. Pediatrics 1994;93:59-62.
Herring JA(ed): Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia. PA. WB Saunders, 2008, pp 2090-2100.

DISCUSSION: The functional motor level of the patient is of prime importance in determining prognosis and
outcome. Patients with thoracic and upper lumbar motor levels will need wheelchairs or hip-knee- ankle-foot orthoses to ambulate at all. Patients with midlumbar motor levels can be household or limited community walkers, whereas children with low lumbar or sacral motor levels are likely to be able to walk in the community.

REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 117-120.
Swank M, Dias L: Myelomeningocele: A review of the orthopaedic aspects of 206 patients treated from birth with no selection criteria. Dev Med Child Neurol 1992;34:1047-1052.

Figure 46a Figure 46b

**2010 Pediatric Orthopaedic Examination
ook • 39**

3. ##### In situ pinning of bilateral hips
4. ##### Bed rest
5. ##### Application of a hip spica cast PREFERRED RESPONSE: 3

2010 Pediatric Orthopaedic Examination Answer Book • 40

DISCUSSION: The patient has left hip pain and clinical and radiographic evidence of a left slipped capital femoral epiphysis. He also has open triradiate cartilage and a grade 1 slip on the right side that, at the present time, is silent. The best treatment is pinning of bilateral slipped capital femoral epiphysis. Reduction is not indicated because of the mild nature of both slips. Although prophylactic pinning of the uninvolved contralateral hip is controversial, this patient shows a clinically silent grade 1 slip on the right side.

REFERENCES: Puylaert D, Dimeglio A, Bentahar T: Staging puberty in slipped capital femoral epiphysis: Importance of the triradiate cartilage. J Pediatr Orthop 2004;24:144-147.
Dewnany G, Radford P: Prophylactic contralateral fixation in slipped upper femoral epiphysis: Is it safe? J Pediatr Orthop B 2005;14:429-433.

DISCUSSION: Numerous reports suggest an increased frequency of nutritional rickets in the US in children with dark skin pigmentation who are breast fed past 6 months of age without vitamin D supplementation. Nutritional rickets is rare in light-skinned children or those who are formula fed.
REFERENCES: Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, p 1918.
Weisberg P, Scanlon KS, Li R, et al: Nutritional rickets among children in the United States: Review of cases reported between 1986 and 2003. Am J Clin Nutr 2004;80:1697S-1705S.
Jacobsen ST, Hull CK, Crawford AH: Nutritional rickets. J Pediatr Orthop 1986;6:713-716. Question 48
A 10-year-old girl has had nontraumatic swelling of the left knee for the past month. No other joints are swollen and there is no history of fever, although the patient’s mother does reca**l** the child having a localized, but expanding “target-like” rash a few months ago when the family was vacationing in Connecticut. Examination of the knee reveals moderate swelling with no tenderness and near full range of motion. The child lacks perhaps the final 15 degrees of extension and the final 20 degrees of flexion. Laboratory studies show a normal CBC count but the erythrocyte sedimentation rate is 35 mm/h (0-20 normal). Antinuclear antibody test and rheumatoid factor tests are negative. What is the most likely diagnosis?

41. ##### • American Academy of Orthopaedic Surgeons

1. ##### Acute rheumatic fever
2. ##### Septic arthritis
3. ##### Transient synovitis
4. ##### Lyme arthritis
5. ##### Gout

PREFERRED RESPONSE: 4
DISCUSSION: Lyme arthritis is associated with a tick bite and is endemic to certain areas of Connecticut. The earliest presentation of the disease is manifested by erythema migrans which is the classic expanding rash that occurs at the site of the tick bite and can develop within 1 week to 1 month after exposure. Joint involvement with manifestation of Lyme arthritis can occur months to years after the initial infection. Most patients have single joint involvement with the knee being the most affected site. Lyme arthritis is a low-grade inflammatory synovitis that can present with large and relatively painless joint effusion. The most effective treatment is with a single 4-week course of oral amoxicillin or doxycycline.

REFERENCES: Feder HM Jr: Lyme disease in children. Infect Dis Clin North Am 2008;22:315-
326/. Gerber MA, Zemel LS, Shapiro ED: Lyme arthritis in children: Clinical epidemiology and long-term outcomes. Pediatrics 1998;102:905-908.

DISCUSSION: The child has a near complete central physeal arrest of the distal femur. She will develop worsening limb-length discrepancy. She is growing at the average rate for the population. The distal femoral physis grows roughly at a rate of 9 mm/year. Girls finish their growth roughly at 14 years. Thus, at maturity, the uninjured side will be 6.4 cm longer than the injured side. Since she has not developed an angular deformity at this point and her arrest is central, she is unlikely to develop angular deformity in any plane.

REFERENCES: Little DG, Nigo L, Aiona MD: Deficiencies of current methods for the timing of epiphysiodesis. J Pediatr Orthop 1996;16:173-179.
Moseley CF: Assessment and prediction in leg-length discrepancy. Instr Course Lect 1989;38:325-330.

42. ##### • American Academy of Orthopaedic Surgeons

Figure 50

DISCUSSION: The radiographs show an extension type II supracondylar fracture with hyperextension of the distal fragment. There is medial impaction of the fracture as well. If the fracture heals in this aligmnent, the result will be cubitus varus with a loss of flexion of the elbow. Management should consist of closed reduction that potentially converts the fracture to an unstable fracture. Percutaneous pinning is recommended as cast treatment alone could lead to loss of reduction. Treatment in a cast with hvperflexion may lead to compartment syndrome.

REFERENCES: Mehserle WL, Meehan PL: Treatment of displaced supracondylar fractures of the humerus (type III) with closed reduction and percutaneous cross-pin fixation. J Pediatr Orthop 1991;11:705-711.
Herring JA: Upper extremity injuries: Supracondylar fractures of the humerus, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, pp 2470-2471.

3 _AL_. _-M_ E _ad_ m _en_ e _a_ rg _C_ e _o_ n _p_ t _y_
knee arthroscopy

2010 Pediatric Orthopaedic Examination
ook • 43

4. ##### Four-compartment calf fasciotomy
5. ##### Non-weight-bearing, a knee immobilizer, and follow- up in 1 week

PREFERRED RESPONSE: 1
DISCUSSION: The anatomic lesion in this patient is not exactly defined, but she has most likely sustained an injury about the knee. A Salter-Harris type I proximal tibial physeal fracture is likely. The normal radiograph reading can be misleading because these injuries may displace and spontaneously reduce. The child is at risk of compartment syndrome although she is currently not displaying signs of it. Thus, even though this injury may seem trivial by radiographic findings, it should be treated like a knee dislocation with a risk of late developing compartment syndrome. MRI or CT may be necessary to define the injury. She does not require emergent treatment, but merits close observation for possible compartment syndrome. Any of the possible injuries about the knee can be unstable and require internal fixation after reduction.

REFERENCES: McGuigan JA, O’Reilly MJ, Nixon JR: Popliteal arterial thrombosis resulting from disruption of the upper tibial epiphysis. Injury 1984;16:49-50.
Burkhart SS, Peterson HA: Fractures of the proximal tibial epiphysis. J Bone Joint Surg Am
1979;61:996- 1002.

DISCUSSION: The patient has failed to respond to Pavlik harness treatment. If use of the Pavlik harness fails to maintain reduction at 2 weeks, use of the harness should be discontinued to avoid creating further deformity of the acetabulum. Alternative treatments considered later include bracing, closed reduction, and spica casting, or open reduction and spica casting. With a Pavlik harness, continued abduction and hip flexion of the displaced hip may lead to posterolateral acetabular dysplasia.

44 • American Academy of Orthopaedic Surgeons

REFERENCES: Guille JT, Pizzutillo PD, MacEwen GD: Development dysplasia of the hip from birth to six months. J Am Acad Orthop Surg 2000;8:232-242.
Hedequist D, Kasser J, Emans J: Use of an abduction brace for developmental dysplasia of the hip after failure of Pavlik harness use. J Pediatr Orthop 2003;23:175-177.

2010 Pediatric Orthopaedic Examination Answer Book • 45

Figure 53a Figure 53b Figure 53c Figure 53d

DISCUSSION: The radiographs and clinical photographs reveal a child with posteromedial bowing of the tibia. This is a congenital anomaly that is associated with a calcaneal valgus foot. It is a relatively benign condition. The severity of the bow diminishes with time; however, the child will be left with a limb-length discrepancy, usually in the range of 4 cm. The residual limb- length discrepancy presents the greatest challenge for orthopaedic management. This, however, can usually be handled with limb- lengthening techniques. Casting can be used for severe cases with unresolving significant contracture; however, gradual spontaneous correction is usually the norm. This condition is quite different from anterior lateral bowing that can be associated with neurofibromatosis and pathologic fracture or pseudoarthrosis of the tibia.
REFERENCES: De Maio F, Corsi A, Roggini M, et al: Congenital unilateral posteromedial bowing of the tibia and fibula: Insights regarding pathogenesis from prenatal pathology. A case report. J Bone Joint Surg Am 2005;87:1601-1605.
Schoenecker PL, Rich MM: The lower extremity in pediatric orthopaedics, in Morrissy RT, Weinstein SL (eds): Love**l** and Winter’s Pediatric Orthopaedics, ed 6. Philadelphia, PA, Lippincott, Wi**l** iams and Wilkins, 2006, pp 1198-1200.

46 • American Academy of Orthopaedic Surgeons
Figure 54a Figure 54b

DISCUSSION: The foot shows all the classic signs of a clubfoot with hindfoot equinus, heel varus, supination, and forefoot adduction. The Ponseti method is now well recognized as the best treatment for idiopathic clubfoot. It calls for manipulation of the clubfoot on a weekly basis with the application of long leg cast to slowly achieve correction. A percutaneous heel cord tenotomy is often required, followed by an additional 3-week period of casting and eventual use of a foot abduction orthosis. AFO night splints will not achieve any correction. Anterior tibial tendon transfer is sometimes performed for a clubfoot with recurrence or if there is supination in the swing phase of gait. Short leg casts are not sufficient to achieve full correction of a clubfoot.
REFERENCES: Herzenberg JE, Radler C, Bor N: Ponseti versus traditional methods of casting for idiopathic clubfoot. J Pediatr Orthop 2002;22:517-521.
Morcuende JA, Dolan LA, Dietz FR, et al: Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics 2004; 113:376-380.

DISCUSSION: In 95% of patients with Ewing’s sarcoma, there is a translocation, t(l 1:22). This results in EWS/FLI-1 transcription factor that results in tumor cell proliferation. Other mechanisms causing

2010 Pediatric Orthopaedic Examination Answer Book • 47
tumor cell proliferation include inactivation of tumor suppressor genes, or activation of proto-oncogenes.

REFERENCES: Arndt CA, Crist WM: Common musculoskeletal tumors of childhood and adolescence. N Engl J Med 1999;341:342-352.
Pierz KA, Womer RB, Dormans JP: Pediatric bone tumors: Osteosarcoma Ewing’s sarcoma, and chondrosarcoma associated with multiple hereditary osteochondromatosis. J Pediatr Orthop 2001
;21:412- 418.

for this condition.
DISCUSSION: Spontaneous resolution of adolescent tibia vara is uncommon. Orthotic treatment has not been shown to be effective. Surgical elevation of the medial tibial plateau is a procedure that is occasionally necessary in individuals with early onset Blount’s disease but is not indicated for individuals with late onset Blount’s disease. Distal femoral varus deformity is commonly present and must be addressed.

2010 Pediatric Orthopaedic Examination Answer Book • 48
REFERENCES: Gordon JE, King DJ, Luhmann SJ, et al: Femoral deformity in tibia vara. J Bone Joint
Surg Am 2006;88:380-386.
Gordon JE, Heidenreich FP, Carpenter CJ, et al: Comprehensive treatment of late-onset tibia vara. J Bone Joint Surg Am 2005;87:1561-1570.

DISCUSSION: ACL injuries are five to eight times more common in young women. The highest incidence is associated with basketball and soccer. These sports require rapid directional and rotational changes. Use of neuromuscular training programs has not been associated with a decrease in ACL injuries. It is recommended that there be more frequent rests. ACL injuries are commonly associated with meniscal injury.

REFERENCES: Shea KG: ACL Injury: Epidemiology and Prevention Presented at Sports Related Injuries in the Skeletally Mature Athlete. POSNA: One Day Course, 2008.
Millett PJ, Willis AA, Warren RF: Associated injuries in pediatric and adolescent anterior cruciate
ligament tears: Does a delay in treatment increase the risk of meniscal tears? Arthroscopy 2002; 18:955- 959.

DISCUSSION: Flexible retrograde intramedullary nailing is now the preferred treatment for most length- stable diaphyseal femur fractures in school-aged children. The most commonly described complication is irritation about the knee at the rod insertion sites that resolves with rod removal. Limb-length discrepancy and weakness have also been described at lower rates. Malunion or rod bending is usually related to
_AL-Madena Cop,_ ^SIONSE: 2

2010 Pediatric Orthopaedic Examination
ook • 49
placement of the rods in an unstable fracture pattern or in a larger patient.

REFERENCES: Flynn JM, Hresko T, Reynolds RA, et al: Titanium elastic nails for pediatric femur fractures: A multicenter study of early results with analysis of complications. J Pediatr Orthop 2001
;21:4- 8.
Flynn JM, Schwend RM: Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347-359.

DISCUSSION: The hindfoot varus in this individual with a cavovarus deformity is nonstructural as shown by the “block test”. Therefore, surgical procedures directed at correcting the hindfoot deformity are not necessary. Observation is not in order and shoe modifications have not been shown to be effective in managing this problem. The patient is symptomatic; therefore, the treatment of choice is plantar release with first metatarsal osteotomy and possible tendon transfers.
REFERENCES: Paulos L, Coleman SS, Samuelson KM: Pes cavovarus: Review of a surgical approach
using selective soft-tissue procedures. J Bone Joint Surg Am 1980;62:942-953.
McCluskey WP, Lovell WW, Cummings RJ: The cavovarus foot deformity: Etiology and management. Clin Orthop Relat Res 1989;247:27-37.
Ward CM, Dolan LA, Bennett DL, et al: Long-term results of reconstruction for treatment of a flexible
cavovarus foot in Charcot-Marie-Tooth disease. J Bone Joint Surg Am 2008;90:2631-2642.

50 • American Academy of Orthopaedic Surgeons
Figure 60a Figure 60b Figure 60c

DISCUSSION: The radiographs show a transphyseal fracture separation of the distal humerus. Secondary ossification centers are not yet apparent. The radius and ulna maintain a normal relationship to each other, but not with the humerus. Commonly, as in these radiographs, displacement is medial. Elbow dislocation is more often lateral displacement. These physeal injuries are often stable; however, anatomic reduction and percutaneous pinning is recommended to prevent late deformity. Child abuse can be associated with these fractures.
REFERENCES: Flynn JM, Sarwark JF, Waters PM, et al: The surgical management of pediatric fractures of the upper extremity. Instr Course Lect 2003;52:635-645.
Oh CW, Park BC, Ihn JC, et al: Fracture separation of the distal humeral epiphysis in children younger
than three years old. J Pediatr Orthop 2000;20:173-176.

Figure 61

DISCUSSION: More muscle activity occurs during stance phase than during swing phase. During stance phase, the muscles of the leg and foot work to stabilize the plantigrade foot. In swing phase, momentum generated by the gastrocsoleus and hip flexors at terminal stance carries the leg forward. Knee flexion in early swing and then extension at terminal swing occur passively. The main concentric contraction that occurs during swing phase is that of the anterior tibialis, which dorsiflexes the foot for easier clearance during swing and prepositions the foot for initial contact.

REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, pp 79-85.
Ounpuu S, Gage JR, Davis RB: Three-dimensional lower extremity joint kinetics in normal pediatric
gait. J Pediatr Orthop 1991;11:341-349.
Kadaba MP, Ramakrishnan HK, Wootten ME: Measurement of lower extremity kinematics during level walking. J Orthop Res 1990;8:383-392.

52 • American Academy of Orthopaedic Surgeons

DISCUSSION: Posttraumatic physeal arrest occurs most commonly in the distal medial tibia. Using MRI, Echlund and associates confirmed this finding. Arrest of the distal radius and proximal humerus are rare after trauma. Traumatic injuries of the distal femoral and distal ulnar physis have a high incidence of growth arrest as well.

REFERENCES: Ecklund K, Jaramillo D: Patterns of premature physeal arrest: MR imaging of 111 children. AJR Am J Roentgenol 2002; 178:967-972.
_YAtotoartanadQpyiQter_ GN: Physeal bridge resection. J Am Acad Orthop Surg 2005; 13:4

Figure 64a Figure 64b

DISCUSSION: Mild to moderate metatarsus adductus is best treated with observation and possible passive stretching exercises because most of these feet will self correct. Numerous types of shoes, braces, and splints have been devised but the efficacy of these have not been determined. Serial casting is reserved for severe metatarsus adductus in the infant, although a medial surgical release may be indicated if the deformity is symptomatic and persists beyond age 4 years.
REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academ _A_ y _L-_ o _M_ f _ad_ O _en_ r _a_ th _C_ o _o_ p _p_ a _y_ edic Surgeons, 2006, pp 240-241.
Farsetti P, Weinstein SL, Ponseti IV: The Long-term functional and radiographic outcomes of untreated

2010 Pediatric Orthopaedic Examination Answer Book • 53

and non-operatively treated metatarsus adductus. J Bone Joint Surg Am 1994;76:257-265. Question 65
A 4-year-old girl has been limping for the past 2 months. There is no history of trauma, previous injury, fever, or other systemic complaints. Examination reveals a moderate right knee effusio n with a 10-degree knee flexion contracture. What is the next most appropriate step in evaluation?

1. ##### Arthroscopy
2. ##### Antinuclear antibody
3. ##### MRI
4. ##### Bone scan
5. ##### HLA-B27 PREFERRED RESPONSE: 2
DISCUSSION: The patient presents with juvenile idiopathic arthritis manifestations. The American
College of Rheumatology defines this as one or more joints involved with swelling of 6 weeks or longer. A positive antinuclear antibody test would be diagnostic. Consideration should be made to have the patient see an ophthalmologist for evaluation of possible uveitis. Although the patient could have Lyme disease, that choice is not an option. The presence of an elevated antinuclear antibody by itself should not necessarily be used for diagnosing arthritis; however, the test does have clinical utility as a screening test. The frequency of a positive antinuclear antibody test is greatest in younger girls with oligoarticular disease and carries an increased risk for anterior uveitis. Arthroscopy might be indicated if this patient was presenting with a discoid meniscus, but there is no history of clicking, which is often one of the classic signs of discoid meniscus. MRI would not be used to diagnose juvenile idiopathic arthritis, but
MRI would be useful to help diagnose discoid meniscus. A bone scan would show increased uptake in the patient’s knee but again, this would not help diagnose her condition. HLA-B27 has no role in diagnosing juvenile idiopathic arthritis, especially in females.

REFERENCES: Iesaka K, Kubiak EN, Bong LR, et al: Orthopaedic surgical management of hip and knee involvement in patients with juvenile rheumatoid arthritis. Am J Orthop 2006;35:67-73.
Wright DA: Juvenile idiopathic arthritis, in Morrissey RT, Weinstein SL (eds): Love**l** and Winter’s Pediatric Orthopaedics, ed 6. Philadelphia PA, Lippincott Williams and Wilkins, 2006, pp 405-438. Question 66
An 18-month-old girl is brought in by her parents because of concerns about intoeing, bowlegs, and tripping and fa**l** ing. Prenatal and birth history are otherwise unremarkable. The child’s growth and

54 • American Academy of Orthopaedic Surgeons

development appear to be normal and she has a normal neurologic exam, a straight spine with no defects, and the hips are stable. Examination reveals hip internal rotation of 40 degrees and hip external rotation of 60 degrees. The thigh-foot angle is internal 30 degrees. Feet are straight and supple. Gait is characterized by intoeing with occasional tripping and falling. Based on these findings, what is the most appropriate action?
1. ##### No treatment because internal tibial torsion slowly resolves on its own
2. ##### Immediate treatment with a Denis-Browne bar
3. ##### Distal tibial osteotomies
4. ##### Proximal femoral derotational osteotomies
5. ##### Treatment with twister cables PREFERRED RESPONSE: 1
DISCUSSION: The child has classic internal tibial torsion that is very commonly seen in younger children who are just beginning to walk. The normal outcome is for slow resolution of this problem and it seldom requires any treatment. Treatment with a Denis-Browne bar or with twister cables has not been proven to be effective. Surgical treatment at this point is premature and clearly not indicated.
REFERENCES: Lincoln TL, Suen PW: Common rotational variations in children. J Am Acad Orthop Surg 2003;11:312-320.
Staheli LT, Corbett M, Wyss C, et al: Lower-extremity rotational problems in children: Normal values to guide management. J Bone Joint Surg Am 1985;67:39-47.

Figure 67

DISCUSSION: The child has a Salter-Harris type IV injury involving both the growth plate and the articular surface of the ankle. This injury pattern has a high risk of physeal arrest; open reduction and internal fixation is indicated to realign the physis and joint surface. The best method of fixation to avoid growth arrest is one that does not cross the physis. This is usually achieved by an epiphyseal screw or pins parallel to the physis. If the metaphyseal fragment were large enough, a transverse metaphyseal screw could be used. The incidence of growth arrest following physeal ankle injuries is high and longterm follow- up is indicated.

REFERENCES: Cass JR, Peterson HA: Salter-Harris type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus. J Bone Joint Surg Am 1983;65:1059-1070. Barmada A, Gaynor T, Mubarak SJ: Premature physeal closure following distal tibia physeal fractures: A new radiographic predictor. J Pediatr Orthop 2003;23:733-739.

DISCUSSION: In open fractures, the hematoma that forms beneath the periosteum and around the ends of the fracture site is lost from the open wound. In addition, the irrigation process washes out the hematoma that contains growth factors and cytokines from the platelets. While loss of blood supply at the fracture site and soft-tissue coverage are important factors, the most important is loss of the factors that initiate the inflammatory phase of fracture healing. Infection may also delay healing, but is less common in this population.
REFERENCES: Buckwalter JA, Einhom TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 377-381.
Green NE, Swiontkowski MF (eds): Skeletal Trauma in Children, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1-14.

2010 Pediatric Orthopaedic Examination Answer Book • 57

DISCUSSION: Tuberculosis of the spine typically has an indolent presentation. Unlike pyogenic infections of the spine, the disk space is usually preserved. Most commonly, the thoracic and lumbar spine are affected. Laboratory studies may be nonspecific. Delayed presentation usually results in neurologic compromise and a kyphotic deformity. Treatment includes a multidrug regimen. Surgery is indicated for deformity correction or failure of medical treatment.
REFERENCES: Rajasekaran S: Buckling collapse of the spine in childhood spinal tuberculosis. Clin Orthop Relat Res 2007;460:86-92.
_TAL-MaeKXCpy I_ Hu SS: Spinal infections. J Am Acad Orthop Surg 2002; 10:188-197fcUa-MJ ^

Figure 71a Figure 71b Figure 71c Figure 71 d Question 71
A 10-year-old child was referred for spinal curvature and a 2-year history of back pain. She has pain
during the day and pain at night that wakes her from sleep and is temporarily relieved with nonsteroidal anti-inflammatory drugs. Examination shows very tight hamstrings and an irritative spinal curvature. Figures 71a through 71 d show radiographs, a bone scan, and a CT scan. What is the most appropriate treatment?

1. ##### Bracing with a thoracolumbosacral orthosis (TLSO)
2. ##### Observation with repeat radiographs of the scoliosis in 3 months and nonsteroidal antiinflammatory drugs for the pain
3. ##### MRI of the neuro-axis
4. ##### Surgical removal
5. ##### Radiofrequency ablation
PREFERRED RESPONSE: 4
DISCUSSION: The history, examination findings, and studies are consistent with an osteoid osteoma. The CT scan shows a classic “target” lesion, and the bone scan has intense uptake at the site of the osteoid osteoma. The child has had a 2-year history of pain that even wakes her from sleep, so
obs _A_ e _L_ rv _-M_ at _a_ io _de_ n _na_ a _C_ n _o_ d _py_ anti-inflammatory drugs is not a preferred treatment. Bracing will not help with the

58 • American Academy of Orthopaedic Surgeons

discomfort because the pain is not mechanical in nature. MRI would not be needed in addition to the studies already completed. The osteoid osteoma is close to the spinal cord so radiofrequency ablation is not preferred. Surgical removal and biopsy is the treatment of choice.

REFERENCES: Frassica FJ, Waltrip RL, Sponseller PD, et al: Clinicopathologic features and treatment of osteoid osteoma and osteoblastoma in children and adolescents. Orthop Clin North Am 1996;27:559-
574/. Cantwell CP, Obyme J, Eustace S: Current trends in treatment of osteoid osteoma with an emphasis on radiofirequency ablation. Eur Radiol 2004;14:607-617.

Figure 72

DISCUSSION: Although flexible intramedullary nails are a good treatment alternative for femoral shaft fractures in older children, patients weighing more than 100 pounds have a higher incidence of complications that include bending of the nails. Therefore, transtrochanteric solid intramedullary nail fixation is most likely the best option for this patient. Using a greater trochanteric entry point avoids the piriformis fossa and the possibility of osteonecrosis. External fixation is not a good alternative for this patient because of the transverse nature of the fracture. External fixation of this fracture pattern has been associated with a high refracture rate. Traction and casting can be performed but results in a lengthy hospital stay and a very large cast in an overweight 10-year-old child.
REFERENCES: Flynn JM, Schwend RM: Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347-359.
Gordon JE, Swenning TA, Burd TA, et al: Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children. J Bone Joint Surg Am 2003;85:1295-1301.

62 • American Academy of Orthopaedic Surgeons

Figure 71a Figure 71b Figure 71c Figure 71d Question 71
A 10-year-old child was referred for spinal curvature and a 2-year history of back pain. She has pain during the day and pain at night that wakes her from sleep and is temporarily relieved with nonsteroidal anti-inflammatory drugs. Examination shows very tight hamstrings and an irritative spinal curvature. Figures 71a through 7Id show radiographs, a bone scan, and a CT scan. What is the most appropriate treatment?

1. ##### Bracing with a thoracolumbosacral orthosis (TLSO)
2. ##### Observation with repeat radiographs of the scoliosis in 3 months and nonsteroidal antiinflammatory drugs for the pain
3. ##### MRI of the neuro-axis
4. ##### Surgical removal
5. ##### Radiofrequency ablation
PREFERRED RESPONSE: 4
DISCUSSION: The history, examination findings, and studies are consistent with an osteoid osteoma. The CT scan shows a classic “target” lesion, and the bone scan has intense uptake at the site of the osteoid osteoma. The child has had a 2-year history of pain that even wakes her from sleep, so observation and anti-inflammatory drugs is not a preferred treatment. Bracing will not help with the discomfort because the pain is not mechanical in nature. MRI would not be needed in addition to the studies already completed. The osteoid osteoma is close to the spinal cord so radiofrequency ablation is not preferred. Surgical removal and biopsy is the treatment of choice.

REFERENCES: Frassica FJ, Waltrip RL, Sponseller PD, et al: Clinicopathologic features and treatment of osteoid osteoma and osteoblastoma in children and adolescents. Orthop Clin North Am 1996;27:559-
574/. Cantwell CP, Obyme J, Eustace S: Current trends in treatment of osteoid osteoma with an emphasis on radiofrequency ablation. Eur Radiol 2004;14:607-617.

2010 Pediatric Orthopaedic Examination Answer Book • 63

Figure 72

DISCUSSION: Although flexible intramedullary nails are a good treatment alternative for femoral shaft fractures in older children, patients weighing more than 100 pounds have a higher incidence of complications that include bending of the nails. Therefore, transtrochanteric solid intramedullary nail fixation is most likely the best option for this patient. Using a greater trochanteric entry point avoids the piriformis fossa and the possibility of osteonecrosis. External fixation is not a good alternative for this patient because of the transverse nature of the fracture. External fixation of this fracture pattern has been associated with a high refracture rate. Traction and casting can be performed but results in a lengthy hospital stay and a very large cast in an overweight 10-year-old child.

REFERENCES: Flynn JM, Schwend RM: Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347-359.
Gordon JE, Swenning TA, Burd TA, et al: Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children. J Bone Joint Surg Am 2003;85:1295-1301.

Figure 73a Figure 73b

64 • American Academy of Orthopaedic Surgeons

DISCUSSION: The patient has proximal humeral epiphyseolysis, otherwise known as “Little League shoulder.” This is an overuse injury of the shoulder in the skeletally immature overhead throwing athlete. Most frequently seen in pitchers, it usually develops after an increase in the amount or intensity of throwing activity. Initial treatment involves cessation of throwing activities so the proximal humeral growth plate injury can heal, followed by a gradual return to throwing.

REFERENCES: Chen FS, Diaz VA, Loebenberg M, et al: Shoulder and elbow injuries in the skeletally immature athlete. J Am Acad Orthop Surg 2005;13:172-185.
Keeley DW, Hackett T, Keims M, et al: A biomechanical analysis of youth pitching mechanics. J Pediatr Orthop 2008;28:452-459.
Sabick MB, Kim YK, Torry MR, et al: Biomechanics of the shoulder in youth baseball pitchers:
Implications for the development of proximal humeral epiphysiolysis and humeral retrotorsion. Am J Sports Med 2005;33:1716-1722.

DISCUSSION: In Duchenne’s muscular dystrophy, spinal deformities are common. Spinal deformity usually develops as a child begins sitting in the preteen years. Unlike adolescent idiopathic scoliosis, scoliosis in Duchenne’s muscular dystrophy is treated early; spinal fusion for a 40-degree deformity is not unusual. Although hematology and neurology consults usually are not necessary prior to surgery, every child should have a comprehensive cardiac evaluation, including an EKG and an echocardiogram because cardiomyopathy is part of the pathologic spectrum of Duchenne’s muscular dystrophy requiring preoperative assessment and intervention.

2010 Pediatric Orthopaedic Examination Answer Book • 65

REFERENCE: Fischgrund JS (ed): Orthopedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, p 790.

DISCUSSION: Shaken baby syndrome is associated with chest ecchymosis and head trauma. Retinal
hemorrhages are often found, but are not pathognomonic. Contracoup injury was originally implicated, but more recent evidence shows that the head is actually struck against a hard object that causes a subdural hematoma.
REFERENCES: LeFanu J, Edwards-Brown R: Patterns of presentation of shaken baby syndrome: Subdural and retinal haemorrhages are not necessarily signs of abuse. BMJ 2004;328:767.
Richards PG, Bertocci GE, Bonshek RE, et al: Shaken baby syndrome. Arch Dis Child 2006;91:205-206.

DISCUSSION: Anterolateral bowing of the tibia is associated with confirmed neurofibromatosis in approximately 50% of patients. Although the risk of fracture with the development of pseudarthrosis exists, the initial treatment consists of bracing through maturity.
REFERENCES: Vander Have KL, Hensinger RN, Caird M, et al: Congenital pseudarthrosis of the tibia.

66 • American Academy of Orthopaedic Surgeons
J Am Acad Orthop Surg 2008;16:228-236.
Vitale MG, Guha A, Skaggs DL: Orthopaedic manifestations of neurofibromatosis in children: An update. Clin Orthop Relat Res 2002;401:107-118.

DISCUSSION: This young child with total head involvement LCPD is at some risk of a poor outcome due to the extent of his disease. Most children of this age will recover well with a good outcome. He is more likely to end up with a spherical femoral head than an older child with the same extent of involvement.

REFERENCES: Schoenecker PL, Stone JW, Capelli AM: Legg-Perthes disease in children under 6 years old. Orthop Rev 1993;22:201-208.
Rosenfeld SB, Herring JA, Chao JC: Legg-Calve-Perthes disease: A review of cases with onset before six years of age. J Bone Joint Surg Am 2007;89:2712-2722.

Figure 78

_A_ 4 _L_._-Ma_ P _de_ h _n_ y _a_ se _C_ a _o_ l _py_ bridge resection

2010 Pediatric Orthopaedic Examination
ook • 67

5. Lateral physeal hemiepiphysiodesis plate PREFERRED RESPONSE: 3
DISCUSSION: A diagnosis of Blount’s disease is indicated by the abnormal shape of the medial metaphysis of the tibia, the progressive nature of the deformity, and the focal nature of the angulation. A 4-year-old child with Blount’s disease should undergo surgical correction consisting of a tibial osteotomy before there is a permanent growth arrest that would require physeal bridge resection and/or repeated osteotomies. With a Langenskiold type IV lesion, bracing or hemiepiphyseal plate fixation is not expected to correct the deformity.

REFERENCES: Schoenecker PL, Meade WC, Pierron RL, et al: Blount’s disease: A retrospective review and recommendations for treatment. J Pediatr Orthop 1985;2:181-186.
Langenskiold A: Tibia Vara: A critical review. Clin Orthop Relat Res 1989;246:195-207.
Bowen RE, Dorey FJ, Moseley CF: Relative tibial and femoral varus as a predictor of varus deformities of the lower limbs in young children. J Pediatr Orthop 2002;22:105-111.

Figure 79

DISCUSSION: The hallmark of the juvenile bunion is metatarsus primus varus. Increased flexibility of
the first metatarsal phalangeal joint leads to increased deformity. The hallux valgus angle is less than the adult bunion. Bursal thickenings and prominence of the medial eminence are less in a juvenile bunion.
REFERENCES: Coughlin MJ: Juvenile bunions, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6. Philadelphia, PA, Mosley, 1993, pp 297-339.
Coughlin MJ, Mann RA: The pathophysiology of juvenile bunion. Instr Course Lect 1987;36:123-136.

68 • American Academy of Orthopaedic Surgeons

Figure 80a Figure 80b Figure 80c

DISCUSSION: Salter Harris III and IV fractures of the medial malleolus often contain a large cartilaginous portion, larger than the apparent ossified fragment seen on radiographs. Consequently, articular incongruity is common. As such, open reduction and internal fixation is often required. Growth disturbance and angular deformity are also common complications of Salter Harris III and IV fractures of the distal tibia.

REFERENCES: Flynn JM, Skaggs DL, Sponseller PD, et al: The surgical management of pediatric fractures of the lower extremity. Instr Course Lect 2003;52:647-659.
Kay RM, Matthys GA: Pediatric ankle fractures: Evaluation and treatment. J Am Acad Orthop Surg 2001;9:268-278.

2010 Pediatric Orthopaedic Examination
ook • 69

3. ##### Immediate exploration of the radial nerve with open reduction and plate fixation
4. ##### Monitoring of radial nerve function and application of a sling and swathe
5. ##### Monitoring of radial nerve function and external fixation PREFERRED RESPONSE: 4
DISCUSSION: Humeral shaft fractures in children rarely require open reduction. Shoulder and elbow function does not appear to be affected by up to 40 degrees of angulation in this patient population. Because of the high rate of remodeling in pediatric patients, the standard treatment is immobilization in a sling and swathe, a hanging arm cast, or a compressive dressing. Surgical fixation of humeral shaft fractures is usually only necessary in open injuries, multitrauma, or severely displaced fractures. Most radial nerve injuries associated with humerus fractures are secondary to contusion. Almost all associated radial nerve injuries in pediatric patients can be treated with observation.
REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 304.
Shrader MW: Proximal humerus and humeral shaft fractures in children. Hand Clin 2007;23:431-435. Caviglia H, Garrido CP, Palazzi FF, et al: Pediatric fractures of the humerus. Clin Orthop Relat Res 2005;432:49-56.

DISCUSSION: Infantile idiopathic scoliosis occurs more commonly in boys, with a 3 to 1 male to female ratio. Neural axis abnormalities, hip dysplasia, and congenital heart disease are all associated with the condition; spontaneous correction frequently occurs. Curve progression can be predicted by the rib vertebral angle difference or the phase of the rib head. Rib overlap of the apical vertebral body or a rib vertebral angle difference of greater than 20 degrees indicates that the curve is likely to progress. Gender, family history, and age at presentation have not been found to be risk factors for progression.

REFERENCES: Mehta MH: The rib-vertebra angle in the early diagnosis between resolving and progressive infantile scoliosis. J Bone Joint Surg Br 1972;54:230-243.
Fischgrund JS (ed): Orthopedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, p 697.

70 • American Academy of Orthopaedic Surgeons

DISCUSSION: More than than 90% of preadolescent children who sustain a significant spinal cord injury subsequently develop scoliosis. Conversely, progressive paralytic spinal deformity is uncommon in the postadolescent patient. Bracing has not been shown to be effective in the prevention of scoliosis in the preadolescent patient with spinal cord injury.

REFERENCES: Mayfield JK, Erkkila JC, Winter RB: Spine deformity subsequent to acquired childhood spinal cord injury. J Bone Joint Surg Am 1981;63:1401-1411.
Dearolf WW III, Betz RR. Vogl LC, et al: Scoliosis in pediatric spinal cord-injured patients. J Pediatr Orthop 1990;10:214-218.
Mehta S, Betz RR. Mulcahey MJ, et al: Effect of bracing on paralytic scoliosis secondary to spinal cord injury. J Spinal Cord Med 2004;27:S88-S92.

DISCUSSION: The spectrum of causative bacteria and frequency of occurrence of specific pathogens in septic arthritis are similar to those seen in osteomyelitis, with Staphylococcus aureus being the most common. Other common causative organisms include Kingella Kingae, Streptococcus pneumonia, Klebsiella species, Salmonella, Brucella melitensis, and Haemophilus influenzae.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, p 2109.
Jackson MA, Nelson JD: Etiology and medical management of acute suppurative bone and joint infections in pediatric patients. J Pediatr Orthop 1982;2:313-323.

2010 Pediatric Orthopaedic Examination Answer Book • 71

DISCUSSION: The child has a type III tibial spine avulsion fracture. When the avulsed fragment is completely displaced, the preferred treatment is open or arthroscopic reduction of the fragment and internal fixation with sutures or screws. Type I fractures are nondisplaced and can be treated with a long leg cast; type II fractures are hinged and can be treated in a long leg cast if closed reduction is successful. Many patients have some objective anterior cruciate ligament laxity after a tibial spine avulsion fracture; however, with adequate treatment most patients do not have symptomatic laxity.
REFERENCES: Mah JY, Adili A, Otsuka NY, et al: Follow-up study of arthroscopic reduction and fixation of type III tibial-eminence fractures. J Pediatr Orthop 1998; 18:475-477.
McLennen JG: Lessons learned after second-look arthroscopy in type III fractures of the tibial spine. J Pediatr Orthop 1995;15:59-62.
Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684.

72 • American Academy of Orthopaedic Surgeons

DISCUSSION: Surgical treatment of spinal deformity in a totally involved child with cerebral palsy has been shown on outcomes instruments to significantly improve the caregiver’s perception of the child’s comfort. The other parameters mentioned are difficult to measure and unpredictable.

REFERENCES: Tsirikos Al, Lipton G, Chang WN, et al: Surgical correction of scoliosis in pediatric patients with cerebral palsy using the unit rod instrumentation. Spine 2008;33:1133-1140.
Cassidy C, Craig CL, Perry A, et al: A reassessment of spinal stabilization in severe cerebral palsy. J Pediatr Orthop 1994;14:731-739.

Figure 87

DISCUSSION: The patient has a stable slipped capital femoral epiphysis (SCFE). Preferred treatment of
stable SCFE is in situ pinning. In situ fixation of stable SCFE has an extremely low rate of osteonecrosis. Gentle postural reduction with hip capsulotomy or surgical dislocation of the hip with reduction has been
aPdvRoEcFaEteRdRfEoDr uRnsEtaSbPlOe NSSCEF: E2.
REFERENCES: Aronson DD, Peterson DA, Miller DV: Slipped capital femoral epiphysis: The case for

2010 Pediatric Orthopaedic Examination
ook • 73

internal fixation in situ. Clin Orthop Relat Res 1992;281:115-122.
Loder RT, Richards BS, Shapiro PS, et al: Acute slipped capital femoral epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-1140.

Figure 88a Figure 88b

DISCUSSION: To accurately diagnose skeletal injuries around the elbow in children, the practitioner must be knowledgeable about the progressive ossification centers. In this case, at age 4 years, a female will have a partially ossified capitellum, radial head, and medial epicondyle. The trochlea, olecranon, and lateral epicondyle ossification centers should remain fully cartilaginous at this stage of development. The irregularity in the area of the olecranon on the radiograph represents a displaced fracture requiring accurate reduction and fixation to ensure restoration of articular congruity and full elbow function. The presence of a posterior fat pad sign on the radiograph is indicative of a traumatic effusion, but there is an identifiable fracture in this patient. Olecranon fractures are commonly seen in children with osteogenesis imperfecta.
REFERENCES: Cheng JC, Wing-Man K, Shen WY, et al: A new look at the sequential development of elbow-ossification centers in children. J Pediatr Orthop 1998;18:161-167.
Parent S, Wedemeyer M, Mahar AT, et al: Displaced olecranon fractures in children: A biomechanical analysis of fixation methods. J Pediatr Orthop 2008;28:147-151.
Beaty JH, Kasser JR (eds): Rockwood and Green’s Fractures in Children, ed 6. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 591-660.

74 • American Academy of Orthopaedic Surgeons

DISCUSSION: The history, physical examination, and laboratory studies suggest a septic hip. Recent studies indicate that a child with elevated ESR, a WBC count of greater than 12,000/mm3, a temperature of greater than 38.5 degrees, and unwillingness to walk is very likely to have septic arthritis of the hip versus toxic synovitis. The best way to confirm the diagnosis is by hip aspiration. No medications should be started until a diagnosis is made. Toxic synovitis is common, but significantly less likely if three of the above criteria are present. This condition usually responds well to ibuprofen, but requires close observation. Septic hips are considered urgent conditions and therefore a repeat evaluation in 2 weeks is inappropriate.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, pp 2109-2113.
Abel MF (ed): Orthopaedic Knowlede Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 62-65.
Kocher MS, Mandiga R, Murphy JM, et al: A clinical practice guideline for treatment of septic arthritis
in children: Efficacy in improving process of care and effect on outcome of septic arthritis of the hip. J Bone Joint Surg Am 2003;85:994-999.
Kocher MS, Mandiga R, Zurakowski D, et al: Validation of a clinica l prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am 2004;86:1629-1635.

DISCUSSION: The patient has a grade 2 open fracture and therefore needs wound debridement as a first step, followed by fracture stabilization preferably with an external fixator. A reamed intramedullary nail is not indicated in a 10-year-old child with open growth plates. Submuscular plating is not needed in an open fracture and there is no mention of fracture debridement. Percutaneous Kirschner wires will not provide adequate fracture stabilization, nor will a short leg cast. Flexible nailing should be considered as another form of fixation.
REFERENCES: Buckley SL, Smith G, Sponseller PD, et al: Open fractures of the tibia in children. J Bone Joint Surg Am 1990;72:1462-1469.
Song KM, Sangeorzan B, Benirschke S, et al: Open fractures of the tibia in children. J Pediatr Orthop

DISCUSSION: Brace treatment is recommended for a patient with substantial growth potential (Risser 2), any curve of greater than 30 degrees, or for a patient with a curve of greater than 20 to 25 degrees with more than 5 degrees of documented progression. Skeletally immature patients who have a curve of greater than 25 degrees are not considered for bracing. If a boy has a curve of 20 degrees, progression would be necessary to recommend bracing. A premenarchal girl with the curve of greater

76 • American Academy of Orthopaedic Surgeons

than 45 degrees is best treated with early surgical intervention, as progression is extremely likely. A girl who is Risser 4 with a 30-degree curve on presentation should be observed.

REFERENCE: Fischgrund JS (ed): Orthopedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, p 698.

Figure 93a Figure 93b

DISCUSSION: The fracture is best treated with elastic nails. Traction and a spica cast could be used but requires more time in the hospital and the cast increases family inconvenience for 4 to 6 weeks. There are lateral entry nails that could be used, but to date there is still not a long enough follow-up to determine the risk of osteonecrosis. External fixation may be an alternative for a patient with multiple injuries or extensive soft-tissue damage. Open plating could also be used but in the midshaft location, flexible nails are the most appropriate choice and offer the fewest number of potential complications.

REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 271-279.
Buechsenschuetz KE, Mehlman CT, Shaw KJ, et al: Femoral shaft fractures in children: Traction and
casting versus elastic stable intramedullary nailing. J Trauma 2002;53:914-921.
• b

2010 Pediatric Orthopaedic Examination Answer Book • 77

M

Figure 94

DISCUSSION: Nakamura and associates have reported good results in patients with resection for hemivertebra-related congenital scoliosis who have a progression of their deformity. Because of the progression, observation is not appropriate for this patient’s deformity. Bracing has not been shown to alter the progression of congenital scoliosis. The “growing rod” technique is also not effective in preventing progression related to hemivertebra. Distraction instrumentation carries an increased risk of neurologic complications in children with congenital spine deformities. Progression after posterior arthrodesis alone can occur through the so-ca**l** ed “crankshaft phenomenon.”
REFERENCES: Nakamura H, Matsuda H, Konishi S, et al: Single-stage excision of hemivertebrae via the posterior approach alone for congenital spine deformity: Follow-up period longer than ten years.
Spine 2002;27:110-115.
Ruf M, Harms J: Posterior hemivertebra resection with transpedicular instrumentation: Early correction in children aged 1 to 6 years. Spine 2003;15:2132-2138.

78 • American Academy of Orthopaedic Surgeons

Figure 95a Figure 95b Figure 95c Figure 95d

DISCUSSION: The radiographs and MRI scan show a displaced tibial eminence fracture. Meyer and McKeever classified these injuries, with type 1 being a nondisplaced tibial eminence fracture; type 2 being a displaced tibial eminence fracture with a posterior hinge, and type 3 being a displaced tibial eminence fracture. Tibial eminence fractures in children are equivalent to anterior cruciate ligament tears in adults. Treatment should be anatomic reduction, which often requires an arthroscopic or open procedure, followed by fixation.
REFERENCES: Green NE, Swiontkowski MF: Skeletal Trauma in Children, ed 3. Philadelphia, PA, WB Saunders, 2003, pp xvi, 452-455, 638.
Zionts LE: Fractures around the knee in children. J Am Acad Orthop Surg 2002;10:345-355.

2010 Pediatric Orthopaedic Examination Answer Book • 79

Figure 96

DISCUSSION: The patient has an established nonunion of the ischial tuberosity. Avulsion fractures of the pelvis are generally treated with rest and symptomatic treatment. Avulsion fractures of the ischial tuberosity are the most prone to nonunion. Most patients have few symptoms but some have trouble sitting and returning to sports. Excision of the avulsed fragment or open reduction and internal fixation are indicated for painful nonunions of the ischial tuberosity.
REFERENCES: Fembach SK., Wilkinson RH: Avulsion injuries of the pelvis and proximal femur. AJR Am J Roentgenol 1981;137:581-584.
Watts HG: Fractures of the pelvis in children. Orthop Clin North Am 1976;7:615-624. Question 97
Congenital anomalies of the vertebral column are associated frequently with other organ system problems. In addition to radiographs of the spine, what other screening tests should be ordered?

1. ##### Spinal MRI, coagulation panel
2. ##### Liver enzymes, coagulation panel
3. ##### Renal ultrasound, upper and lower GI
4. ##### Cardiac evaluation/echocardiogram, upper and lower GI

80 • American Academy of Orthopaedic Surgeons

5. ##### Renal ultrasound, cardiac evaluation/echocardiogram, spinal MRI

PREFERRED RESPONSE: 5

DISCUSSION: Approximately 60% of patients with congenital anomalies of the spine have other associated findings. The spine develops around the same time as the cardiovascular system, the genitourinary system, and the musculoskeletal system. Around 20% of patients with congenital scoliosis have an associated urologic abnormality. Approximately 25% of patients with congenital scoliosis have an associated cardiac defect. Spinal cord abnormalities in one study occurred in approximately 37% of patients with congenital scoliosis.
REFERENCES: Basu PS, Elsebaie H, Noordeen MH: Congenital spinal deformity: A comprehensive assessment at presentation. Spine 2002;27:2255-2259.
Ferguson RL: Medical and congenital comorbidities associated with spinal deformities in the immature spine. J Bone Joint Surg Am 2007;89:34-41.
McMaster MJ, Ohtsuka K: The natural history of congenital scoliosis: A study of two hundred and fifty- one patients. J Bone Joint Surg Am 1982;64:1128-1147.

**2010 Pediatric Orthopaedic Examination Answer Book • 81**

Figure 98a Figure 98b

DISCUSSION: The patient has anterior lateral bowing of the tibia with intramedullary sclerosis at the
site of the deformity. This is the prefracture stage of congenital pseudoarthrosis of the tibia and the child is at risk for spontaneous fracture and nonunion. A clamshell orthosis may prevent or delay fracture.
Treatment of established nonunion ranges from bone grafting and intramedullary nailing to Uizarov treatment, vascularized fibula bone grafting, or amputation.

REFERENCES: Herring JA: Disorders of the leg, bowing of the tibia, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, pp 1007-1023.
Ohnishi I, Sato W, Matsuyama J, et al: Treatment of congenital pseudarthrosis of the tibia: A multicenter study in Japan. J Pediatr Orthop 2005;25:219-224.

DISCUSSION: Nonsurgical management of OCD of the talus in skeletally immature individuals frequently results in a fairly rapid decrease in symptoms, but radiographic abnormalities can frequently be found even 6 months after treatment. Spontaneous resolution of this condition is rare. Hyperbaric oxygen treatment has not been shown to be beneficial for this condition. Progression of the condition to the point of requiring ankle fusion is rare.
REFERENCES: Perumal V, Wall E, Babekir N: Juvenile osteochondritis dissecans of the talus. J Pediat Orthop 2007;27:821-825.
Letts M, Davidson D, Ahmer A: Osteochondritis dissecans of the talus in children. J Pediatr Orthop 2003;23:617-625.

DISCUSSION: The child has the clinical and radiographic features of cleidocranial dysostosis. This is a disorder of bones formed by intramembranous ossification. It is inherited as an autosomal-dominant condition. About two thirds of cases are familial.
REFERENCES: Dietz FR, Mathews KD: Update on the genetic bases of disorders with orthopaedic manifestations. J Joint Bone Surg Am 1996;78:1583-1598.
Lee B, Thirunavukkarasu K, Zhou L, et al: Missense mutations abolishing DNA binding of osteoblast- specific transcription factor OSF2/CBFA1 in cleidocranial dysplasia. Nat Genet 1997;16:307-310.
cU.u^Ml **_[**ORTHO MCQS 011 FREE BANK 02**](http://hutaifortho.com/878)_**
---
**_[**ORTHO MCQS 011 FREE BANK**](http://hutaifortho.com/877)_**
**_[**Orthopedic MCQS online Hip and knee ADULT...**](http://hutaifortho.com/876)_**
**_[**ORTHOPEDIC MCQS OB 20 TRAUMA1**](http://hutaifortho.com/875)_**
**_[**ORTHOPEDIC MCQS OB 20 BASIC5**](http://hutaifortho.com/874)_**
**_[**ORTHOPEDIC MCQS OB 20 BASIC7**](http://hutaifortho.com/873)_**
**_[**ORTHOPEDIC MCQS OB 20 BASIC 6**](http://hutaifortho.com/872)_**
**_[**ORTHOPEDIC MCQS OB 20 BASIC 44**](http://hutaifortho.com/871)_**
**_[**ORTHOPEDIC MCQS OB 20 BASIC 4**](http://hutaifortho.com/870)_**
**_[**ORTHOPEDIC MCQS OB 20 BASIC 3**](http://hutaifortho.com/869)_**
**_[**ORTHOPEDIC MCQS OB 20 BASIC 2**](http://hutaifortho.com/868)_**
**_[**ORTHOPEDIC MCQS OB 20 BASIC 1**](http://hutaifortho.com/867)_**
**_[**ORTHOPEDIC MCQS OB 20 SHOULDER AND ELBOW4**](http://hutaifortho.com/865)_**
**_[**ORTHOPEDIC MCQS OB 20 SHOULDER AND ELBOW3**](http://hutaifortho.com/864)_**
**_[**ORTHOPEDIC MCQS OB 20 SHOULDER AND ELBOW 2**](http://hutaifortho.com/863)_**
**_[**1ORTHOPEDIC MCQS OB 20 SHOULDER AND ELBOW**](http://hutaifortho.com/862)_**
**_[**ORTHOPEDIC MCQS BANK WITH ANSWER HIP 01**](http://hutaifortho.com/861)_**
**_[**ORTHOPEDIC MCQS BANK WITH ANSWER PEDS 01**](http://hutaifortho.com/860)_**
**_[**ORTHOPEDIC MCQS BANK WITH ANSWER SPORT 01**](http://hutaifortho.com/859)_**
**_[**ORTHOPEDIC MCQS BANK WITH ANSWER ANATOMY 02**](http://hutaifortho.com/858)_**
**_[**ORTHOPEDIC MCQS BANK WITH ANSWER PATHOLOGY 02**](http://hutaifortho.com/857)_**
**_[**ORTHOPEDIC MCQS BANK WITH ANSWER SHOULDER 02**](http://hutaifortho.com/856)_**
**_[**ORTHOPEDIC MCQS WITH ANSWER FOOT 03**](http://hutaifortho.com/855)_**
**_[**ORTHOPEDIC MCQS WITH ANSWER SPINE 03**](http://hutaifortho.com/854)_**
**_[**ORTHOPEDIC MCQS WITH ANSWER TRAUMA 03**](http://hutaifortho.com/853)_**
**_[**ORTHOPEDIC MCQS WITH ANSWER HIP 04**](http://hutaifortho.com/852)_**
**_[**ORTHOPEDIC MCQS WITH ANSWER PEDS 04**](http://hutaifortho.com/851)_**
**_[**ORTHOPEDIC MCQS WITH ANSWER SPORT 04**](http://hutaifortho.com/850)_**
**_[**ORTHOPEDIC MCQS WITH ANSWER ANATOMY 05**](http://hutaifortho.com/849)_**
**_[**ORTHOPEDIC MCQS WITH ANSWER TUMOR/ONCOLOGY 05**](http://hutaifortho.com/848)_**
**_[**ORTHOPEDIC MCQS WITH ANSWER UPPER LIMB 05**](http://hutaifortho.com/847)_**
**_[**ORTHOPEDIC MCQS WITH ANSWERS ONLINE SPINE 06**](http://hutaifortho.com/846)_**
**_[**ORTHOPEDIC MCQS WITH ANSWERS ONLINE FOOT AND ANKLE...**](http://hutaifortho.com/845)_**
**_[**ORTHOPEDIC MCQS WITH ANSWERS ONLINE TRAUMA 06**](http://hutaifortho.com/844)_**
**_[**ORTHOPEDIC MCQS with Answers ONLINE BASIC 06**](http://hutaifortho.com/843)_**
**_[**ORTHOPEDIC MCQS ONLINE PEDIATRICS 07**](http://hutaifortho.com/842)_**
**_[**ORTHOPEDIC MCQS ONLINE HIP AND KNEE RECON 07**](http://hutaifortho.com/841)_**
**_[**ONLINE ORTHOPEDIC MCQS SPORT07**](http://hutaifortho.com/840)_**
**_[**ONLINE ORTHOPEDIC MCQS UPPER LIMB08**](http://hutaifortho.com/839)_**
**_[**ONLINE ORTHOPEDIC MCQS ONCOLOGY/TUMOR08**](http://hutaifortho.com/838)_**
**_[**ONLINE ORTHOPEDIC MCQS ANATOMY08**](http://hutaifortho.com/837)_**
**_[**ONLINE ORTHOPEDIC MCQS FOOT0 9**](http://hutaifortho.com/836)_**
**_[**ONLINE ORTHOPEDIC MCQS SPINE0 9**](http://hutaifortho.com/835)_**
**_[**ONLINE ORTHOPEDIC MCQS TRAUMA 9**](http://hutaifortho.com/834)_**
**_[**Orthopedic MCQS online sports Medicine**](http://hutaifortho.com/833)_**
**_[**Orthopedic MCQS online Shoulder and Elbow**](http://hutaifortho.com/832)_**
**_[**Orthopedic MCQS online Hip and knee**](http://hutaifortho.com/831)_**
**_[**online orthopedic mcqs**](http://hutaifortho.com/830)_**
**_[**Shoulder and elbow: Mcqs AND EMQS Answers**](http://hutaifortho.com/766)_**
**_[**Shoulder And Elbow: Questions Mcqs AND EMQS**](http://hutaifortho.com/765)_**
**_[**Hand and wrist: Answers MCQS EMQS**](http://hutaifortho.com/764)_**
**_[**Hand and wrist: MCQ AND EMQ Questions**](http://hutaifortho.com/763)_**
**_[**2021 SHOULDER AND ELBOW MCQS FREE**](http://hutaifortho.com/689)_**
**_[**Pediatric Orthopaedic MCQS Self-Assessment...**](http://hutaifortho.com/685)_**
**_[**Self-Assessment Examination 2020 Adult Spine MCQS**](http://hutaifortho.com/684)_**
**_[**Foot and Ankle free MCQS2020 Online**](http://hutaifortho.com/681)_**
**_[**UPDATED ORTHOPEDIC MCQS**](http://hutaifortho.com/680)_**
**_[**FREE Orthopedics MCQS 2022 1951.-2000.**](http://hutaifortho.com/677)_**
**_[**FREE Orthopedics MCQS 2022 1901.-1950.**](http://hutaifortho.com/676)_**
**_[**FREE Orthopedics MCQS 2022 1851-1900.**](http://hutaifortho.com/675)_**
**_[**FREE Orthopedics MCQS 2022 1751-1850..**](http://hutaifortho.com/674)_**
**_[**FREE Orthopedics MCQS 2022 1751-1800..**](http://hutaifortho.com/673)_**
**_[**Foot and Ankle FREE ORTHOPEDICS MCQS Question 11**](http://hutaifortho.com/672)_**
**_[**FREE Orthopedics MCQS 2022 1701-1750.**](http://hutaifortho.com/668)_**
**_[**FREE Orthopedics MCQS 2022 1651-1700**](http://hutaifortho.com/667)_**
**_[**FREE Orthopedics MCQS 2022 1601-1650.**](http://hutaifortho.com/666)_**
**_[**ORTHOPEDIC MCQS FREE 2023**](http://hutaifortho.com/665)_**
**_[**FREE Orthopedics MCQS 2022 1551-1600**](http://hutaifortho.com/664)_**
**_[**FREE Orthopedics MCQS 2022 1501-1550**](http://hutaifortho.com/663)_**
**_[**FREE Orthopedics MCQS 2022 1451-1500**](http://hutaifortho.com/662)_**
**_[**FREE Orthopedics MCQS 2022 1401-1450**](http://hutaifortho.com/661)_**
**_[**FREE Orthopedics MCQS 2022 1351 -1400**](http://hutaifortho.com/660)_**
**_[**ORTHOPEDICS HYPERGUIDE 2022 MCQ-1301-1350**](http://hutaifortho.com/659)_**
**_[**ORTHOPEDICS HYPERGUIDE 2022 MCQ-1251-1300**](http://hutaifortho.com/658)_**
**_[**ORTHOPEDICS HYPERGUIDE 2022 MCQ-1151-1200**](http://hutaifortho.com/656)_**
**_[**ORTHOPEDICS HYPERGUIDE 2022 MCQ-1101 1150**](http://hutaifortho.com/655)_**
**_[**ORTHOPEDICS HYPERGUIDE 2022 MCQ1051-1100**](http://hutaifortho.com/654)_**
**_[**ORTHOPEDICS HYPERGUIDE 2022 MCQ1001-1051**](http://hutaifortho.com/653)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 951-1000**](http://hutaifortho.com/652)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 901-950**](http://hutaifortho.com/651)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 851-900**](http://hutaifortho.com/650)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 800-850**](http://hutaifortho.com/649)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 751-800**](http://hutaifortho.com/647)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 701-750**](http://hutaifortho.com/646)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 651-700**](http://hutaifortho.com/645)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 601-650**](http://hutaifortho.com/644)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 551-600**](http://hutaifortho.com/643)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 501-550**](http://hutaifortho.com/642)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 451-500**](http://hutaifortho.com/641)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 401-450**](http://hutaifortho.com/640)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 351-400**](http://hutaifortho.com/639)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 301-350**](http://hutaifortho.com/638)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 251-300**](http://hutaifortho.com/637)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 201-250**](http://hutaifortho.com/636)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 151-200**](http://hutaifortho.com/635)_**
**_[**ORTHOPEDICS HYPERGUIDE MCQ 101-150**](http://hutaifortho.com/634)_**
**_[**FREE Orthopedics MCQS 2022 51-100**](http://hutaifortho.com/633)_**
**_[**Orthopedics Hyperguide MCQ 1-50**](http://hutaifortho.com/631)_**