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2016Pediatric Orthopaedic

Self-Assessment Examination
AAOS 2016 Pediatrics

Question 1 of 100
Second-impact syndrome following a concussion
1- poses minimal concern for morbidity or mortality.
2- is less common in adolescents than in adults.
3- is related to a disruption of cerebral autoregulation.
4- refers to a second head injury after the athlete has been medically cleared to return to
play.

PREFERRED RESPONSE: 3- is related to a disruption of cerebral autoregulation.

DISCUSSION
According to several consensus statements, no child or adolescent athlete with a
concussion should be allowed to return to play on the same day, regardless of severity. Second-
impact syndrome refers to a second traumatic head injury that occurs while an athlete is still
experiencing symptoms from the first injury. Young athletes are particularly vulnerable to
second-impact syndrome. The mechanism by which this syndrome occurs likely is disruption
of cerebral autoregulation, which may result in cerebral vascular congestion, diffuse brain
swelling, and death.

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Figure 2 Figure 3

Figure 4 Figure 5

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Figure 6a Figure 6b

Figure 6c

RESPONSES FOR QUESTIONS 2 THROUGH 6


1- Curettage and/or grafting

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2- Radiofrequency ablation
3- Intravenous (IV) antibiotics
4- Incision, drainage, and IV antibiotics
5- Neoadjuvant chemotherapy followed by surgical reconstruction
6- Observation alone
For each clinical vignette seen in the figures, select the best initial treatment from the list
above.

Question 2 of 100
Figure 2
1- Curettage and/or grafting
2- Radiofrequency ablation
3- Intravenous (IV) antibiotics
4- Incision, drainage, and IV antibiotics
5- Neoadjuvant chemotherapy followed by surgical reconstruction
6- Observation alone

PREFERRED RESPONSE: 6- Observation alone

Question 3 of 100
Figure 3
1- Curettage and/or grafting
2- Radiofrequency ablation
3- Intravenous (IV) antibiotics
4- Incision, drainage, and IV antibiotics
5- Neoadjuvant chemotherapy followed by surgical reconstruction
6- Observation alone

PREFERRED RESPONSE: 6- Observation alone

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Question 4 of 100
Figure 4
1- Curettage and/or grafting
2- Radiofrequency ablation
3- Intravenous (IV) antibiotics
4- Incision, drainage, and IV antibiotics
5- Neoadjuvant chemotherapy followed by surgical reconstruction
6- Observation alone

PREFERRED RESPONSE: 2- Radiofrequency ablation

Question 5 of 100
Figure 5
1- Curettage and/or grafting
2- Radiofrequency ablation
3- Intravenous (IV) antibiotics
4- Incision, drainage, and IV antibiotics
5- Neoadjuvant chemotherapy followed by surgical reconstruction
6- Observation alone

PREFERRED RESPONSE: 3- Intravenous (IV) antibiotics

Question 6 of 100
Figure 6a through 6c
1- Curettage and/or grafting
2- Radiofrequency ablation
3- Intravenous (IV) antibiotics
4- Incision, drainage, and IV antibiotics
5- Neoadjuvant chemotherapy followed by surgical reconstruction
6- Observation alone

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PREFERRED RESPONSE: 4- Incision, drainage, and IV antibiotics

DISCUSSION
Figure 2 depicts a typical unicameral bone cyst with a pathologic fracture. The decision to
treat this lesion should be based on the amount of cortical thinning. If these lesions involve a
pathologic fracture, many surgeons will treat them nonsurgically to see if the fracture
stimulates healing of the cyst. If the cyst wall remains thin or the patient is symptomatic, then
treatment is directed at decreasing cyst volume, increasing cortical thickness, and eliminating
symptoms. This can be accomplished by curettage and grafting, injection with autogenous
bone marrow, or grafting with 1 of the many available bone void fillers. In some cases, internal
fixation may be required. This typically is accomplished with flexible intramedullary nails.
Figure 3 shows a typical nonossifying fibroma. These benign lesions are usually incidental
findings on a radiograph and often resolve in adulthood. Treatment usually is not required, and
these lesions typically do not produce symptoms.
Figure 4 shows an osteoid osteoma of the femoral neck. This is characterized by a central
radiolucent nidus surrounded by reactive bone with increased radiodensity. These lesions are
painful because of the large amount of prostaglandin they secrete. They temporarily respond
to oral anti-inflammatory drugs. Treatment is directed at eliminating the nidus and can be done
through curettage, but radiofrequency ablation, which allows for a minimally invasive
approach, is often used today.
Figure 5 shows diskitis with vertebral osteomyelitis. The disease is characterized by fever
and back pain. Movement is extremely uncomfortable for these children, and they may adopt
unusual postures to alleviate pain. The MRI shows involvement of 1 vertebrae and an adjacent
disk. Left untreated, this condition often spreads to involve multiple vertebrae and also can
cause an epidural abscess. Treatment during the early stages is IV antibiotics. Many
orthopaedic surgeons also use bracing to prevent late vertebral collapse.
Figures 6a through 6c show septic arthritis of the ankle with metaphyseal osteomyelitis.
The recommended treatment is incision and drainage followed by IV antibiotics. MRI may be
considered before surgery to assess for an associated osteomyelitis or abscess that may also
necessitate surgical debridement. Increasingly, these scenarios are managed with a rapid
transition to oral antibiotics.

Question 7 of 100
Use of titanium elastic nailing for treatment of pediatric femur fractures is associated with
a higher complication rate among
1- patients younger than age 6.5.

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2- patients who bear weight immediately after surgery.


3- patients weighing more than 50 kg (110 pounds).
4- patients with grade 1 open transverse midshaft fractures.

PREFERRED RESPONSE: 3- patients weighing more than 50 kg (110 pounds).

DISCUSSION
Studies of titanium elastic nailing for femur fractures demonstrated a higher rate of
complications, including angular deformity and construct failure, among patients weighing
more than 50 kg (100 pounds). Other methods of fixation are recommended for these patients.
Flexible nails are not commonly needed, but they also are not associated with a higher
complication rate in children younger than age 6.5. Titanium elastic nailing works well in
closed or minimally open transverse midshaft fractures, even in the setting of early or
immediate weight bearing.

Video 8a Video 8b

Question 8 of 100
A 6-year-old boy had a 4-day history of worsening atraumatic right thigh and knee pain.
He was seen in the emergency department, where he had a temperature of 39.1C. Laboratory
studies reveal a white blood cell count of 15000 /L (reference range, 4500-11000 /L). He
had a small knee effusion with range of motion 0 to 90 degrees and a swollen, painful, hot
distal thigh. The knee effusion was aspirated, revealing a white blood cell (WBC) count of
2000 with negative gram stain (reference range < 2000 WBC/mL). The boy was admitted to
the pediatric medical service and intravenous (IV) antibiotics were initiated. The next day, MR

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imaging was obtained and orthopaedics was consulted. Based on Figures 8a and 8b, what is
the most appropriate description of his condition?
1- He has osteomyelitis with a significant subperiosteal abscess that will necessitate open
drainage in the operating room.
2- He has osteomyelitis without any abscess, so continued IV antibiotics and clinical
observation are recommended.
3- He has a muscle abscess that would best be treated by percutaneous drainage in
interventional radiology.
4- The MR image shows cellulitis with some adjacent myositis, so a short course of IV
antibiotics followed by 2 to 3 weeks of appropriate oral antibiotics is recommended.

PREFERRED RESPONSE: 1- He has osteomyelitis with a significant subperiosteal


abscess that will necessitate open drainage in the operating room.

DISCUSSION
The MRI scans show an advanced distal femur osteomyelitis with a substantial
subperiosteal abscess. This necessitates open drainage; by definition, an abscess is avascular,
so antibiotics cannot be delivered to the area without drainage.

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Figure 9a Figure 9b

CLINICAL SITUATION FOR QUESTIONS 9 THROUGH 12


Figures 9a and 9b are the radiographs of a 9-year-old boy who fell from the monkey bars
and sustained a closed fracture of the elbow.

Question 9 of 100
What is the most likely mechanism of injury?
1- Fall directly onto the elbow
2- Fall onto an outstretched elbow and hand
3- The direct impact of the elbow against the bars upon falling
4- Entrapment of the upper extremity under the trunk

PREFERRED RESPONSE: 2- Fall onto an outstretched elbow and hand

Question 10 of 100
Treatment should address predictable
1- instability of the fracture.
2- absence of the radial pulse.
3- inability to oppose the thumb and index finger.
4- rigidity of the forearm muscles.

PREFERRED RESPONSE: 1- instability of the fracture.

Question 11 of 100
The most mechanically stable fixation pattern for this fracture involves
1- lateral pins that diverge at the fracture site.
2- lateral pins that converge at the fracture site.
3- lateral and medial pins.
4- parallel lateral pins.

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PREFERRED RESPONSE: 3- lateral and medial pins.

Question 12 of 100
After reduction and pinning, the radial pulse is absent by both palpation and Doppler.
Capillary refill in the fingers appears normal. What is the most likely explanation?
1- Laceration of the brachial artery during reduction
2- Compression of the brachial artery by a pin
3- Abnormal arterial supply
4- Spasm in the brachial artery

PREFERRED RESPONSE: 4- Spasm in the brachial artery

DISCUSSION
This is a classic extension-type supracondylar elbow fracture typically caused by a fall on
an outstretched hand. The medial comminution of this fracture renders it predictably unstable
and susceptible to varus malunion. Extra attention with fixation is required. In general, use of
lateral-entry pins alone is effective for most supracondylar humeral fractures. The best
technique for fixation with lateral-entry pins only involves maximization of pin separation at
the fracture site, engaging sufficient bone in both the proximal segment and the distal fragment
and using more than 2 lateral entry pins (if needed) for stability. In the presence of medial
comminution, medial fixation also may be necessary.
Brachial artery spasm is the usual cause of absence of radial pulse if capillary refill is
normal. Close postsurgical monitoring is warranted after reduction and pinning.

Question 13 of 100
What is the most appropriate way to communicate instructions to a family when there is a
language barrier?
1- Use a translation program to print out instructions in the familys native language and
ask if they have questions
2- Have the patient translate the instructions if his or her English skills are adequate
3- Use a member of the hospitals nonmedical staff to translate

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4- Use a professional medical interpreter

PREFERRED RESPONSE: 4- Use a professional medical interpreter

DISCUSSION
Ideally, professional medical interpreters should be used in situations involving language
difficulties. Printed instructions are helpful, but, if there is a language barrier, these instructions
cannot substitute for conversing and answering questions. Asking the child to translate (no
matter how fluent he or she may be) is suboptimal. Nonmedical staff may not be fluent enough
to adequately translate medical terms.

Figure 14a Figure 14b Figure 14c

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Figure 14d Figure 14e Figure 15a

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Figure 15b Figure 15c Figure 15d

Figure 16a Figure 16b

RESPONSES FOR QUESTIONS 14 THROUGH 16


1- Aspiration, cultures, surgical irrigation and debridement, and intravenous (IV) nafcillin
2- Aspiration, cultures, surgical irrigation and debridement, and IV vancomycin
3- Aspiration, cultures, Lyme serology, and oral amoxicillin
4- Biopsy, culture, curettage, bone graft, and possible internal fixation
5- Physical therapy, ibuprofen, and an antinuclear antibody test
Select the most appropriate treatment above to address each clinical scenario below.

Question 14 of 100

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Figures 14a through 14e are the clinical photograph, radiographs, and MR images of a 13-
year-old boy with a 10-day history of a painful right ankle following a slide into second base
that resulted in skin abrasions. He cannot bear weight and he has severe pain with any ankle
motion. His primary care physician treated him 2 days ago and 7 days ago with intravenous
ceftriaxone, but there has been no improvement. His temperature is 38.8C, his white blood
cell count (WBC) is 21000 /L (reference range [rr], 4500-11000 /L), C-reactive protein
(CRP) is 6.8 mg/L (rr, 0.08-3.1 mg/L), and erythrocyte sedimentation rate (ESR) is 95 mm/h
(rr, 0-20 mm/h).
1- Aspiration, cultures, surgical irrigation and debridement, and intravenous (IV) nafcillin
2- Aspiration, cultures, surgical irrigation and debridement, and IV vancomycin
3- Aspiration, cultures, Lyme serology, and oral amoxicillin
4- Biopsy, culture, curettage, bone graft, and possible internal fixation
5- Physical therapy, ibuprofen, and an antinuclear antibody test

PREFERRED RESPONSE: 2- Aspiration, cultures, surgical irrigation and debridement,


and IV vancomycin

Question 15 of 100
Figures 15a through 15d are the clinical photographs and radiographs of a 7-year-old girl
with a markedly swollen left knee, a limp (but she can bear weight), and a rash on her inner
left thigh. Her temperature is 38.1C, WBC is 14000 /L (rr, 4500-11000 /L), CRP is 2.1
mg/L (rr, 0.08-3.1 mg/L), and ESR is 34 mm/h (rr, 0-20 mm/h). She has no pain with knee
range of motion from 45 to 110 degrees. The patient vacationed in central Connecticut 1 month
ago.
1- Aspiration, cultures, surgical irrigation and debridement, and intravenous (IV) nafcillin
2- Aspiration, cultures, surgical irrigation and debridement, and IV vancomycin
3- Aspiration, cultures, Lyme serology, and oral amoxicillin
4- Biopsy, culture, curettage, bone graft, and possible internal fixation
5- Physical therapy, ibuprofen, and an antinuclear antibody test

PREFERRED RESPONSE: 3- Aspiration, cultures, Lyme serology, and oral amoxicillin

Question 16 of 100

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Figures 16a and 16b are the radiograph and MR image of a 15-year-old dance athlete with
2 weeks of pain at the left distal femur, a limp, and an inability to dance. Knee motion is 0 to
135 degrees with minimal pain and there is no effusion. Her temperature is 37.0C, WBC is
12000 /L (rr, 4500-11000 /L), CRP is 0.8 mg/L (rr, 0.08-3.1 mg/L), and ESR is 21 mm/h
(rr, 0-20 mm/h).
1- Aspiration, cultures, surgical irrigation and debridement, and intravenous (IV) nafcillin
2- Aspiration, cultures, surgical irrigation and debridement, and IV vancomycin
3- Aspiration, cultures, Lyme serology, and oral amoxicillin
4- Biopsy, culture, curettage, bone graft, and possible internal fixation
5- Physical therapy, ibuprofen, and an antinuclear antibody test

PREFERRED RESPONSE: 4- Biopsy, culture, curettage, bone graft, and possible internal
fixation

DISCUSSION
Figures 14a through 14e show a 13-year-old boy with osteomyelitis of the distal tibia and
a large subperiosteal abscess. The patient has failed treatment with IV ceftriaxone, and
methicillin-resistant Staphylococcus aureus infection is likely. Aspiration, cultures, irrigation
and debridement, IV vancomycin, an infectious disease consult, and an evaluation for possible
deep vein thrombosis is prudent initial treatment. Figure 15a through 15c show a 7-year-old
girl who sustained a deer tick bite while vacationing in Connecticut. She has Lyme arthritis
and a Lyme bulls-eye rash on the same leg. Aspiration, cultures, Lyme serology, and oral
amoxicillin for 30 days is prudent initial treatment. Figures 16a and 16b are the radiograph
and MR image of a 15-year-old dance athlete with a probable minor fracture via a benign cyst
of the distal femur. The geographic cyst may be a nonossifying fibroma, eosinophilic
granuloma, Brodie abscess, or simple bone cyst. Biopsy, culture, curettage and bone graft, and
possible internal fixation is reasonable initial treatment.

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Figure 17

Question 17 of 100
Figure 17 is the radiograph of a 3-year-old girl who has shoulder pain after a fall. What is
the best next step?
1- 4 to 6 weeks of immobilization
2- Incisional biopsy followed by curettage and bone grafting
3- Irrigation and debridement and then antibiotics based on culture findings
4- Radical excision

PREFERRED RESPONSE: 1- 4 to 6 weeks of immobilization

DISCUSSION
Patients with a pathologic fracture of a unicameral bone cyst or simple bone cyst should
first pursue nonsurgical treatment and 4 to 6 weeks of immobilization. Spontaneous healing
occurs in fewer than 10% of patients, possibly due to cyst decompression. The most
appropriate form of surgical treatment is controversial. Many substances have been injected
with variable results. Injection with steroid, bone marrow, demineralized bone matrix, and
calcium phosphate/calcium sulfate have been attempted. Curettage and bone grafting and

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decompression have been attempted. Indications for treatment are based on cyst size,
symptoms, and location. Unicameral bone cysts typically resolve as patients reach skeletal
maturity.

Figure 18

CLINICAL SITUATION FOR QUESTIONS 18 THROUGH 23


Figure 18 is the lateral radiograph of the lumbar spine of an 11-year-old boy who has had
lower back pain for 2 months. There is no history of injury. He denies radiating pain to his
legs, numbness, weakness, and bowel or bladder changes. His usual activities include soccer
practices and games 3 to 5 times per week. He has used over-the-counter anti-inflammatory
medications, but has had no other treatment.

Question 18 of 100
An examination most likely will reveal pain with
1- forward bending of the back.
2- hyperextension of the back.
3- flexion, abduction, and external rotation testing of the hips.
4- passive straight-leg raising.

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PREFERRED RESPONSE: 2- hyperextension of the back.

Question 19 of 100
The addition of oblique lumbar radiographs has been shown to
1- allow easier classification of the condition severity.
2- allow easier determination of the stage of healing.
3- provide greater diagnostic accuracy for the condition.
4- provide no significant benefit.

PREFERRED RESPONSE: 4- provide no significant benefit.

Question 20 of 100
Initial treatment for this condition should include
1- activity modification and therapy to support the lumbar musculature.
2- a thoracolumbar sacral orthosis to immobilize the lower lumbar spine.
3- a diagnostic/therapeutic injection of the defect.
4- open treatment with fusion and instrumentation of the defect.

PREFERRED RESPONSE: 1- activity modification and therapy to support the lumbar


musculature.

Question 21 of 100
The family is curious about the likelihood that the condition could worsen. What is the
main risk factor for progression of this condition?
1- Male gender
2- Age
3- The involved level
4- Ethnicity

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PREFERRED RESPONSE: 2- Age

Question 22 of 100
What is the statistical likelihood that this boy could develop a progressive deformity for
which surgery would be necessary?
1- Lower than 5%
2- 10%
3- 25%
4- 50%

PREFERRED RESPONSE: 1- Lower than 5%

Question 23 of 100
This condition is most prevalent in people of which ancestry?
1- Northern European
2- Asian
3- Native American
4- Sub-Saharan African

PREFERRED RESPONSE: 3- Native American

DISCUSSION
The radiograph of the lateral lumbosacral spine reveals an isthmic spondylolysis with a
Meyerding grade 1 spondylolisthesis. The incidence of spondylolysis in the general population
is around 5%, and grade 1 or 2 slips are present in the majority of children with a spondylolysis.
Many cases of spondylolysis are painless and discovered incidentally, but, when painful,
hyperextension of the lumbar spine may stress the area of the pars defect and exacerbate a
patients symptoms. A diagnosis can usually be determined with a lateral radiograph of the
lumbar spine. Although oblique lumbar radiographs are frequently ordered, several studies
have shown that they do not increase diagnostic or prognostic accuracy. Progression of an
isthmic spondylolysis, with or without a grade 1 or 2 listhesis, to a serious slip that might

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necessitate surgical intervention is rare and occurs in fewer than 5% of patients. Chance for
progression diminishes with age, with patients at highest risk prior to the adolescent growth
spurt. Spondylolysis may have a genetic component; an increased prevalence has been found
in some families and in some ethnic groups, especially among the Native American population.

Figure 24a Figure 24b

Question 24 of 100
Figures 24a and 24b are the radiographs of a 7-year-old boy who fell off the monkey bars
and has a closed injury. His hand appears warm and well perfused with an absent radial pulse.
What is the best initial treatment?
1- Immediate open reduction with an anterior approach
2- Immediate open reduction with a posterior approach
3- Obtain an immediate arteriogram
4- Perform closed reduction and reassess perfusion and pulse

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PREFERRED RESPONSE: 4- Perform closed reduction and reassess perfusion and pulse

DISCUSSION
In displaced extension-type supracondylar fractures, the neurovascular structures get
kinked anteriorly or anteromedially related to the displacement. In almost all cases, there is a
spontaneous resolution of this kink following closed fracture reduction.

Question 25 of 100
A concussion diagnosis is made when there is
1- a 20% decrease in the neurocognitive score from baseline.
2- a brain MRI with abnormal findings.
3- a loss of consciousness for longer than 15 seconds.
4- evidence of a traumatic brain injury that alters the way the brain functions.
PREFERRED RESPONSE: 4- evidence of a traumatic brain injury that alters the way the
brain functions.
YOUR RESPONSE: 3- a loss of consciousness for longer than 15 seconds.
DISCUSSION
Neurocognitive testing is a helpful tool in the management of concussions, but testing does
not independently determine if an athlete has experienced a concussion or when he or she can
return to play. Neuroimaging findings typically are normal in concussive injury. Loss of
consciousness occurs in fewer than 10% of patients with concussions. A concussion diagnosis
is difficult to determine because of the lack of objective clinical and/or imaging findings. In
general, a concussion is a disturbance in brain function caused by a direct or indirect force to
the head.

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Figure 26 Figure 27a

Figure 27b Figure 28

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Figure 29 Figure 30

Figure 31a Figure 31b

RESPONSES FOR QUESTIONS 26 THROUGH 31


1- Plain radiographs

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2- CT scan
3- MRI
4- Arthrogram
Which imaging method listed above is most appropriate for definitive diagnosis and
management of each clinical scenario described below?

Question 26 of 100
Figure 26 is a radiograph of an 11-year-old boy with insidious-onset anterior knee pain.
1- Plain radiographs
2- CT scan
3- MRI
4- Arthrogram

PREFERRED RESPONSE: 3- MRI

Question 27 of 100
Figures 27a and 27b are the radiographs of a 2-month-old with a swollen ankle and
abdominal bruising.
1- Plain radiographs
2- CT scan
3- MRI
4- Arthrogram

PREFERRED RESPONSE: 1- Plain radiographs

Question 28 of 100
Figure 28 is the radiograph of a 14-year-old boy with an ankle injury.
1- Plain radiographs
2- CT scan
3- MRI

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4- Arthrogram

PREFERRED RESPONSE: 2- CT scan

Question 29 of 100
Figure 29 is the radiograph of a 12-year-old female gymnast with elbow pain.
1- Plain radiographs
2- CT scan
3- MRI
4- Arthrogram

PREFERRED RESPONSE: 3- MRI

Question 30 of 100
Figure 30 is the radiograph of a newborn admitted to the neonatal intensive care unit
(NICU) with a swollen elbow following a difficult birth.
1- Plain radiographs
2- CT scan
3- MRI
4- Arthrogram

PREFERRED RESPONSE: 4- Arthrogram

Question 31 of 100
Figures 31a and 31b are the radiographs of a 5-year-old boy with an elbow injury.
1- Plain radiographs
2- CT scan
3- MRI
4- Arthrogram

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PREFERRED RESPONSE: 1- Plain radiographs

DISCUSSION
Figure 26 shows lucent areas of both femoral condyles. This may represent a variation of
ossification, in which case this boys knee pain is coincidental. Another possibility is atypical
osteochondritis dissecans. An MRI will distinguish between the 2 entities and will guide
treatment.
Figures 27a and 27b show healing rib and distal tibia fractures. These fractures likely are
attributable to child abuse. A plain radiographic skeletal survey is sufficient for orthopaedic
needs.
A triplane fracture of the distal tibia is revealed in Figure 28. A CT scan will quantify
displacement and identify fracture fragments for planning of screw trajectories if open
reduction and internal fixation is indicated (displacement > 2 mm).
In Figure 29, the linear lucency of the capitellum indicates an early osteochondritis
dissecans. An MRI will allow staging of the lesion.
Figure 30 shows that the left radius and ulna do not align with the humerus; this is the
likely result of a transphyseal fracture of the distal humerus. An arthrogram will outline the
unossified distal humerus and allow for reduction. For an unstable neonate, this likely can be
performed in the NICU.
Figures 31a and 31b reveal a widely displaced lateral condyle fracture for which open
reduction and internal fixation is required. No advanced imaging is necessary.

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Figure 32

Question 32 of 100
Figure 32 is the current right femur lateral radiograph of a 9-year-old boy who went to the
emergency department after falling from his skateboard. He has acute right leg pain, deformity,
and cannot bear weight. Vascular and neurologic examination findings are normal. His skin is
intact; however, he has a healed 3-inch scar on the lateral side of his right thigh. The boy
weighs 90 pounds. Treatment should include
1- a 1-1/2 hip spica cast.
2- removal of the plate and insertion of flexible titanium nails.
3- removal of the plate and insertion of a rigid reamed nail with an entry point for the nail
starting at the piriformis fossa.
4- placement of a proximal tibial traction pin for 4 weeks of skeletal traction followed by
a 1-leg spica cast.

PREFERRED RESPONSE: 2- removal of the plate and insertion of flexible titanium nails.

DISCUSSION

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This patients first femur fracture at age 7 was treated with a compression plate after he
was struck by a motor vehicle. He sustained a second femur fracture at the end of the plate
after a fall from a skateboard. Spica casting typically is recommended patients up to the age
of 6 who weigh less than 25 kg. Tibial traction pins are not recommended for children because
of risk for injury to the proximal tibial physis. A trochanteric entry rigid nail can be used, but
a piriformis entry nail is not recommended for children because of risk for avascular necrosis
of the femoral head. Removal of the plate and fixation with flexible titanium nails is a prudent
option to fix the transverse fracture with a load-sharing device. Flexible nails are indicated for
children weighing up to 50 kg.

CLINICAL SITUATION FOR QUESTIONS 33 THROUGH 36


A 10-year-old girl has right knee pain related to activity. An avid soccer player, she has
noted pain after the first 15 minutes of running but no swelling or mechanical symptoms.
Radiographs show a large 2-cm osteochondritis dissecans (OCD) lesion.

Question 33 of 100
What is the most appropriate treatment?
1- Activity restriction and follow-up radiographs in 3 months
2- Long-leg casting for 3 months
3- Arthroscopic evaluation and drilling
4- Arthroscopic vs an open osteochondral autograft transfer system (OATS) procedure

PREFERRED RESPONSE: 1- Activity restriction and follow-up radiographs in 3 months

Question 34 of 100
The patient returns after 3 months and the lesion is still present radiographically, with
minimal appreciable healing. Her symptoms are controlled with activity restriction. What is
the best next step at this stage?
1- Activity restriction and follow-up radiographs in 3 months
2- Long-leg casting for 3 months
3- Arthroscopic evaluation and drilling
4- Arthroscopic vs an open OATS procedure

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PREFERRED RESPONSE: 1- Activity restriction and follow-up radiographs in 3 months

Question 35 of 100
The patient falls and undergoes imaging that demonstrates the lesion is unstable. What is
the best next step?
1- Continued observation for 3 more months
2- Arthroscopic evaluation and drilling
3- Arthroscopic evaluation and fixation
4- Open debridement and osteochondral autograft transfer

PREFERRED RESPONSE: 3- Arthroscopic evaluation and fixation

Question 36 of 100
The patient does well initially but returns for the 4-month postsurgical evaluation with
ongoing stiffness and pain despite going to physical therapy twice weekly and working on
motion at home. She is unable to bear weight comfortably. What is the best next step?
1- Manipulate the knee under anesthesia
2- Aspirate the knee for persistent hematoma to improve motion
3- Obtain advanced imaging to evaluate the lesion and fixation
4- Prescribe more intensive physical therapy 3 to 5 times a week to achieve motion

PREFERRED RESPONSE: 3- Obtain advanced imaging to evaluate the lesion and


fixation

DISCUSSION
In a skeletally immature patient with OCD and minor symptoms, the lesion can be
observed and healing obtained with activity limitations if the cartilage is stable (but this cannot
be determined radiographically or clinically). Activity restriction and serial follow-up are
appropriate if an MRI reveals a stable lesion. MRI is indicated when there is concern that a
lesion may be unstable. Surgical treatment depends on MRI findings.

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Observation is recommended for OCD lesions in growing patients for 6 months because
healing has been observed. Early surgical procedures, although they may be needed in the
future, are not appropriate for patients with well-controlled symptoms.
If symptoms continue for longer than 6 months, arthroscopic drilling is not indicated for
unstable OCD. The appropriate treatment is OCD fixation. Debridement is not appropriate
with a stable lesion.
Evaluation of the fixation and stability of the lesion with advanced imaging after weight
bearing and therapy initiation is the most appropriate option. Manipulating the knee without
determining whether the stiffness is attributable to subsidence of the fixation or mechanical
block is not appropriate. After 4 months, aspiration of a hematoma (if still present) would not
yield much benefit. More therapy is not likely to be useful when a patient is attending therapy
regularly and working on a home program.

Figure 37a Figure 37b Figure 37c

Question 37 of 100
Figure 37a is the initial radiograph of a 7-year-old boy who fell from monkey bars 4 hours
ago. He has intact motor function in his fingers and normal capillary refill, but his radial pulse
is not palpable. Figures 37b and 37c are the radiographs following closed reduction and
pinning. This boys hand and fingers remain pink, but his radial pulse remains nonpalpable.
What is the best next step?
1- An arteriogram to evaluate the brachial artery
2- Open exploration and repair of the brachial artery

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3- Pin removal to rereduce the fracture


4- Additional splinting and continued observation in the hospital

PREFERRED RESPONSE: 4- Additional splinting and continued observation in the


hospital

DISCUSSION
Figure 37a shows a completely displaced supracondylar humerus fracture. The first step
in the situation described, which involves a pink pulseless hand, is to perform an urgent closed
manipulation and pinning. The vascular examination should be reassessed following the
reduction. When adequate reduction has been achieved and the pulse remains nonpalpable but
the hand is pink and capillary refill is normal, the fracture may be splinted and the patient
observed closely in the hospital. Arteriography is not useful and may delay revascularization
or increase vessel spasm. Although some investigators have concluded that exploration of the
brachial artery may be indicated, the algorithm that includes observation only is the most
supported and the most commonly practiced treatment. The radiographs show adequate
reduction and fixation without medial widening at the fracture site, which might indicate a site
of brachial artery entrapment. Therefore, pin removal and fracture rereduction is not indicated.

RESPONSES FOR QUESTIONS 38 THROUGH 45


1- Sclerosis of the proximal femoral epiphysis with subchondral lucency
2- Abnormal femoral head-neck junction offset
3- Widening of the proximal femoral physis with normal femoral head-neck junction offset
4- Absence of the proximal femoral epiphysis secondary ossification center
For each clinical scenario below, select the most likely associated radiographic finding
from the list above.

Question 38 of 100
A 6-year-old boy has a 2-month history of intermittent, mild, unilateral thigh pain and a
limp. An examination reveals a Trendelenburg sign and restricted hip abduction and internal
rotation.
1- Sclerosis of the proximal femoral epiphysis with subchondral lucency
2- Abnormal femoral head-neck junction offset
3- Widening of the proximal femoral physis with normal femoral head-neck junction offset

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4- Absence of the proximal femoral epiphysis secondary ossification center

PREFERRED RESPONSE: 1- Sclerosis of the proximal femoral epiphysis with


subchondral lucency

Question 39 of 100
An 11-year-old obese boy has a 5-month history of unilateral knee pain and a limp. An
examination reveals obligate external rotation with flexion and pain with attempted hip
internal rotation.
1- Sclerosis of the proximal femoral epiphysis with subchondral lucency
2- Abnormal femoral head-neck junction offset
3- Widening of the proximal femoral physis with normal femoral head-neck junction offset
4- Absence of the proximal femoral epiphysis secondary ossification center

PREFERRED RESPONSE: 2- Abnormal femoral head-neck junction offset

Question 40 of 100
An 18-month-old girl was treated at the age of 4 months with medial open reduction of a
unilateral developmental hip dislocation.
1- Sclerosis of the proximal femoral epiphysis with subchondral lucency
2- Abnormal femoral head-neck junction offset
3- Widening of the proximal femoral physis with normal femoral head-neck junction offset
4- Absence of the proximal femoral epiphysis secondary ossification center

PREFERRED RESPONSE: 4- Absence of the proximal femoral epiphysis secondary


ossification center

Question 41 of 100
A 15-year-old boy who underwent in situ fixation of a stable slipped capital femoral
epiphysis 2 years ago now has groin pain and mechanical symptoms.

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1- Sclerosis of the proximal femoral epiphysis with subchondral lucency


2- Abnormal femoral head-neck junction offset
3- Widening of the proximal femoral physis with normal femoral head-neck junction offset
4- Absence of the proximal femoral epiphysis secondary ossification center

PREFERRED RESPONSE: 2- Abnormal femoral head-neck junction offset

Question 42 of 100
A 10-year-old boy has chronic renal failure and activity-related groin pain.
1- Sclerosis of the proximal femoral epiphysis with subchondral lucency
2- Abnormal femoral head-neck junction offset
3- Widening of the proximal femoral physis with normal femoral head-neck junction offset
4- Absence of the proximal femoral epiphysis secondary ossification center

PREFERRED RESPONSE: 3- Widening of the proximal femoral physis with normal


femoral head-neck junction offset

Question 43 of 100
A 12-year-old girl was treated with open reduction and internal fixation for an unstable
slipped capital femoral epiphysis. Anatomic alignment with normal femoral head-neck offset
was achieved, but she now has worsening groin pain. Examination reveals an antalgic gait,
and her hip has limited passive internal and external rotation.
1- Sclerosis of the proximal femoral epiphysis with subchondral lucency
2- Abnormal femoral head-neck junction offset
3- Widening of the proximal femoral physis with normal femoral head-neck junction offset
4- Absence of the proximal femoral epiphysis secondary ossification center

PREFERRED RESPONSE: 1- Sclerosis of the proximal femoral epiphysis with


subchondral lucency

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Question 44 of 100
A 17-year-old male baseball catcher has groin pain and intermittent hip locking.
Examination demonstrates reproduction of the pain with hip flexion, internal rotation, and
adduction. MR imaging reveals an anterosuperior labral tear.
1- Sclerosis of the proximal femoral epiphysis with subchondral lucency
2- Abnormal femoral head-neck junction offset
3- Widening of the proximal femoral physis with normal femoral head-neck junction offset
4- Absence of the proximal femoral epiphysis secondary ossification center

PREFERRED RESPONSE: 2- Abnormal femoral head-neck junction offset

Question 45 of 100
A 10-month-old boy has an untreated developmental hip dislocation.
1- Sclerosis of the proximal femoral epiphysis with subchondral lucency
2- Abnormal femoral head-neck junction offset
3- Widening of the proximal femoral physis with normal femoral head-neck junction offset
4- Absence of the proximal femoral epiphysis secondary ossification center

PREFERRED RESPONSE: 4- Absence of the proximal femoral epiphysis secondary


ossification center

DISCUSSION
Early radiographic findings of avascular necrosis (AVN) of the hip include sclerosis and a
subchondral lucency. A common presentation of Legg-Calve-Perthes disease (idiopathic
pediatric hip AVN) is intermittent pain in the thigh, groin, or knee with an examination
localizing to the hip; a Trendelenburg gait or sign; and painful, restricted passive hip range of
motion. AVN also may be observed in association with a slipped capital femoral epiphysis
(SCFE). AVN risk is highest in the setting of an unstable SCFE (10%-60%); risk is 0% to
1.4% when the SCFE is stable. A multicenter review of the modified Dunn procedure for
treatment of unstable SCFE noted an AVN rate of 26%.
The most common deformity associated with SCFE is proximal femoral varus, flexion,
and external rotation leading to an abnormal femoral head-neck junction offset. This causes a
loss of passive hip flexion and internal rotation and the phenomenon of obligate external

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rotation with flexion. The residual deformity frequently results in femoroacetabular


impingement. Labral tears also are associated with cam impingement secondary to underlying
osseous abnormalities including abnormal femoral head-neck junction offset.
Endocrinopathies potentially are associated with SCFE because of hormone-related
physeal changes and subsequent mechanical insufficiency of the proximal femoral physis.
With renal osteodystrophy, the physeal widening results from secondary hyperparathyroidism
and progressive proximal femoral deformity may develop. Optimal medical management of
hyperparathyroidism is essential. Surgical stabilization via in situ fixation of the proximal
femur is indicated when SCFE is diagnosed.
The proximal femoral epiphysis secondary ossification center commonly appears between
the ages of 4 and 7 months. In the setting of developmental hip dislocation, the appearance of
the secondary ossification center is commonly delayed. After closed or open reduction of
developmental dysplasia of the hip, failure of the femoral head ossific nucleus to appear within
12 months following the reduction is a sign of proximal femoral growth disturbance and AVN.

Figure 46a Figure 46b

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AAOS 2016 Pediatrics

Figure 46c Figure 46d

Question 46 of 100
Figures 46a through 46d are the injury radiographs and postsurgical open treatment
radiographs of a 13-year-old girl who fell while on a trampoline and sustained an injury to her
right-dominant elbow. The skin is closed and she has normal vascular and neurologic
examination findings. Which complication most likely could occur as a result of this injury
and treatment?
1- Compartment syndrome
2- Loss of elbow motion
3- Avascular necrosis (AVN) of the radial head
4- Nonunion of the fracture site

PREFERRED RESPONSE: 2- Loss of elbow motion

DISCUSSION
This girl sustained a fracture dislocation of the elbow with a severely displaced and rotated
radial neck fracture. Required treatment was open reduction and internal fixation (ORIF). Less
severely displaced radial neck fractures can be treated with closed reduction, percutaneous
pinning, or flexible nail manipulation. In this scenario, interposed capsular tissue and rotation
of the radial head were indications for ORIF. ORIF is associated with a higher risk for poor

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outcomes. Complications following ORIF of radial neck fractures in children include posterior
interosseous neuropraxia, valgus angulation, premature closure of the radial head physis, AVN
of the radial head, nonunion, and elbow stiffness. Stiffness is most common. Compartment
syndrome, infection, and anterior interosseous nerve palsy are less common complications.

Figure 47a Figure 47b

CLINICAL SITUATION FOR QUESTIONS 47 THROUGH 50


A 6-year-old boy arrives at the emergency department with forearm pain. Today he was
picking up his backpack when he felt a pop in his forearm that resulted in the current injury.
His history is significant for 6 other fractures treated nonsurgically. His mother states that she
had 15 fractures during childhood but is healthy now. Both the boy and his mother have blue
sclera. Figures 47a and 47b are the radiographs of his injured forearm.

Question 47 of 100
Based on this history and radiographic examination, how should you advise the family?
1- Many people fracture during childhood, so no further workup is indicated.
2- The boy likely has osteogenesis imperfecta (OI).
3- The boy has rickets and needs treatment with vitamin D.
4- The fracture pattern does not match the history and is suspicious for nonaccidental
trauma.

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AAOS 2016 Pediatrics

PREFERRED RESPONSE: 2- The boy likely has osteogenesis imperfecta (OI).

Question 48 of 100
What is the most likely underlying bone problem?
1- None; this is suspicious for nonaccidental trauma
2- A genetic defect in the type I collagen gene
3- A genetic defect in the type II collagen gene
4- A genetic defect in the prolyl 3-hydroxylase 1 gene (LEPRE1)

PREFERRED RESPONSE: 2- A genetic defect in the type I collagen gene

Question 49 of 100
The fracture location and pattern can be explained because
1- there is a sudden change in elasticity between the plated and unplated bone.
2- there is probably an unrecognized infection from the original open fracture.
3- the plates were put in improperly.
4- the original fracture never completely healed.

PREFERRED RESPONSE: 1- there is a sudden change in elasticity between the plated


and unplated bone.

Question 50 of 100
Which treatment of the current fracture will provide the best long-term outcome?
1- Casting it in its current position, which is acceptable alignment
2- Closed reduction and casting
3- Functional brace because this is a stable fracture
4- Open reduction with revision of the current implants

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AAOS 2016 Pediatrics

PREFERRED RESPONSE: 4- Open reduction with revision of the current implants

DISCUSSION
Many patients with mild dominant OI (the most common type) appear normal, and a
diagnosis cannot be made without a careful personal history, family history, and observance
of blue sclera. More than 3 fractures during childhood places someone outside of the mean
and should merit further investigation. There is no sign of rickets on this radiograph (physeal
widening/cupping). Similarly, the history and examination finding of blue sclera in the patient
and his mother should raise concern for OI. Many parents of children with OI have
inappropriately been accused of abuse despite obvious examination, radiograph, and family
history findings that suggest OI. Low-energy mechanisms that create displaced fractures are a
hallmark of OI and do not in isolation raise suspicion for nonaccidental trauma.
Based on the history and examination, mild-form OI caused by a defect in the type I
collagen gene is most likely. Defects in type II collagen genes affect articular cartilage and
cause epiphyseal dysplasia. Defects in the LEPRE cause severe-form OI involving clinically
bowed limbs, marked short stature, and white sclera. There is no sign on radiographs of rickets,
so severe vitamin D deficiency is not present. The history, examination, and radiographs all
point toward OI/osteoporosis rather than nonaccidental trauma.
Peri-implant fractures occur because of a difference in elasticity between the bone with
implants and the bone adjacent to it without implants. This is particularly important in the
setting of osteoporotic bone in which the difference in elasticity and rigidity will be much more
pronounced than in normal bone. Load-sharing implants are preferred when possible. The
original fracture occurred proximal to the current fracture in the middle of the plated bone and
looks healed with no sign of infection.
This fracture is in unacceptable alignment with subluxation of the radiocapitellar joint. The
plates are bent, so closed reduction will not solve the alignment problem. In early childhood,
load-sharing implants (flexible rods or wires) should be used to solve the elasticity mismatch
that contributed to the current fracture.

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Figure 51a Figure 51b Figure 51c

CLINICAL SITUATION FOR QUESTIONS 51 THROUGH 54


Figures 51a through 51c are the radiographs of an 8-year-old boy with a shoulder deformity
and limited cervical range of motion. He has no significant medical problems and plays
baseball, pitching with his right arm. His active shoulder abduction is 180 degrees on the left
and 150 degrees on the right.

Question 51 of 100
The workup to exclude other congenital abnormalities should include evaluation of which
systems?
1- Cardiac, renal, and gastrointestinal (GI)
2- Cardiac, renal, and auditory
3- Cardiac, pulmonary, and GI
4- Cardiac, pulmonary, and neural axis

PREFERRED RESPONSE: 2- Cardiac, renal, and auditory

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AAOS 2016 Pediatrics

Question 52 of 100
This shoulder deformity often is associated with an abnormal connection between the
scapula and the
1- posterior ribs.
2- clavicle.
3- humerus.
4- spine.

PREFERRED RESPONSE: 4- spine.

Question 53 of 100
Recommendations for sports activity should include
1- full participation without restrictions.
2- avoidance of contact or collision sports.
3- avoidance of racquet sports.
4- avoidance of throwing sports.

PREFERRED RESPONSE: 2- avoidance of contact or collision sports.

Question 54 of 100
Genetic mutations that may result in the cervical abnormalities noted in the figures
generally affect the
1- embryonic process of neurulation.
2- embryonic process of gastrulation.
3- segmentation or resegmentation of somites.
4- differentiation of somites into sclerotome, myotome, and dermatome segments.

PREFERRED RESPONSE: 3- segmentation or resegmentation of somites.

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DISCUSSION
The figures are characteristic of a child with Klippel-Feil syndrome (congenital cervical
spine abnormalities) in association with congenital scoliosis in the upper thoracic spine and a
right-sided Sprengel deformity (congenital elevation of the scapula). Sprengel deformity
occurs in as many as 30% of children with Klippel-Feil syndrome. Other congenital conditions
that are commonly associated with Klippel-Feil, and that should be screened for, include
deafness in 30%, genitourinary abnormalities in 25% to 35%, and cardiovascular
abnormalities in 4% to 29% of children with Klippel-Feil syndrome.
In Sprengel deformity, there is usually a tether called the omovertebral connection between
the abnormally elevated scapula and the spinous processes in the upper thoracic region. This
tether is most commonly bony but also may be cartilaginous or fibrous. Although there also
may be abnormalities in the ribs, clavicle, or humerus, they are morphologic abnormalities
only, not tethers.
Patients with Klippel-Feil syndrome should be discouraged from participating in contact
or collision sports if they have a massive fusion of the cervical spine, any involvement of C2,
or limited cervical motion. Fusions at 1 or 2 interspaces below C3 and normal cervical motion
do not preclude participation in activities. A Sprengel deformity may limit abduction of the
shoulder and normal racquet or throwing mechanics, but, in the absence of pain, is not a
contraindication to attempted participation.
Klippel-Feil syndrome affects a heterogenous cohort of patients and different inheritance
patterns have been seen, including autosomal-dominant and autosomal-recessive types, with
varying levels of penetrance. The first human Klippel-Feil syndrome locus was identified on
chromosome 8 and is called SGM1. Other candidates for mutations in Klippel-Feil include
PAX genes and Notch pathway genes. In general, the involved genes help regulate the
formation and segmentation of the vertebrae.
Between days 20 and 30 following conception, the paraxial mesoderm subdivides into
segments called somites. As they mature, somites develop into 3 layers called the sclerotome,
myotome, and dermatome. The sclerotome undergoes a process of resegmentation during
which the caudal section from 1 somite joins with the rostral section of the immediately caudal
somite to form the vertebral bodies. It is during the processes of segmentation and
resegmentation that the abnormalities leading to Klippel-Feil syndrome occur. Gastrulation
refers to the phase early in embryonic development when the single-layered blastula is
reorganized into a trilaminar structure with 3 germ layers: the ectoderm, mesoderm, and
endoderm. Neurulation refers to the process by which the notochord induces formation of the
neural tube from the neural plate, forming the brain and spinal cord.

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Figure 55a Figure 55b Figure 55c

Question 55 of 100
Figures 55a through 55c are the clinical photograph and radiographs of a 5-year-old boy
who fell and injured his right elbow. His radial pulse is thready. Which neurologic deficit most
commonly is associated with this injury?
1- Anesthesia in the first dorsal web space
2- Inability to extend the fingers
3- Inability to abduct the fingers
4- Inability to flex the thumb interphalangeal (IP) joint

PREFERRED RESPONSE: 4- Inability to flex the thumb interphalangeal (IP) joint

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AAOS 2016 Pediatrics

DISCUSSION
This injury is a type III supracondylar humerus fracture with posterolateral displacement.
The area of ecchymosis is anteromedial, corresponding to the proximal spike of the humeral
metaphysis. The brachial artery is likely tented over this spike, leading to diminished
perfusion. The median nerve also resides in this area, and any neurological deficit is likely in
its most vulnerable fibers, those of the anterior interosseous nerve (AIN). The AIN contains
no sensory fibers, and its motor function involves flexion of both the thumb IP joint and the
index distal IP joint.
First dorsal web space anesthesia and an inability to extend the fingers would indicate
radial nerve neuropraxia, which would be more likely with posteromedially displaced fractures
and lead to anterolateral ecchymosis. Finger abduction is controlled by the ulnar nerve, which
most often is injured in flexion injuries and iatrogenically by medially placed pins.

Figure 56

Question 56 of 100
Figure 56 is the radiograph of an otherwise healthy 3-year-old boy who fell and sustained
the isolated injury shown. What is the best treatment modality?
1- Elastic intramedullary nailing
2- Submuscular plating
3- Early hip spica casting
4- Traction as definitive treatment

PREFERRED RESPONSE: 3- Early hip spica casting

DISCUSSION

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AAOS 2016 Pediatrics

At 3 years of age, children do well with nonsurgical treatment with early spica casting and
early mobilization. There is no indication to perform surgical stabilization in such a closed
isolated injury. The fracture is not shortened unacceptably according to clinical practice
guidelines, and traction for this fracture is unnecessary. Traction also may be problematic for
the family and healthcare system.

RESPONSES FOR QUESTIONS 57 THROUGH 62


1- Cortical thickening in the region of the lesion
2- Erosive metaphyseal lesion with loss of cortical integrity
3- Normal bony anatomy on radiographs
4- Diffuse articular erosion with loss of joint space
5- Round, expansive, well-circumscribed metaphyseal lesion with thinning of the cortex
6- Eccentric well-circumscribed metaphyseal lesion with a scalloped border
Match the orthopaedic condition described below with the expected radiographic finding
listed above.

Question 57 of 100
Osteomyelitis with 72 hours of symptoms
1- Cortical thickening in the region of the lesion
2- Erosive metaphyseal lesion with loss of cortical integrity
3- Normal bony anatomy on radiographs
4- Diffuse articular erosion with loss of joint space
5- Round, expansive, well-circumscribed metaphyseal lesion with thinning of the cortex
6- Eccentric well-circumscribed metaphyseal lesion with a scalloped border

PREFERRED RESPONSE: 3- Normal bony anatomy on radiographs

Question 58 of 100
Osteomyelitis with 14 days of symptoms
1- Cortical thickening in the region of the lesion
2- Erosive metaphyseal lesion with loss of cortical integrity
3- Normal bony anatomy on radiographs

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AAOS 2016 Pediatrics

4- Diffuse articular erosion with loss of joint space


5- Round, expansive, well-circumscribed metaphyseal lesion with thinning of the cortex
6- Eccentric well-circumscribed metaphyseal lesion with a scalloped border

PREFERRED RESPONSE: 2- Erosive metaphyseal lesion with loss of cortical integrity

Question 59 of 100
Septic arthritis with 48 hours of symptoms
1- Cortical thickening in the region of the lesion
2- Erosive metaphyseal lesion with loss of cortical integrity
3- Normal bony anatomy on radiographs
4- Diffuse articular erosion with loss of joint space
5- Round, expansive, well-circumscribed metaphyseal lesion with thinning of the cortex
6- Eccentric well-circumscribed metaphyseal lesion with a scalloped border

PREFERRED RESPONSE: 3- Normal bony anatomy on radiographs

Question 60 of 100
Osteoid osteoma with 1 year of symptoms
1- Cortical thickening in the region of the lesion
2- Erosive metaphyseal lesion with loss of cortical integrity
3- Normal bony anatomy on radiographs
4- Diffuse articular erosion with loss of joint space
5- Round, expansive, well-circumscribed metaphyseal lesion with thinning of the cortex
6- Eccentric well-circumscribed metaphyseal lesion with a scalloped border

PREFERRED RESPONSE: 1- Cortical thickening in the region of the lesion

Question 61 of 100

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AAOS 2016 Pediatrics

Unicameral bone cyst


1- Cortical thickening in the region of the lesion
2- Erosive metaphyseal lesion with loss of cortical integrity
3- Normal bony anatomy on radiographs
4- Diffuse articular erosion with loss of joint space
5- Round, expansive, well-circumscribed metaphyseal lesion with thinning of the cortex
6- Eccentric well-circumscribed metaphyseal lesion with a scalloped border

PREFERRED RESPONSE: 5- Round, expansive, well-circumscribed metaphyseal lesion


with thinning of the cortex

Question 62 of 100
Nonossifying fibroma
1- Cortical thickening in the region of the lesion
2- Erosive metaphyseal lesion with loss of cortical integrity
3- Normal bony anatomy on radiographs
4- Diffuse articular erosion with loss of joint space
5- Round, expansive, well-circumscribed metaphyseal lesion with thinning of the cortex
6- Eccentric well-circumscribed metaphyseal lesion with a scalloped border

PREFERRED RESPONSE: 6- Eccentric well-circumscribed metaphyseal lesion with a


scalloped border

DISCUSSION
Early osteomyelitis and septic arthritis appear as normal bony anatomy on radiographs,
with perhaps only soft-tissue swelling seen. Radiographic changes with metaphyseal erosion
appear in a delayed fashion, often after 7 or more days in indolent infections, but may present
earlier in association with virulent infections such as methicillin-resistant Staphylococcus
aureus. Osteoid osteoma has a radiolucent small nidus that may be difficult to see on
radiograph; however, chronic cases cause marked cortical hypertrophy. Unicameral bone cysts
are expansile metaphyseal lesions that are never wider than the physis. They are symmetric,
well circumscribed, and can have cortical thinning. When fractures through the cyst are

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AAOS 2016 Pediatrics

present, the fallen leaf sign is visible as cortical fragments fall to the bottom of the cyst.
Nonossifying fibromas are eccentric metaphyseal lesions with scalloped borders.

Question 63 of 100
In the United States, groups at risk for community-acquired methicillin-resistant
Staphylococcus aureus (CA-MRSA) within the pediatric and adolescent populations include
1- tennis players.
2- toddlers in daycare.
3- children who are home schooled.
4- African Americans.

PREFERRED RESPONSE: 2- toddlers in daycare.

DISCUSSION
CA-MRSA is a growing problem in the United States. Groups at risk for CA-MRSA
include athletes in contact sports and children in daycare. Tennis players, golfers, and runners
are at lowest risk because their sports do not require close contact with teammates or
competitors. Outbreaks have been noted in Alaskan native, Native American, and Pacific
Islander minority populations.

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AAOS 2016 Pediatrics

Figure 64a Figure 64b

Figure 64c Figure 64d

CLINICAL SITUATION FOR QUESTIONS 64 THROUGH 68

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AAOS 2016 Pediatrics

Figures 64a through 64d are the radiographs of an 11-year-old boy with a prolonged history
of activity-related ankle pain. An examination is notable for restricted subtalar motion and
moderate pes planovalgus.

Question 64 of 100
The diagnosis is
1- Freiberg infraction.
2- tarsal coalition.
3- accessory navicular.
4- neglected clubfoot.

PREFERRED RESPONSE: 2- tarsal coalition.

Question 65 of 100
Which inheritance pattern has been described for the condition shown in Figures 64a
through 64d?
1- Autosomal recessive
2- Autosomal dominant
3- X-linked recessive
4- X-linked dominant

PREFERRED RESPONSE: 2- Autosomal dominant

Question 66 of 100
The condition shown in Figures 64a through 64d is overrepresented among
craniosynostosis syndromes with mutations in
1- MSX-2 and MSX-3.
2- EFNB-1.
3- TWIST-1.
4- FGFR-1, FGFR-2, and FGFR-3.

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AAOS 2016 Pediatrics

PREFERRED RESPONSE: 4- FGFR-1, FGFR-2, and FGFR-3.

Question 67 of 100
The patient fails nonsurgical treatment. What is the best next step?
1- CT scan
2- MRI
3- Bone scan
4- Laboratory studies: complete blood count (CBC) with differential, erythrocyte
sedimentation rate (ESR), C-reactive protein (CRP), antinuclear antibody (ANA), and
rheumatoid factor (RF)

PREFERRED RESPONSE: 1- CT scan

Question 68 of 100
The CT scan shows the involvement area is approximately 30% of the posterior facet.
What is the most appropriate treatment?
1- Surgical resection
2- Lateral column lengthening
3- Coalition resection and lateral column lengthening
4- Triple arthrodesis

PREFERRED RESPONSE: 1- Surgical resection

DISCUSSION
Radiographs reveal a talocalcaneal coalition. The incidence of tarsal coalition in the
general population ranges between 2% and 13%. The incidence of tarsal coalition among
patients with FGFR-related craniosynostosis syndromes is much higher than among the
general population. Tarsal coalitions have been noted in FGFR-1-, FGFR-2-, and FGFR-3-
related craniosynostosis syndromes of Apert, Pfeiffer, Crouzon, Jackson-Weiss, and Muenke,
but not in Beare-Stevenson or Crouzonodermoskeletal syndromes. The FGFR genes are
involved in cell proliferation, differentiation, migration, apoptosis, and pattern formation.

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Additionally, nonsyndromic familial coalitions have been described with autosomal-dominant


patterns of inheritance.
Cross-sectional imaging should always be obtained prior to resection of a radiographically
evident coalition to define the extent of the coalition and determine the coexistence of an
additional coalition. CT scan is the gold standard test; however, MRI can be helpful to define
a suspected fibrous coalition if a CT scan is nondiagnostic. A bone scan may be useful if pain
or history is atypical for a symptomatic coalition. Laboratory tests such as CBC, ESR, CRP,
ANA, and RF may be indicated if the imaging evaluation does not confirm a tarsal coalition
and if there is concern for malignancy, infection, or inflammatory arthritis.
Investigators have suggested that larger talocalcaneal coalitions with surface areas larger
than 33% to 50% of the size of the posterior facet are unsuitable for resection and primary
arthrodesis should be considered. However, a study by Koshbin and associates found that with
long-term follow-up, favorable functional outcomes were seen even with resections of large
talocalcaneal coalitions occupying more than 50% of surface area.

Question 69 of 100
A 4-year-old girl who attends daycare had knee swelling for 21 days. She has been afebrile,
her white blood cell (WBC) count is 13000/mm3 (reference range [rr], 4500-11000 /L), and
her C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are slightly elevated.
The child is unable to walk because of her pain. Radiographs show a knee effusion. A sedated
knee aspiration reveals 22000 cells/ml (a normal result is less than 1000 cells/mL). A culture
of the aspirate is pending. What is the best next step?
1- Presumptively treat for toxic synovitis of the knee
2- Presumptively treat for juvenile idiopathic arthritis
3- Perform polymerase chain reaction (PCR) screening for Kingella kingae (K. kingae)
4- Perform arthroscopic debridement and knee irrigation

PREFERRED RESPONSE: 3- Perform polymerase chain reaction (PCR) screening for


Kingella kingae (K. kingae)

DISCUSSION
K. kingae is variably invasive and is a facultative anaerobic gram-negative bacillus. K.
kingae is a common bacteria that causes osteoarticular infections in young children.
Presentation is often delayed because of the moderate course of the infection. Ten percent of
young children are colonized with K. kingae. Colonization occurs in the oropharynx and is a
prerequisite for invasive K. kingae septic arthritis. The PCR test screens for the RTX protein,

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the factor responsible for the bacterias cytotoxicity. Among children in daycare centers, 28%
are colonized. The sensitivity of the oropharyngeal swab PCR has been reported at 100%, and
the specificity is 90.5%.

RESPONSES FOR QUESTIONS 70 THROUGH 74


1- Thrower's elbow/physeal irritation of the medial epicondylar physis
2- Osteochondritis dissecans (OCD)
3- Supracondylar humeral stress fracture
4- Patellar sleeve fracture
5- Distal femoral physeal fracture
6- Sinding-Larsen-Johansson syndrome/inferior pole patella apophysitis
7- Medial meniscal tear
8- Patellar tendon rupture
9- Patellofemoral pain syndrome
10- Popliteal cyst
11- Osteochondroma
12- Synovial sarcoma
Match the appropriate orthopaedic condition above with the clinical scenario below.

Question 70 of 100
A 10-year-old Little League pitcher has elbow pain and stiffness. Upon examination, he
has a flexion contracture of 10 degrees and lateral elbow pain on palpation.
1- Thrower's elbow/physeal irritation of the medial epicondylar physis
2- Osteochondritis dissecans (OCD)
3- Supracondylar humeral stress fracture
4- Patellar sleeve fracture
5- Distal femoral physeal fracture
6- Sinding-Larsen-Johansson syndrome/inferior pole patella apophysitis
7- Medial meniscal tear
8- Patellar tendon rupture
9- Patellofemoral pain syndrome
10- Popliteal cyst

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11- Osteochondroma
12- Synovial sarcoma

PREFERRED RESPONSE: 2- Osteochondritis dissecans (OCD)

Question 71 of 100
An 8-year-old basketball player jumped up and felt a pop in his knee. He has diffuse
anterior swelling and pain, and he is unable to perform a straight-leg raise. A small fleck of
bone is seen distal to the patella on his radiograph.
1- Thrower's elbow/physeal irritation of the medial epicondylar physis
2- Osteochondritis dissecans (OCD)
3- Supracondylar humeral stress fracture
4- Patellar sleeve fracture
5- Distal femoral physeal fracture
6- Sinding-Larsen-Johansson syndrome/inferior pole patella apophysitis
7- Medial meniscal tear
8- Patellar tendon rupture
9- Patellofemoral pain syndrome
10- Popliteal cyst
11- Osteochondroma
12- Synovial sarcoma

PREFERRED RESPONSE: 4- Patellar sleeve fracture

Question 72 of 100
A 13-year-old soccer player describes popping and catching on the medial side of his knee
with activity. This has slowly worsened during the season. Upon examination, there is medial
joint line tenderness and medial pain with McMurray testing.
1- Thrower's elbow/physeal irritation of the medial epicondylar physis
2- Osteochondritis dissecans (OCD)
3- Supracondylar humeral stress fracture

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4- Patellar sleeve fracture


5- Distal femoral physeal fracture
6- Sinding-Larsen-Johansson syndrome/inferior pole patella apophysitis
7- Medial meniscal tear
8- Patellar tendon rupture
9- Patellofemoral pain syndrome
10- Popliteal cyst
11- Osteochondroma
12- Synovial sarcoma

PREFERRED RESPONSE: 7- Medial meniscal tear

Question 73 of 100
A 9-year-old cheerleader is brought in for concern regarding a knee mass. She has no pain
but is experiencing waxing and waning swelling at the back of her knee. There is no anterior
swelling, and range of motion is full. Upon examination, the 3-cm x 3-cm posteromedial mass
is mobile and it transilluminates.
1- Thrower's elbow/physeal irritation of the medial epicondylar physis
2- Osteochondritis dissecans (OCD)
3- Supracondylar humeral stress fracture
4- Patellar sleeve fracture
5- Distal femoral physeal fracture
6- Sinding-Larsen-Johansson syndrome/inferior pole patella apophysitis
7- Medial meniscal tear
8- Patellar tendon rupture
9- Patellofemoral pain syndrome
10- Popliteal cyst
11- Osteochondroma
12- Synovial sarcoma

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PREFERRED RESPONSE: 10- Popliteal cyst

Question 74 of 100
A 13-year-old girl has had to restrict her activity because of anterior knee pain. Upon
examination, she has no point tenderness or effusion with normal knee range of motion. She
has a normal gait and normal knee alignment and appearance. A ligamentous examination is
stable. There is mild patellofemoral crepitation. Her radiograph findings are normal.
1- Thrower's elbow/physeal irritation of the medial epicondylar physis
2- Osteochondritis dissecans (OCD)
3- Supracondylar humeral stress fracture
4- Patellar sleeve fracture
5- Distal femoral physeal fracture
6- Sinding-Larsen-Johansson syndrome/inferior pole patella apophysitis
7- Medial meniscal tear
8- Patellar tendon rupture
9- Patellofemoral pain syndrome
10- Popliteal cyst
11- Osteochondroma
12- Synovial sarcoma

PREFERRED RESPONSE: 9- Patellofemoral pain syndrome

DISCUSSION
OCD of the capitellum presents in throwing athletes with lateral pain and a flexion
contracture vs medial epicondylar physeal overuse, which is associated with medial pain and
possible widening of the physis on radiograph.
Midsubstance patellar tendon rupture is rare in skeletally immature patients; usually,
disruption of the extensor mechanism occurs either through a tibial tubercle physis fracture or
a patellar sleeve fracture because these cartilaginous areas are structurally weaker than the
patellar tendon. Often, only a small bony fleck is seen, and the main fracture is cartilaginous.
Medial joint line pain and a positive McMurray test result are most consistent with a medial
meniscal tear. Sinding-Larsen-Johansson syndrome would produce soreness over the inferior
pole of the patella.

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Because the knee mass is painless and cystic, synovial sarcoma is unlikely because these
sarcomas are solid, progressive, and painful. An osteochondroma would be a bony protrusion
and would not transilluminate, which is a feature of cystic masses. It also would not change
size. Popliteal cysts are common in children, with most resolving spontaneously over several
years.
Patellofemoral pain syndrome can cause mild anterior compartment crepitation but does
not produce point tenderness over a specific apophysis like Sinding-Larsen-Johansson
syndrome (inferior pole of patella tenderness). It is common in pubertal girls and is treated
with rest, ice, nonsteroidal anti-inflammatory drugs, and therapy exercises with resolution in
most cases.

Figure 75a Figure 75b

Question 75 of 100
Figures 75a and 75b are the radiographs after attempted reduction of an injury in a 9-year-
old girl. Which anatomic structure is most likely to be interposed?
1- Brachialis muscle
2- Radial nerve
3- Median nerve
4- Ulnar nerve

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PREFERRED RESPONSE: 4- Ulnar nerve

DISCUSSION
The injury shown is a flexion-type supracondylar humerus fracture. The most commonly
interposed anatomic structure is the ulnar nerve. The brachialis muscle is often interposed in
extension-type fractures, as are the median nerve and radial artery. The radial nerve is at risk
for entrapment in a humeral shaft fracture or distal third humeral fracture.

Figure 76

CLINICAL SITUATION FOR QUESTIONS 76 THROUGH 80


Figure 76 is the clinical photograph of an infant with foot deformities.

Question 76 of 100
The pathogenesis of this condition is associated with
1- a PITX1 mutation.
2- a point polymorphism in a regulatory sequence for the COLIA-1 gene.

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3- mutations in the EXT gene family.


4- mutations in the COL5A or COL3A genes.

PREFERRED RESPONSE: 1- a PITX1 mutation.

Question 77 of 100
The idiopathic form of this condition may be associated with
1- absence of the anterior tibial artery.
2- absence of the fibula.
3- duplication of the first ray.
4- postaxial polydactyly.

PREFERRED RESPONSE: 1- absence of the anterior tibial artery.

Question 78 of 100
The bony abnormalities in this condition occur mostly in the
1- tibiotalar joint.
2- tarsal bones.
3- tarsal-metatarsal joint.
4- forefoot.

PREFERRED RESPONSE: 2- tarsal bones.

Question 79 of 100
The infant underwent Ponseti casting for 5 weeks. Afterward, a heel cord release was done
1 cm proximal to the insertion site of the Achilles tendon and was casted in long-leg casts with
the knee flexed and an external rotation mold on the leg for 3 weeks. Straight-last shoes with
an abduction bar set at 70 degrees of external rotation were fitted. The infants feet remained
in the corrected position at a 1-month check, but, at a 3-month check, ankle equinus and
forefoot varus were present. Recurrence of the deformity is most likely attributable to

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1- noncompliance with postsurgical bracing.


2- insufficient length of time in postsurgical casts.
3- proximal placement of the incision for heel cord release.
4- excessive rotation of postsurgical bracing.

PREFERRED RESPONSE: 1- noncompliance with postsurgical bracing.

Question 80 of 100
Recurrence of this deformity after initial treatment should be treated with
1- recasting.
2- anterior tibialis tendon transfer.
3- extensive posteromedial-lateral release.
4- tibial osteotomy.

PREFERRED RESPONSE: 1- recasting.

DISCUSSION
Single nuclear polymorphism (SNP) on chromosome 12q24.31, an intergenic SNP, is the
PITX1-TBX4 transcriptional pathway that codes for hindfoot formation and is associated with
clubfoot. The COLIA-1 gene is related to osteoporosis. Mutations in EXT genes that control
formation of tumors cause multiple hereditary exostosis. Mutations in the COL5A or COL3A
genes are associated with Ehlers-Danlos syndrome. All idiopathic clubfeet involve
abnormalities of or around the talus.
The classic Ponseti technique is associated with a low recurrence rate when followed
precisely. The most common reason for recurrence is noncompliance with postsurgical
bracing. The initial treatment for recurrence after Ponseti casting is recasting.

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Figure 81a Figure 81b

Question 81 of 100
Figure 81a is the radiograph of a 4-year-old boy who sustained a subtrochanteric femur
fracture after a fall. Figure 81b is the radiograph of the contralateral femur. At the time of
definitive fixation, an open biopsy was performed, and the frozen section was consistent with
a benign lesion. What are the expected molecular alterations from the diagnostic
histopathology?
1- Fusion transcripts of HEY1-NCOA2
2- Fusion transcripts of CDH11-USP6
3- Activating missense mutations of GNAS
4- Ring chromosomes with CDK4 and MDMK amplification

PREFERRED RESPONSE: 3- Activating missense mutations of GNAS

DISCUSSION
Fibrous dysplasia is a benign lesion with histology characterized by bland spindle cells
that surround misshapen trabeculae of woven bone. Monostotic or polyostotic lesions are
caused by activating missense mutations of GNAS. Rearrangement that results in HEY1-

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NCOA2 fusion transcripts has been noted in mesenchymal chondrosarcoma. Ring


chromosomes with CDK4 and MDM2 amplification may be identified with low-grade central
osteosarcoma or parosteal osteosarcoma. Fusion transcripts of CDH11-USP6 have been
observed in aneurysmal bone cysts.

Figure 82a Figure 82b

Video 85

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CLINICAL SITUATION FOR QUESTIONS 82 THROUGH 85


Figures 82a and 82b are the radiographs of a 10-year-old girl who was an unrestrained
back seat passenger in a motor vehicle collision. Her sole injury is to her left leg. She has a
deformed valgus knee with lateral swelling and bruising, and no wound is visible. Upon
examination, she has symmetric pulses to her right leg but diminished sensation on the dorsum
of the foot and in the first web space. She cannot dorsiflex her left foot or toes but can plantar
flex and invert them. Weak ankle eversion is present. Sensation to the plantar foot, medial
ankle, and lateral ankle is intact. She likely will reach skeletal maturity at age 14.

Question 82 of 100
What is the zone of injury?
1- Proliferative zone
2- Resting zone
3- Hypertrophic zone
4- Zone of maturation

PREFERRED RESPONSE: 3- Hypertrophic zone

Question 83 of 100
The examination suggests a neurologic deficit of which nerve?
1- Common peroneal nerve
2- Superficial peroneal nerve
3- Deep peroneal nerve
4- Tibial nerve

PREFERRED RESPONSE: 1- Common peroneal nerve

Question 84 of 100
The patient is treated with emergent open reduction and internal fixation via a lateral
approach to the distal femur. The peroneal nerve is found intact but is under pressure by a
proximal bone fragment. After fixation, there is near-anatomic fracture reduction and no
tension on the nerve. The patient is comfortable at a postsurgical check 4 hours later. Her toes

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are warm and pink and there is no pain with passive dorsiflexion/plantar flexion of the toes.
However, she continues to have absent first web space sensation, diminished dorsal foot
sensation, and absent toe/ankle dorsiflexion. What is the best next step?
1- Return to surgery emergently for 4-compartment fasciotomy because she has a
compartment syndrome and the nerve will not otherwise recover
2- Return to surgery urgently within the next few days for nerve exploration and potential
microsurgical repair (vs cable grafting) to the damaged nerve to speed repair
3- Observe the nerve injury with further workup/intervention only if there is no sign of
nerve recovery by 3 months after surgery
4- Observe the nerve injury with further workup/intervention only if there is no sign of
nerve recovery by 12 months after surgery

PREFERRED RESPONSE: 3- Observe the nerve injury with further workup/intervention


only if there is no sign of nerve recovery by 3 months after surgery

Question 85 of 100
Six months later, the patients fracture has healed and a CT scan to further evaluate the
physis is performed (Video 85). Based on these findings, how should you advise the family?
1- The fracture is healed and the physis is growing well with no problems expected.
2- Complete physeal closure has occurred. There will be no significant leg length
difference because the patient is almost done growing.
3- Complete physeal closure has occurred. There will be a significant (> 2-cm) leg length
difference if no other surgical treatment is offered.
4- Asymmetric physeal closure has occurred. There will be an increasing angular
deformity at the knee as well as a significant (> 2-cm) leg length difference if no other surgical
treatment is offered.

PREFERRED RESPONSE: 4- Asymmetric physeal closure has occurred. There will be an


increasing angular deformity at the knee as well as a significant (> 2-cm) leg length difference
if no other surgical treatment is offered.

DISCUSSION
The hypertrophic zone is the weakest biomechanical zone of the physis and is most likely
to fracture. The deep peroneal nerve supplies motor innervation to the ankle and toe

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dorsiflexors (anterior compartment) and the first web space, which, in this history, have
deficits. The superficial peroneal nerve supplies sensation to the dorsum of the foot and motor
to the lateral compartment peroneal musculature (ankle evertors), which also has deficits. The
injury must involve both peroneal branches (the common peroneal nerve). Because sensation
to the sole of the foot and toe/ankle plantar flexion is intact, the tibial nerve is intact.
Because the nerve was visualized intact, a neuropraxia is the most likely type of nerve
injury. This should recover in time and does not necessitate urgent exploration. In pediatric
patients, an advancing Tinel sign and partial nerve recovery by 3 months is expected and can
be followed clinically. If there is no sign of nerve recovery, an electromyogram should be
ordered with consideration for nerve exploration if there is no sign of reinnervation. There is
no sign of compartment syndrome because the patient has an unchanged neurologic deficit, is
comfortable, and has no pain with passive range of motion.
These injuries are associated with a very high rate of growth arrest (up to 80% in some
studies). The CT scan shows an asymmetric growth arrest, which suggests angulation through
the distal femur.

Question 86 of 100
A 17-year-old cross country athlete runs 7 miles per day, 6 days per week. She has new-
onset right groin pain. Passive flexion of her hip is normal, but internal rotation of the hip,
resisted hip flexion, and knee extension reproduce the pain. Hip radiograph findings are
normal. What is the best next step?
1- Recommend decreasing her training regimen
2- Obtain a bone scan
3- Obtain an MRI
4- Obtain a dual-energy x-ray absorptiometry (DEXA) scan

PREFERRED RESPONSE: 3- Obtain an MRI

DISCUSSION
A stress fracture of the femoral neck or pelvis should be ruled out in this patient. She
should be placed on crutches and not allowed to run. The consequences of missing such a
diagnosis can be devastating. Superior cortical femoral neck stress fractures are tension
injuries and can progress to a complete fracture and avascular necrosis. Surgical fixation may
be indicated. Plain radiographic findings often do not appear until late in the clinical course.
MRI is more accurate, more specific, and is superior to radionuclide bone scanning for the
diagnosis of stress fracture in young endurance athletes. MRI detects early changes in osseous

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stress injury and allows precise definition of the anatomy and extent of injury. This patient
may have the female athletic triad: disordered eating, amenorrhea, and osteoporosis. However,
the workup for this condition (including a possible DEXA scan) may be delayed until after the
stress fracture is diagnosed and treated.

Figure 87a

Figure 87b Figure 88

Figure 89 Figure 90

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CLINICAL SITUATION FOR QUESTIONS 87 THROUGH 90


Figures 87a and 87b are the clinical photograph and radiograph of a 14-year-old high
school football player who fractured his dominant right clavicle. The skin is closed and
vascular and neurologic examination findings are normal.

Question 87 of 100
What is the best initial treatment?
1- A sling and careful follow-up
2- Open reduction and internal fixation (ORIF) using an intramedullary pin
3- ORIF using a 4-hole semitubular plate
4- ORIF using an 8-hole pelvic reconstruction plate

PREFERRED RESPONSE: 1- A sling and careful follow-up

Question 88 of 100
Figure 88 is the current radiograph. The patient received nonsurgical treatment. Two
months later he is pain free and vascular and neurological examination findings have remained
normal, but he has a large palpable bony bump under his skin. What is the best next step?
1- Open reduction of the clavicle and compression plating
2- Open reduction of the clavicle malunion and compression plating
3- Open reduction of the clavicle malunion and intramedullary fixation with a flexible
titanium nail
4- Observation and careful follow-up

PREFERRED RESPONSE: 4- Observation and careful follow-up

Question 89 of 100
Figure 89 is the radiograph of this boy 3 months later. The patient and family ask if he can
safely play baseball in the spring. He is pain free at this time. What is the best advice?
1- No sports allowed; recommend clavicle bump resection, contouring, and plating
2- No sports allowed; recommend clavicle bump resection (no plate needed)

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3- Allow baseball as tolerated and careful follow-up


4- Recommend an electrical stimulator and advise him to change his sport and join the
swim team
PREFERRED RESPONSE: 3- Allow baseball as tolerated and careful follow-up

Question 90 of 100
Figure 90 is the radiograph of this patient 5 months later when he returned for his preseason
football physical. He is asymptomatic. What is the best next step?
1- Advise against football because of increased risk for clavicle fracture
2- Order a bone density test prior to return to football
3- Allow football as tolerated and follow up as the situation demands
4- Perform a clavicular osteotomy and plating

PREFERRED RESPONSE: 3- Allow football as tolerated and follow up as the situation


demands

DISCUSSION
This patient has a closed midshaft clavicle fracture with significant displacement that has
healed and remodeled nicely with nonsurgical treatment. Functional disability or nonunion
after nonsurgical treatment of clavicle fractures in adolescents is rare. Schulz and associates
showed no differences in pain, strength, range of motion, or subjective outcome scores
between injured and uninjured limbs treated nonsurgically to address displaced, shortened
midshaft clavicle fractures in adolescents. Bae and associates demonstrated that clavicle
fracture malunions in adolescents do not cause loss of motion or strength.

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Figure 91a Figure 91b Figure 92

Figure 93 Figure 94a Figure 94b

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Figure 94c Figure 95a Figure 95b

Figure 96

RESPONSES FOR QUESTIONS 91 THROUGH 96


1- Chromosome 17 mutation

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2- MYH3 mutation
3- Embryonic vascular interruption
4- Infantile vascular interruption
5- Chromosome 11 mutation
6- Sporadic inheritance
Select the appropriate etiology listed above for each pictured syndrome.

Question 91 of 100
Figures 91a and 91b
1- Chromosome 17 mutation
2- MYH3 mutation
3- Embryonic vascular interruption
4- Infantile vascular interruption
5- Chromosome 11 mutation
6- Sporadic inheritance

PREFERRED RESPONSE: 3- Embryonic vascular interruption

Question 92 of 100
Figure 92
1- Chromosome 17 mutation
2- MYH3 mutation
3- Embryonic vascular interruption
4- Infantile vascular interruption
5- Chromosome 11 mutation
6- Sporadic inheritance

PREFERRED RESPONSE: 4- Infantile vascular interruption

Question 93 of 100

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Figure 93
1- Chromosome 17 mutation
2- MYH3 mutation
3- Embryonic vascular interruption
4- Infantile vascular interruption
5- Chromosome 11 mutation
6- Sporadic inheritance

PREFERRED RESPONSE: 6- Sporadic inheritance

Question 94 of 100
Figures 44a through 94c
1- Chromosome 17 mutation
2- MYH3 mutation
3- Embryonic vascular interruption
4- Infantile vascular interruption
5- Chromosome 11 mutation
6- Sporadic inheritance

PREFERRED RESPONSE: 2- MYH3 mutation

Question 95 of 100
Figures 95a and 95b
1- Chromosome 17 mutation
2- MYH3 mutation
3- Embryonic vascular interruption
4- Infantile vascular interruption
5- Chromosome 11 mutation
6- Sporadic inheritance

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PREFERRED RESPONSE: 1- Chromosome 17 mutation

Question 96 of 100
Figure 96
1- Chromosome 17 mutation
2- MYH3 mutation
3- Embryonic vascular interruption
4- Infantile vascular interruption
5- Chromosome 11 mutation
6- Sporadic inheritance

PREFERRED RESPONSE: 5- Chromosome 11 mutation

DISCUSSION
Poland syndrome and Sprengel deformity (Figure 91) are hypothesized to occur as the
result of interruption of the embryonic subclavian blood supply. Poland syndrome occurs
proximal to the internal thoracic artery and distal to the vertebral artery; Sprengel deformity is
thought to occur via interruption of the subclavian, internal thoracic, or suprascapular artery.
Hair tourniquet syndrome (Figure 92) occurs most often in children younger than 2 years
of age. Human hair, which is often not seen in the band, circumferentially strangulates a digit
or extremity. If not recognized and treated promptly, auto-amputation distal to the hair
tourniquet may occur.
No known genetic or environmental factors are associated with the etiology of Fibular
hemimelia (Figure 93). Nearly all of these patients have an absent Anterior Cruciate Ligament.
Additional associations include, absent rays of the foot, tarsal coalition, hypoplastic or aplastic
fibula, leg-length discrepancy, femoral and tibial hypoplasia and lower extremity angular
deformity.
Freeman-Sheldon syndrome, Sheldon-Hall Syndrome and Distal arthrogryposis (Figure
94) have been associated with mutations of MYH3, the gene which codes for myosin heavy
chain 3.
Fifty percent of patients with Neurofibromatosis type 1(NF1) (Figure 95) will have
musculoskeletal manifestation of the disease; most commonly scoliosis and pseudarthrosis of
the tibia. Twenty percent of patients with NF1 present with scoliosis. Dystrophic scoliosis is
typical of NF1. Dystrophic features of include: scalloped vertebra, penciled ribs, severe

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rotation, sharp and short (4-6 vertebrae) kyphoscoliosis. Although NF1 has autosomal
dominant inheritance, 50% of new cases are due to sporadic mutation. The NF1 gene on
chromosome 17 codes for neurofibromin, a tumor suppressor.
Beckwith-Wiedemann syndrome (Figure 96) is associated with chromosome 11 mutations
near the IGF gene. Neonatal hypoglycemia; macroglossia; visceromegaly; hemihypertrophy;
and embryonal tumors, especially Wilms tumor, are associated with mutations of chromosome
11.

50
Figure 100a Figure 100b

CLINICAL SITUATION FOR QUESTIONS 97 THROUGH 100


A 12-year-old boy with a 2-day history of fever and right knee pain is admitted to the
pediatric service. You are asked to provide an orthopaedic consultation. The patient denies
recent trauma. His temperature is 39.4C and his gait is antalgic. There is no palpable knee
effusion and mild tenderness and swelling of the distal thigh area. Hip and knee range of
motion is not limited. Radiographs of the femur are unremarkable. His white blood cell (WBC)
count is within defined limits, and the differential shows 80% segmented neutrophils. His
erythrocyte sedimentation rate is 46 mm/h (reference range [rr], 0-20 mm/h), and his C-
reactive protein level is 5.6 mg/L (rr, 0.08-3.1 mg/L).

Question 97 of 100
What is the best next step?
1- Knee aspiration

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2- Blood cultures
3- Indium-labeled WBC scan
4- Pelvic radiographs

PREFERRED RESPONSE: 2- Blood cultures

Question 98 of 100
The pediatric service orders an MRI, and findings are unremarkable. Results from the tests
ordered above are pending. The clinician should recommend
1- discharge home on crutches with an ibuprofen prescription.
2- discharge home with an oral antibiotic prescription.
3- initiation of intravenous (IV) antibiotics.
4- a knee CT scan.

PREFERRED RESPONSE: 3- initiation of intravenous (IV) antibiotics.

Question 99 of 100
Blood cultures drawn by the pediatric intern grow gram-positive cocci. Antibiotics should
include coverage for
1- H. influenza.
2- Methicillin-resistant Staphylococcus aureus (MRSA).
3- Anaerobic organisms.
4- Kingella kinga.

PREFERRED RESPONSE: 2- Methicillin-resistant Staphylococcus aureus (MRSA).

Question 100 of 100


Two days later, the patient is not showing any clinical improvement. His fever spikes to
39.2C and he has persistent knee pain, a limp, and distal thigh swelling. Repeat MR images
are shown in Figures 100a and 100b. What is the best next step?

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1- Change of IV antibiotics and splinting


2- Arthroscopic irrigation and debridement
3- CT-guided needle aspiration
4- Open debridement

PREFERRED RESPONSE: 4- Open debridement

DISCUSSION
In an acutely febrile child with bone pain and elevated acute-phase reactants, osteomyelitis
is suspected. Blood cultures will yield the offending organism in 30% to 60% of patients and
are the most appropriate next step. Knee aspiration in the absence of an effusion likely will not
be helpful. Although a bone scan may show an osteomyelitic focus, an indium-labeled WBC
scan is unnecessarily complex and costly in this case. Pelvic radiographs would add little to
the unremarkable femur films.
Initiating IV antibiotics after obtaining blood cultures is appropriate, even in the presence
of an MRI with normal findings. Observation or discharge may be considered, but suspicion
for infection should be strong in this clinical situation and delay is not warranted. A CT scan
of the knee in the setting of normal MRI findings will not be helpful.
Most hematogenous osteomyelitis cases among children are attributable to S. aureus. In
many areas of the country, MRSA is endemic, and initial coverage for resistance is appropriate.
The other listed organisms would rarely be seen in this scenario.
The MR images show early abscess formation in the distal medial femoral metaphysis.
Because the formation developed during antibiotic treatment, surgical drainage (rather than a
change of antibiotic) is appropriate. Arthroscopy is not helpful because this is not an intra-
articular process. Although aspiration prior to surgical debridement could be considered, the
organism has already been identified from the blood culture, and CT guidance is not needed
to locate this large abscess in such an accessible area.

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