Trauma Drama
The Foot Club
Hip Hip Hooray
Bugs everywhere
Genes, Screens, and NAT
100
A 10-year-old boy presents 8 months after a displaced supracondylar humerus fracture treated at an outside hospital. The family reports that he had severe forearm pain and transient numbness after the injury, followed by progressive stiffness of the fingers.
Examination reveals:
Flexion contractures of the wrist and fingers.
The fingers flex further when the wrist is flexed and extend partially when the wrist is passively extended.
Weakness of the flexor pollicis longus and index finger flexor digitorum profundus.
Decreased sensation in the median nerve distribution.
A warm hand with palpable radial and ulnar pulses.
What is the diagnosis?
What is Volkmann's ischemic contracture?
100
These are the four deformities that make up a clubfoot.
What are cavus, adductus, varus, and equinus?
100
A 10-week-old infant has a unilateral dislocated hip. A Pavlik harness was applied 3 weeks ago. Serial ultrasound continues to show the femoral head superior and lateral to the acetabulum. The harness is being worn correctly. What is the best next step?
What is stop Pavlik and proceed with trial of abduction brace, and quickly to Closed reduction if that is not effective
100
A child presenting with a septic hip holds the affected hip in this position.
What is FABER (flexion, abduction, external rotation)?
Because this position of comfort maximized hip capsular volume
100
The alpha angle on hip ultrasound measures the angle between (1) these two structures, and is (2) considered normal in this range.
What are (1) lines of the acetabulum and the ilium, and (2) greater than 60 degrees?
200
A 12-year-old boy sustains a right distal femoral physeal fracture resulting in complete growth arrest of the right distal femoral physis. The left distal femoral physis remains normal. There is no tibial length discrepancy.
Current standing radiographs demonstrate no difference in lengths.
His skeletal age is 10 years. Assume the left distal femoral physis has 6 years of growth remaining and Assume the right distal femoral physis will contribute no further growth, and all other growth is equal between the limbs.
What is the predicted total leg-length discrepancy at skeletal maturity and what intervention must be discussed before skeletal maturity?
What is 36cm and epiphysiodesis of the contralateral side?
200
This is the most common cause of late failure after correction with the Ponseti method.
What is poor compliance with bracing?
200
Patients with SCFE present with this exam finding on supine hip exam.
What is a obligatory external rotation?
200
An aspiration of the hip that reveals the Gram stain in the picture is due to this organism.
What is staph aureus?
200
An 18 mo child presents with what appears to be an acute elbow dislocation on radiographs? What further steps are needed to ensure appropriate diagnosis and treatment?
What is Arthrogram vs MRI or US and NAT work-up?
Elbow dislocations in children under two are transphyseal fractures until proven otherwise. The epiphysis stays with the radius and ulna and the metaphysis translates.
American Academy of Pediatrics (AAP) recommends an abuse evaluation—including a radiographic skeletal survey—for any infant with a distal humerus fracture/epiphyseal (transphyseal) separation, because this pattern has moderate specificity for abuse and is 13 times more likely to be abusive than a displaced supracondylar fracture.
300
This is the nerve most likely injured in the fracture type shown.
What is the ulnar nerve?
300
In the Ponseti method, premature correction of this deformity can result in a rocker-bottom foot.
What is equinus?
300
What Nerve is most at risk during placement of the anterior portal during hip arthroscopy?
What is the LFCN?
300
(1) These are the 4 components of the original Kocher criteria.
(2) This is the probability of septic arthritis for having 1/4 Kocher criteria, 2/4 criteria, and 3/4 criteria.
What are (1) WBC >12K, inability to bear weight, Fever, ESR >40mm/h,
and (2) 1/4 criteria = 3%, 2/4 criteria = 40%, 3/4 criteria = 93%, 4/4 criteria = 99.6%.
300
This is the (1) most common and (2) second most common presentation of child abuse.
What are (1) skin lesions, and (2) fractures?
400
Risk to the ulnar nerve is highest when medial pins are placed with the elbow in this position.
What is hyperflexion?
400
A 12-year-old boy presents with a 1-year history of progressively worsening pain along the lateral aspect of both feet. The pain is worse with running and cutting sports. He has recurrent ankle sprains and difficulty walking on uneven ground. Examination demonstrates bilateral pes planovalgus, restricted subtalar motion, and pain with attempted hindfoot inversion and eversion. The arch does not reconstitute when he stands on his toes. Radiographs are equivocal.
What test is most likely to give the diagnosis?
What is CT for talocalcaneal coalition?
400
This is the artery that provides the most blood to the hip in a patient older than age 4 years.
What is the medial femoral circumflex artery (3)?
400
Some strains of MRSA have genes encoding for this cytotoxin that has been implicated in MRSA-associated DVTs.
What is PVL (Panton-Valentine leukocidin) cytotoxin?
400
A child is undergoing 8 plate placement for genu valgum in the setting of Morquio syndrome to address the deformity? What presurgical testing is necessary prior to intubation?
What is flex-ex cervical spine radiographs to assess instability? Pulmonary function testing also crucial.
500
A 6-year-old presents with a displaced extension-type supracondylar humerus fracture. The hand is pale and cool, the radial pulse is absent, and capillary refill is 5 seconds. After urgent reduction and pin fixation, the hand remains poorly perfused. What is the next best step?
What is Urgent brachial artery exploration and restoration of perfusion?
500
A newborn is referred for evaluation of a deformity of the left foot. The foot rests in marked dorsiflexion and hindfoot valgus. The forefoot is abducted, and the plantar surface is convex, producing a rocker-bottom appearance. The deformity cannot be passively corrected. The infant also has mild hypotonia.
What is imaging is most likely to make the diagnosis?
What is a maximal plantarflexion view to diagnose congenital vertical talus?
CVT is rigid deformity characterized by hindfoot equinovalgus, forefoot abduction and dorsiflexion, and a convex plantar surface. The talonavicular joint is dorsally dislocated and stays that way despite plantarflexion.
500
SCFE affects this zone of the physis.
What is the hypertrophic zone?
500
These joints have intraarticular metaphyses and therefore are at higher risk for septic arthritis secondary to metaphyseal osteomyelitis.
What are the shoulder, hip, elbow and ankle?
500
What is the best first step in management of this fracture?
What is work up for non-accidental trauma?
600
This is the (1) latest-appearing ossification center of the elbow and can be seen on XR at (2) this age.
What is (1) lateral epicondyle at (2) 12 years of age?
Mnemonic to remember: CRITOE
600
Clubfoot is commonly associated with hypoplasia or absence of this structure.
What is the anterior tibial artery?
600
After closed reduction, a 9-month-old child's hip is stable only when held in extreme abduction. The arthrogram shows that reduction is lost when the hip is brought toward a more physiologic position. What is the most important concern and response?
What is AVN risk with extreme abduction and need for improvement of the safe zone
600
This diagnosis of exclusion is characterized by episodic fever, multiple sites of osteomyelitis, negative cultures, no response to antibiotics, but can be treated symptomatically with NSAIDs and may resolve in 3-5 years.
What is CRMO (chronic recurrent multifocal osteomyelitis)?
600
This gene is associated with hypoplastic clavicles and other cleidocranial deformities.
What is Runx2 gene mutation? HIps also show coxa vara
700
Volkmann ischemic contracture following a type II SCH fx is likely due to this.
What is compression of the brachial artery with casting in flexion >90 deg (hyperflexion)?
700
In recurrent clubfoot deformity, the tibialis anterior causes this abnormality during gait. (*Bonus points for demonstrating this appropriately)
Dynamic Supination
700
A 9-year-old boy presents with a 3-month history of progressive right hip and thigh pain and a limp. He denies any specific injury. His height is below the 5th percentile for age, and his weight is at the 40th percentile. Examination demonstrates limited internal rotation of the right hip, with obligatory external rotation during hip flexion. Radiographs demonstrate a moderate, stable right slipped capital femoral epiphysis (SCFE).
What other steps should be performed in addition to in-situ fixation of the right hip?
What is in situ fixation of the left hip and further laboratory work up for thyroid disorder and other endocrinopathies?
700
Arthrocentesis fluid should be grown in this culture medium in order to isolate Kingella kingae.
What is a blood culture bottle?
700
A 7-year-old boy with a FDFR3 mutation is brought to clinic because his parents have noticed that he walks more slowly, trips frequently, and asks to be carried after short distances. Over the past 3 months, he has developed urinary incontinence. Reflexes are hypoactive in his lower extremities and normal in his uppers.
Which is the next best step?
What is MRI of the spine and likely decompression of lumbar stenosis?
800
This is the most common malunion deformity after supracondylar humerus fracture.
Cubitus varus deformity (gunstock deformity)
800
A teenage girl presents with abnormal gait pattern and recurrent ankle sprains. Lower extremity imaging reveals suggests cavovarus foot deformity and significant bilateral hip dysplasia. The initial presenting deformity of her foot deformity was?
What is plantar flexion of the first ray?
This is initial presenting deformity in CMT due to relative strength peroneus longus to tib ant.
There is intrinsic muscle wasting,with then clawing of toes and contracture with ant tib and peroneaus brevis weakening causing cavovarus
PMP22 on chromosome 17
800
This is the structure labeled #4.
What is the labrum?
800
In septic arthritis, inflammatory and synovial cells activate (1) this cell signaling pathway, and release (2) these mediators, which can destroy cartilage and damage the articular surface within 8 hours.
What is the (1) NFKB pathway, and (2) matrix metaloproteinases (MMPs) or proteolytic enzymes?
800
An 8-year-old boy is referred for bilateral knee pain with activity, intermittent ankle discomfort, and difficulty keeping up with peers during sports. His height is at the 15th percentile. Examination shows a mildly waddling gait, genu valgum, and limited hip internal rotation. His father developed early-onset hip and knee osteoarthritis and is 5 feet 5 inches tall.
Radiographs show irregular, flattened epiphyses of the distal femora and proximal tibiae, with delayed ossification of the femoral heads. Vertebral body heights are preserved. What gene is responsible for this condition?
What is COMP, which encodes cartilage oligomeric matrix protein?
Normal COMP-non-collagenous extracellular matrix glycoprotein that interacts with matrix components and contributes to cartilage organization and function.
Early joint degeneration-need for guided growth and early joint replacement.