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2. Trauma MCQs

Practice Set 268 of 640

This practice set contains high-yield board review questions covering key concepts in 2. Trauma. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 5341

Topic: 2. Trauma
A 22-year-old man who sustained a Gustilo-Anderson grade IIIC open fracture of the right tibia and fibula was treated with an immediate open transtibial amputation. After two serial debridements, he underwent wound closure with a posterior myocutaneous soft-tissue flap. What is the preferred method of early rehabilitation?
. Bulky gauze dressings with no compression of the traumatized tissues and early non-weight-bearing ambulation
. Bulky gauze dressings with snug compression of the residual limb and early non-weight-bearing ambulation
. Immediate intraoperative prosthetic fitting with a vacuum-formed prosthetic limb, followed by immediate weight bearing
. Rigid plaster dressing, a cast change at 5 to 7 days, and partial weight bearing with an attached pylon when the wound shows signs of healing without infection
. Compression dressing and delayed application of a weight-bearing pylon until the sutures are removed and the wound is well healed

Correct Answer & Explanation

. Rigid plaster dressing, a cast change at 5 to 7 days, and partial weight bearing with an attached pylon when the wound shows signs of healing without infection

Explanation

There is no evidence that early weight bearing enhances ultimate rehabilitation. At the other extreme, weight bearing should not be delayed for a prolonged period of time. In a young, healthy individual, the rigid plaster dressing appears to be the safest method of protecting the wound during the early postoperative period. If the wound appears to be secure, early partial weight bearing can be safely initiated. Burgess EM, Romano RL, Zettl JH: The Management of Lower Extremity Amputations. Washington, DC, US Government Printing Office, 1969, also at: www.prs-research.org.

Question 5342

Topic: 2. Trauma
Which of the following factors is a significant predictor of reoperation following open reduction and internal fixation of intertrochanteric fractures with a sliding-compression hip-screw device?
. Standard obliquity fracture pattern
. Tip-apex distance of 15 mm
. Fracture through the lateral femoral cortex
. Sliding-compression hip-screw device with a two-hole side plate
. Fracture of the lesser trochanter

Correct Answer & Explanation

. Fracture through the lateral femoral cortex

Explanation

As shown by Palm and associates from the Hip Fracture Study group, the integrity of the lateral femoral cortex in intertrochanteric hip fractures is a significant predictor of reoperation. Baumgartner and associates have shown that a tip-apex distance of greater than 25 mm is associated with a high risk of femoral head cut-out. Lastly, intertrochanteric hip fractures can be described as standard obliquity or reverse obliquity when describing the fracture pattern. Mechanistically, a reverse obliquity pattern is important to recognize because it reflects the presence or absence of a lateral buttress to which the proximal fracture fragment may compress. Palm H, Jacobsen S, Sonne-Holm S, et al: Integrity of the lateral femoral wall in intertrochanteric hip fractures: An important predictor of a reoperation. J Bone Joint Surg Am 2007;89:470-475. Sadowski C, Lübbeke A, Saudan M, et al: Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: A prospective, randomized study. J Bone Joint Surg Am 2002;84:372-381.

Question 5343

Topic: 2. Trauma

A 65-year man has right hip pain after a fall. Radiographs reveal a reverse oblique intertrochanteric femoral fracture. Treatment consists of reduction and internal fixation. Which of the following implants is most commonly associated with nonunion and hardware failure?

Trauma Board Review 2000: High-Yield MCQs (Set 2) - Figure 2

. Sliding hip screw
. Dynamic condylar screw
. 95 degree blade plate
. Cephalomedullary nail
. Intramedullary hip screw

Correct Answer & Explanation

. Sliding hip screw

Explanation

Reverse oblique intertrochanteric femoral fractures account for 5% of all intertrochanteric or subtrochanteric fractures. They are uncommon but not rare and will be encountered in practice. The sliding hip screw is associated with the most problems because of its design. When reverse oblique fractures are fixed with a sliding hip screw, the action of the construct causes medial displacement of the distal fragment rather than compression of the proximal and distal fragments. All of the other implants prevent medial displacement of the distal segment. It should not be assumed that simply using one of the other implants is reason for success. There is a significant failure rate for each of these implants with reverse oblique fractures. The implant must be ideally placed and the fracture must be reduced. Haidukewych GJ, Israel TA, Berry DB: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650. Sanders RW, Regazzoni P: Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma 1989;3:206-213.

Question 5344

Topic: 2. Trauma

A 12-year-old girl sustains an acute injury to the right elbow in a fall. An AP radiograph is shown in Figure 5. Nonsurgical management will most likely result in

Trauma 2000 Practice Questions: Set 1 (Solved) - Figure 10

. a painful nonunion.
. asymptomatic nonunion.
. chronic elbow instability.
. tardy ulnar nerve palsy.
. cubitus varus.

Correct Answer & Explanation

. asymptomatic nonunion.

Explanation

The patient has a significantly displaced medial epicondyle fracture. The only absolute indication for surgical treatment is irreducible incarceration in the joint. Nonsurgical management usually results in a painless nonunion with good elbow function and little elbow instability. Prolonged immobilization should be avoided to prevent stiffness. Tardy ulnar nerve palsy and cubitus varus are not complications of medial epicondyle fractures. Chamber HG, Wilkins KE: Part IV: Apophyseal injuries of the distal humerus, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 801-812.

Question 5345

Topic: 2. Trauma
Which of the following factors is the strongest predictor of vertebral fracture in postmenopausal women?
. Positive family history of vertebral fracture
. Menopause before age 40 years
. History of two vertebral fractures without significant trauma
. Bone mineral density two standard deviations below normal
. Positive history for smoking

Correct Answer & Explanation

. History of two vertebral fractures without significant trauma

Explanation

If a woman has two or more osteoporotic compression fractures, her risk of another is increased 12-fold. A decrease of two standard deviations in bone mineral density increases the risk four to six-fold, a positive family history 2.7-fold, premature menopause 1.6-fold, and smoking 1.2-fold. It should be noted that these studies were carried out in Caucasian and Asian women. Melton LJ III: Epidemiology of spinal osteoporosis. Spine 1997;22:2S-11S.

Question 5346

Topic: 2. Trauma

A 66-year-old woman who previously underwent hemiarthroplasty 2 years ago for a fracture continues to have severe pain and loss of motion despite undergoing physical therapy. A radiograph is shown in Figure 2. What is the most likely reason that this patient has failed to improve her motion?

Upper Extremity 2008 Practice Questions: Set 1 (Solved) - Figure 4

. She was noncompliant in physical therapy.
. The original surgery should have included resurfacing the glenoid.
. The humeral head was too large.
. The humeral component was placed too proud.
. The tuberosities are malpositioned.

Correct Answer & Explanation

. The tuberosities are malpositioned.

Explanation

The radiograph shows tuberosity malposition. The effect of improper prosthetic placement has also been associated with poor outcomes. However, the malposition of the tuberosity seen on the radiograph clearly explains loss of motion in this patient. It has been demonstrated that the functional results after hemiarthroplasty for three- and four-part proximal humeral fractures appear to be directly associated with tuberosity osteosynthesis. The most significant factor associated with poor and unsatisfactory postoperative functional results was malposition and/or migration of the tuberosities. Factors associated with a failure of tuberosity osteosynthesis in a recent study were poor initial position of the prosthesis, poor position of the greater tuberosity, and women older than age 75 years (most likely with osteopenic bone). Greater tuberosity displacement has been identified by Tanner and Cofield as being the most common complication after prosthetic arthroplasty for proximal humeral fractures. Furthermore, Bigliani and associates examined the causes of failure after prosthetic replacement for proximal humeral fractures and found that although almost all failed cases had multiple causes, the most common single identifiable reason was greater tuberosity displacement. Bigliani LU, Flatow EL, McCluskey G, et al: Failed prosthetic replacement for displaced proximal humeral fractures. Orthop Trans 1991;15:747-748. Boileau P, Krishnan SG, Tinsi L, et al: Tuberosity malposition and migration: Reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg 2002;11:401-412.

Question 5347

Topic: 2. Trauma

Figure 5 shows the radiograph of a 10-year-old girl who reports chronic shoulder pain after her gymnastics classes. Examination reveals pain on internal and external rotation but no instability. What is the most likely diagnosis?

Pediatrics 2004 Practice Questions: Set 1 (Solved) - Figure 18

. Acromial fracture
. Humeral stress fracture
. Acromioclavicular joint separation
. Fracture of the surgical neck of the scapula
. Triceps avulsion fracture

Correct Answer & Explanation

. Humeral stress fracture

Explanation

The patient has a very wide humeral growth plate, indicating the presence of a proximal humeral stress fracture, an uncommon diagnosis in gymnasts. Gymnasts are prone to stress fractures of the scaphoid, distal radius, elbow, and clavicle. Proximal humeral stress fractures are more commonly seen in those participating in racket or throwing sports. Stress fractures can lead to growth arrest or inhibition, particularly in the distal radius. The radiograph shows normal findings for the acromion, acromioclavicular joint, scapula, and triceps origin. Fallon KE, Fricker PA: Stress fracture of the clavicle in a young female gymnast. Br J Sports Med 2001;35:448-449. Sinha AK, Kaeding CC, Wadley GM: Upper extremity stress fractures in athletes: Clinical features of 44 cases. Clin J Sports Med 1999;9:199-202. Caine D, Howe W, Ross W, Bergman G: Does repetitive physical loading inhibit radial growth in female gymnasts? Clin J Sports Med 1997;7:302-308.

Question 5348

Topic: 2. Trauma

A 26-year-old man is brought to the emergency department unresponsive and intubated after being found lying on the side of the road. He has a Glasgow Coma Scale score of 6. A chest tube has been inserted on the right side of the chest for a pneumothorax. An abdominal CT scan reveals a small liver laceration and minimal intraperitoneal hematoma. A pneumatic antishock garment (PASG) is on but not inflated. He has bilateral tibia fractures. A pelvic CT scan shows an anterior minimally displaced left sacral ala fracture and left superior and inferior rami fractures. He has received 2 L of saline solution and 4 units of blood but remains hemodynamically unstable. What is the next most appropriate step in management?

Trauma 2000 Practice Questions: Set 1 (Solved) - Figure 34

. Inflation of the abdominal portion of the PASG
. Application of a pelvic clamp
. Application of a pelvic external fixator
. Rapid infusion of 4 more units of blood
. Angiography and embolization

Correct Answer & Explanation

. Angiography and embolization

Explanation

There is no identifiable thoracic, abdominal, or long bone source of ongoing bleeding. The patient has a lateral compression Burgess-Young type I pelvic ring injury. This injury does not increase the pelvic volume because it is not unstable in external rotation. Application of a PASG, a pelvic clamp, or an external fixator may be helpful if the patient has a pelvic injury that is unstable in external rotation or translation but would be of little use in this injury pattern. Persistent hemodynamic instability after administration of 4 units of blood is the decision point where most authors would recommend angiography and embolization. If the pelvis is unstable in external rotation or translation, inflation of the PASG trousers or application of an external fixator is recommended before angiography. Attributing the hemodynamic instability to the head injury before ruling out the pelvis as a source is not indicated. Burgess AR, Eastridge BJ, Young JW, et al: Pelvic ring disruptions: Effective classification system and treatment protocols. J Trauma 1990;30:848-856. Evers BM, Cryer HM, Miller FB: Pelvic fracture hemorrhage: Priorities in management. Arch Surg 1989;124:422-424.

Question 5349

Topic: 2. Trauma

An 18-year-old man was in a motor vehicle accident and sustained a closed head injury, right displaced scapular body and glenoid fractures, a right proximal humeral fracture, fractures of ribs one through three, facial fractures, and bilateral pubic rami fractures with minimal displacement. He has a systolic blood pressure of 80/40 mm Hg despite fluid resuscitation. A radiograph is shown in Figure 17. Spiral CT does not identify any thoracic or abdominal injuries. What is the next most appropriate step in management?

Trauma Board Review 2006: High-Yield MCQs (Set 2) - Figure 12

. Pelvic angiography
. Intracranial pressure monitoring
. Pelvic external fixation
. Evaluation of peripheral pulses
. Urgent open stabilization of the clavicular and humeral fractures

Correct Answer & Explanation

. Evaluation of peripheral pulses

Explanation

The patient has sustained high-energy upper extremity and chest injuries. He continues to remain hemodynamically unstable with no obvious thoracic or abdominal injury responsible for bleeding. The pelvic fracture is unlikely to be causing significant bleeding. A scapulothoracic dissociation and possible disruption of one of the great vessels of the upper extremity should be considered. Evaluation of peripheral pulses or blood pressure indices bilaterally in the upper extremities is a simple way to evaluate the need for further work-up. If there is any discrepancy or further concern, angiography of the involved extremity is necessary. Althausen PL, Lee MA, Finkemeier CG: Scapulothoracic dissociation: Diagnosis and treatment. Clin Orthop 2003;416:237-244.

Question 5350

Topic: 2. Trauma

A 64-year-old woman has left wrist pain and deformity after falling on her hand. Examination shows intact skin and no neurologic or vascular injuries. Radiographs are shown in Figures 43a and 43b. What is the most appropriate management for the injury?

. Closed reduction and above-elbow cast immobilization in supination
. Closed reduction and joint spanning external fixation
. Closed reduction and percutaneous pinning followed by cast immobilization
. Open reduction through a dorsal approach and fixation with an angular stable plate
. Open reduction through a volar approach and stabilization with a buttress plate

Correct Answer & Explanation

. Open reduction through a volar approach and stabilization with a buttress plate

Explanation

The patient has a volar displaced two-part intra-articular distal radial fracture-dislocation of the wrist. Although a closed reduction is usually easily obtained, it is very difficult to maintain the reduction without internal fixation. The approach is determined by the direction of the dislocation, in this case volar. Stabilization with a buttress plate neutralizes the axial loading forces on the fractured fragment. A dorsal placed angular stable plate will not provide this buttress effect and will make the reduction difficult.

Question 5351

Topic: 2. Trauma

A 26-year-old man was thrown from a car and sustained the injury seen in Figures 44a and 44b. Nonsurgical management of this injury is recommended. Which of the following factors increases the risk of nonunion?

. Male gender
. Diaphyseal location
. Comminuted displaced fracture
. Young age
. Associated injuries

Correct Answer & Explanation

. Comminuted displaced fracture

Explanation

The patient has a displaced comminuted clavicle middle one third fracture from a high-energy mechanism. Recent literature on high-energy clavicular fractures suggests a higher rate of nonunion than previously reported. A nonunion rate of 30% has been reported by Hill and associates when the fracture fragments are displaced more than 1.5 cm. In addition, several patients had neurologic symptoms related to the injury. Robinson and associates reported an increased risk of nonunion in women, elderly patients, comminuted fractures, and injuries with a lack of cortical contact. Hill JM, McGuire MH, Crosby LA: Closed treatment of displaced middle-third fractures of the clavicle gives poor results. J Bone Joint Surg Br 1997;79:537-539. Wick M, Muller EJ, Kollig E: Midshaft fractures of the clavicle with a shortening of more than 2 cm predispose to nonunion. Arch Orthop Trauma Surg 2001;121:207-211.

Question 5352

Topic: Lower Extremity Trauma

During a posterior cruciate ligament-sacrificing total knee arthroplasty with anterior referencing, 8 mm of distal femur is resected. It is noted that the flexion gap is tight and the extension gap appears stable. What is the next most appropriate step in management?

. Cut more proximal tibia.
. Cut more distal femur.
. Cut both the proximal tibia and distal femur.
. Decrease the size of the femoral component.
. Decrease the tibial polyethylene insert thickness.

Correct Answer & Explanation

. Decrease the size of the femoral component.

Explanation

If the flexion gap is tight and the extension gap is correct, it is preferable to change only the flexion gap and leave the extension gap unchanged; therefore, the treatment of choice is to decrease the size of the femoral component. The smaller component will be smaller in both medial-lateral as well as anterior-posterior dimensions. A smaller anterior-posterior size will allow more space for the flexion gap without significantly affecting the extension gap. Decreasing the size of the tibial polyethylene insert thickness or cutting more proximal tibia will affect both the flexion and extension gaps. Cutting more distal femur will increase the extension gap and not change the flexion gap, making the described situation worse. Cutting both the proximal tibia and distal femur will increase both the flexion and extension gaps.

Question 5353

Topic: 2. Trauma

Figure 40 shows the radiographs of a 2-year-old boy who has a deformed leg. The patient is ambulatory and has no pain. What is the most appropriate management?

Pediatrics Board Review 2007: High-Yield MCQs (Set 4) - Figure 12

. Observation
. Patellar tendon bearing (PTB) orthosis
. Osteotomy to correct the deformity and fixation with an intramedullary rod
. Vascularized fibular graft from the contralateral leg
. Amputation

Correct Answer & Explanation

. Patellar tendon bearing (PTB) orthosis

Explanation

The patient has a prefractured stage of congenital pseudarthrosis of the tibia and is at risk for fracture. The PTB orthosis may prevent or delay the fracture. Osteotomy is frequently complicated by nonunion. When established nonunion does not respond to intramedullary nailing and bone grafting, vascularized grafting may succeed. Amputation is a salvage procedure. Murray HH, Lovell WW: Congenital pseudarthrosis of the tibia: A long-term follow-up study. Clin Orthop 1982;166:14-20.

Question 5354

Topic: Upper Extremity Trauma
A 29-year-old quarterback falls onto his dominant shoulder and sustains the injury shown in Figures 14a and 14b. Management should consist of
. an arm sling.
. nonsteroidal anti-inflammatory drugs and a rapid return to activity.
. arthroscopic partial claviculectomy.
. acromioclavicular joint reduction and stabilization.
. acromionectomy.

Correct Answer & Explanation

. acromioclavicular joint reduction and stabilization.

Explanation

Type V acromioclavicular dislocations are characterized by elevation of the clavicle of 100% to 300% and involve extensive soft-tissue stripping. The treatment of choice is surgical reduction of the acromioclavicular joint and some type of stabilization.

Question 5355

Topic: 2. Trauma

A 25-year-old man sustained the closed injury shown in Figures 22a and 22b. Examination reveals that this is an isolated injury, and he is hemodynamically stable. Treatment should consist of

. multiple flexible intramedullary nails.
. unreamed intramedullary nailing with static interlocking.
. unreamed intramedullary nailing with dynamic interlocking.
. reamed intramedullary nailing with static interlocking.
. reamed intramedullary nailing with dynamic interlocking.

Correct Answer & Explanation

. reamed intramedullary nailing with static interlocking.

Explanation

The treatment of choice for closed diaphyseal femoral fractures in adults is reamed intramedullary nailing with static interlocking. Reaming allows placement of a larger, stronger implant and offers better healing rates than unreamed nailing. Static interlocking ensures that there is no loss of reduction because of underappreciated fracture lines or comminution. Brumback RJ, Virkus WW: Intramedullary nailing of the femur: Reamed versus nonreamed. J Am Acad Orthop Surg 2000;8:83-90.

Question 5356

Topic: 2. Trauma

A 10-year-old girl has a midshaft both bone forearm fracture. After attempted closed reduction, alignment consists of bayonet apposition, 10 degrees of malrotation, and 8 degrees of volar angulation. Management should now consist of

Trauma Board Review 2006: High-Yield MCQs (Set 2) - Figure 35

. open reduction and plating of the radius to restore the radial bow.
. open reduction of the ulna and plating.
. closed reduction and nailing of the bones with flexible nails.
. a long arm cast and follow-up of alignment in 5 days.
. a short arm cast for 6 weeks.

Correct Answer & Explanation

. a long arm cast and follow-up of alignment in 5 days.

Explanation

Acceptable alignment in both bone forearm fractures is related to age and location. In children younger than age 9 years, angulations of 15 degrees and malrotation of 45 degrees are acceptable. In children older than age 9 years, acceptable alignment is 10 degrees of angulation and 30 degrees of malrotation. Bayonet apposition is acceptable provided that the angular and rotational reductions are held within these guidelines. A long arm cast provides better control of deforming forces than a short arm cast. Do TT, Strub WM, Foad SL, et al: Reduction versus remodeling in pediatric distal forearm fractures: A preliminary cost analysis. J Pediatr Orthop B 2003;12:109-115. Flynn JM: Pediatric forearm fractures: Decision making, surgical techniques, and complications. Instr Course Lect 2002;51:355-360. Ring D, Waters PM, Hotchkiss RN, et al: Pediatric floating elbow. J Pediatr Orthop 2001;21:456-459.

Question 5357

Topic: Upper Extremity Trauma
A 21-year-old football player had severe pain and immediate swelling in the left anteromedial chest wall while bench pressing near maximal weights several days ago. Examination at the time of injury revealed a mass on the anteromedial chest wall. Follow-up examination now reveals decreased swelling, and axillary webbing is observed. The patient has weakness to adduction and forward flexion. The injured muscle originates from the
. proximal clavicle and sternocostal margin.
. proximal humerus.
. coracoid process.
. distal clavicle and acromion.
. anterior scapula.

Correct Answer & Explanation

. proximal humerus.

Explanation

The patient has a pectoralis major rupture. The pectoralis major originates from the proximal clavicle and the border of the sternum, including ribs two through six.

Question 5358

Topic: 2. Trauma
Figures 15a and 15b show the radiographs of an 18-year-old mountain biker who came off of a 15-foot ramp and sustained an injury to his ankle. Because the local rural hospital had no orthopaedic surgeon available, he was transported to a Level 1 emergency department 10 hours after his initial injury. Examination reveals that the injury remains closed. Management should consist of
. immediate CT to define the fragments.
. closed reduction and short leg casting, followed by delayed open reconstruction of the fracture in 2 weeks.
. immediate open reduction and internal fixation of the fracture.
. application of an external fixator with traction for provisional reduction and delayed open reconstruction.
. primary fusion of the ankle.

Correct Answer & Explanation

. application of an external fixator with traction for provisional reduction and delayed open reconstruction.

Explanation

High-energy tibial pilon fractures involve disruption of the soft-tissue envelope with significant lower extremity edema. Definitive reconstruction of the comminuted distal tibia should be delayed for at least 7 days to allow edema to dissipate. An external fixator is the best method to keep the ankle at anatomic length while preventing skin necrosis.

Question 5359

Topic: 2. Trauma
A 68-year-old man fell off a 20-foot mountain cliff and was seen in the emergency department the following morning. A radiograph is shown in Figure 12. He is a nonsmoker with medical comorbidities of hypertension and hypercholesterolemia that is well controlled with medicine and diet. Capillary refill and sensation are intact distally and the patient is able to move his toes with mild discomfort. Serosanguinous fracture blisters are present laterally, and the foot is swollen and red. What is the most appropriate management?
. Short leg cast for 6 weeks
. Splinting with early range of motion at 3 weeks
. Immediate open reduction and internal fixation through a medial approach
. Delayed open reduction and internal fixation
. Fusion

Correct Answer & Explanation

. Delayed open reduction and internal fixation

Explanation

Given the condition of the soft tissues at presentation, delayed fixation is recommended for displaced intra-articular calcaneal fractures.

Question 5360

Topic: 2. Trauma

A 2-year-old child has refused to bear weight on his leg for the past 2 days. His parents report that he will crawl, has no fever, and has painless full range of motion of his hip and knee. Examination reveals no deformity or bruising, but there is mild swelling and tenderness over the anterior tibia. C-reactive protein, WBC count, and erythrocyte sedimentation rate studies are normal. Radiographs are negative. What is the best course of action?

. Application of a long leg cast
. Aspiration of the tibial metaphysis
. Bone scan
. MRI
. Observation

Correct Answer & Explanation

. Observation

Explanation

Despite the negative radiographic findings, the child's age and presentation are most consistent with a toddler's fracture. There is often not a witnessed injury. The differential diagnosis of infection is unlikely given that the child is afebrile and shows no signs of illness. Immobilization will make the child more comfortable and will often allow weight bearing. Repeat radiographs at the end of treatment will show a healing fracture and confirm the diagnosis. Aspiration of the tibial metaphysis would be indicated to obtain material for culture. The bone scan and MRI would show abnormalities, but these studies are nonspecific, costly, and time-consuming. Occasionally, oblique radiographs will show the fracture. Halsey MF, Finzel KC, Carrion WV, Haralabatos SS, et al: Toddler's fracture: Presumptive diagnosis and treatment. J Pediatr Orthop 2001;21:152-156.

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