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4. Pediatrics MCQs

Practice Set 76 of 334

This practice set contains high-yield board review questions covering key concepts in 4. Pediatrics. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 1501

Topic: 4. Pediatrics

An 18-month-old infant with myelomeningocele and rigid clubfeet has grade 5 quadriceps and hamstring strength, but no muscles are functioning below the knee. What is the best treatment option for the rigid clubfeet?

. Triple arthrodesis
. Soft-tissue releases as necessary
. Tendon transfers to balance the feet in a neutral plantigrade position
. Physical therapy for range of motion and stretching
. Botulinum injections followed by serial casting

Correct Answer & Explanation

. Triple arthrodesis

Explanation

DISCUSSION: This child has the potential to walk and therefore should have all the contracted structures in the feet released as necessary to place the feet in a plantigrade position for fitting of ankle-foot orthoses.  Physical therapy, manipulation, and casting may provide some benefit in a newborn with flexible feet but are not effective in an older infant with rigid clubfeet.  Botulinum injections and tendon transfers are of no use because there are no muscles functioning below the knee.  Tendon releases are more effective than tendon transfers in children with myelomeningocele.REFERENCES: Mazur JM: Management of foot and ankle deformities in the ambulatory child with myelomeningocele, in Sarwark JR, Lubicky JP (eds): Caring for the Child with Spina Bifida.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2001, pp 155-160.Dias LS: Surgical management of acquired foot and ankle deformities, in Sarwark JR, Lubicky JP (eds): Caring for the Child with Spina Bifida.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 2001, pp 161-170.

Question 1502

Topic: 4. Pediatrics

A 12-year-old boy reports limping and chronic knee pain that is now inhibiting his ability to participate in sports. Clinical examination and radiographs of the knee are normal. Additional evaluation should include

. mechanical alignment radiographs.
. stress radiographs of the knee.
. comparison radiographs of both knees.
. an erythrocyte sedimentation rate and a C-reactive protein.
. examination of the hip.

Correct Answer & Explanation

. mechanical alignment radiographs.

Explanation

DISCUSSION: While all of the answers may be appropriate, radiating pain from hip pathology must be excluded.  At this age, a slipped capital femoral epiphysis is likely.  Therefore, the hip must be examined.REFERENCES: Kocher MS, Bishop JA, Weed B, et al: Delay in diagnosis of slipped capital femoral epiphysis.  Pediatrics 2004;113:322-325.Matava MJ, Patton CM, Luhmann S, et al: Knee pain as the initial symptom of slipped capital femoral epiphysis: An analysis of initial presentation and treatment.  J Pediatr Orthop 1999;19:455-460.

Question 1503

Topic: 4. Pediatrics

A 10-year-old girl has been unable to walk for the past 5 days because of bilateral hip pain. Administration of IV morphine has provided some pain relief. She is afebrile. History reveals that she had an upper respiratory tract infection 3 weeks ago that resolved uneventfully. Examination reveals moderate pain with internal rotation and abduction, while log rolling maneuvers do not cause significant pain. An MRI scan shows a small effusion of one hip; however, a bone scan and plain radiographs are normal. Initial laboratory studies showed a markedly elevated WBC count, which subsequently declined to normal levels with IV antibiotics. Current studies show an erythrocyte sedimentation rate (ESR) of 100 mm/h. Aspiration of the hip obtains 3 mL of fluid; Gram stain is negative for bacteria, but a cell count shows a WBC count of 16,500/mm 3 . Streptozyme titer of the peripheral blood is 200 units (normal is less than 100 units). Management should now consist of

. discontinuation of antibiotics and administration of nonsteroidal anti-inflammatory drugs, followed by physical therapy.
. incision and drainage of both hips.
. in situ pinning of both hips.
. broad-spectrum antibiotics in accordance with the recommendations of a pediatric infectious diseases consultant.
. continued use of IV antibiotics for 2 weeks, followed by oral antibiotics until the ESR returns to normal.

Correct Answer & Explanation

. discontinuation of antibiotics and administration of nonsteroidal anti-inflammatory drugs, followed by physical therapy.

Explanation

DISCUSSION: This clinical situation requires careful analysis because some data suggest infection and some a noninfectious inflammatory process.  Bilateral hip involvement, the absence of significant fluid collection or fever, the streptozyme level, and the history of upper respiratory infection all suggest poststreptococcal toxic synovitis as the most likely cause for the clinical presentation.  In the first 24 hours, this type of presentation might warrant incision and drainage given uncertainty of the diagnosis and the risks associated with missing an infection.  However, 5 days after onset, surgery is not warranted, especially given that the patient remains afebrile and her symptoms are improving.  Cardiology consultation would be appropriate.  There is no evidence to suggest slipped capital femoral epiphysis.  Treatment with antibiotics is not advised because there is no bacteriologic data on which to base treatment.REFERENCES: De Cunto CL, Giannini EH, Fink CW, et al: Prognosis of children with poststreptococcal reactive arthritis.  J Pediatr Infect Dis 1988;7:683-686.Haueisen DC, Weiner DS, Weiner SD: The characterization of “transient synovitis of the hip” in children.  J Pediatr Orthop 1986;6:11-17.

Question 1504

Topic: 4. Pediatrics
Examination of a 6-year-old boy who sustained a displaced Salter-Harris type II fracture of the distal radius reveals 35 degrees of volar angulation. A satisfactory reduction is obtained with the aid of a hematoma block. At the 10-day follow-up examination, radiographs show loss of reduction and 35 degrees of volar angulation. Management should now consist of
. acceptance of the malalignment and continued cast immobilization.
. repeat closed reduction with the aid of IV morphine and midazolam.
. repeat closed reduction with the aid of IV ketamine.
. repeat closed reduction with the patient under general anesthesia.
. gentle open reduction with smooth cross-pin fixation.

Correct Answer & Explanation

. acceptance of the malalignment and continued cast immobilization.

Explanation

DISCUSSION: In a 6-year-old child with a physeal fracture, the healing response 10 days after injury is so advanced that manipulation would have to be very forceful to be successful. A forceful manipulation in a patient this age increases the risk of early growth arrest and a significant disability because 80% of the growth of the radius comes from the distal physis. Because of the large contribution of growth from the distal radial physis and the angulation being in the plane of wrist motion, the potential for remodeling of this fracture is great. It is highly probable that this fracture will completely remodel in 1 to 2 years of growth. In this patient, even a “gentle” open reduction would probably require enough force that the physis would be damaged. REFERENCES: Dimeglio A: Growth in pediatric orthopaedics, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 33-62. Waters PM: Forearm and wrist fractures, in Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 251-258.

Question 1505

Topic: 4. Pediatrics

A 10-year-old girl is seen in the emergency department after being involved in a motor vehicle accident. She has right hip pain and is unable to bear weight. She has no neurovascular deficits and no other injuries. Radiographs reveal a posterior dislocation of the right hip without apparent fracture. The acetabulum appears to be developing normally. What is the best course of treatment? Review Topic

. Open reduction under general anesthesia
. Closed reduction under general anesthesia with fluoroscopy
. Closed reduction under general anesthesia without fluoroscopy
. Conscious sedation in the emergency department and closed reduction with fluoroscopy
. Conscious sedation in the emergency department and closed reduction without fluoroscopy

Correct Answer & Explanation

. Open reduction under general anesthesia

Explanation

Hip dislocation in the pediatric population is a rare event. However, prompt recognition and rapid care for this injury is imperative to avoid future hip problems including osteonecrosis of the femoral head (a devastating problem for a pediatric patient). Reduction maneuvers can create violent impact between the posterior wall of the (intact) acetabulum and the femoral head, resulting in shearing of the proximal femoral physis and displacement of the epiphysis from the remainder of the femoral head in skeletally immature patients. Therefore, deep sedation with good muscle relaxation, such as that achieved with general anesthetic, is recommended. Reduction is best accomplished with fluoroscopy for a number of reasons, including assessment of concentricity of the hip joint after reduction, and to detect any catastrophic femoral head physeal separation that occurs during the reduction maneuver. Sedation in the emergency department is often insufficient to achieve acceptable muscle relaxation for the patient. Open reduction is only indicated if closed reduction fails completely or if the hip is not concentric after an apparently successful closed reduction

Question 1506

Topic: 4. Pediatrics
A 30-month-old boy underwent open reduction of his right hip to address developmental hip dysplasia. The reduction was performed through an anterior approach, and a shortening femoral osteotomy was not performed. Four months after surgery, hip radiographs reveal absence of ossification of the femoral epiphysis and fragmentation of the ossific nucleus. What is the likely cause of this complication?
. Intraoperative damage to the medial femoral circumflex artery
. Intraoperative damage to the lateral femoral circumflex artery
. Excessive pressure on the femoral head after reduction
. Incarceration of the acetabular labrum in the reduction

Correct Answer & Explanation

. Excessive pressure on the femoral head after reduction

Explanation

The incidence of pediatric hip dysplasia is approximately 1 per 100 live births, with hip dislocation present in 1 in 1000 births. Two surgical approaches primarily are used for surgical reduction in the dislocated pediatric hip: the modified medial approach as described by Weinstein and the anterior Smith-Petersen approach. The Weinstein modification of the Ludloff approach exploits the interval between the pectineus muscle and the femoral neurovascular bundles rather than the interval between the pectineus and the adductor longus and brevis. The modified “bikini” anterior Smith-Petersen approach passes between the sartorius and tensor fascia lata superficially and between the rectus and gluteus medius during deep dissection. When using the medial approach, the neurovascular bundle is particularly at risk, including the medial circumflex femoral vessels that supply blood to the femoral head ossific nucleus. Damage to this structure increases risk for osteonecrosis of the femoral head. Unlike the anterior approach, the medial approach does not allow for the performance of a capsulorrhaphy, poses higher risk for post-procedure redislocation, and is less useful in children of walking age. Identification of the ligamentum teres during deep dissection assists in localization of the true bony acetabulum. The anatomic structure primarily at risk during the anterior approach is the lateral femoral cutaneous nerve. Excessive traction or transection of this structure will result in numbness in the proximal lateral thigh. This surgical approach allows for identifying and addressing all potential impediments to reduction: the redundant capsule, hypertrophic labrum, hypertrophic ligamentum teres, pulvinar, iliopsoas tendon, and transverse acetabular ligament. In older children who undergo open reduction with periacetabular osteotomy without a concomitant proximal femoral shortening osteotomy, reduction may be accompanied by increased pressure on the femoral head which, in turn, may result in secondary osteonecrosis of the femoral head.

Question 1507

Topic: 4. Pediatrics

A 6-year-old boy presents to the emergency room after falling off a trampoline and landing on his elbow. Examination reveals good radial and ulnar pulses, and a warm, pink, sensate extremity. Radiographs are shown in Figures A and

. He is taken to the operating room for fluroscopic-guided closed reduction and the surgeon creates a 2 pin construct. He then notices that the pulses have disappeared and in spite of ambient warming and blood pressure elevation, are undetectable by doppler ultrasound for half an hour. The hand is paler and cooler than the contralateral side. What is the next best step? Review Topic
. Splint and observe postoperatively.
. Remove the pins and perform closed reduction without internal fixation
. Explore the brachial artery
. Remove the pins and pin the fracture in the initial displaced position
. Arteriogram evaluation of the brachial artery

Correct Answer & Explanation

. He is taken to the operating room for fluroscopic-guided closed reduction and the surgeon creates a 2 pin construct. He then notices that the pulses have disappeared and in spite of ambient warming and blood pressure elevation, are undetectable by doppler ultrasound for half an hour. The hand is paler and cooler than the contralateral side. What is the next best step? Review Topic

Explanation

This child has an extension Gartland type III supracondylar fracture of the humerus with an initially warm, pink, extremity with progressive circulatory compromise after reduction/pinning. Exploration is indicated.Pulselessness occurs 10-20% of the time following extension type supracondylar fractures. Most authors recommend observation of the pink, pulseless limb as in the majority of cases, vascular spasm will resolve in 12-24 hours and/or the collateral circulation will be adequate. Isolated nerve injuries are usually neuropraxia and can be observed. Pulseless hands with AIN or median nerve palsy warrant early exploration because of the high probability of arterial entrapment at the fracture site, or tethering.Choi et al. performed a review of 1255 pediatric supracondylar fractures treated at a single institution. There were 33 pulseless fractures (2.6%). All 24 well perfused patients did well postoperatively without vascular repair, although 10 remained pulseless. Of the 9 poorly perfused patients, 4 underwent vascular repair and 2 developed compartment syndrome. They concluded that patients with poor perfusion were at increased risk of vascular repair and compartment syndrome.Franklin et al. reviewed pediatric supracondylar fractures with neurovascular compromise. They recommend: (1) observation for 48h for the pulseless, well-perfused hand, (2) exploration if the pulse disappears after reduction, (3) exploration for pulseless hands with AIN/median nerve palsy, (4) delay of 8-21 hours did not increase the risk of complications.Figures A and B are AP and lateral radiographs showing a Gartland type III supracondylar fracture of the humerus.Incorrect Answers:

Question 1508

Topic: 4. Pediatrics
A newborn girl is referred for evaluation of suspected hip instability. What information from her history would place her in the highest risk category?
. History of maternal diabetes mellitus
. Frank breech presentation
. Female gender
. Concomitant metatarsus adductus
. Twin gestation

Correct Answer & Explanation

. Frank breech presentation

Explanation

Breech positioning has been noted as the risk factor that most increases the relative risk of developmental dysplasia of the hip in multiple series and meta-analyses. All the other factors also increase the risk but to a lesser magnitude.

Question 1509

Topic: Pediatric Hip

03 Figure 72 shows the radiograph of a 4 y/o girl who has a painless right Trendelenburg limp. Management should consist of

. – closed reduction
. – open reduction with femoral shortening and pelvic osteotomy
. – traction followed by closed reduction
. – medial soft tissue release, traction, and closed reduction
. – pelvic osteotomy without reduction of the jointback answerQuestion 201.03

Correct Answer & Explanation

. – open reduction with femoral shortening and pelvic osteotomy

Explanation

Many high dislocations in children with DDH may remain mobile and pain free for decades despite an inefficient gait. Unilateral dislocations usually create difficulties with limb-length discrepancies and spinal malalignment(unlike their bilateral counterparts which generally do not need to be reduced). Open reduction is used to obtain absolute concentric reduction. In the dislocated hip reduced at age 15 mths or older, there is usually enough associated bony deformity, either femoral, acetabular, or both to require stabilizing osteotomy to maintain the concentric reduction. Femoral shortening is often necessary to relax soft tissues before a perfect reduction is possible in children > 2 y/o.back to this question next question

Question 1510

Topic: 4. Pediatrics
What condition favors pollicization in hypoplasia of the thumb?
. Extrinsic tendon abnormalities involving the flexor and extensor
. Narrowing of the first web space
. Insufficiency of the ulnar collateral ligament of the metacarpophalangeal joint
. Unstable carpometacarpal joint

Correct Answer & Explanation

. Unstable carpometacarpal joint

Explanation

DISCUSSION: The decision to ablate and pollicize vs preserve and reconstruct is based on the stability of the carpometacarpal joint. A stable thumb is more easily used in prehension activities of grasping and pinching. All other responses are associated with surgical options for reconstruction of the thumb. The carpometacarpal joint is the “keystone” for thumb-to-hand attachment. Without a stable carpometacarpal joint, pollicization may be required. No other response necessitates pollicization. RECOMMENDED READINGS: McCarroll HR. Congenital anomalies: a 25-year overview. J Hand Surg Am. 2000 Nov;25(6):1007-37. Review. PubMed PMID: 11119659. Manske PR, Goldfarb CA. Congenital failure of formation of the upper limb. Hand Clin. 2009 May;25(2):157-70. doi: 10.1016/j.hcl.2008.10.005. Review. PubMed PMID: 19380058.

Question 1511

Topic: 4. Pediatrics
Which of following side effects is most commonly seen in a pediatric patient undergoing ketamine anesthesia?
. Respiratory depression
. Increased salivary secretion
. Hypertension
. Emergence phenomena
. Cerebral vasoconstriction

Correct Answer & Explanation

. Increased salivary secretion

Explanation

The most common deleterious side effect of ketamine is increased salivation and tracheobronchial secretions. For this reason, an antisialagogue agent should be given. While lack of sufficient respiratory depression is one of the major advantages of using ketamine, apnea can occur if the drug is given too rapidly intravenously. Emergence phenomena is common in adults but relatively rare in children.

Question 1512

Topic: 4. Pediatrics
A 6-year-old boy with spastic diplegic cerebral palsy has a crouched gait. Examination reveals hip flexion contractures of 15 degrees and popliteal angles of 70 degrees. Equinus contractures measure 10 degrees with the knees extended. Which of the following surgical procedures, if performed alone, will worsen the crouching?
. Iliopsoas release from the lesser trochanter
. Iliopsoas release at the pelvic brim
. Hamstring lengthening
. Heel cord lengthening
. Split posterior tibial tendon transfer

Correct Answer & Explanation

. Heel cord lengthening

Explanation

Children with spastic diplegic cerebral palsy often have contractures of multiple joints. Because the gait abnormalities can be complex, isolated surgery is rarely indicated. To avoid compensatory deformities at other joints, it is preferable to correct all deformities in a single operation. Isolated heel cord lengthening in the presence of tight hamstrings and hip flexors will lead to progressive flexion at the hips and knees, thus worsening a crouched gait. Split posterior tibial tendon transfer is used for patients with hindfoot varus, which is not present in this patient.

Question 1513

Topic: 4. Pediatrics
Figure 1 is the radiograph of an 11-year-old baseball pitcher who has had right shoulder pain for the past 3 months. He has full range of motion and normal strength in both external rotation and abduction, although all tests cause him discomfort over the lateral and anterior shoulder. What is the most likely basis for his injury?
. Increased external rotation with an associated decrease in internal rotation
. Excessive pitch counts
. Use of breaking pitches such as sliders and curve balls
. Congenital humeral cyst

Correct Answer & Explanation

. Excessive pitch counts

Explanation

The radiograph reveals a widened lateral physis at the proximal humerus, consistent with a physeal stress fracture or “Little Leaguer’s shoulder.” Numerous studies have established that children and adolescents are particularly prone to such overuse injuries. With regard to baseball participation, a major contributor is over-pitching, i.e., excessive numbers of pitches, excessive innings pitched, and insufficient rest days. Altered range of rotational motion, a gradual adaptation to the increased stresses of throwing, can predispose to long-term injury, especially internal impingement and labral pathology. A unicameral or aneurysmal bone cyst can often occur in the proximal humerus, but has a distinct radiographic appearance and would predispose to fracture. There is evidence that breaking pitches place increased stresses on the elbow and shoulder, but it remains controversial whether such throws should be avoided at certain ages.

Question 1514

Topic: 4. Pediatrics
Figure 38 shows the radiograph of a 5-year-old child who sustained a type III supracondylar fracture. Examination reveals the absence of a radial pulse, but an otherwise well-perfused hand. Following closed reduction and percutaneous pinning, the radial pulse remains absent; however, the hand is pink and well perfused. Management should now include
. close observation with frequent neurovascular checks.
. emergency angiography.
. emergency exploration of the brachial artery.
. removal of pin fixation and exploration of the brachial artery.
. thrombectomy.

Correct Answer & Explanation

. close observation with frequent neurovascular checks.

Explanation

DISCUSSION: In a study of over 400 patients with displaced supracondylar fractures, 3.2% of the fractures were associated with the absence of the radial pulse with an otherwise well-perfused hand. Based on this study, a period of close observation with frequent neurovascular checks should be completed before attempting invasive correction of the problem. Because of the satisfactory results with expectant management, angiography, exploration, removal of fixation and exploration, and thrombectomy are contraindicated. REFERENCE: Sabharwal S, Tredwell SJ, Beauchamp RD, Mackenzie WG, Jakubec DM, Cairns R: Management of pulseless pink hand in pediatric supracondylar fractures of humerus. J Pediatr Orthop 1997;17:303-310.

Question 1515

Topic: 4. Pediatrics
A 2-year-old girl has had a swollen right knee for the past 7 weeks. There is no history of significant trauma, and she has not had a fever or been ill. Her parents report that she is stiff in the morning but otherwise does not report pain. A CBC count and erythrocyte sedimentation rate are normal. Treatment with naproxen at appropriate doses for the past 2 weeks has resulted in some improvement. Radiographs show only soft-tissue swelling. Examination reveals a healthy-appearing child with a warm and swollen right knee that is only slightly tender but lacks full extension by 20 degrees. What is the next most appropriate step in management?
. MRI
. Arthrocentesis for synovial fluid cell count and bacterial culture
. Ophthalmology consultation
. Angiotensin converting enzyme (ACE) level
. Technetium radioisotope bone scan

Correct Answer & Explanation

. Ophthalmology consultation

Explanation

Up to 30% of children with juvenile idiopathic arthritis (JIA) already have potentially damaging uveitis at the time of diagnosis. This patient has typical oligoarticular JIA and therefore is at significant risk for uveitis. MRI, radioisotope scanning, or an ACE level most likely would not provide additional useful diagnostic information because intra-articular derangement, osteomyelitis, or sarcoidosis are all unlikely.

Question 1516

Topic: 4. Pediatrics
A 12-year-old child with spina bifida paraplegia requires brace management for ankle stability. Which of the following principles applies to brace management in this individual?
. A shorter lever arm is more effective in limiting pressure.
. Limbs with mild contractures do better with bracing than flaccid limbs through increased force concentration.
. Three-point pressure effect works best to prevent the joint from buckling.
. Four-point pressure effect works best to prevent the joint from buckling.
. Smaller base support provides increased stability.

Correct Answer & Explanation

. Three-point pressure effect works best to prevent the joint from buckling.

Explanation

Bracing for spina bifida paraplegia provides both support and improved function of the movable limb. An orthosis has value in controlling unstable joints. The three-point pressure effect applies a force above and below the joint to prevent it from buckling. A four-point pressure effect is only required for a two-joint system (this patient has problems only at the ankle). A longer lever arm brace and a brace with a greater area of support provide better stability. Finally, a straighter limb, without contracture, applies less pressure to the brace and lessens overload to the skin.

Question 1517

Topic: 4. Pediatrics
A mother brings in her 6-month-old infant with a knee deformity. The child had previously been treated with serial casting in flexion for 3 months at an outside facility. Examination reveals passive hyperextension to 25° and passive flexion to 15° as shown in Figures A and B respectively. A lateral radiograph of the knee is shown in Figure C. What is the most appropriate next step in treatment?
. Serial above-knee casting in extension for 4 weeks.
. Serial above-knee casting in flexion for 4 weeks.
. Arthroscopic anterior cruciate ligament division, followed by above-knee casting
. Percutaneous quadriceps recession, followed by above-knee casting
. Open VY quadriceps plasty, followed by above-knee casting

Correct Answer & Explanation

. Open VY quadriceps plasty, followed by above-knee casting

Explanation

The clinical presentation is consistent with recurrent Grade III congenital dislocation of the knee (CDK) that has not responded to casting in a six-month-old infant. VY quadricepsplasty (VYQ) is the most appropriate next step in treatment. Congenital knee dislocation is rare. The etiology is thought to be quadriceps contracture. It is associated with developmental dysplasia of the hip (DDH) and clubfoot (CTEV). In a newborn infant, casting or bracing with the knee in flexion should be performed. If this fails, percutaneous or open VY quadricepsplasty, followed by above-knee casting, is indicated.

Question 1518

Topic: 4. Pediatrics
A 6-year-old boy with severe spastic quadriplegic cerebral palsy is nonambulatory. Examination reveals 10° of hip abduction on the left and 30° on the right with the hips and knees extended. The Thomas test shows 20° of flexion bilaterally, and Ely test results are 3+/4 bilaterally. Radiographs show a center edge angle of 0° on the left and -10° on the right. The neck shaft angles are 170° bilaterally. Which of the following procedures would offer the best results?
. Proximal femoral resections
. Bilateral adductor, iliopsoas, and hamstring lengthenings
. Bilateral varus derotation shortening osteotomies
. Injection of botulinum toxin into the adductors bilaterally
. Posterior branch obturator neurectomies bilaterally

Correct Answer & Explanation

. Bilateral varus derotation shortening osteotomies

Explanation

The patient has bilateral subluxated hips, with nearly vertical neck shaft angles; therefore, the treatment of choice is varus derotation osteotomy. Shortening of the bone on one or both sides may be necessary to allow adequate range of motion postoperatively. In patients this age and with this degree of bony deformity, soft-tissue releases are not likely to lead to hip stability. Botulinum toxin has been shown to be effective in the treatment of ankle equinus, but its efficacy in other areas has not been demonstrated as yet. The indications for obturator neurectomy are unclear at present. Proximal femoral resection is a salvage procedure for long-standing hip dislocations that are symptomatic and not reconstructable.

Question 1519

Topic: Pediatric Upper Extremity & Spine

What risk factor is most associated with progression of idiopathic scoliosis to a curve requiring surgery? Review Topic

. Curve magnitude of more than 20 degrees at menarche
. Curve magnitude of more than 30 degrees at the peak height velocity
. Curve magnitude of more than 30 degrees at skeletal age 12 years
. Curve magnitude of more than 30 degrees at Risser grade 2
. Curve flexibility of less than 50% at Risser grade 2

Correct Answer & Explanation

. Curve magnitude of more than 20 degrees at menarche

Explanation

The magnitude of the curve at the time of the peak height velocity is the most prognostic sign in relationship to surgery. More than 70% of curves that measure more than 30 degrees at this time are likely to reach surgical range.

Question 1520

Topic: 4. Pediatrics

-Video 3 shows the physical examination of the right hip of a 14-day-old full-term female infant. There is no history of breech presentation, she was born vaginally, and is the second child born to her mother. She is otherwise healthy and has been eating and gaining weight appropriately. What is the most appropriate course of action at this time?

. Observation, with a repeat clinical examination in 2 weeks
. Application of a hip abduction device and early follow-up to confirm reduction
. Arthrogram and closed reduction of the right hip under general anesthetic, followed by spica casting
. Open reduction of the right hip with a capsulorrhaphyDISCUSSION-The video shows an unstable right hip in a female infant. The visual ”clunk“ of the positive Barlow and Ortolani tests is readily evident. Initial treatment in a young infant consists of application of an abduction device to achieve and maintain hip location. Confirmation of successful hip location is usually performed by ultrasound examination. In the United States, the Pavlik harness remains the most commonly used hip abduction device, although others, such as hip abduction braces and the Frejka pillow, are available and have been shown to have similar success.Observation is not necessary when the examination shows clear instability. Arthrogram, closed manipulation, and spica casting are reserved for an older age group (those between 6 and 18 months of age). Open reduction is appropriate if the hip remains dislocated after 18 months of age.

Correct Answer & Explanation

. Observation, with a repeat clinical examination in 2 weeks

Explanation

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