Achondroplasia

 FGFR3
 rhizomelic shortening of the limbs, midface hypoplasia, frontal bossing, lower extremity
malalignment, hyperlordosis and thoracolumbar kyphosis
 MRI C spine prior to surgery to evaluate for foramen stenosis

ACL tear
 XR showing avulsion fx of proximal lateral tibia (Segond fx) is pathognomonic . Next step is MRI
 Physeal sparing and physeal respecting ACLR minimize risk of growth disturbance, tibial
recurvatum, angular deformity
 significant risk of sustaining a similar injury to the contralateral knee
 The most common deformity after ACL reconstruction in a skeletally immature patient includes
valgus deformity
 Adolescent tx: best success with autograft, if skeletally immature w growth remaining extra-
articular ITB reconstruction

Adolescent idiopathic scoliosis

 Most common: R thoracic with hypokyphosis
 Minimal number of hours to wear brace to prevent surgery due to curve progression: 18 hours
 Brace if curve >20. Brace wear >17.6 hours per day corresponded to a 90% success rate
 72% of patients able to avoid curve progression to ≥50 by wearing a brace for 13 or more hours
per day.
 Posterior spinal fusion is reserved for progressive deformities that exceed 50°; observation is
indicated for deformities less than 20°
 Selective thoracic fusion is indicated for patients who have primary thoracic curvatures (Lenke
type 1 and 2 curves) with flexible lumbar curves.
 The most critical determinant of whether or not a selective thoracic fusion will be successful is
an apical vertebral translation ratio >1.2.
 Patients who received corticosteroids were more likely to stand at their initial PT evaluation and
had no difference in wound dehiscence or infection rates from their non-corticosteroid cohort.
Decreased use of narcotics while admitted postoperatively
 ERAS pain pathway post-op: decrease time to ambulation and decreased pain

AIIS avulsion
 Rectus

Amniotic band constriction

 associated with low birth weight, preterm delivery, clubfoot, cleft palate

Ankle equinus
 Tx: try non-op, then surgery
 lengthening can occur in 3 zones – the muscle belly of the gastrocnemius, in the
musculotendinous junction of the gastrocnemius and/or soleus, or in the Achilles tendon
 If ankle dorsiflexion increases by more than 10° with knee flexion, gastrocnemius release should
be considered over an Achilles tendon lengthening
 The Silfverskiold maneuver, the ability to dorsiflex the ankle past neutral with the knee flexed,
indicates that if the gastrocnemius is relaxed, the Achilles tendon is not tight
ASIS avulsion
 Sartorius/TFL origin
 Tx: Pain management, protected weight bearing, and activity restriction

Bipartite patella
 Accessory center of patella; do not be fooled for patella fx
 Superolateral pole
 50% bilateral
 Tx if symptomatic: NSAIDs, PT

Bisphosphonates
 Inhibit osteoclastic bone resorption

Blood supply
 in children until about age 4, the primary supply to the proximal femoral physis arises from the
posterosuperior branch to the lateral cervical ascending artery, which comes from the medial
femoral circumflex artery.

Blount disease
 Tibia vara (can be normal under age of 2)
 Infantile: never observe if >4, mild dx metaphyseal-diaphyseal angle (Drennan angle) >16°
treated with guided growth, advanced dx (>20 degrees) treated with corrective osteotomy
 A/w HTN
 Adolescent: tx is always surgical (guided growth of proximal tibia vs tibial osteotomies). For full
correction, corticotomy followed by gradual adjustment with the use of an external fixator is the
safest, most reliable option. Gradual correction also allows for immediate knee range of motion
and weight bearing. Guided growth is not sufficient for correction of large multidimensional
deformities.
 The best construct to avoid screw failure would be 2 solid stainless steel screws in the epiphysis
and 2 in the metaphysis

Brachial plexus birth injury

 glenoid retroversion, humeral head flattening, posterior subluxation of the humeral head, and
overall incongruity
 Risk factors: shoulder dystocia, mechanically assisted delivery, induced labor, prolonged labor,
maternal DM, infant size >90th percentile
 Vast majority (in the range of 90%) of brachial plexus birth palsies resolve without intervention.
 Spontaneous recovery may occur for up to 2 years, but early (antigravity) recovery of biceps
function suggests a favorable outcome and high likelihood of complete recovery
 Preganglionic avulsions have little chance of spontaneous recovery and can be indicated by
evidence of Horner syndrome (i.e., disruption of the sympathetic chain) or winged scapula from
long thoracic nerve palsy.
 Erb's palsy: C5-6
 Timing of nerve surgery is variable, but it can be considered as early as 3 months if the child is
not demonstrating antigravity biceps function
Broadie abscess
 Insidious onset often after a long period of recurrent pains in the extremity
 Usually no fever
 Tx: abx, drainage

Buckle fx
 No difference in outcomes or pain control with brace vs cast

Capitellum fx
 Tx: ORIF

Caffey disease (infantile cortical hyperostosis)

 Presents like osteomyelitis
 Mandible is involved in 70 to 90%
 Usually spontaneous regression of the findings by 2 years of age

Calcaneovalgus foot
 a/w posterior medial bow of tibia (get XRs tibia)
 Tx: follow until maturity
 Must differentiate against congenital vertical talus which ALSO has hindfoot equinus

Chance fx
 flexion-distraction injury resulting in compression injury to the anterior portion of the vertebral
body and distraction injury to the posterior elements
 3 column spine injury
 30-50% chance of abdominal injury, /hallow viscus duodenum most common
 "lap belt" injury because of its association with the older lap seat belts or with improperly used
modern seat belts

Clavicle fx
 Definitive indications for surgical fixation of clavicle fractures in the adolescent population
include open fractures, floating shoulder injuries, and associated neurovascular injuries
 Non-op: most likely outcome is union
 ORIF faster return to activity

Cleft hand
 AD inheritance
Clubfoot
 Tx: serial casting and Achilles tenotomy; if the deformity recurs, the standard of care is to repeat
serial casting in order to obtain correction. Afterward, the correction must be maintained. In an
infant or very young child, the correction is maintained with use of a boots-and-bar orthosis or
one of several options. In an older, more independent and ambulatory child, it is more typical to
maintain correction with a tibialis anterior tendon transfer
 PITX1-TBX4

Chondroblastoma
 2nd decade, epiphysis, lytic
 Tx: curettage and bone graft

Compartment syndrome
 Measure within 5mm of fx site

Congenital femoral deficiency

 Absence or hypoplasia of the cruciate ligaments of the knee is a common occurrence.
Therefore, when performing intramedullary lengthening, it is important to monitor the knee
closely for subluxation

Compartment syndrome
 3 A's: increasing analgesic requirements, agitation, and anxiety

Concussion
 Follow return to play protocol, must be asymptomatic at rest
 Second hit: disruption of cerebral autoregulation

Congenital scoliosis
 not seem to have any genetic link or hereditary basis of transmission

Congenital vertical talus

 Tx: Reverse Ponseti serial casting with stabilization of the talonavicular joint and Achilles
tenotomy

Cozen phenomenon
 Valgus overgrowth of proximal tibia physis in response to proximal tibia fx, tx is observation

CP
 UE tendon transfer shown to provide measurable improvement in supination and wrist
extension
 Rate of hip dislocation: GMFCS I negligible; GMFCS II 15%; GMFCS III 40%; GMFCS IV 70%;
GMFCS V 90%.
 Grouch gait tx: ground reaction AFO
 Spastic foot: posterior tibialis spasticity is what causes ankle/foot varus; the gastrocsoleus
complex contributes to the ankle equinus; can treat with Botulinum toxin
Discitis/OM
 Anti-staph abx. If no improvement, or if there are risk factors for other organisms, (foreign
travel, immunocompromised, exposure to unpasteurized milk), CT-guided biopsy may be
indicated

DDH
 Observe until 6 weeks, then can start Pavlik
 US for diagnosis when <6 months, otherwise AP/frog lateral XR
 Risk factors: first-born status, female sex, breech intrauterine position, or a family history
-Tx: Pavlik (<6 mo), Spica (6-18 mo), open reduction/femoral osteotomy/acetabular osteotomy
(>2y)
Blocks to reduction: TAL, ligamentum teres, Pulvinar, Labrum
Discoid meniscus
 congenital variant that comprises a spectrum of meniscal shape and stability
 Usually lateral
 Symptomatic patients will typically present with an extension clunk, decreased range of motion,
and lateral joint-line pain. Many parents/patients will present to clinic with complaints of an
abnormal gait and the feeling that the knee is "dislocating."
 Decreased number of Type 1 collagen, disorganized
 For patients who have pain, decreased range of motion, and/or an extension clunk, arthroscopic
saucerization with repair (if peripheral instability is present) is indicated

Distal femur physeal fx

 Think NAT, skeletal survey, social work/CPS consult
 Independent risk factor for need of additional surgery to treat LLD: ossification of tibial
tuberosity
 #1 complication: Premature physeal closure leading to LLD/angular deformity

Down Syndrome
 ADI is between 4.5 mm and 10 mm in a patient with no decrease in physical activities and no
abnormal neurological finding; athletes with Down syndrome may participate in most activities
but have been advised to avoid high-risk sports such as diving and football.

Duchenne MD
 Waddling gait, Trendelenburg gait with lumbar hyperextension, trouble getting up from a seated
to a standing position from the floor
 XLR (daughter would be 0% chance of getting)
 Posterior spinal instrumentation and fusion are recommended in those whose spinal curve is
>20°, are prepubertal, and are not on glucocorticoids because progression of the curve is
expected. It is recommended that those with a pelvic obliquity of >15° also have stabilization
and fusion into the pelvis
 Cannot have Succinylcholine as may cause malignant hyperthermia-type reaction that can cause
fatal rhabdomyolysis and hyperkalemia

DVT
 Risk factors: Obesity, oral contraceptive use, and gastrointestinal or renal issues
 Sarcoma patients at risk due to tumor activation of Factor X to Xa
Elbow ossification:
 capitellum, radial head, medial epicondyle, trochlea, olecranon, and lateral epicondyle

Elbow pain
 Risk factors for elbow pain in young athletes include age (>11 years), height (>150 cm or recent
increase), pitcher, days of training, grip strength at least 25 kg, external rotation of the shoulder
less than <130°, and increased muscle strength of the shoulder.

Elbow dislocation
 a/w medial epicondyle fracture, if entrapped: ORIF
 Radial head ORIF: #1 complication is stiffness

Exercise induced asthma

 B2 agonist

FAI
 either asphericity on the femoral head-neck junction (CAM) or overcoverage on the acetabular
side of the hip joint (pincer)
 Try NSAIDs/PT before surgery

Female triad
 Disordered eating, hypoprolactinemic amenorrhea, osteoporosis
 If have joint pain and XRs negative get MRI to eval for stress fx

Femoral anteversion
 In-toeing gait
 Sits in W position
 Can be associated with external tibial torsion
 Hip increased IR, decreased ER
 Patella internally rotated (kissing patella)
 Tx: observation and parental reassurance, bracing, use of inserts, physical therapy, and sitting
restrictions; Operative indications are appropriate for children >9 to 10 years of age with <10° of
external rotation on physical examination

Femoral shaft fx
 <6 mo: Pavlik
 6mo - 5 yo: Spica (single leg walking spica has been shown to have similar to possibly better
results than a traditional double hip spica cast)
 5-11, <49 kg, length stable: flexible IMN
 5-11, >49 kg, length unstbale: submuscular bridge plate. Recommendation is plate removal after
union
 >11, >49 kg, unstable: antegrade rigid IMN
 LLD: Length unstable fracture patterns and decreased "canal fill" by the flexible nails (nail canal
diameter ratio <0.8) have both been associated with femoral overgrowth.
Fibrous dysplasia
 GNAS

Freiberg dx
 Metatarsal head osteochondrosis
 adolescent females and is typically caused by repetitive second metatarsal head stress
 Tx: initial is non-op (cast v boot)

Gene valgum
 Skeletally immature: medial distal femur hemiepiphysiodesis
 Skeletally mature tx: distal femur lateral opening wedge osteotomy

Genu varum
 Most of time physiologic, lateral thrust is NOT physiologic
 generally improves as the children approach 16 to 18 months-old
 metaphyseal-diaphyseal (Drennan's) angle <11 degrees likely to not progress
 Orthotic management could be considered in those with angles >9°
 Bracing should be instituted in those individuals with angles >16°.
 Hemiepiphysiodesis and valgus osteotomies are typically undertaken around the age of 4 years-
old if bracing fails to adequately correct the deformity.
 Ddx: Blount disease, skeletal dysplasias, and metabolic disorders, such as rickets
 Next step: send for blood work, calcium, phosphorus, alkaline phosphatase, and vitamin D, as
well as renal function tests.

GIRD
 decreased shoulder rotational arc of motion

Grisel syndrome
 upper respiratory infection or recent head/neck surgery can cause spasm of the
sternocleidomastoid muscle and acute head tilt/rotation in the setting of relative ligamentous
neck laxity
 Next step: Anteroposterior and open mouth odontoid radiographs of the cervical spine, look for
asymmetry in distance from the lateral masses
 CT is gold standard

Growing rods
 Increase in FVC only

Gymnasts wrist
 Distal radial physeal stress syndrome
 Widened growth plate with ill-defined borders
 Initial tx: rest NSAIDs immobilization 3-6 weeks
 Sx: resect physeal bridge vs ulnar epiphysiodesis +/- shortening radial osteotomy

Halo pins
 1 cm above the orbital rim over the lateral 1/3 of the eyebrow
 Skeletally immature: 8 pins, 2-4 pounds
Hip dislocation
 Traumatic: Reduce and order MRI
 Congenital: >18 mo tx is open reduction with femoral/pelvic osteotomy

Hip dysplasia
 Tx: Older (Open reduction and capsulorrhaphy, acetabular osteotomy, and proximal femoral
varus osteotomy)
 Periacetabular osteotomy: Superior pubic rami, ilium, posterior column, and ischium. Anterior
(Smith-Peterson) approach: interval b/n sartorius(femoral n) and TFL (superior gluteal n)

Hurler syndrome
 Abnormality in lysosomal accumulation of dermatan sulfate and heparan sulfate

Infantile scoliosis
 Deformity progression is linked to the curve magnitude at presentation, being either ≤25° or
≥25°

Intraarticular joints
 Shoulder, Hip, Elbow, Ankle

Intoeing
 3 causes: femoral anteversion
 Reach adult anteversion b/n 8-10

Spondylosis
 young athletes such as volleyball players, football linemen, and gymnasts who perform
repetitive hyperextension
 Look for hamstring tightness

Jaffe-Campanacci syndrome
 NF1
 Multiple NOF, café-au-lait macules in individuals without neurofibromas

Kocher criteria
 Hip septic arthritis, low sensitivity for knee
 non-weight bearing, temperature >38.5°C (101.3°F), erythrocyte sedimentation rate >40 mm/hr,
and white blood cell count >12,000/mm3. Serum C-reactive protein (CRP) level was later studied
as a fifth data point

Kohler dx
 AVN tarsal navicular
 Supplied by the terminal posterior tibial and anterior tibial arteries

Kyphosis
 Lowest instrumented vertebral level: draw posterior sacral line, the most proximal vertebra
touched by this line represents an appropriate lowest instrumented vertebrae
Langerhans cell histiocytosis
 Vertebral plana (tx is non-op)
 Langerhans cells with tennis racquet-shaped birbeck granules
 + CD1a and CD207.

Larsen syndrome
 multiple congenital joint dislocations (bilateral elbows, hips, and knees), facial dysmorphism and
ligamentous laxity
 FNLB

Lateral condyle fx
 Tx: <2 mm cast, 2-4 mm CRPP, >4 mm ORIF

Legg-Calve-Perthes
 Unknown etiology
 Femoral head deformity
 5-8 yo
 Prognostic indicators: extent of the femoral head deformity and loss of hip joint congruity at
maturity (Stulberg classification), age at onset, lateral pillar height at the fragmentation stage
(lateral pillar classification), and premature physeal closure
 Younger pt: Activity modification, non-steroidal anti-inflammatory drugs, physical therapy, and
close follow-up
 Surgical intervention is recommended for older patients, with more severe disease, or with loss
of concentricity of the hip

Lesser trochanter avulsion

 Iliopsoas avulsion

Little League Shoulder

 Late cocking phase
 XR: widened physis
 Hypertrophic zone
 Tx: Complete rest from throwing for 6 weeks and then a graduated return to throwing

LLD
 An accommodative shoe lift would be useful for an LLD <2-2.5 cm
 Surgical treatment in the form of epiphysiodesis, shortening osteotomy, or distraction
osteogenesis should be reserved for discrepancies >2.5 cm.
 A limb length discrepancy of >5 cm is typically treated with distraction osteogenesis of the short
limb.

Lyme dx
 First line screening is ELISA
Lyme arthritis
 Differentiate from septic arthritis: progesses relatively slowly; children often remain ambulatory,
and fevers are less likely to be >38.5°C. Synovial fluid cell counts are often >50,000, neutrophil
differential in Lyme arthritis is typically <90%
 Dx: confirmed with serologic lyme testing and confirmatory Western blot analysis
 Tx: 28-day course of oral amoxicillin or doxycycline NSAIDs and does not require surgical lavage

MACI procedure for cartilage defect

 Type I and 2 collagen

Madelung deformity
 congenital dyschondrosis of the ulnar volar physis that leads to growth deformity of the distal
radial physis
 a/w Leri-Weill dyschondrosteosis, SHOX mutation
 Tx skeletal immature if observation fails: physiolysis of the ulnar volar physis with release of
Vickers ligament

Marfan syndrome
 AD
 FBN1 gene
 Scoliosis treatment with higher fixation failure, CSF leak, fx

Medial condyle fx
 Arthrogram/pre-op MRI followed by ORIF

Medial tibial stress syndrome

 exercise-induced pain localized to the distal two-thirds of the posteromedial tibia
 reported risk factors include female sex, greater body weight or body mass index, increased
navicular drop, prior use of orthotics, previous running injury, reduced running experience, and
greater hip external rotation

MHE
 AD, 50% transmission rate, female 96% penetrance, male 100% penetrance

Milroy disease (congenital familial lymphedema)

 FLT4 mutation

Monteggia fx
 Fixing ulna is key for getting radial head back.
 If chronic and missed, ulna osteotomy

MHE
 AD
 EXT 1/2
MRSA
 PVL toxin
 a/w DVT, get a duplex US
 If develop SOB etc: order CT chest (look for PE)
 Coagulase: activation of prothrombin to thrombin leading to clot and abscess formation

Mucopolysaccharide disorder
 Dysplastic vertebral bodies
 Thoracolumbar gibbus
 Dx: Urinary glycosaminoglycan quantitative analysis

Myelomenigocele
 a/w dislocated hips, likely tx is observe/PT

Nail-patella syndrome (hereditary osteo-onychodysplasia (HOOD)

 XR pelvis: iliac horns
 aplastic or hypoplastic patellae and associated patellar instability
 hypoplastic capitellum and radial heads, causing limited range of motion at the elbows
 Hypoplastic nails
 a/w glaucoma

NAT
 Metaphyseal corner fx, posteromedial rib fractures, scapular fractures, spinous process
fractures, and sternal fractures
 children younger than 26 months with a diaphyseal femur fracture be evaluated for child abuse,
also if nonambulatory
 Next step: skeletal survey, report to CPS

Neurofibroma
 NF1
 Chromosome 17
 Scoliosis: migration of the rib heads into the spinal canal, dural ectasia with scalloping of the
vertebral bodies
 tibial pseudarthrosis, multiple café au lait spots, iris hamartomas, optic glioma
 AL bowing: treatment of the anterolateral bowing with intact cortices is a knee-ankle-foot
orthosis and restricted activities in an attempt to offload the bone and possibly prevent or at
least delay progression to fracture

Odontoid fx
 Type 1: collar
 Type 2: <40 halo, 40-80 surgery, >80 collar
 Type III: collar

Osteoid osteoma
 Night pain, relieved w NSAIDs
 Tx: RFA; if near neurovascular structures can do excision
Osteochondritis dissecans (OCD)
 Knee: medial condyle, mechanical sx, MRI to evaluate fluid signal, bony edema, cartilage
fissuring
 Elbow: gymnastics, baseball; repetitive micro trauma to capitellum
 Tx: conservative (estrict weightbearing, initiate immobilization, and recheck imaging in 6 weeks);
if unstable arthroscopy with loose body removal and associated microdrilling

Osteofibrous dysplasia
 Eccentric, lytico
 Osteoblastic rimming
 Tx: observe

Osteomyelitis
 CRP level was an independent risk factor for the development of VTEs.
 #1 always S. aureus. Do have to think about salmonella for African Americans
 In the management of pediatric acute osteomyelitis, early transition to oral antibiotic therapy
has been demonstrated to have a similar risk of treatment failure as prolonged IV therapy via a
PICC. Lower rate of rehospitalization or return visit to the emergency department
 MRI w subperiosteal abscess: operative debridement and abx

Osteopetrosis
 Hard brittle bone
 Dysregulated osteoclast function

OI
 COL1A1 (type I collagen)
 Olecranon fx's

Osgood Schlatter
 traction apophysitis of the tibial tubercle as a result of overuse repetitive strain on the
secondary ossification center
 XR: irregularity of the apophysis, separation from the tibial tubercle, and fragmentation
 Tx: Rest Ice NSAIDs

Osteochondritis dissecans
 Femoral OD in baseball catchers: More posterior location on femoral condyles

Osteochondral lesions
 Ankle: medial (chronic) vs lateral (acute)
 If contained: conservative treatment with limited weight bearing followed by protected weight
bearing and physical therapy

Patella dislocation
 First time: PT

Patellar sleeve fx:

 Tx: open surgical repair
Popliteal cyst
 most commonly the gastrocnemius-semimembranosus bursa
 Tx: observe

Posterior ankle impingement syndrome

 painful, usually limited plantar flexion of the ankle due to posterior impingement of either soft
tissue or a bony structure (such as an os trigonum or large posterior process of the talus)
between the posterior distal end of the tibia (medial malleolus) and the posterior tuberculum of
the calcaneus

Pre-axial polydactyly
 a/w longitudinal epiphyseal bracket
 Tx: remove the duplicated medial digit, then excise the bracket (physiolysis)

Proximal humerus fx
 Most of time non-op due to the amount of growth that occurs from the proximal humeral physis
(80%)

Postaxial polydactyly
 AD, high penetrance

Radial clubhand
 Mode of inheritance: spontaneous mutation
 1/3 of the time a/w cardiac, hematologic, or renal abnormalities

Radius fx
 If tx is flexible nail, complication is EPL injury

Radial neck fx
 LAC: acceptable alignment of a pediatric radial neck fracture is considered to be <30%
translation and <30° of angulation
 If not acceptable after closed reduction, next do percutaneous reduction of the fracture with a
Steinman pin. If still not acceptable, open reduction.

Rickets
 Genu varum
 XLD (familial hypophosphatemic): elevated levels of serum alkaline phosphatase and decreased
serum phosphate levels
SCFE
 slipping of the metaphysis away from the epiphysis
 Hypertrophic zone of physis
 Increased risk: Obesity (elevated leptin)
 Risk of contralateral SCFE: age, obesity, metabolic disorders, skeletal maturity, as well as
numerous radiographic measures such as superior epiphyseal extension ratio, posterior
epiphyseal extension angle >10, and epiphyseal-diaphyseal angle difference
 *Examine hip when complain of knee pain
 PE: increased hip ER with passive hip flexion
 Tx: in situ fixation (more anterior and proximal than adults); can get FAI due to acquired CAM
deformity
 Reason for AVN: medial femoral circumflex artery arising from the posteromedial aspect of the
deep femoral artery; leads to the worst long-term prognosis in slipped capital femoral epiphysis
(SCFE), most likely requiring total hip arthroplasty

SCH fx
 Anterior skin puckering with ecchymosis is caused by impingement of the brachialis fascia by
the proximal bone fragment
 Pre-op pink pulseless hand, urgent CRPP. 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. Basically if pre-op is pink and pulseless and so is
post-op, just observe.
 If cool and pulseless: emergent CRPP in ED, open reduction may be required if the vascular
compromise persists after closed reduction and pinning or if adequate closed reduction cannot
be achieved
 Pulseless, warm hand, with nerve palsy: emergent closed reduction and percutaneous pinning
 Acute loss of perfusion in a previously well-perfused extremity following a closed reduction and
pinning of a displaced supracondylar fracture: next step is remove the fixation, redisplace the
fracture, and reassess the limb perfusion
 Flexion type: most commonly interposed anatomic structure is the ulnar nerve, a/w ulnar n.
palsy
 Extension type: most common palsy is AIN
 The most commonly used radiographic landmarks to judge reduction of a supracondylar
humerus fracture (to ensure sagittal plane alignment) is to ensure that the anterior humeral line
passes through the capitellum on the lateral radiograph
 Physical therapy has not been shown to be of benefit in treating these injuries when compared
with observation and/or a home-based exercise program
 If medial column unstable after 2 pins, add 3rd lateral or medial pin
 Complication from tx: cubitus varus (varus, extension, and rotational deformity of the distal
humerus)
Scheuermann disease
 adolescents who participate in sports that require repeated flexion and extension movements
such as gymnastics, wrestling, football, weight lifting, rowing, tennis, and bicycle racing
 wedging of the vertebrae at the thoracolumbar spine, there is a loss of lumbar lordosis and the
back appears straight or mildly kyphotic
 generally is nonprogressive and treated with exercise and conditioning programs and restriction
of sport until the athlete is pain free

Schottle point
 Origin of MPFL
 Skeletally immature: 5 mm distal to physis

Scoliosis
 Any curve >20° in a patient with early onset scoliosis should undergo MRI of the entire spine to
assess for intraspinal pathology

Seat belt sign

 a/w spine trauma
 Indicates ruptured hallow viscus
 Tx: general surgical exploratory laparotomy followed by staged instrumented reduction and
fusion of the Chance fracture of the lumbar spine

Septic arthritis
 Most common us S. aureus. If cx neg think Kingella. <4: Staph aureus, Kingella, Strep pyogenes.
Newborn: Beta-hemolytic streptococcus
 Most common etiology is hematogenous spread
 Tx: surgical debridement. If continue to have pain/elevated inflammatory markers 72 hours
after, get rpt MRI

Sever disease
 Heel pain
 Overuse injury of the calcaneal apophysis
 Tx: symptomatic (Rest, ice, use of heel pads, physical therapy, and nonsteroidal anti-
inflammatory drugs)

Septal hematoma
 Urgent decompression

Sickle cell
 Ratio of hemoglobin to hematocrit: strong predictive factor for femoral head osteonecrosis
 Crisis tx: intravenous fluids, oxygenation, NSAIDS and parenteral opioids

Spondylolysis
 LBP worse with extension
 abnormality in the pars interarticularis
 XR: just need AP/Lateral
Syndromic scoliosis
 Mehta casting can delay need for future spinal surgery

Tarsal coalition
 Child with flatfoot , recurrent ankle sprains
 Limited subtalar motion
 Talocalcaneal: "C" sign on XR
 Calcaneonavilcular
 CT scan
 Initial tx: CAM boot, arch suppor

Thrombocytopenia absent radius

 bilateral complete absence of the radii with presence of both thumbs and thrombocytopenia

Tibial bowing
 Posteromedial: probably mild, a/w calcaneovalgus foot, most likely like term outcome is LLD
 Anterolateral: always look for something else
 Anteromedial: always missing (fibular hemimelia, ACL deficiency, ball and socket ankle joint,
lateral femoral hypoplasia)

Tibial eminence/spine fx
 a/w meniscal entrapment (anterior horn medial meniscus)
 Tx: fractures with more than 5 mm of anterior displacement or completely displaced fractures
should be treated with operative reduction and fixation. Reduction can be performed both open
or arthroscopically, and fixation is typically either screws or sutures
 Most common complication: symptomatic arthrofibrosis; most likely to have concomitant ACL
tear

Tibial shaft fx
 Acceptable criteria: fracture shortening <1cm, coronal angulation <10°, sagittal angulation <15°,
and rotation <10°
 0° of varus/valgus and 10° of procurvatum/recurvatum are acceptable in children <8 years-old
 Open fx: abx, tetanus, I&D, IMN, +/- WVAC and rpt I&D
 WBAT vs NWB in cast in acceptable criteria: no other differences in union rates, malunion rates,
or final shortening, greater functional improvement at 6 weeks. Decreased fracture healing time
with no increase in complications.
 Intact fibula: fall into varus. Tibia and Fibula: fall into valgus

Tibial tubercle fx
 Monitor for compartment syndrome due to rupture of anterior tibial recurrent artery
 #1 complication with sx: bursitis over screw heads / symptomatic implants
 If presenting w compartment syndrome: ORIF of fx with fasciotomy (need anatomic reduction of
fx first)
Tillaux fx
 anterior-inferior tibiofibular ligament avulses an epiphyseal fragment off the anterolateral tibia
 commonly occurs in the 18 months before complete distal tibial physeal closure
 distal tibial physis closes sequentially, centrally, medially, and then laterally, making the lateral
portion of the physis most susceptible to injury in this transitional period.
 The injury occurs with a supination-eversion mechanism

Transphyseal distal humerus fx (distal humerus physeal separation)

 proximal radius and ulna are not in line with the distal humeral metaphysis, but they maintain
an appropriate radiographic relationship with each other
 arthrogram can help delineate the relationship between the distal humeral epiphysis and
metaphysis during reduction and pinning
 Tx: CRPP

Trevor disease (dysplasia epiphysealis hemimelica)

 asymmetric osteochondral overgrowth of the epiphyseal cartilage

Trigger thumb
 Acquired “popping” or fixed flexion contracture of the thumb IP joint due to a mismatch in the
size of the flexor pollicis longus (FPL) tendon near the A1 pulley. Notta nodule"
 Spontaneous resolution is possible but usually occurs by age 2. Continued nonsurgical treatment
in children age 4 or older is not likely beneficial and may impair manual tasks if symptoms are
present
 Tx: release A1 pulley

Toxic shock syndrome

 Hypotension, multiorgan involvement
 Renal impairment; coagulopathy; abnormal liver function tests; acute respiratory distress
syndrome; generalized erythematous macular rash; or soft tissue necrosis

Winking owl sign

 Seen on lumbar XR
 Next step: MRI

X-linked hypophosphatemic rickets

 XLD
 PHEX gene
 Increase in FGF 23, leads to reduction of the proteins involved in renal phosphate reabsorption
and 1,25-dihydroxyvitamin D production. This leads to phosphaturia and ultimately in decreased
mineralization of the long bones and teeth
 Decreased phosphorous, increased alk phos, normal calcium, normal vit D 25-OH