Pediatrics: APGAR, Hip Dysplasia, and More

Apgar Score

• Body weight is not a component of the Apgar score
• The components of the Apgar score are: skin color, respiratory rate, pulse rate, and muscle tone

Weight Conversion

• A 45lb child is approximately 20kg

Severe Hip Dysplasia

• Spinal muscular atrophy is most likely to cause severe hip dysplasia as a complication

Trendelenberg Sign

• A positive Trendelenberg sign occurs when the buttock is lower on the non-weight bearing side

Hip Flexion Contracture

• The Thomas's supine test is most useful in diagnosing hip flexion contracture in the presence of significant lumbar lordosis

Rectus Definition

• Rectus describes foot and ankle joint complexes when the plane of the forefoot is at right angles to the heel bisection and the heel bisection is in line with the long axis of the tibia

Fully Compensated Forefoot Varus

• A clinical feature is that the forefoot is balanced on the ground when the rearfoot is in valgus, but the STJ is not yet fully pronated

Congenital Convex Pes Valgus

• The talar trochlea retaining its convexity is NOT a change of congenital convex pes valgus
• A change of congenital convex pes valgus is that the talar neck becomes shorter

Congenital Convex Pes Valgus Ligaments

• The spring ligament is consistently elongated in congenital convex pes valgus

Congenital Convex Pes Valgus X-Ray

• Reversal of the calcaneal inclination angle on the lateral x-ray is the most reliable finding for the diagnosis of congenital convex pes valgus

Grice Extra Articular Subtalar Arthrodesis

• Valgus deformity of the foot where the STJ may recur with growth is a drawback to the performance of a Grice extra articular subtalar arthrodesis

Talipes Calcaneovalgus

• Contracture of the anterior ankle capsule would most likely be seen in early infancy in a baby with talipes calcaneovalgus
• Closed reduction with stretching casts positioning the foot initially in equinus or equinovarus is the treatment of choice in the management of talipes calcaneovalgus

Hallux Varus

• Hallux Varus in infants and children is most likely associated with metatarsus adductus

Rubenstein-Tabybi Syndrome

• The form of HAV for patients known to have Rubenstein-Tabybi syndrome is best classified as teratologic HAV

Juvenile & Adolescent HAV

• In juvenile and adolescent HAV, a key issue is dealing with metatarsus primus adductus
• Abducting osteotomy of the base of the 1st MT may be an option to manage this component, but is made difficult because the physis for the 1st metatarsal can be injured

Hallux Flexion Deformity

• A 13 year old male can be considered for surgically fusing the joint if he has severe flexion deformity of the left hallux and cerebral palsy from birth trauma, especially if the IPJ is fixed in 20 degrees of flexion and cannot be extended

Premenarchal Female w/Erythematous Toe

• A 12 year old premenarchal female complains of discomfort at the medial aspect base of the right great toe for six months
• The dorsomedial aspect of the metatarsophalangeal joint is erythematous, mildly edematous and tender
• X-rays reveal a hallux abductus angle of 15 degrees, an intermetatarsal angle of 11 degrees, a proximal articular set angle of 3 degrees, a first metatarsal epiphysis that is still open, and a normal rearfoot with no signs of pronation
• Based on the above, wider shoes are initially recommended

Hallux Abducto Valgus

• A fourteen-year-old girl presents with painful unilateral hallux abductovalgus of three years duration, and the following data is obtained:
• There is irritation on the dorsomedial first metatarsal head
• The great toe is laterally deviated, there is a full painless range of dorsiflexion and plantarflexion
• Talocalcaneal angle: 15 degrees on the AP, Lateral talocalcaneal angle is 22 degrees, Calcaneal inclination angle is 19 degrees
• Metatarsus adductus angle is 29 degrees, IM angle is 10 degrees, Hallux abductus angle is 29 degrees, Proximal articular set angle is 18 degrees, Distal articular set angle is 13 degrees, and epiphyseal plates are closed
• The deformity is is not complicated by metatarsus primus adductus according to the above data

Second Toe Deformities

• The second toe hammer digit deformities are MOST likely to be pure flexion deformities in the sagittal plane

Flexion Toe Deformity

• Flexion deformity of the second toe is more likely to occur in boys age 8-10

Congenital Curly Toe

• The deforming muscle in congenital curly toe, with flexion and varus deformity, is most likely the flexor digitorum longus

Second Deformed Toe in Infant

• For a 4 month old female, with a second toe that is obviously deformed, and can be fully extended but reverts to the position seen in the radiograph when released, a tendon balancing procedure is recommended

Treatment for Varus Position Toes

• If the 3rd and 4th toes are in a varus position, observing the child every 6 months to watch for progression is the proper treatment

Preoperative Flexor Tendon Transfer

• Before doing a flexor tendon transfer in a 3 and 4 toe, it is important to mention that the toe undergoing surgery will be longer than anticipated compared to the other toes

Digit Flexion and Varus

• The 1st toe is least likely to develop a flexion and varus deformity

Digiti Quinti Varus

• Release of the dorsal, medial, and lateral capsule of the 5th MTPJ is NOT a component of the surgical correction

Wilson V to Y Approach

• The biggest disadvantage of the Wilson V to Y skin lengthening approach to the correction of digiti quinti varus deformity of the 5th toe is that there is an excessive scar

Butler Skin Advancing

• The biggest disadvantage of the Butler skin advancing approach in the correction of digiti quinti varus is that a vascular complication may occur

OKC Motion

• Pronation and supination in OKC is not a triplane motion, DF and PF of the foot is not only be seen when the patient is observed by looking on the sagittal plane, the correct answer is false

Flatfoot

• In all the variations of flatfoot, the principle issue is the excessive peritalar pronation

Flexible Forefoot

• Fixed forefoot varus being present at all ages is NOT usually in the case of flexible forefoot.

Forefoot Supinatus Deformity

• Forefoot supinatus is a supple non-rigid forefoot deformity associated with a pronated rearfoot
• If it persists over time, the most likely result is a rigid forefoot varus associated with some form of sagittal medial column collapse

Sagittal Plane Prone

• Sagittal plane dominant pronation is usually associated with ankle equinus, true

STJ ROM

• With a STJ ROM of: 30 inversion, 10 eversion, ankle dorsiflexion10 degrees with a knee extended and 20 degrees with the knee flexed, the transverse plane is the major plane of dominance

Pronation Comorbidity

• Primary ankle valgus deformity is most likely to make a foot with a “normal” appearance to be pronated

Arthroereisis Contraindications

• Arthroereisis procedures are contraindicated in all of the following: children with tarsal coalitions, rigid pronated feet in the absence of tarsal coalition, transverse dominant plane pronation, primary ankle valgus deformity

Indication for SMO

• A 4yo female with down syndrome and 20 degrees of flexible heel eversion is the best indication for an SMO

Most Efficient Non Pronating Orthosis

• The UCBL orthosis is the most efficient non-pronating orthosis

Likely Preoperative Diagnosis

• The most likely preoperative diagnosis is transverse dominant pronation with FF valgus

Developmental Landmarks

• Preferential left hand dominance at 10 months of age is NOT an appropriate developmental age to achieve this at

Suspect OM Bone Imaging

• Pathology other than infection is likely to be indicated with imaging of the bone and joint showing a photon deficient “cold” bone

Nerve Conduction

• Loss of myelin best explains nerve conduction of 7.2 when the average is 50+

Hallux Valgus Statements

• Hallux abductus angle = 25 degrees, intermetatarsal angle = 16 degrees
• Distal articular set angle = 0 degrees
• Proximal articular set angle = 1 degree
• An osteotomy of the 1st MT head may be performed in order to narrow the intermetatarsal angle for this case of hallux valgus

Hallux Varus Association

• Metatarsus adductus is MOST likely to be associated with hallux varus

Congenital Curly Toe Tendon

• Lumbricals are the deforming tendon

Physiological Pronation Problems

• Normal contours off-weight bearing are the most important physical finding to help distinguish simple physiological pronation from other more clinically relevant pronation problems

Flexible Flatfoot Radiographic Findings

• The talar bisection lie falls lateral to the 1st MT bisection line is NOT consistent with a diagnosis of "flexible flatfoot"

Flexible Flatfoot Preoperative

• An order for a weight bearing AP radiographs of the ankle should be done as a part of the preoperative work-up for children with severe flexible flatfoot

Low Muscle Tone Pronation

• SMOs for children with low muscle tone and moderate to severe pronation are the most efficient option

Talipes Calcaneovalgus Findings

• Plantarflexion to 55 degrees below neutral is NOT a clinical finding in talipes calcaneovalgus

Talipes Calcaneovalgus Complex

• In talipes calcaneovalgus, enlargement of the distal and medial calcaneus in the region of the anterior subtalar facet is most likely to be an impediment to full resupination of the STJ complex

Calcaneovalgus Talipes Management

• Closed reduction with stretching casts positioning the foot in equinus or equinovarus is the treatment of choice in the management of talipes calcaneovalgus

Talipes Calcaneovalgus Segmental

• Given there is a neurological basis for a particular case of talipes calcaneovalgus, being neuroanatomically segmental, L5 would be the predicted LOWEST neurologically functional level

APGAR Score

• Pulse is 88bpm, respirations are 5/min and irregular, trunk skin is pink, extremity skin is blue
• The infant is flaccid, and stimulating the nose causes altered facial expression
• Based on the observations made of a newborn ten minutes after birth, the APGAR score is 4

Cafe Au Lait Spots Abnormality

• Fibrous dysplasia is most likely to be associated with cafe au lait spots on the skin

Ankle ROM

• In most normal individuals, DF increases with knee flexion when the knee is moved from a fully extended to a flexed position

Hip Position

• Flexion is most likely to produce a measurable increase in external rotation of the thigh at the hip joint

Perineal Angle

• The angle formed by both femurs when the thighs are flexed to 90 degrees and fully abducted best defines the perineal angle

Ryder’s Test

• The Ryder’s test is specifically for Femoral anteversion

MRC Muscle Scale

• The medial research council muscle strength grading scale grades movement occurring while the limb is positioned so that gravity does not exert an effect on movement as 2

Elixir Dose Calculation

• Acetaminophen elixir with codeine is available with 12mg of codeine and 120 mg of acetaminophen per 5mL
• The recommended amount of codeine is 1mg/kg
• For a 27lb boy, acetaminophen elixir with codeine may be given 5ml every 4 hours

Scoliosis Type

• Segmental bars, butterfly vertebrae, and hemivertebrae will all produce congenital scoliosis

Adolescent Scoliosis

• The approximate incidence of treatable idiopathic adolescent scoliosis in the unselected pediatric population is 2%

Diagnostic Test for Hip

• The Barlow's test is considered diagnostic for unstable hip dysplasia

Dislocated Hip in Infant

• Limited hip abduction will be a more reliable indicator of a dislocated hip as an infant reaches 3 months when there is also less reliability of using Ortolani's sings

Femoral Head Location

• If the femoral head is located outside the acetabulum, the femoral head should lie inferior to Shenton's line

Examination Following Form

• There is no way of telling which side is dislocated if your secretary spilled coffee on the examination form

Cause of Pediatric Pes Cavus

• CMT syndrome is the most common cause of pes cavus in the pediatric population

Arthrogryposis Multiplex Congenital

• Premature delivery is not a likely result

Clinical Myotonia Symptom

• Myotonia as a clinical symptom can be recognized by inability to relax after contraction

Muscle dystrophy

• Calf muscles in boys with Duchenne muscular dystrophy are the first to become weak is incorrect

Duchene Muscular

• The initial treatment is tendo-achilles lengthening bilateral
• Ankle DF is 5° above neutral with knees both extended as well as flexed
• Knee extension lacks about 10° short of full extension
• Hip extension is full
• Quadriceps strength is 2/5 bilateral
• Hip extensors are 2/5 bilateral

Systemic Onset Juvenile

• Positive rheumatoid factor and ANA is not seen in a systemic onset juvenile

Rheumatic Fever Work Up

• Tests for Antistreptolysin O titer are most useful

High Risk RA

• ANA should be used indicate high risk iridocyclitis

Arhtiritis

• A Septic Arhtiritis must be determined to be

Collagen RA

• Granuloma annulare is one of the following

Subacute OM

• Subacute is what Brodies is

Metaphyseal OM

• Vessels to then joint

Hematogenous Infections

• S. Aureus most likely

Twelve Year Old Base Pain

• First do orthodics and wide shoes if base pain

Information to Add

• Head Shaft angle needs to be found

Hallacus surgical

• All is ok

Bunionectomy Contraditications

• High reccurance

Feet Statements Correct

• Doral ski

curly toes

• FDL IS WHAT CURVES

Hammer toe toe

• To long toe

Gangrene

• The gangrene of the fith foe is the

cuff

• Wide does