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, 2025 Pediatric Orthopaedic Examination Answer Book · 7




Figure Y 1a Figure Y 1b

Question Y 1

A Y5-year-old Yboy Y has Y had Y a Ylimp Yfor Ythe Y past Y4 Y weeks Ywith Yintermittent Ypain Y at Ythe Y foot. Y He
Y remains Ynormally Y active Yand Y has Yno Yhistory Y of Ytrauma. Y He Yhas Yno Yfevers, Y rashes, Y or Yswelling.
Y Examination Yreveals Ytenderness Yat Ythe Ymid-dorsum Yof Ythe Yfoot Ymedially. Y Radiographs Yare Yseen Yin
Y Figures Y 1a Yand Y lYb. Y Treatment Yshould Yinclude Ywhich Yof Ythe Yfollowing?


1. MRl Yof Ythe Yfoot Y with Y gadolinium
2. Open Y biopsy Y of Ythe Y lesion
3. Needle Y aspiration Y and Y culture, Y followed Y by Yantibiotic Y treatment
4. Observation Yor Yan Yorthotic Yarch Ysupport
5. Steroid Yinjection Yof Ythe


lesion YPREFERRED YRESPONSE: Y4
Y




DISCUSSION: YOsteochondrosis Yof Ythe Ytarsal Ynavicular Yis Ymost Ycommonly Yidentified Ybetween Ythe
Y ages Yof Y2 Yand Y9 Yyears. Y The Ycondition Yis Ybenign Yand Yself Ylimited Yin Ynature. Y In Ypatients Ywith
severe Ypain, Ya Yperiod Yof Ycasting Ymay Ybe Ywarranted, Ybut Yotherwise Ymanagement Yusually Yconsists Yof
Y


observation Yor Ya Ysupportive Yorthotic.
Y




REFERENCES: YDiGiovanni YCW, YPatelYA, YCalfee YR, Yet Yal: YOsteonecrosis Yin Ythe Yfoot. Y JAmYAcad
Orthop YSurg Y2007; Y15 Y:208-217.
Y


Williams YGA, YCowell YHR: YKohler's Ydisease Yof Ythe Ytarsal Ynavicular. Y Clin YOrthop YRelat YRes Y 198Y1;
158:53- Y58.
Y

,8 American Academy of Orthopaedic Surgeons
•




Figure Y 2


Question Y 2

A Y3Y-year-old Y girl Y has Y had Y pain Y and Y swelling Y in Yher Y left Y thigh Y for Y the Y past Y 3 Y weeks. Y Her Ymother
Y states Y she Yhas Y had Y a Ytemperature Y as Y high Y as Y 100.4 Y degrees Y F Y (38 Y degrees Y C) Y and Y a Yweight Y loss
Y of Y5 Y pounds. Y A Y CBC Yshows Y a YWBC Y count Yof Y11 Y ,000/mm3 Y, Y an Yerythroc Yyte Y sedimentation Yrate Y of
Y 13 Y mmlh, Y and Y a Y C-reactive Yprotein Y of Y0.3. Y A Yradiograph Y is Y shown Y in Y Figure Y Y What Y is Y the
Y next Y step Y in Y management?


1. Biopsy Y and Yculture Y of Ythe Y lesion
2. MRI Y of Y the Y left Y femur
3. IV Y antibiotics Y for Y 6 Y weeks
4. Incision Y and Y drainage Y ofYthe Y left Y femur
5. Repeat Y radiograph Y in Y 3 Y months

PYREFERRED Y REYSPONYSE: Y 2


DI YSCUYSSION: Y The Y history Yand Y laboratory Y studies Y indicate Y that Y this Y is Y not Y an Y infection. Y A Ylesion
Y in Y this Ylocation Y and Y in Y this Y age Y group Y is Y likely Y a Y Ewing's Y sarcoma. Y The Y presentation Y is Y usually
Y a Y painful Y mass. Y About Y 20% Y of Ypatients Y have Y a Y fever. Y The Y radiograph Y shows Y a Y typical Y mottled,
Y permeative Y lesion Ywith Yperiosteal Y reaction. Y Y An Y MRIscan Y should Y be Y obtained Y to Y further Y evaluate
Y the Y soft-tissue Y mass. Y Y Staging Y of Y the Y lesion Y should Y take Y place Y before Ybiopsy, Y which Y should Ybe
Y done Y by Ythe Ysurgeon Y who Y would Ybe Y perfo Yrming Ythe Y next Y stage Y of Ysurgical Y treatment, Y ideally Y an
Y orthopaedic Y oncologist.


REFE YRENCEYS: Y Gibbs Y CP Y Jr, Y Weber Y K, Y Scarborough Y MT: Y Malignant Y bone Y tumors Y. Y Instr Y Course
Y Lect Y2002;5 Y 1 Y:4 Y1 Y3-428.
Meyer Y IS, Y Nadel Y HR, Y Marina Y N, Y et Y al: Y Imaging Y guidelines Y for Y children Y with Y Ewing Y s Yarcoma
Y and Yosteosarcoma: Y A Y report Y from Y the Y Children's Y Oncology Y Group Y Bone Y Tumor Y Committee. Y


Y Pediatr Y Blood YCancer Y2008;5 Y 1 Y: Y1 6 3 - 1 Y70 Y. Y

, 2025 Pediatric Orthopaedic Examination Answer Book · 9




Figure Y3


Question Y 3

A Y9-year-old Ygirl Yhas Yhad Ybilateral Yknee Yand Yleg Ypain Yfor Ythe Ypast Y2 Yyears. Y The Yfamily Yhas Ynoted
increasing Ydeformity Yin Yboth Ylower Yextremities.
Y Y She Yis Yless Ythan Ythe Yfifth Ypercentile Yfor Yheight.
Y Examination Yreveals Ybilateral Yfemoral Ybowing, Ymild Ymedial-lateral Ylaxity YofYthe Yknees, Yand Ythe
Y deformities Yshown Yin Ythe Yradiograph Yseen Yin YFigure Y3. Y What Yis Ythe Ymost Ylikely Ydiagnosis?


1. Renal Y osteodystrophy
2. Diastrophic Y dysplasia
3. Metaphyseal Y dysplasia
4. Osteogenesis Yimperfecta
5. Fibrous Y dysplasia

PREFERRED Y RESPONSE: Y Y 1


DISCUSSION: YThe Ywidening, Ybowing, Yand Ycupping Yof Ythe Yphyses Yindicate Ysome Yform Yof
metabolic Ybone Ydisease; Ytherefore, Ythe Ymost Ylikely Ydiagnosis Yis Yrenal Yosteodystrophy.
Y Y The Yage
Y ofYonset Ymakes
X- linked Yhypophosphatemic Yrickets Yless Ylikely. Y The Yground Yglass Ylesions Yand Ywidening YofYthe
Y medullary Ycanal Ycharacteristic Y of Yfibrous Ydysplasia Y are Ynot Ypresent. Y There Y are Yno Yfractures
Y creating Ythe Ydeformities Yindicating Yosteogenesis Yimperfecta. Y There Yis Yan Yasymmetry Yof Ythe
Y deformities Ythat Ymakes Y diastrophic Ydysplasia Yless Ylikely.


REFERENCES: YGoldberg YMJ, YYassir YW, YSadeghi-NejadYA: YClinical Yanalysis YofYshort Ystature. Y J
Pediatr YOrthop Y2002;22:690-696.
Y


Parmar YVS, YStanitski YDF, YStanitski YCL: YInterpretation Yof Yradiographs Yin Ya Ypediatric Ylimb Ydeformity
Y practice: YDo Yradiologists Ycontribute? Y JYPediatr YOrthop Y 1999; Y19:732-734.