Pediatric Orthopaedic Scored and 1
Recorded Self-Assessment Examination 2025
,Question 1 of 100
Figures 1 and 2 are the radiographs of an 11-year-old girl who is having right elbow pain after “trying
to beat up a snowman.” She cannot extend her elbow, has point tenderness to palpation over the
proximal ulna. Her underlying condition is associated with a mutation in which gene?
A. Fibroblast growth factor receptor 3 (FGFR3)
B. Diastrophic dysplasia sulfate transporter (DTDST)
C. COL1A1, COL1A2
D. COL2A1
R:C
This patient has a fracture of the olecranon, which is a common injury seen in children with
osteogenesis imperfecta (OI), particularly type 1 OI. The genetic abnormality in OI is either
autosomal dominant or recessive, with a mutation in collagen type 1, affecting COL1A1 and COL1A2
genes. FGFR3 mutations are associated with achondroplasia. DTDST mutations are seen in
diastophic dysplasia. COL2A1 mutations are seen in spondyloepiphyseal dysplasia (SED), Kniest
dysplasia, and Stickler syndrome.
Question 2 of 100
Figures 1 through 3 are the radiographs of a 7-year-old girl who sustained complex orthopaedic
injuries falling from an all-terrain vehicle. She underwent successful treatment, which healed all of
the injuries with no evidence of avascular necrosis or physeal arrest of the right proximal femur, but
complete physeal arrest of the distal femur is noted 12 months post-injury. She returns at age 13
years complaining of leg-length discrepancy (LLD). Bone age is age 13. Based on her predicted leg
length discrepancy at maturity, which procedure is most appropriate?
A. Contralateral closed femoral shortening
B. Limb lengthening with distraction osteogenesis
C. Open Phemister epiphysiodesis of the contralateral femur
D. Guided growth epiphysiodesis of the contralateral distal femur
R: B
,distal femur physis is responsible for 9 mm of longitudinal growth per year. She is expected to reach skeletal
maturity at age 14 years. Her projected LLD at maturity is ~6 cm. A limb length discrepancy of >5 cm is
typically treated with distraction osteogenesis of the short limb. Closed femoral shortening >5 cm may result
in quadriceps insufficiency. An accommodative shoe lift would be useful for an LLD <2-2.5 cm. Phemister is
an open technique for physeal ablation by removing a segment of bone and reinserting it in a flipped position.
Guided growth epiphysiodesis using staples or eight plates placed at the distal femur is also an option;
however, given her remaining growth, neither Phemister, nor guided growth techniques will provide sufficient
correction.
Question 3 of 100
A 13-year-old boy is complaining of elbow and wrist pain following a fall off a bike. Radiographs are taken
in the emergency department (Figures 1 through 4). The wrist injury is unstable, and the patient is taken to the
operating room for closed reduction and pinning of the distal radius fracture, closed treatment of the proximal
fractures. Subsequent to surgery, the patient is noted to have increased irritability and progressively requires
more IV pain medication throughout the night. He is anxious, argumentative, and refuses to comply with
neurovascular assessments of his upper extremity. What is the best next step in treatment for this patient?
A. Provide diazepam (Valium) for anxiety and muscle spasms
B. Continue with ice, elevation, anti-inflammatory drugs to improve pain and swelling
C. Measure compartment pressures within the volar and dorsal forearm compartments
D. Return to the operating room for emergent volar and dorsal compartment fasciotomies
R: D
This patient is manifesting the signs of acute compartment syndrome (ACS). In the pediatric population, the
5 P's are less reliable signs of ACS. Instead, pediatric patients manifest increasing analgesic requirements,
agitation, and anxiety in the evolution of ACS. Given this patient's clinical signs and risk factors for developing
ACS (increased age/adolescence, male predominance, multiple fractures within an extremity), the appropriate
treatment is to proceed with emergent forearm fasciotomies.
Administering diazepam (Valium) for the anxiety only masks the underlying condition, which may result in a
poorer prognosis if the diagnosis is further delayed. Providing ice and elevation may be useful to diminish
swelling and pain, but will not successfully treat the compartment syndrome. Importantly, the diagnosis of
ACS is primarily a clinical one. Measuring compartment pressures may be more useful to help confirm or rule
out the diagnosis in an obtunded child or one with severe mental/communication difficulty.
, Question 4 of 100
Figure 1 and 2 are the radiographs of a 5-year-old girl who is being evaluated for back pain and intermittent
headaches. Her parents deny any injury, changes in bowel or bladder function, or significant family history.
Her neurological exam is normal. What is the best next step in her management?
A. Physical therapy
B. Observation
C. MRI of the entire spine
D. Thoracolumbar sacral orthosis (TLSO)
R: C
This is a 5-year-old girl with a new diagnosis of scoliosis, having an isolated right thoracic curve. This is
considered juvenile onset idiopathic scoliosis, which presents between the ages of 3-9 years old. The initial
radiographs show a curve measuring 41°. Any curve >20° in a patient with early onset scoliosis should
undergo MRI of the entire spine to assess for intraspinal pathology, with an average of 20% of patients having
underlying diagnoses, i.e. Arnold-Chiari, syringomyelia. Observation or TLSO bracing may be indicated;
however, an MRI is still the first line of management in this patient. Physical therapy may be useful for adjunct
treatment, but the MRI is still required at this stage of evaluation and diagnosis.
Question 5 of 100
Figure 1 is the radiograph of a 4-year-old girl who is being evaluated for genu varum. She has a family history
of bowed legs and short stature. She has a mutation in the PHEX gene. Identify the laboratory studies most
consistent with this diagnosis.
Recorded Self-Assessment Examination 2025
,Question 1 of 100
Figures 1 and 2 are the radiographs of an 11-year-old girl who is having right elbow pain after “trying
to beat up a snowman.” She cannot extend her elbow, has point tenderness to palpation over the
proximal ulna. Her underlying condition is associated with a mutation in which gene?
A. Fibroblast growth factor receptor 3 (FGFR3)
B. Diastrophic dysplasia sulfate transporter (DTDST)
C. COL1A1, COL1A2
D. COL2A1
R:C
This patient has a fracture of the olecranon, which is a common injury seen in children with
osteogenesis imperfecta (OI), particularly type 1 OI. The genetic abnormality in OI is either
autosomal dominant or recessive, with a mutation in collagen type 1, affecting COL1A1 and COL1A2
genes. FGFR3 mutations are associated with achondroplasia. DTDST mutations are seen in
diastophic dysplasia. COL2A1 mutations are seen in spondyloepiphyseal dysplasia (SED), Kniest
dysplasia, and Stickler syndrome.
Question 2 of 100
Figures 1 through 3 are the radiographs of a 7-year-old girl who sustained complex orthopaedic
injuries falling from an all-terrain vehicle. She underwent successful treatment, which healed all of
the injuries with no evidence of avascular necrosis or physeal arrest of the right proximal femur, but
complete physeal arrest of the distal femur is noted 12 months post-injury. She returns at age 13
years complaining of leg-length discrepancy (LLD). Bone age is age 13. Based on her predicted leg
length discrepancy at maturity, which procedure is most appropriate?
A. Contralateral closed femoral shortening
B. Limb lengthening with distraction osteogenesis
C. Open Phemister epiphysiodesis of the contralateral femur
D. Guided growth epiphysiodesis of the contralateral distal femur
R: B
,distal femur physis is responsible for 9 mm of longitudinal growth per year. She is expected to reach skeletal
maturity at age 14 years. Her projected LLD at maturity is ~6 cm. A limb length discrepancy of >5 cm is
typically treated with distraction osteogenesis of the short limb. Closed femoral shortening >5 cm may result
in quadriceps insufficiency. An accommodative shoe lift would be useful for an LLD <2-2.5 cm. Phemister is
an open technique for physeal ablation by removing a segment of bone and reinserting it in a flipped position.
Guided growth epiphysiodesis using staples or eight plates placed at the distal femur is also an option;
however, given her remaining growth, neither Phemister, nor guided growth techniques will provide sufficient
correction.
Question 3 of 100
A 13-year-old boy is complaining of elbow and wrist pain following a fall off a bike. Radiographs are taken
in the emergency department (Figures 1 through 4). The wrist injury is unstable, and the patient is taken to the
operating room for closed reduction and pinning of the distal radius fracture, closed treatment of the proximal
fractures. Subsequent to surgery, the patient is noted to have increased irritability and progressively requires
more IV pain medication throughout the night. He is anxious, argumentative, and refuses to comply with
neurovascular assessments of his upper extremity. What is the best next step in treatment for this patient?
A. Provide diazepam (Valium) for anxiety and muscle spasms
B. Continue with ice, elevation, anti-inflammatory drugs to improve pain and swelling
C. Measure compartment pressures within the volar and dorsal forearm compartments
D. Return to the operating room for emergent volar and dorsal compartment fasciotomies
R: D
This patient is manifesting the signs of acute compartment syndrome (ACS). In the pediatric population, the
5 P's are less reliable signs of ACS. Instead, pediatric patients manifest increasing analgesic requirements,
agitation, and anxiety in the evolution of ACS. Given this patient's clinical signs and risk factors for developing
ACS (increased age/adolescence, male predominance, multiple fractures within an extremity), the appropriate
treatment is to proceed with emergent forearm fasciotomies.
Administering diazepam (Valium) for the anxiety only masks the underlying condition, which may result in a
poorer prognosis if the diagnosis is further delayed. Providing ice and elevation may be useful to diminish
swelling and pain, but will not successfully treat the compartment syndrome. Importantly, the diagnosis of
ACS is primarily a clinical one. Measuring compartment pressures may be more useful to help confirm or rule
out the diagnosis in an obtunded child or one with severe mental/communication difficulty.
, Question 4 of 100
Figure 1 and 2 are the radiographs of a 5-year-old girl who is being evaluated for back pain and intermittent
headaches. Her parents deny any injury, changes in bowel or bladder function, or significant family history.
Her neurological exam is normal. What is the best next step in her management?
A. Physical therapy
B. Observation
C. MRI of the entire spine
D. Thoracolumbar sacral orthosis (TLSO)
R: C
This is a 5-year-old girl with a new diagnosis of scoliosis, having an isolated right thoracic curve. This is
considered juvenile onset idiopathic scoliosis, which presents between the ages of 3-9 years old. The initial
radiographs show a curve measuring 41°. Any curve >20° in a patient with early onset scoliosis should
undergo MRI of the entire spine to assess for intraspinal pathology, with an average of 20% of patients having
underlying diagnoses, i.e. Arnold-Chiari, syringomyelia. Observation or TLSO bracing may be indicated;
however, an MRI is still the first line of management in this patient. Physical therapy may be useful for adjunct
treatment, but the MRI is still required at this stage of evaluation and diagnosis.
Question 5 of 100
Figure 1 is the radiograph of a 4-year-old girl who is being evaluated for genu varum. She has a family history
of bowed legs and short stature. She has a mutation in the PHEX gene. Identify the laboratory studies most
consistent with this diagnosis.
