Pre Exam Course Pediatric Viva

PRE EXAM COURSE PEDIATRIC VIVA
Desember 2025

By. Dr. dr. Udi Heru Nefihancoro, Sp.B., Sp.OT.Subsp.A(K)

CASE 1

• ​Girl, 6 year old

• Chief complain : Unequal lower limb

• Her parents noticed when patient walked, she had limping gait

• No pain

• No history of trauma

• Patient had breech presentation delivery, without any abnormal condition in post natal care.

Multiple Choice

1. What is your diagnosis ?

• Old dislocation of right Hip

• Proximal Femur Focal Deficiency

• Residual effects of Hip infective arthritis

• Developmental Dysplasia of Right Hip

• Right Femoral Neck fracture

ANSWER

"Developmental dysplasia of the hip"

Occurs due to an abnormal hip development, presenting in infancy or early childhood with a spectrum ranging from dysplasia to dislocation of the hip joint.
Developmental dysplasia of the hip encompasses several hip abnormalities, including instability, acetabular dysplasia, subluxation, and dislocation. 

Multiple Choice

2. What is the possible risk factors may occur in this case?

• Family history

• Swaddling

• Breech position

• In utero infection

• In utero restriction

ANSWER

"Breech position": 

In the last trimester, breech position is the most significant risk factor for developmental dysplasia of the hip, with an odds ratio of 5.47 (2.58 to 11.6).
Procedures that decrease the time spent in the breech position (eg. external cephalic version and prelabor cesarean section) reduce the risk for developmental dysplasia of the hip.

Multiple Choice

3. What is clinical examination should be performed in Newborn Screening ?

• Ortolani manuver

• Barlow manuver

• Klissic tes

• All of Them

• Ortolani maneuver & Barlow maneuver

ANSWER

Newborn Screening

• Ortolani maneuver: 

With the infant in the supine position, the hip is flexed at 90° and in neutral rotation. The infant should be calm with clothes and diapers removed. This maneuver aims to reduce the dislocated hip by holding the hip so that the thumb is on the inner aspect and the index and ring finger are on the greater trochanter. While applying anterior force on the greater trochanter, gently abduct the hip. Clinicians will feel a jerk or clunk if the hip is dislocated. However, "hip clicks" are clinically insignificant without instability.

• Barlow maneuver: 

Employing the same initial position as the Ortolani maneuver, force may be applied posteriorly to the trochanter, although the AAP recommends against posterior force, and the hip is adducted.
A clunk or jerk is felt if the hip can be dislocated. This maneuver should be performed gently, as forceful adduction can cause instability.

Multiple Choice

4. What treatment will you proposed ?

• Hip Abduction Splint

• Closed reduction + hip spica cast

• Open reduction only

• Open reduction + Acetabuloplasty if needed

• None

Explanation

4. PATIENT PREPARATION IN OT

This scenario is an open technique of Anterior Hip approach
We will setup involves positioning of the patient supine on an operating table.

Explanation

5.  Anterior approach to the pediatric proximal femur

​Preliminary remarks

The anterior approach provides the most direct access to the anterior aspect of the hip. Many surgeons prefer this approach for reduction of femoral head and neck fractures.

Note: Fixation of femoral neck fractures reduced through this approach will require separate percutaneous screw insertion, or a separate lateral incision.

Vascular anatomy

The deep branch of the medial femoral circumflex artery provides the main relevant blood supply to the femoral head.
The medial femoral circumflex artery originates from the deep femoral artery (profunda femoris), courses between the iliopsoas and pectineus muscles, and runs posteriorly between the femur and the pelvis.

During its course, a small branch supplies the inferior retinaculum (ligament of Weitbrecht).

The main branch of the medial femoral circumflex artery is related to the inferior border of the obturator externus muscle and passes posterior to the femur, towards the intertrochanteric crest.

It then crosses posterior to the obturator externus and anterior to the triceps coxae (obturator internus and the superior and inferior gemelli).

Before crossing the triceps coxae, a small branch passes to the greater trochanter.

The vessel enters the joint capsule between the gemellus superior and the piriformis muscles.

Note: The approach must always be cranial to the piriformis muscle. This anatomical detail is  crucial when starting to prepare the capsule.

After perforating the capsule, the vessel passes along the superior retinaculum and splits into 3-4 branches. Provided the obturator externus muscle remains intact, it will protect the medial femoral circumflex artery.

​Skin incision

Superficial dissection

​A bikini incision is used. The level of the incision is below the anterior superior iliac spine and centered on the anterior inferior iliac spine.

​After incision of the skin and fat, the deep fascia is encountered.

The interval between tensor fascia lata and sartorius is identified by palpation and the fascia incised.

​Deep dissection

​The fascia should be carefully incised and the lateral cutaneous nerve of the thigh identified and protected.

Note:
Dissection within the medial edge of tensor fascia lata is preferred by some surgeons and helps to protect the lateral cutaneous nerve of the thigh.

CASE 2

• Boy 6 y.o

• Chief complain : Severe pain in right elbow

• After fell-down from kindergarten monkey bar, 1 hour ago

• Accompanied by his mother and teacher 

• Hematoma on anterior part of right elbow, no bruise

• Normal pulse of radial artery

• Numbness on 2nd & 3rd fingers

Multiple Choice

1. WHAT IS YOUR DIAGNOSIS ? 

• CLOSED SUPRA CONDYLAR FRACTURE WITH MEDIAN NERVE INJURY
• CLOSED FRACTURE LATERAL CONDYLE HUMERUS WITH MEDIAN NERVE INJURY

• CLOSED FRACTURE LATERAL CONDYLE HUMERUS WITH RADIAL NERVE INJURY

• CLOSED FRACTURE MEDIAL CONDYLE HUMERUS WITH MEDIAN NERVE INJURY

CASE 2
1. WHAT IS YOUR DIAGNOSIS ? 

CLOSED SUPRACONDYLAR FRACTURE WITH MEDIAN NERVE INJURY

Multiple Choice

2. WHAT IS PUCKER SIGN ?

• Skin discoloration caused by hematoma formation

• Soft tissue defect from proximal fragment penetration into subcutaneous tissue, indicating significant soft tissue injury and possible median nerve/brachial artery entrapment

• Swelling of the soft tissue distal to the fracture

• Dimpling of the skin due to severe edema

CASE 2
2. WHAT IS PUCKER SIGN ?

A soft tissue defect ( proximal fracture fragment penetration through the brachialis muscle and anterior fascia into subcutaneous tissue ) and is indicative of significant soft tissue injury from an extension-type fracture with potential entrapment of median nerve and brachial artery

Multiple Choice

3. WHAT CLASSIFICATION OF THIS TYPE FRACTURE

• Salter-Harris Type II

• Gartland Extension Type II

• Gartland Extension Type III

• Gustilo-Anderson Type II

CASE 2
3. WHAT CLASSIFICATION OF THIS TYPE FRACTURE

GARTLAND EXTENSION TYPE 3

Multiple Choice

4. WHAT WILL YOU DO ?  HOW TO MANAGED THE FRACTURE ?

• PUT ON SPLINT, RECHECK THE NUMBNESS IF STILL PRESENT, WE PLAN TO DO OPEN REDUCTION & EXPLORATION
• OPEN REDUCTION & EXPLORATION

• PUT ON SPLINT

• OBSERVATION

CASE 2
4. WHAT WILL YOU DO ?  HOW TO MANAGED THE FRACTURE ?

PUT ON SPLINT, RECHECK THE NUMBNESS IF STILL PRESENT,  WE PLAN TO DO OPEN REDUCTION & EXPLORATION

Multiple Choice

5. EXPLAIN YOUR SURGICAL TECHNIQUE PLAN

• This scenario is an open technique of posterior approach.

• This scenario is an open technique of lateral approach.

• This scenario is an open technique of anterior approach.

• This scenario is an open technique of medial approach.

CASE 2
5. EXPLAIN YOUR SURGICAL TECHNIQUE PLAN

This scenario is an open technique of anterior approach.
The setup involves positioning of the patient supine on an operating table with a radiolucent hand table attached

Anterior Approach, indications :

• Irreducible extension-type fractures

• Suspected interposition brachialis muscle and fascia

• Median nerve sensory deficits

• Vascular exploration

• The anterior approach provides direct access to interposed soft tissue in irreducible extension-type fractures. can also be extended to facilitate neurovascular repair when necessary. 

​Anterior Approach

​Anterior Approach

CASE 3

• Girl, 4 year old

• Chief complaint :  Pain of the left hip

• The patient felt pain on the left hip since 3 months ago and worsen since 1 month ago.  She couldn’t walk anymore.

• There was history of cough, fever, decrease of weight, decrease of appetite, and night sweating. Patient has consumed Anti TB drugs since 1 month ago

CASE 3

Multiple Choice

1. What is your most possible diagnosis ?

• Avascular Necrosis

• Coxitis TB

• Chondro sarcoma

• SCFE

• Not all of them

CASE 3

Multiple Choice

2. What treatment do you suggest ?

• Effective chemotherapy

• Skeletal traction

• Synovectomy and joint debridement

• Effective chemotherapy, synovectomy and joint debridement

• Not all of them

Development of interval between tensor fascia lata and sartorius

CASE 4

• Male

• 13 year old

• Chief complain : Unable to straightened and bent maximally on right elbow

• Patient had history of fell down from tree

CASE 4

CASE 4
X-Ray Right Elbow AP/ Lat

CASE 4
CT-Scan Right Elbow AP/ Lat

Multiple Choice

1. What is the diagnosis ?

• Malunion supracondylar humerus fracture

• Malunion lateral condylar humerus fracture

• Malunion medial epicondyle humerus fracture

• None

1. WHAT IS THE DIAGNOSIS?

Malunion medial epicondyle humerus fracture

Multiple Choice

2. What treatment do you suggest ?

• POSTERIOR WEDGE SUPRACONDYLAR OSTEOTOMY

• LATERAL WEDGE SUPRACONDYLAR OSTEOTOMY

• MEDIAL WEDGE SUPRACONDYLAR OSTEOTOMY

• ANTERIOR WEDGE SUPRACONDYLAR OSTEOTOMY

2. WHAT TREATMENT DO YOU SUGGEST?
ANTERIOR WEDGE SUPRACONDYLAR OSTEOTOMY

Since the patient is right-handed, they should be able to bring food to their mouth with their right hand. Therefore, we should consider adding elbow flexion, as opposed to extension

THANK YOU