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  VerticalAlign, PageNumber, NumberFormat, Header, Footer, TabStopType,
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} = require('docx');
const fs = require('fs');

// ─── COLOUR PALETTE ───────────────────────────────────────────────────────────
const DARK_BLUE  = "1B3A6B";  // heading bg
const MID_BLUE   = "2E5FA3";  // sub-heading text
const LIGHT_BLUE = "D6E4F7";  // intro box bg
const ACCENT     = "C0392B";  // important markers
const WHITE      = "FFFFFF";
const BLACK      = "000000";
const GREY_TEXT  = "444444";
const LIGHT_GREY = "F2F4F7";  // bullet row alt bg

// ─── HELPERS ──────────────────────────────────────────────────────────────────
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// ─── TABLE OF CONTENTS ────────────────────────────────────────────────────────
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// ─── QUESTION CONTENT ─────────────────────────────────────────────────────────
const questions = [
  {
    title: "Supracondylar Fracture of Humerus in Children",
    stars: "★★★★★",
    content: (fns) => [
      fns.subHeading("Introduction"),
      fns.introBox("Supracondylar fracture is the most common elbow fracture in children (60–70%), typically affecting the 5–8-year age group. It carries significant risk of neurovascular injury and Volkmann ischemic contracture, making it a surgical emergency in certain presentations."),
      spacer(),
      fns.subHeading("Classification – Gartland"),
      fns.keyPoint("Type I", "Undisplaced – anterior humeral line still crosses capitellum"),
      fns.keyPoint("Type II", "Displaced, posterior cortex intact (hinge fracture)"),
      fns.keyPoint("Type III", "Completely displaced, no cortical contact"),
      fns.keyPoint("Type IV", "Multidirectional instability (added later – rotational instability)"),
      spacer(),
      fns.subHeading("Clinical Features"),
      fns.bullet("Extension type (97–98%): fall on outstretched hand, elbow pushed posteriorly"),
      fns.bullet("Flexion type (2–3%): fall on posterior elbow"),
      fns.bullet("S-shaped deformity, swelling, reluctance to move elbow"),
      fns.bullet("Always assess neurovascular status before and after reduction"),
      spacer(),
      fns.subHeading("Neurovascular Injury"),
      fns.keyPoint("Most common nerve", "Anterior interosseous nerve (AIN) – branch of median nerve; unable to make 'OK' sign"),
      fns.keyPoint("Artery", "Brachial artery – check radial pulse + capillary refill"),
      fns.keyPoint("Radial nerve", "Type II extension fractures; wrist drop"),
      fns.importantNote("Non-perfused limb = surgical emergency. Operate immediately to prevent Volkmann ischemic contracture. Compartment syndrome occurs in 0.1–0.3% of cases."),
      spacer(),
      fns.subHeading("Management"),
      fns.bullet("Type I: Above-elbow posterior slab cast (90° flexion, neutral rotation) for 3 weeks"),
      fns.bullet("Type II: Closed reduction + cast if stable; CRPP if unstable"),
      fns.bullet("Type III: CRPP (closed reduction percutaneous pinning) – gold standard"),
      fns.bullet("Open fractures / vascular injury / failed CRPP: ORIF"),
      fns.bullet("K-wire configuration: 2 lateral wires preferred (avoids ulnar nerve); cross-pin if lateral wires inadequate"),
      spacer(),
      fns.subHeading("Complications"),
      fns.bullet("Cubitus varus (gunstock deformity) – most common late complication due to malunion (not AVN)"),
      fns.bullet("Cubitus valgus – less common; tardy ulnar nerve palsy can follow"),
      fns.bullet("Volkmann ischemic contracture – due to compartment syndrome / vascular injury"),
      fns.bullet("Myositis ossificans – excessive soft tissue manipulation"),
      fns.bullet("Pin-track infection, stiffness"),
    ]
  },
  {
    title: "Developmental Dysplasia of the Hip (DDH)",
    stars: "★★★★★",
    content: (fns) => [
      fns.subHeading("Introduction"),
      fns.introBox("DDH encompasses a spectrum from mild acetabular dysplasia to frank dislocation of the femoral head. It is the most common hip disorder in children, with a prevalence of 1–3 per 1000 live births. Early diagnosis and treatment give excellent outcomes; delayed treatment leads to irreversible joint damage."),
      spacer(),
      fns.subHeading("Risk Factors"),
      fns.bullet("Female sex (F:M = 6:1), first-born child"),
      fns.bullet("Breech presentation (risk 30x), oligohydramnios"),
      fns.bullet("Positive family history, left hip more common (75%), bilateral 25%"),
      fns.bullet("Postural factors: swaddling with hips extended"),
      spacer(),
      fns.subHeading("Clinical Examination"),
      fns.keyPoint("Ortolani test", "Relocates dislocated hip – clunk on abduction (positive = dislocated hip)"),
      fns.keyPoint("Barlow test", "Provokes dislocation – posterior pressure on flexed/adducted hip (positive = dislocatable hip)"),
      fns.keyPoint("Galeazzi sign", "Unequal knee heights in supine flexed position (true shortening)"),
      fns.keyPoint("Trendelenburg gait", "Lurch towards affected side – seen in walking children"),
      spacer(),
      fns.subHeading("Investigations"),
      fns.bullet("< 6 months: Ultrasound (Graf classification) – Gold standard in neonates"),
      fns.bullet("  Graf Type I (normal) → Type IV (dislocated)"),
      fns.bullet("> 6 months: Pelvis X-ray – ossification of femoral head begins"),
      fns.bullet("X-ray landmarks: Hilgenreiner's line (horizontal through triradiate cartilage), Perkins' line (vertical through lateral acetabulum), Shenton's arc (smooth arc from femoral neck to obturator foramen – broken in DDH)"),
      fns.bullet("Acetabular Index: >30° abnormal in infants"),
      fns.importantNote("MRI / arthrogram used intra-operatively to confirm reduction."),
      spacer(),
      fns.subHeading("Treatment by Age"),
      fns.keyPoint("0–6 months", "Pavlik harness (flexion 90–100°, abduction 50–70°) – success rate 85–90%"),
      fns.keyPoint("6–18 months", "Closed reduction under GA + arthrogram + hip spica cast; open reduction if CR fails"),
      fns.keyPoint("18 months – 8 years", "Open reduction + Salter innominate osteotomy + femoral shortening"),
      fns.keyPoint("> 8 years", "Salvage procedures: Chiari osteotomy, shelf acetabuloplasty; joint replacement if arthritic"),
      spacer(),
      fns.subHeading("Complications"),
      fns.bullet("AVN of femoral head – most feared complication (from forceful reduction or compression in spica)"),
      fns.bullet("Redislocation, residual dysplasia, early osteoarthritis"),
      fns.bullet("Pavlik harness: avascular necrosis if harness too tight, femoral nerve palsy (rare)"),
    ]
  },
  {
    title: "Legg-Calvé-Perthes Disease",
    stars: "★★★★★",
    content: (fns) => [
      fns.subHeading("Introduction"),
      fns.introBox("Perthes disease is idiopathic avascular necrosis of the femoral head in children aged 4–8 years. The femoral epiphysis undergoes a cycle of necrosis, fragmentation, re-ossification, and remodelling. The goal of management is 'containment' – keeping the femoral head within the acetabulum during the healing phase to promote spherical remodelling."),
      spacer(),
      fns.subHeading("Epidemiology"),
      fns.bullet("Age 4–8 years (range 2–14), male:female = 4:1"),
      fns.bullet("Bilateral in 10–15% (but asymmetric and not simultaneous)"),
      fns.bullet("Associated with: delayed bone age, ADHD, second-hand smoke, thrombophilia (protein C/S deficiency)"),
      spacer(),
      fns.subHeading("Waldenstrom Radiological Stages"),
      fns.keyPoint("Stage 1 – Initial/Ischaemic", "Dense (sclerotic) femoral epiphysis, small epiphysis, widened joint space"),
      fns.keyPoint("Stage 2 – Fragmentation", "Fragmented, irregular epiphysis with radiolucent areas"),
      fns.keyPoint("Stage 3 – Re-ossification", "New bone formation from periphery inward"),
      fns.keyPoint("Stage 4 – Residual/Healed", "Final shape determined; coxa magna/plana if poorly contained"),
      spacer(),
      fns.subHeading("Classifications"),
      fns.bullet("Catterall (Groups I–IV): based on proportion of head involved – historical"),
      fns.bullet("Herring Lateral Pillar Classification (A/B/B-C/C): current standard – based on height of lateral pillar on AP X-ray during fragmentation"),
      fns.bullet("  Pillar A: full height = excellent prognosis"),
      fns.bullet("  Pillar B: >50% height = good if treated"),
      fns.bullet("  Pillar C: <50% height = poor prognosis regardless of treatment"),
      fns.importantNote("MRI is earliest investigation – detects ischaemia before X-ray changes appear."),
      spacer(),
      fns.subHeading("Management"),
      fns.keyPoint("Age < 6, Pillar A/B", "Conservative – physiotherapy, maintain ROM; bracing controversial"),
      fns.keyPoint("Age 6–8, Pillar B", "Containment: Petrie abduction cast, Scottish Rite orthosis, or surgery"),
      fns.keyPoint("Age > 8 or Pillar B/C, C", "Surgical containment: femoral varus osteotomy (FVO) or Salter innominate osteotomy"),
      fns.bullet("Shelf acetabuloplasty: for late cases with hinge abduction"),
      fns.subHeading("Prognosis"),
      fns.bullet("Mose method: spherical femoral head at maturity = best predictor of good outcome"),
      fns.bullet("Stulberg classification (I–V): Grades I–II = no arthritis; Grades IV–V = early OA"),
    ]
  },
  {
    title: "Slipped Capital Femoral Epiphysis (SCFE)",
    stars: "★★★★★",
    content: (fns) => [
      fns.subHeading("Introduction"),
      fns.introBox("SCFE is a disorder of the adolescent hip in which the femoral epiphysis slips posteroinferiorly relative to the femoral neck, through the hypertrophic zone of the physis. It is the most common hip disorder in adolescents and must be diagnosed promptly to prevent AVN."),
      spacer(),
      fns.subHeading("Epidemiology"),
      fns.bullet("Age 10–16 years; obese males (typical) OR tall thin rapid-growth adolescent"),
      fns.bullet("Male:Female = 2.4:1; bilateral in 20–40% (often sequential)"),
      fns.bullet("Associated conditions: hypothyroidism, growth hormone deficiency, renal osteodystrophy"),
      spacer(),
      fns.subHeading("Classification"),
      fns.keyPoint("Stability (Loder)", "Stable: can bear weight (with or without pain) – low AVN risk (<10%). Unstable: cannot bear weight – AVN risk ~50%"),
      fns.keyPoint("Severity (Southwick angle)", "Mild <30°, Moderate 30–60°, Severe >60°"),
      fns.keyPoint("Chronicity", "Acute (<3 weeks), Chronic (>3 weeks), Acute-on-chronic"),
      spacer(),
      fns.subHeading("Clinical Features"),
      fns.bullet("Painful limp; pain in thigh/knee (referred) – exam often finds hip problem in 'knee pain' patient!"),
      fns.bullet("Obligatory external rotation with hip flexion (due to posterior slip)"),
      fns.bullet("Limited internal rotation and abduction"),
      spacer(),
      fns.subHeading("Radiological Signs"),
      fns.keyPoint("Klein's line", "Line along superior femoral neck should intersect lateral 1/4 of epiphysis – fails to do so in SCFE (AP view)"),
      fns.keyPoint("Trethowan sign", "Same as Klein's line test"),
      fns.keyPoint("Steel sign / Capener sign", "On AP: crescent of metaphysis overlaps posterior acetabular wall"),
      fns.keyPoint("Frog-lateral view", "Best view to demonstrate the slip and its severity"),
      fns.importantNote("Always X-ray both hips. Never manipulate an unstable SCFE – forceful reduction dramatically increases AVN risk."),
      spacer(),
      fns.subHeading("Treatment"),
      fns.keyPoint("All SCFE", "In situ fixation with a single central cannulated screw – standard of care for all severities"),
      fns.keyPoint("Stable SCFE", "Elective surgery within days to weeks; single screw fixation"),
      fns.keyPoint("Unstable SCFE", "Urgent surgery (< 24 hours); gentle positioning before fixation; consider gentle reduction under image intensifier"),
      fns.keyPoint("Severe chronic SCFE", "Subcapital realignment: Modified Dunn procedure (better anatomy, higher AVN risk) or intertrochanteric osteotomy (safer)"),
      fns.keyPoint("Contralateral hip", "Prophylactic pinning if: young age, endocrine disorder, Risser 0–1"),
      spacer(),
      fns.subHeading("Complications"),
      fns.bullet("AVN (most feared) – especially in unstable SCFE"),
      fns.bullet("Chondrolysis – narrowing of joint space; associated with pin penetration or unrecognised arthrotomy"),
      fns.bullet("Femoroacetabular impingement (FAI) – long-term complication of residual deformity"),
    ]
  },
  {
    title: "Congenital Talipes Equinovarus (CTEV / Clubfoot)",
    stars: "★★★★☆",
    content: (fns) => [
      fns.subHeading("Introduction"),
      fns.introBox("Clubfoot is a complex three-dimensional congenital foot deformity comprising equinus, varus, adductus, and cavus. With an incidence of 1–2 per 1000 live births, it is the most common congenital musculoskeletal condition. The Ponseti method has revolutionised management, achieving correction in >95% of cases without extensive surgery."),
      spacer(),
      fns.subHeading("Components – CAVE Mnemonic (order of correction)"),
      fns.keyPoint("C – Cavus", "High arch (plantarflexed first ray) – FIRST to correct"),
      fns.keyPoint("A – Adductus", "Forefoot adduction – correct second"),
      fns.keyPoint("V – Varus", "Heel varus – corrected with adductus"),
      fns.keyPoint("E – Equinus", "Plantar flexion of entire foot – LAST to correct"),
      spacer(),
      fns.subHeading("Classification"),
      fns.bullet("Pirani score (0–6): based on 6 clinical signs – guides treatment and predicts Achilles tenotomy need"),
      fns.bullet("Dimeglio score (0–20): grades severity"),
      fns.bullet("Idiopathic (most common) vs Syndromic (arthrogryposis, spina bifida)"),
      spacer(),
      fns.subHeading("Ponseti Method (Gold Standard)"),
      fns.bullet("Serial casting: 5–7 casts changed weekly; foot manipulated and held in corrected position"),
      fns.bullet("Order of correction: Cavus → Adductus/Varus → Equinus"),
      fns.bullet("Supination maintained initially – abduction used as the corrective force"),
      fns.bullet("Achilles tendon tenotomy: required in ~80% of cases for residual equinus"),
      fns.bullet("Post-tenotomy: final cast x 3 weeks, then Denis Browne boots and bar (abducted 60–70°) for 23 hrs/day for 3 months, then nights/naps until age 4–5 years"),
      fns.importantNote("Compliance with boots and bar is the single most important factor in preventing relapse (relapse rate <10% with compliance, >80% without)."),
      spacer(),
      fns.subHeading("Relapse Management"),
      fns.bullet("Recasting ± tenotomy repeat"),
      fns.bullet("Tibialis anterior tendon transfer to third cuneiform (for dynamic supination in children >2.5 years)"),
      fns.bullet("Posteromedial release (Cincinnati incision): reserved for failed Ponseti or resistant cases"),
      spacer(),
      fns.subHeading("Differential Diagnosis"),
      fns.bullet("Positional talipes: flexible, corrects with gentle passive stretching – no treatment needed beyond reassurance and stretching"),
      fns.bullet("Metatarsus adductus: only forefoot adducted, heel normal"),
      fns.bullet("Vertical talus: rocker-bottom, forefoot dorsiflexed"),
    ]
  },
  {
    title: "Pediatric Septic Arthritis and Acute Hematogenous Osteomyelitis",
    stars: "★★★★☆",
    content: (fns) => [
      fns.subHeading("Introduction"),
      fns.introBox("Bone and joint infections in children are orthopaedic emergencies. The unique metaphyseal vasculature and lack of phagocytic activity predispose to haematogenous seeding. Delayed diagnosis results in permanent joint destruction, physeal damage, and limb deformity. The hip joint is at particular risk due to its intra-capsular location."),
      spacer(),
      fns.subHeading("Pathophysiology of Osteomyelitis"),
      fns.bullet("Metaphysis most affected: sluggish sinusoidal blood flow, lack of phagocytes, sharp vascular loops"),
      fns.bullet("Bacteria seed from transient bacteraemia; infection spreads via Haversian canals"),
      fns.bullet("Subperiosteal abscess → cortical necrosis → sequestrum (dead bone) formation"),
      fns.bullet("Involucrum: new periosteal bone surrounding sequestrum"),
      fns.bullet("Cloaca: opening in involucrum through which pus drains (sinus tract)"),
      spacer(),
      fns.subHeading("Organisms by Age"),
      fns.keyPoint("Neonates (< 2 months)", "Group B Streptococcus, S. aureus, Gram-negatives"),
      fns.keyPoint("1 month – 5 years", "S. aureus (#1), H. influenzae (now rare – vaccination), S. pyogenes"),
      fns.keyPoint("5–15 years", "S. aureus (dominant in all age groups)"),
      fns.keyPoint("Sickle cell disease", "Salmonella species"),
      fns.keyPoint("Sexually active adolescent", "Neisseria gonorrhoeae"),
      spacer(),
      fns.subHeading("Kocher Criteria – Septic Hip vs Transient Synovitis"),
      fns.bullet("1. Fever > 38.5°C"),
      fns.bullet("2. Non-weight-bearing"),
      fns.bullet("3. ESR > 40 mm/hr"),
      fns.bullet("4. WBC > 12,000 cells/mm³"),
      fns.bullet("(CRP > 2.0 mg/dL added as 5th criterion by Caird)"),
      fns.keyPoint("Probability", "4 criteria = 99%, 3 criteria = 93%, 2 criteria = 40%, 1 criterion = 3%"),
      fns.importantNote("Tom Smith Arthritis: Septic arthritis of hip in neonates/infants. Pathological dislocation occurs due to capsular distension + AVN of femoral head. Results in severe hip deformity."),
      spacer(),
      fns.subHeading("Investigations"),
      fns.bullet("Blood cultures (positive in 30–50%)"),
      fns.bullet("WBC, CRP, ESR, Procalcitonin"),
      fns.bullet("MRI: investigation of choice – detects early osteomyelitis, subperiosteal abscess, soft tissue spread"),
      fns.bullet("Ultrasound: rapid, detects effusion; guides aspiration of hip joint"),
      fns.bullet("Bone scan (Tc-99m): useful for multifocal / occult disease; early 'cold' scan = ischaemia"),
      spacer(),
      fns.subHeading("Treatment"),
      fns.bullet("Empirical IV antibiotics: Flucloxacillin (or Vancomycin if MRSA suspected) + Cefotaxime for neonates"),
      fns.bullet("Duration: IV until clinical improvement (48–72 hrs) then step down to oral for total 4–6 weeks"),
      fns.bullet("Septic arthritis: surgical washout/drainage – URGENT (prevents AVN and cartilage destruction)"),
      fns.bullet("Osteomyelitis: IV antibiotics; surgical drainage only if abscess > 2 cm, no improvement at 48 hrs, or chronic changes"),
      fns.bullet("Chronic osteomyelitis: sequestrectomy + saucerisation + bone graft ± Ilizarov for large defects"),
    ]
  },
  {
    title: "Adolescent Idiopathic Scoliosis (AIS)",
    stars: "★★★★☆",
    content: (fns) => [
      fns.subHeading("Introduction"),
      fns.introBox("Scoliosis is a three-dimensional spinal deformity defined as a lateral curvature of the spine with Cobb angle > 10°, accompanied by vertebral rotation. Adolescent idiopathic scoliosis (AIS) is the most common type (80%), affecting girls more than boys (F:M = 7:1 for curves requiring treatment). Management depends on skeletal maturity and curve magnitude."),
      spacer(),
      fns.subHeading("Measurement – Cobb Angle"),
      fns.bullet("Identify the most tilted vertebra at top (upper end vertebra) and bottom (lower end vertebra) of the curve"),
      fns.bullet("Draw perpendicular lines from each end plate; angle of intersection = Cobb angle"),
      fns.bullet("Progression likely if Cobb angle increases > 5° on serial X-rays"),
      spacer(),
      fns.subHeading("Skeletal Maturity – Risser Sign"),
      fns.keyPoint("Risser 0", "No ossification of iliac apophysis – maximum growth remaining, highest risk of progression"),
      fns.keyPoint("Risser 1–2", "25–50% ossification – still growing, bracing effective"),
      fns.keyPoint("Risser 3–4", "50–100% ossification – near maturity"),
      fns.keyPoint("Risser 5", "Fusion of apophysis – skeletal maturity, minimal progression risk"),
      spacer(),
      fns.subHeading("Classification – Lenke System"),
      fns.bullet("6 curve types based on location and flexibility"),
      fns.bullet("Type 1 (main thoracic): most common – right thoracic structural curve"),
      fns.bullet("Also characterises lumbar modifier (A/B/C) and sagittal modifier (-/N/+)"),
      fns.bullet("Guides which curves to fuse surgically"),
      spacer(),
      fns.subHeading("Adam's Forward Bend Test"),
      fns.bullet("Patient bends forward to 90°; rib hump (right thoracic) or lumbar prominence seen"),
      fns.bullet("Scoliometer measures angle of trunk rotation (ATR); >7° = refer for X-ray"),
      spacer(),
      fns.subHeading("Management"),
      fns.keyPoint("Cobb < 25°", "Observation: clinical + X-ray review every 4–6 months during growth"),
      fns.keyPoint("25–40°, Risser 0–2", "Bracing: Boston TLSO (underarm) for thoracolumbar/lumbar; Milwaukee brace for thoracic (apex above T8); 18–23 hrs/day"),
      fns.keyPoint("Cobb > 45–50°", "Surgical correction: posterior spinal instrumentation and fusion"),
      fns.subHeading("Surgery"),
      fns.bullet("Pedicle screw constructs + contoured rods – current gold standard"),
      fns.bullet("3-column correction: derotation, translation, and compression/distraction"),
      fns.bullet("Selective fusion: non-structural compensatory curves left unfused"),
      fns.bullet("Complications: neurological injury (wake-up test / SSEP/MEP monitoring), infection, pseudarthrosis, adding-on"),
    ]
  },
  {
    title: "Salter-Harris Classification of Physeal Injuries",
    stars: "★★★★☆",
    content: (fns) => [
      fns.subHeading("Introduction"),
      fns.introBox("The physis (growth plate) is the weakest part of the immature skeleton – weaker than ligaments. Injuries involving the physis are classified by the Salter-Harris system, which guides prognosis and management. Growth arrest and angular deformity are the feared complications. The mnemonic SALTR (or SLIPPERY) helps recall the types."),
      spacer(),
      fns.subHeading("Classification – SALTR Mnemonic"),
      fns.keyPoint("Type I – S (Slipped)", "Transverse fracture through physis only. X-ray often normal. Diagnose clinically. Good prognosis. Cast immobilisation."),
      fns.keyPoint("Type II – A (Above)", "Most common (75%). Fracture through physis + extends into METAPHYSIS. Thurston-Holland fragment (metaphyseal spike). Usually closed reduction + cast. Good prognosis."),
      fns.keyPoint("Type III – L (Lower)", "Fracture through physis + extends into EPIPHYSIS. Intra-articular. ORIF required for anatomic joint reduction. Fair prognosis."),
      fns.keyPoint("Type IV – T (Through)", "Fracture through METAPHYSIS + PHYSIS + EPIPHYSIS. Intra-articular. Anatomic ORIF essential – even small displacement causes physeal bridge. Poor prognosis if not reduced."),
      fns.keyPoint("Type V – R (Rammed)", "Crush/compression of physis. Often missed initially. Worst prognosis – premature physeal closure. Diagnosed retrospectively when growth arrest evident."),
      spacer(),
      fns.importantNote("Mnemonic: SALTR = Slipped, Above (metaphysis), Lower (epiphysis), Through (all 3 zones), Rammed (crushed). Types III and IV are intra-articular – require ORIF."),
      spacer(),
      fns.subHeading("Peterson Classification (Additional Types)"),
      fns.bullet("Type VI: Periosteal injury – localised physeal arrest"),
      spacer(),
      fns.subHeading("Growth Arrest"),
      fns.bullet("Physeal bar (bridge) forms across physis after injury"),
      fns.bullet("Peripheral bar → angular deformity; Central bar → shortened limb"),
      fns.bullet("MRI or CT: map the bar; if bar <50% of physeal area → bar resection + fat interposition"),
      fns.bullet("Surgical options: Langenskiold bar resection, epiphysiodesis of unaffected side, corrective osteotomy"),
      spacer(),
      fns.subHeading("Common Examples by Site"),
      fns.keyPoint("Distal radius", "Most common physeal fracture – usually Type I or II; closed reduction + cast"),
      fns.keyPoint("Distal femur", "High-energy; Type III/IV risk; high rate of physeal arrest"),
      fns.keyPoint("Proximal tibia", "Popliteal artery injury risk"),
      fns.keyPoint("Lateral condyle humerus", "Type IV – requires ORIF; risk of non-union and cubitus valgus"),
      fns.keyPoint("Triplane fracture ankle", "Type III + IV equivalent; CT for characterisation; ORIF if >2 mm displaced"),
    ]
  },
  {
    title: "Cerebral Palsy – Orthopaedic Management",
    stars: "★★★☆☆",
    content: (fns) => [
      fns.subHeading("Introduction"),
      fns.introBox("Cerebral palsy (CP) is a permanent, non-progressive disorder of movement and posture resulting from a disturbance to the developing fetal or infant brain. While the brain lesion is static, the musculoskeletal consequences are progressive. Orthopaedic management aims to prevent deformity, improve function, and relieve pain."),
      spacer(),
      fns.subHeading("Classification"),
      fns.keyPoint("Spastic (most common, 70–80%)", "Upper motor neuron – hypertonicity, clasp-knife rigidity"),
      fns.bullet("  Hemiplegia (one side): ambulatory, upper > lower limb involvement"),
      fns.bullet("  Diplegia (bilateral lower > upper): Little's disease; associated with prematurity"),
      fns.bullet("  Quadriplegia (all four limbs): most severely affected; rarely ambulatory"),
      fns.keyPoint("Dyskinetic", "Athetosis, choreoathetosis – extrapyramidal; basal ganglia lesion"),
      fns.keyPoint("Ataxic", "Cerebellar involvement; uncommon"),
      fns.keyPoint("Mixed", "Spastic + dyskinetic combination"),
      spacer(),
      fns.subHeading("Functional Assessment – GMFCS"),
      fns.bullet("Gross Motor Function Classification System (GMFCS) I–V"),
      fns.bullet("GMFCS I–II: ambulate independently; GMFCS III: ambulate with aids; GMFCS IV–V: wheelchair dependent"),
      spacer(),
      fns.subHeading("Common Orthopaedic Deformities"),
      fns.keyPoint("Foot", "Equinus (most common) – tight Achilles; equinovarus or equinovalgus"),
      fns.keyPoint("Knee", "Flexion contracture, crouch gait, patella alta"),
      fns.keyPoint("Hip", "Flexion + adduction contracture → subluxation → dislocation; spastic diplegia most at risk"),
      fns.keyPoint("Spine", "Neuromuscular scoliosis – rapid progression in non-ambulators; affects respiratory function"),
      fns.keyPoint("Upper limb", "Thumb-in-palm, wrist flexion, elbow flexion, shoulder adduction/IR"),
      spacer(),
      fns.subHeading("Spasticity Management – Ladder Approach"),
      fns.bullet("1. Physiotherapy, stretching, splinting (AFOs), serial casting"),
      fns.bullet("2. Botulinum toxin A injection: temporary (3–6 months); useful for dynamic spasticity; best in children 2–7 years"),
      fns.bullet("3. Oral Baclofen: for generalised spasticity; sedating side effects"),
      fns.bullet("4. Intrathecal Baclofen (ITB) pump: for severe spasticity in GMFCS III–V"),
      fns.bullet("5. Selective Dorsal Rhizotomy (SDR): selective cutting of afferent L2–S1 dorsal rootlets; for pure spastic diplegics, GMFCS II–III, preserved strength"),
      spacer(),
      fns.subHeading("SEMLS – Single Event Multilevel Surgery"),
      fns.bullet("Address all lower limb deformities in one anaesthetic episode"),
      fns.bullet("Superior to staged procedures: fewer total surgeries, less anaesthetic exposure, better gait outcomes"),
      fns.bullet("Guided by 3D gait analysis: identifies true primary deformities from compensatory ones"),
      fns.bullet("Typical components: Achilles lengthening, psoas recession, adductor tenotomy, distal femoral extension osteotomy, tibial derotation osteotomy"),
      spacer(),
      fns.subHeading("Hip Surveillance Protocol"),
      fns.bullet("Annual AP pelvis X-rays in non-ambulatory CP from age 2"),
      fns.bullet("Migration percentage (Reimer's index): normal <33%; > 33% = subluxation; 100% = dislocation"),
      fns.bullet("> 50% migration = surgical intervention (varus derotation osteotomy ± pelvic osteotomy)"),
    ]
  },
  {
    title: "Limb Length Discrepancy (LLD)",
    stars: "★★★☆☆",
    content: (fns) => [
      fns.subHeading("Introduction"),
      fns.introBox("Limb length discrepancy refers to a difference in the length of the lower extremities. It may be anatomical (true bone shortening) or functional (pelvic obliquity, contracture). Management ranges from shoe raises for minor discrepancies to complex surgical limb lengthening for major ones. Accurate assessment and growth prediction are essential for optimal timing of intervention."),
      spacer(),
      fns.subHeading("Causes"),
      fns.keyPoint("Congenital", "DDH, fibular/tibial hemimelia, proximal femoral focal deficiency (PFFD), coxa vara"),
      fns.keyPoint("Growth plate injury", "Physeal arrest after Salter-Harris fracture"),
      fns.keyPoint("Infection", "Stimulation (acute osteomyelitis) or arrest (chronic / physeal involvement)"),
      fns.keyPoint("Neurological", "Poliomyelitis, cerebral palsy"),
      fns.keyPoint("Tumour/Irradiation", "Physeal damage from radiotherapy"),
      fns.keyPoint("Vascular", "Haemangioma, A-V malformation → overgrowth"),
      spacer(),
      fns.subHeading("Assessment"),
      fns.bullet("Clinical: blocks under short limb until pelvis level – measures functional LLD"),
      fns.bullet("Galeazzi sign: unequal knee heights with hips and knees flexed 90° (identifies femoral vs tibial shortening)"),
      fns.keyPoint("Scanography (orthoroentgenogram)", "Most accurate – single cassette, three exposures at hip, knee, ankle; minimal magnification error"),
      fns.keyPoint("CT scanogram", "Fastest, least radiation; accurate for both bone and soft tissue"),
      fns.keyPoint("EOS imaging", "Low-dose biplanar – best for concurrent spinal assessment"),
      spacer(),
      fns.subHeading("Growth Prediction Methods"),
      fns.bullet("Green-Anderson growth remaining charts: based on skeletal age (Greulich-Pyle)"),
      fns.bullet("Moseley straight-line graph: plots limb lengths vs skeletal age; intuitive visual prediction"),
      fns.bullet("Multiplier method (Paley): most modern; uses multiplier tables based on bone age – quick, accurate"),
      spacer(),
      fns.subHeading("Treatment Algorithm"),
      fns.keyPoint("< 2 cm", "Shoe raise, observation"),
      fns.keyPoint("2–5 cm", "Epiphysiodesis (shortening of longer limb) OR contralateral lengthening OR shoe raise"),
      fns.keyPoint("> 5 cm", "Limb lengthening + ± contralateral epiphysiodesis"),
      fns.keyPoint("> 15–20 cm", "Prosthetic fitting ± amputation (e.g., fibular hemimelia)"),
      spacer(),
      fns.subHeading("Epiphysiodesis"),
      fns.bullet("Permanent: Phemister technique (open), percutaneous drill/curette"),
      fns.bullet("Temporary (guided growth): 8-plate or staples on convex side of physis"),
      fns.bullet("Timing: critical – must be done while physis still open; use Moseley graph or multiplier to calculate timing"),
      spacer(),
      fns.subHeading("Ilizarov Limb Lengthening"),
      fns.bullet("Principle of distraction osteogenesis: cortical osteotomy (corticotomy) + gradual distraction"),
      fns.bullet("Rate: 1 mm/day in 4 increments of 0.25 mm (allows regenerate bone formation)"),
      fns.bullet("Consolidation: 1 day per mm of lengthening as a guide"),
      fns.importantNote("Complications: pin-track infection (most common), joint contracture (knee/ankle), premature consolidation, non-union, nerve traction injury, regenerate fracture after frame removal."),
    ]
  }
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