Pediatric Orthopaedics

Pediatric Orthopaedics Indian Medical PG Question 1: What is the most common bone fractured in children?

• A. Fracture of the distal radius
• B. Fracture of the supracondylar humerus
• C. Fracture of the radius/ulna
• D. Fracture of the clavicle (Correct Answer)

Pediatric Orthopaedics Explanation: ***Fracture of the clavicle*** - The clavicle is the **most commonly fractured bone in children**, especially during falls onto an outstretched hand or direct trauma. - Its subcutaneous location and an **S-shape** make it prone to injury. *Fracture of the distal radius* - While common, especially in older children or adolescents, **distal radius fractures** are not as frequent as clavicle fractures across all pediatric age groups. - These fractures often result from a **fall onto an outstretched hand** (FOOSH). *Fracture of the supracondylar humerus* - **Supracondylar humerus fractures** are common in children, particularly between ages 5 and 7 years, usually due to falls. - However, they are associated with more potential complications (like **nerve or vascular injury**) but are less common overall than clavicle fractures. *Fracture of the radius/ulna* - **Fractures of the midshaft radius and/or ulna** are common in children but often require more significant trauma compared to clavicle fractures. - These often present as **greenstick or torus fractures** in younger children.

Pediatric Orthopaedics Indian Medical PG Question 2: A 6-year-old boy presents with a painful limp, tenderness in the femoral triangle, and some limitation of hip movements. The X-ray is normal. What is the next investigation?

• A. MRI (Correct Answer)
• B. CT scan
• C. Arthroscopy
• D. Bone scan

Pediatric Orthopaedics Explanation: ***MRI*** - An **MRI** is the most sensitive imaging modality for detecting early changes in bone marrow and soft tissues, such as **avascular necrosis of the femoral head** (Legg-Calvé-Perthes disease), which can present with a painful limp and normal initial X-rays. - It can visualize bone edema, cartilage irregularities, and effusions that are not apparent on plain radiographs. *CT scan* - While useful for detailed bone anatomy, a **CT scan** exposes the child to significant **radiation** and is less effective than MRI for detecting early soft tissue and bone marrow changes in conditions like Perthes disease. - It is often reserved for complex fracture assessments or when MRI is contraindicated. *Arthroscopy* - **Arthroscopy** is an **invasive surgical procedure** used for direct visualization, diagnosis, and treatment of joint problems. - It is not a primary diagnostic investigation for a painful limp with a normal X-ray, as less invasive imaging like MRI should be performed first. *Bone scan* - A **bone scan** (scintigraphy) is sensitive for detecting increased **metabolic activity** in bone, such as in infections or tumors, but it is less specific than MRI for detailed anatomical changes in early Perthes disease. - It involves radiation exposure and may not provide the detailed soft tissue information needed to differentiate various causes of a painful hip.

Pediatric Orthopaedics Indian Medical PG Question 3: A child presents with painful limp and restricted hip rotation. ESR and CRP are elevated. Initial plain radiograph is normal. What is the next best imaging study?

• A. CT Scan
• B. MRI with contrast (Correct Answer)
• C. Bone Scan
• D. Plain Radiograph

Pediatric Orthopaedics Explanation: ***MRI with contrast*** - An **MRI with contrast** is the most sensitive and specific imaging modality for detecting early changes in **osteomyelitis** or **septic arthritis**, which are serious conditions given the child's symptoms and elevated inflammatory markers. - It can visualize soft tissue and bone marrow edema, joint effusions, and abscesses, guiding immediate treatment. *CT Scan* - While useful for bony detail, a CT scan is **less sensitive than MRI** for detecting early bone marrow changes or soft tissue inflammation in the hip joint. - It also involves **radiation exposure**, which should be limited in children when other effective modalities are available. *Bone Scan* - A bone scan using **technetium-99m** is sensitive for detecting increased bone turnover, but it is **not specific for infection** and cannot differentiate between inflammatory processes, tumors, or fractures. - It provides less anatomical detail compared to MRI, making precise localization of an infection more challenging. *Plain Radiograph* - Plain radiographs are typically the **initial imaging study** for orthopedic complaints but are often **normal in early stages** of septic arthritis or osteomyelitis. - Significant radiographic changes, such as bone erosion or joint space widening, usually appear much later in the disease process.

Pediatric Orthopaedics Indian Medical PG Question 4: A 10-year-old boy presenting with cubitus varus deformity and a history of trauma 3 months prior, on clinical examination, has preserved the normal relationship of the three bony points of the elbow. What is the most probable diagnosis?

• A. Old unreduced elbow dislocation
• B. Malunited intercondylar fracture of the humerus
• C. Malunited supracondylar fracture of the humerus (Correct Answer)
• D. Non-union of lateral condylar fracture of the humerus

Pediatric Orthopaedics Explanation: ***Malunited supracondylar fracture of the humerus*** - A malunited **supracondylar fracture** is the most common cause of **cubitus varus** deformity, also known as gunstock deformity, in children, which results from the medial displacement and internal rotation of the distal fragment. - The **normal relationship of the three bony points** (medial epicondyle, lateral epicondyle, and olecranon) is preserved because the fracture is usually extra-articular and the trochlea and capitellum maintain their normal relationship with the ulna and radius. *Old unreduced elbow dislocation* - An **elbow dislocation** would disrupt the normal anatomical relationship between the radius, ulna, and humerus, leading to an **abnormal relationship of the three bony points** of the elbow. - While it can cause deformity, it typically presents with obvious joint incongruity and significant functional limitations that would be evident on examination. *Malunited intercondylar fracture of the humerus* - An **intercondylar fracture** involves the articular surface of the humerus, suggesting an intra-articular injury. - Such a fracture, even if malunited, would likely disrupt the **normal alignment of the trochlea and capitellum** with the olecranon and radial head, thus altering the relationship of the three bony points. *Non-union of lateral condylar fracture of the humerus* - A **non-union of a lateral condylar fracture** can lead to progressive valgus deformity (cubitus valgus) or instability, not typically cubitus varus. - While it affects the elbow joint, the primary issue is joint instability and changes in the carrying angle, not the varus deformity described with preserved bony point relationships.

Pediatric Orthopaedics Indian Medical PG Question 5: Which of the following is NOT a common fracture in children?

• A. Supracondylar humerus
• B. Fracture of hand (Correct Answer)
• C. Radius-ulna fracture
• D. Lateral condyle humerus

Pediatric Orthopaedics Explanation: ***Fracture of hand*** - While hand fractures can occur in children, they are generally **less common** compared to fractures of the long bones, especially those of the **upper extremity**, due to the types of activities and falls children typically experience. - The small bones of the hand are often better protected or less frequently exposed to severe direct trauma in routine childhood activities that lead to fractures elsewhere. *Lateral condyle humerus* - This is a common and often challenging fracture in children, particularly affecting those aged 6-10 years. - It usually results from a fall on an **outstretched hand**, with the elbow in extension. *Supracondylar humerus* - This is one of the **most common elbow fractures** in children and is typically due to a fall on an **outstretched hand** with the elbow extended or hyperextended. - Its significance lies in the potential for neurovascular complications due to its proximity to vital structures. *Radius-ulna fracture* - **Forearm fractures** involving the radius, ulna, or both are extremely common in children, often resulting from falls onto an **outstretched hand**. - The **distal radius** is a particularly frequent site of fracture in this age group.

Pediatric Orthopaedics Indian Medical PG Question 6: Which one of the following is the most ideal treatment for a displaced fracture of the lateral condyle of the humerus in a 7-year-old child?

• A. Open reduction and internal fixation (Correct Answer)
• B. Open reduction with plaster immobilization
• C. Closed reduction with plaster immobilization
• D. All of the above

Pediatric Orthopaedics Explanation: ***Open reduction and internal fixation*** - **Displaced lateral condyle fractures** in children require **anatomical reduction** and stable fixation to prevent complications like **non-union** and **cubitus valgus deformity**. - **Internal fixation** provides the necessary stability for healing and allows for earlier mobilization, which is crucial for elbow joint function. *Open reduction with plaster immobilization* - While it achieves open reduction, relying solely on **plaster immobilization** after reducing a displaced fracture of the lateral humeral condyle in a child often leads to **loss of reduction**. - This method does not provide adequate stability for this type of fracture, increasing the risk of **displacement** and **malunion**. *Closed reduction with plaster immobilization* - **Closed reduction** is typically attempted only for **minimally displaced** or **undisplaced fractures** of the lateral condyle. - Given that the fracture is described as **displaced**, closed reduction is unlikely to achieve and maintain an adequate anatomical alignment.

Pediatric Orthopaedics Indian Medical PG Question 7: Combination of appearance in CTEV

• A. Equinus, eversion, forefoot adduction, cavus
• B. Equinus, inversion, forefoot adduction, planus
• C. Equinus, inversion, forefoot adduction, cavus (Correct Answer)
• D. Equinus, eversion, forefoot abduction, cavus

Pediatric Orthopaedics Explanation: ***Equinus, inversion, forefoot adduction, cavus*** - The classic presentation of **clubfoot** (CTEV) involves a characteristic combination of deformities: **equinus** (fixed plantarflexion of the ankle), **inversion** (tilting of the heel inward), **forefoot adduction** (inward turning of the front of the foot), and **cavus** (an abnormally high arch). - These four components are essential for the diagnosis and classification of CTEV. *Equinus, eversion, forefoot adduction, cavus* - This option incorrectly lists **eversion** instead of inversion. Eversion involves the outward tilting of the heel and is not a feature of CTEV. - While equinus, forefoot adduction, and cavus are typical, the presence of eversion rules out classic CTEV. *Equinus, inversion, forefoot adduction, planus* - This option incorrectly lists **planus** (pes planus or flatfoot) instead of cavus. Cavus (high arch) is a defining characteristic of CTEV, not a flatfoot. - While equinus, inversion, and forefoot adduction are correct, the presence of planus makes this option incorrect. *Equinus, eversion, forefoot abduction, cavus* - This option incorrectly lists both **eversion** and **forefoot abduction**. Eversion is the outward tilting of the heel, and forefoot abduction is the outward turning of the front of the foot. - Both eversion and forefoot abduction are opposite to the deformities seen in classical CTEV.

Pediatric Orthopaedics Indian Medical PG Question 8: Fracture at which site affects the longitudinal growth of a bone?

• A. Epiphyseal plate (Correct Answer)
• B. Diaphysis
• C. Epiphysis
• D. Metaphysis

Pediatric Orthopaedics Explanation: ***Epiphyseal plate*** - The **epiphyseal plate**, also known as the **growth plate**, is a cartilaginous disc responsible for the **longitudinal growth** of long bones. - A fracture in this region can damage the **chondrocytes** and disrupt the normal ossification process, potentially leading to **growth arrest** or limb length discrepancies. *Diaphysis* - The **diaphysis** is the **shaft** or central part of a long bone. - While a fracture here can cause pain and instability, it typically does not directly affect the **longitudinal growth** potential of the bone. *Epiphysis* - The **epiphysis** is the end part of a long bone, initially separated from the main bone by cartilage but later fused with it. - Although it contains the epiphyseal plate in growing individuals, a fracture to the epiphysis itself (excluding the growth plate) primarily affects the **joint surface** and stability, rather than longitudinal growth directly. *Metaphysis* - The **metaphysis** is the transitional zone between the diaphysis and the epiphysis, adjacent to the growth plate. - While fractures in this area can be close to the growth plate, a metaphyseal fracture generally does not directly damage the **growth plate cartilage** to the same extent as a fracture through the plate itself, making its impact on longitudinal growth less direct or severe.

Pediatric Orthopaedics Indian Medical PG Question 9: Which of the following statements is true regarding supracondylar fractures of the humerus?

• A. Extension type most common (Correct Answer)
• B. Flexion type is less common than extension type
• C. Both types are equally common
• D. More common in adults

Pediatric Orthopaedics Explanation: **Extension type most common** - **Extension-type supracondylar fractures** account for the vast majority (about 95%) of all supracondylar humerus fractures. - This type typically results from a fall on an **outstretched hand** with the elbow in extension, forcing the distal fragment posteriorly. *More common in adults* - **Supracondylar fractures of the humerus** are predominantly observed in children, especially between 5 and 10 years of age. - They are the **most common elbow fracture in children**, making this statement incorrect. *Flexion type is less common than extension type* - While flexion-type fractures do occur, they are significantly less common, representing only about 5% of all supracondylar fractures. - This type typically results from a direct blow to the posterior aspect of the elbow, with the distal fragment displaced anteriorly. *Both types are equally common* - As established, extension-type fractures are far more prevalent than flexion-type fractures, making them not equally common. - The significant disparity in incidence confirms that this statement is incorrect.

Pediatric Orthopaedics Indian Medical PG Question 10: Which one of the following statements about Compartment Syndrome is NOT correct?

• A. Pain is on active movement but not on passive movement of muscles (Correct Answer)
• B. Fasciotomy is the treatment of choice
• C. It is commonest in a closed fracture
• D. Volkmann's Ischaemic contracture is a late complication

Pediatric Orthopaedics Explanation: ***Pain is on active movement but not on passive movement of muscles*** - This statement is incorrect because pain in compartment syndrome is characteristically **out of proportion to the injury** and is **exacerbated by passive stretching of the muscles** within the affected compartment. - While active movement can cause pain, the hallmark sign related to pain is its intensification with passive stretching due to increased pressure. *Fasciotomy is the treatment of choice* - **Fasciotomy** is indeed the definitive surgical treatment for compartment syndrome to relieve pressure and prevent irreversible tissue damage. - It involves incising the fascia to decompress the affected muscle compartment. *It is commonest in a closed fracture* - Compartment syndrome most frequently occurs after a **closed fracture**, particularly in the tibia and forearm, because the intact fascial compartments restrict expansion, leading to increased pressure. - The swelling and hemorrhage associated with the fracture are contained, causing pressure to rise rapidly. *Volkmann's Ischaemic contracture is a late complication* - **Volkmann's ischemic contracture** is a severe and debilitating late complication of unresolved or undertreated compartment syndrome, primarily affecting the forearm muscles. - It results from prolonged ischemia, causing muscle necrosis, fibrosis, and subsequent shortening and contracture.

Pediatric Orthopaedics Flashcard 1 of 10

Question: _____ fractures and torus fractures are both common fractures in pediatric populations

Answer: Greenstick

Pediatric Orthopaedics Flashcard 2 of 10

Question: Type I and II spondylolisthesis (Wiltse-Newman) are commonly seen in _____ most commonly at the L5-S1 level.

Answer: childhood and adolescence

Pediatric Orthopaedics Flashcard 3 of 10

Question: What is the management of fracture neck of femur if patient age 3 weeks (MRI shows viability) ?_____

Answer: fixation with osteotomy

Pediatric Orthopaedics Flashcard 4 of 10

Question: A _____ fracture occurs due when axial force is applied to immature bone, leading to a simple buckle fracture of the cortex.

Answer: torus

Pediatric Orthopaedics Flashcard 5 of 10

Question: Hip fractures in the pediatric population are classified according to _____ classification

Answer: Delbet's

Pediatric Orthopaedics Flashcard 6 of 10

Question: Tom-Smith's arthritis causes severe destruction of the _____ of the femur as it is cartilaginous at this age.

Answer: head

Pediatric Orthopaedics Flashcard 7 of 10

Question: What is the pathogenesis of Perthe's disease? _____

Answer:

Pediatric Orthopaedics Flashcard 8 of 10

Question: Which of the following is associated with acute hip/knee pain and altered gait (outward facing toe gait)? _____

Answer: Slipped Capital Femoral Epiphysis

Pediatric Orthopaedics Flashcard 9 of 10

Question: _____ disease is intraarticular epiphyseal osteochondromas.

Answer: Trevor's

Pediatric Orthopaedics Flashcard 10 of 10

Question: Which of the following usually occurs in children between 12-14 years old? _____

Answer: Slipped Capital Femoral Epiphyses