Pediatric Orthopaedics Practice Questions

Q: A 2-year-old child with a history of old knee injury now has varus deformity of the left knee. Deformity persists on flexion; blood report is normal. X-ray shows unilateral genu varum and angulated tibia. What is the diagnosis?

Malunion of tibial fracture. ### ***Malunion of tibial fracture*** - The history of an **old knee injury** combined with a fixed **varus deformity** that persists on flexion is classic for malunion following a previous tibial fracture in a young child. - The X-ray finding of an **angulated tibia** in a unilateral distribution supports the diagnosis of a sequela from trauma rather than a developmental or metabolic bone disorder. *Osteofibrous dysplasia* - This typically presents as a **lytic lesion** located specifically in the **diaphysis** of the tibia rather than being a post-traumatic angular deformity. - It is a benign fibro-osseous lesion that generally evolves slowly and is not caused by a history of acute trauma. *Rickets* - This condition is consistently associated with **abnormal blood biochemistry**, specifically hypocalcemia, hypophosphatemia, or elevated alkaline phosphatase levels, which are absent here. - Rickets typically presents with **bilateral** genu varum and symmetric bowing, rather than a unilateral deformity following injury. *Focal fibrocartilaginous dysplasia* - This is a rare, self-limiting cause of unilateral infantile tibia vara that typically presents with a **characteristic metaphyseal lucency**. - It is a developmental condition rather than a post-traumatic one, and the history here strongly emphasizes a prior injury as the etiology.

Q: A child presents with a Gower sign. What does this finding indicate?

Proximal muscle weakness. ***Proximal muscle weakness*** - The **Gowers sign** is a classic clinical finding where a child must use their hands and arms to 'walk' up their own body to transition from a seated or squatting position to a standing one. - It indicates significant weakness of the **proximal hip and thigh muscles**, typically associated with conditions like **Duchenne muscular dystrophy**. *Sensory neuropathy* - While sensory neuropathies can cause gait disturbances or balance issues, they do not cause the structural weakness of proximal muscles required for the **Gowers maneuver**. - Symptoms typically include **numbness**, **tingling**, or **sensory loss** in a stocking-glove distribution rather than motor weakness. *Joint laxity* - Joint laxity often relates to connective tissue disorders like **Ehlers-Danlos syndrome** and typically results in joint instability or hypermobility. - Patients with laxity do not exhibit the specific compensatory motor pattern seen in **Gowers sign** unless there is a concurrent myopathy. *Distal muscle weakness* - Distal muscle weakness often manifests as **foot drop** or difficulty with fine motor tasks, rather than core and thigh strength deficits. - Conditions affecting distal muscles, such as **Charcot-Marie-Tooth disease**, typically present with atrophy of the lower legs rather than the proximal compensatory movements seen here.

Q: Epiphyseal enlargement is seen in which of the following conditions?

Juvenile Rheumatoid Arthritis. **Explanation:** The correct answer is **Juvenile Rheumatoid Arthritis (JRA)**. **Why JRA is correct:** In JRA (now more commonly termed Juvenile Idiopathic Arthritis), chronic synovial inflammation leads to **increased blood flow (hyperemia)** to the affected joint. This persistent hyperemia stimulates the adjacent growth plates, resulting in **accelerated osseous maturation** and **epiphyseal enlargement**. This is a classic radiological and clinical feature, often manifesting as "ballooning" of the epiphyses, particularly in the knees or wrists. **Why the other options are incorrect:** * **Rickets:** The hallmark of Rickets is **metaphyseal** changes, specifically widening, fraying, and cupping of the metaphysis due to failure of mineralization. While the joint may appear swollen clinically, the primary pathology is at the metaphysis, not the epiphysis. * **Scurvy:** Scurvy is characterized by subperiosteal hemorrhages and specific metaphyseal signs (e.g., Trummerfeld zone, Wimberger’s ring sign, Pelkan spur). It typically causes **epiphyseal atrophy** or "ground-glass" appearance rather than enlargement. * **Spondyloepiphyseal Dysplasia (SED):** This is a genetic bone dysplasia characterized by **small, flattened, or fragmented epiphyses** (epiphyseal dysgenesis), leading to short stature. It does not cause enlargement. **High-Yield Clinical Pearls for NEET-PG:** * **Epiphyseal Enlargement:** Think JRA, Hemophilia (due to repeated hemarthrosis/hyperemia), and Beckwith-Wiedemann Syndrome. * **Epiphyseal Dysgenesis (Stippled Epiphyses):** Think Hypothyroidism (most common), Conradi-Hünermann syndrome, and Warfarin embryopathy. * **Metaphyseal Widening:** Think Rickets, Scurvy, and Achondroplasia. * **Wimberger’s Sign:** In Scurvy, it refers to a thin sclerotic rim around a lucent epiphysis; in Congenital Syphilis, it refers to erosion of the medial proximal tibial metaphysis.

Q: Slipped capital femoral epiphysis is seen most commonly in which age group?

Adolescents. **Explanation:** **Slipped Capital Femoral Epiphysis (SCFE)** is a classic hip disorder characterized by the displacement of the capital femoral epiphysis from the femoral neck through the physeal plate. 1. **Why Adolescents is correct:** The condition occurs most commonly during the **adolescent growth spurt** (typically ages 10–16 years). During this period, the growth plate (physis) thickens and weakens under the influence of growth hormones, while the periosteum thins. This mechanical instability, often combined with **obesity**, leads to a "slip" where the epiphysis remains in the acetabulum while the neck moves anteriorly and superiorly. 2. **Why other options are incorrect:** * **Infants:** Hip pathology in this group is usually Developmental Dysplasia of the Hip (DDH) or Septic Arthritis. * **Childhood:** The most common hip pathology in younger children (ages 4–8) is **Legg-Calvé-Perthes disease** (avascular necrosis). * **Old age:** Hip issues in the elderly are typically related to Osteoarthritis or Neck of Femur fractures. **High-Yield Clinical Pearls for NEET-PG:** * **Typical Profile:** An obese adolescent male presenting with a limp and hip or **referred knee pain**. * **Clinical Sign:** **Drehmann Sign** (obligate external rotation of the hip during passive flexion). * **Radiology:** Look for **Trethowan’s Sign** (Klein’s line fails to intersect the femoral head). * **Associated Conditions:** If seen in younger children, suspect endocrine disorders like **Hypothyroidism** or Growth Hormone deficiency. * **Management:** The definitive treatment is **In-situ pinning** (Internal fixation with a single cannulated screw).

Q: A 4-year-old child sustained a fall on an outstretched hand. X-rays revealed a fracture line at the physis with a small metaphyseal fragment. There was no epiphyseal fracture. What type of injury, according to the Salter-Harris classification, is this?

Type II. ### Explanation The **Salter-Harris classification** is the standard system used to describe physeal (growth plate) injuries in children. The key to identifying the correct type lies in observing which anatomical components (Physis, Metaphysis, or Epiphysis) are involved. **Why Type II is Correct:** In this case, the fracture line travels through the **physis** and exits through the **metaphysis**, creating a triangular metaphyseal fragment known as the **Thurston-Holland sign**. Crucially, the epiphysis remains uninvolved. Type II is the **most common** type of physeal injury, typically occurring in children over 10 years old, though it can occur at any age. **Analysis of Incorrect Options:** * **Type I (S):** The fracture occurs purely through the physis (Separation). There is no bony fragment from the metaphysis or epiphysis. It is often a clinical diagnosis as X-rays may appear normal. * **Type III (A):** The fracture runs through the physis and exits through the **epiphysis** (Above/Articular). This is an intra-articular fracture and requires anatomical reduction. * **Type IV (T):** The fracture line passes **Through** all three elements: the metaphysis, the physis, and the epiphysis. It carries a high risk of growth disturbance. **NEET-PG High-Yield Pearls:** * **Mnemonic (SALTER):** * **S** (Type I): **S**traight across/Separated. * **A** (Type II): **A**bove (Metaphysis). * **L** (Type III): **L**ower (Epiphysis). * **T** (Type IV): **T**hrough everything. * **ER** (Type V): **ER**asure/Crush of the growth plate (worst prognosis). * **Thurston-Holland Sign:** Pathognomonic for Salter-Harris Type II. * **Prognosis:** Generally, Types I and II have a good prognosis and can be managed closed, while Types III and IV often require ORIF (Open Reduction Internal Fixation) to prevent growth arrest and joint incongruity.

Question 1

A 2-year-old child with a history of old knee injury now has varus deformity of the left knee.
Deformity persists on flexion; blood report is normal. X-ray shows unilateral genu varum and
angulated tibia. What is the diagnosis?

Accepted Answer

Malunion of tibial fracture

Answer

Osteofibrous dysplasia

Answer

Rickets

Answer

Focal fibrocartilaginous dysplasia

Question 2

A child presents with a Gower sign. What does this finding indicate?

Accepted Answer

Proximal muscle weakness

Answer

Sensory neuropathy

Answer

Joint laxity

Answer

Distal muscle weakness

Question 3

Epiphyseal enlargement is seen in which of the following conditions?

Accepted Answer

Juvenile Rheumatoid Arthritis

Answer

Rickets

Answer

Scurvy

Answer

Spondyloepiphyseal dysplasia

Question 4

Slipped capital femoral epiphysis is seen most commonly in which age group?

Accepted Answer

Adolescents

Answer

Infants

Answer

Old age

Answer

Childhood

Question 5

A 4-year-old child sustained a fall on an outstretched hand. X-rays revealed a fracture line at the physis with a small metaphyseal fragment. There was no epiphyseal fracture. What type of injury, according to the Salter-Harris classification, is this?

Accepted Answer

Type II

Answer

Type I

Answer

Type III

Answer

Type IV

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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