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.

Q: Which provocative test is used for the detection of developmental dysplasia of the hip (CDH)?

Barlow test. **Explanation:** Developmental Dysplasia of the Hip (DDH), formerly known as Congenital Dislocation of the Hip (CDH), requires early clinical screening. The **Barlow test** is a provocative maneuver used to detect an unstable hip that is currently reduced but "dislocatable." 1. **Why Barlow test is correct:** The test is performed by adducting the hip while applying a posterior force through the femur. If the hip is unstable, the femoral head slips out of the acetabulum with a palpable "clunk." It essentially "pushes the hip out." 2. **Why other options are incorrect:** * **Peterson test:** This is not a standard orthopedic test for DDH; it is often confused with the Perthes disease classification or unrelated clinical signs. * **Perkin’s test:** This refers to **Perkin’s line**, a vertical line drawn downward from the lateral edge of the acetabulum on a pelvic X-ray. It is a radiological marker, not a provocative clinical test. * **Von Rosen test:** This refers to a specific **radiographic view** (AP view with legs abducted 45° and internally rotated) used to diagnose DDH in infants, rather than a clinical provocative maneuver. **High-Yield Clinical Pearls for NEET-PG:** * **Ortolani Test:** The counterpart to Barlow; it is a **reductive maneuver** used to "put the hip back in" by abducting the flexed hip. * **Mnemonic:** **B**arlow **B**acks it out (Dislocates); **O**rtolani **O**pens it (Reduces). * **Galeazzi Sign:** Look for apparent shortening of the femur (uneven knee heights) in older infants. * **Klisic Test:** Used to assess the position of the greater trochanter relative to the iliac spine. * **Ultrasound:** The gold standard for diagnosis in infants <6 months (before the femoral head ossifies).

Q: A 12-year-old child presents with tingling sensation and numbness in the little finger and gives a history of fracture in the elbow region 4 years back. What is the probable previous injury?

Lateral condyle fracture humerus. ### Explanation The clinical presentation of delayed ulnar nerve symptoms (tingling and numbness in the little finger) years after an elbow injury is a classic description of **Tardy Ulnar Nerve Palsy**. **1. Why Lateral Condyle Fracture is Correct:** Lateral condyle fractures in children are prone to **non-union**. If the fracture fails to unite, it leads to a progressive **Cubitus Valgus** (increased carrying angle) deformity. As the valgus deformity increases over years, the ulnar nerve is chronically stretched as it passes behind the medial epicondyle. This "tardy" (late) stretching results in ulnar neuropathy, typically appearing 3–20 years after the initial injury. **2. Why Other Options are Incorrect:** * **Injury to ulnar nerve:** While the symptoms are ulnar nerve-related, the question asks for the *previous injury* (the fracture) that led to this state. * **Supracondylar fracture humerus:** This is the most common elbow fracture in children, but it typically leads to **Cubitus Varus** (Gunstock deformity). Cubitus varus does not stretch the ulnar nerve and is rarely associated with tardy ulnar palsy. * **Dislocation of elbow:** Acute dislocations can cause immediate nerve injuries (usually median or ulnar), but they do not typically cause progressive valgus deformities leading to delayed palsy years later. **3. NEET-PG High-Yield Pearls:** * **Lateral Condyle Fracture:** Known as the "Fracture of Necessity" because it almost always requires open reduction and internal fixation (ORIF) to prevent non-union. * **Milch Classification:** Used for lateral condyle fractures. * **Tardy Ulnar Nerve Palsy Treatment:** Surgical **anterior transposition** of the ulnar nerve. * **Most common complication of Lateral Condyle Fracture:** Non-union and Cubitus Valgus. * **Most common complication of Supracondylar Fracture:** Cubitus Varus (Malunion) and Volkmann’s Ischemic Contracture (Vascular).

Q: What is the spot diagnosis for a foot deformity described as a rocker bottom foot?

Rocker bottom foot. ### **Explanation** **Correct Answer: B. Congenital Vertical Talus (CVT)** *(Note: While the provided key marks "Rocker bottom foot" as the answer, in clinical practice and NEET-PG exams, **Congenital Vertical Talus** is the pathological diagnosis synonymous with a "Rocker bottom foot" appearance.)* The "Rocker bottom foot" is a classic clinical description where the sole of the foot is convex, the heel is in equinus, and the forefoot is dorsiflexed at the midtarsal joint. The underlying pathology is a **fixed dorsal dislocation of the navicular on the head of the talus**. This forces the talus into a vertical position (plantarflexed), making its head the most prominent point on the sole, creating the "rocker" shape. #### **Why other options are incorrect:** * **A. Congenital Talipes Equinovarus (CTEV):** Characterized by the **CAVE** mnemonic (Cavus, Adduction, Varus, and Equinus). The foot is inverted and the sole is concave, the exact opposite of a rocker bottom foot. * **D. Pes Cavus:** Refers to an abnormally high medial longitudinal arch. It is often associated with neurological conditions (e.g., Friedreich's ataxia) but does not present with a convex sole. * **C. Rocker bottom foot:** This is a descriptive term for the deformity itself, while Congenital Vertical Talus is the specific orthopedic diagnosis. #### **High-Yield Clinical Pearls for NEET-PG:** * **Associations:** CVT is frequently associated with **Trisomy 18 (Edwards Syndrome)**, myelomeningocele, and arthrogryposis. * **Radiology:** The hallmark is a **non-reducible** vertical talus. On a lateral X-ray in maximal dorsiflexion, the talus remains vertical and does not align with the first metatarsal. * **Differential:** Must be distinguished from "Oblique Talus," which is a milder deformity that reduces on plantarflexion. * **Treatment:** Reverse Ponseti technique (serial casting) followed by surgical correction (e.g., pinning the talonavicular joint).

Q: Siffert-Katz sign is seen in which of the following conditions?

Blount's disease. **Explanation:** **Blount’s Disease (Tibia Vara)** is the correct answer. The **Siffert-Katz sign** is a clinical/radiological finding specific to this condition. It refers to the **depression or "beaking" of the medial tibial metaphysis** along with an associated defect in the medial epiphysis. In Blount’s disease, disordered ossification of the medial aspect of the proximal tibial physis leads to progressive varus deformity. The Siffert-Katz sign specifically highlights the characteristic sloping and irregularity of the medial tibial plateau seen in advanced stages. **Why other options are incorrect:** * **Chondromalacia Patella:** This involves softening of the articular cartilage of the patella. Key clinical signs include the **Clarke’s test** (Patellar grind test) and Movie-goer’s sign (pain after prolonged sitting). * **Congenital Talipes Equinovarus (CTEV):** This is characterized by CAVE deformities (Cavus, Adduction, Varus, Equinus). High-yield signs include the **Pirani score** for clinical assessment and the **Kite’s angle** on X-ray. * **Rocker Bottom Foot:** This is a vertical talus deformity. It is often associated with Trisomy 18 (Edwards syndrome) and is characterized by a convex plantar surface, not the tibial changes seen in Blount’s. **High-Yield Clinical Pearls for NEET-PG:** * **Blount’s Disease:** Differentiated from physiological bowing by the **Drennan’s Metaphyseal-Diaphyseal Angle (>16° is diagnostic).** * **Langenskiöld Classification:** Used to stage the severity of Blount’s disease (Stages I-VI). * **Treatment:** Bracing (KAFO) is effective in early stages (Stage I-II), while osteotomy is required for advanced stages or older children.

Q: Which physical examination maneuver is depicted?

Galeazzi's test. ***Galeazzi's test*** - **Galeazzi's test** (also known as **Allis sign**) involves positioning the infant supine with **hips and knees flexed to 90°** and comparing knee heights to detect **unequal femoral lengths**. - A **positive test** shows unequal knee heights, indicating **developmental dysplasia of the hip (DDH)** with potential **hip dislocation** or **femoral shortening**. *O'Malley's test* - This is **not a recognized orthopedic examination maneuver** in standard medical literature or pediatric hip assessment. - The test name appears to be a **distractor** and is not part of the **DDH screening protocol**. *Skin-fold test* - The **skin-fold asymmetry test** involves examining **asymmetric thigh creases** in infants, but this is a **visual inspection** rather than a positioning maneuver. - While **asymmetric skin folds** can suggest DDH, they are **less reliable** than dynamic tests like Galeazzi's, Ortolani's, or Barlow's tests. *Barlow's test* - **Barlow's test** is a **dynamic provocation test** that attempts to **dislocate a reducible hip** by applying posterior pressure with hip adduction. - This test involves **active manipulation** of the hip joint, not a **static positioning** assessment like Galeazzi's test for comparing limb lengths.

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

Question 6

Which provocative test is used for the detection of developmental dysplasia of the hip (CDH)?

Accepted Answer

Barlow test

Answer

Peterson test

Answer

Perkin's test

Answer

Von Rosen test

Question 7

A 12-year-old child presents with tingling sensation and numbness in the little finger and gives a history of fracture in the elbow region 4 years back. What is the probable previous injury?

Accepted Answer

Lateral condyle fracture humerus

Answer

Injury to ulnar nerve

Answer

Supracondylar fracture humerus

Answer

Dislocation of elbow

Question 8

What is the spot diagnosis for a foot deformity described as a rocker bottom foot?

Accepted Answer

Rocker bottom foot

Answer

Congenital Talipes Equinovarus (CTEV)

Answer

Congenital vertical talus

Answer

Pes Cavus

Question 9

Siffert-Katz sign is seen in which of the following conditions?

Accepted Answer

Blount's disease

Answer

Chondromalacia patella

Answer

Congenital Talipes Equinovarus (CTEV)

Answer

Rocker bottom foot

Question 10

Which physical examination maneuver is depicted?

Accepted Answer

Galeazzi's test

Answer

O'Malley's test

Answer

Skin-fold test

Answer

Barlow's test

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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