Pediatric Orthopaedics Practice Questions

Q: Which of the following tests is useful in the diagnosis of congenital dislocation of the hip?

Barlow's test. **Explanation:** **Developmental Dysplasia of the Hip (DDH)**, formerly known as congenital dislocation of the hip, is a condition where the femoral head has an abnormal relationship with the acetabulum. **1. Why Barlow’s Test is Correct:** Barlow’s test is a **provocative maneuver** used to detect hip instability. It identifies a "dislocatable" hip by attempting to push the femoral head out of the acetabulum. * **Mechanism:** The clinician adducts the hip and applies a gentle posterior pressure. If the hip is unstable, the femoral head slips out of the acetabulum with a palpable "clunk." * **Note:** It is often paired with the **Ortolani maneuver**, which reduces a dislocated hip back into the socket (the "test of reduction"). **2. Why Other Options are Incorrect:** * **Thomas Test:** Used to detect **fixed flexion deformity (FFD)** of the hip. It is commonly used in conditions like hip tuberculosis or osteoarthritis, not for neonatal screening of DDH. * **Hibb’s Test:** Used to assess the **sacroiliac (SI) joint**. It involves internal rotation of the hip while the patient is prone to elicit SI joint pain. * **Laguerre’s Test:** Also used to detect **sacroiliac joint** pathology. It is performed by flexing, abducting, and externally rotating the hip (similar to a Patrick/FABER test) to stress the SI joint. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Ultrasound (USG) is the investigation of choice for infants **<6 months** (as the femoral head is not yet ossified). X-rays are preferred after 6 months. * **Galeazzi Sign:** Look for apparent shortening of the femur (uneven knee heights) in older infants with unilateral dislocation. * **Treatment:** The **Pavlik Harness** is the initial treatment of choice for infants under 6 months of age.

Q: A 10-year-old girl sustained an upper limb injury two years ago. She now presents with a valgus deformity of the elbow and paresthesias over the medial aspect of her hand. What is the most likely diagnosis?

Lateral condyle fracture of the humerus. **Explanation:** The clinical presentation of a **valgus deformity** (cubitus valgus) following an old elbow injury in a child, associated with **tardy ulnar nerve palsy** (paresthesias over the medial hand), is a classic complication of a **Lateral Condyle Fracture of the Humerus**. **Why it is correct:** Lateral condyle fractures are "fractures of necessity" (requiring ORIF) because they are intra-articular and prone to non-union. If left untreated or if union fails, the lateral growth plate is disrupted while the medial side continues to grow. This asymmetrical growth leads to a progressive **cubitus valgus** deformity. As the valgus angle increases, the ulnar nerve is stretched around the medial epicondyle, leading to delayed-onset ulnar neuropathy, known as **Tardy Ulnar Nerve Palsy**. **Why other options are incorrect:** * **Supracondylar fracture:** The most common complication is **cubitus varus** (Gunstock deformity). While it can cause immediate nerve injuries (Median/AIBN), it rarely causes tardy ulnar nerve palsy. * **Medial condyle fracture:** This is rare in children and would typically lead to a varus deformity, not valgus. * **Fracture of the proximal ulna:** Isolated ulna fractures do not typically result in progressive elbow valgus or delayed ulnar nerve symptoms. **High-Yield Pearls for NEET-PG:** * **Lateral Condyle Fracture:** Second most common elbow fracture in children; known as the **"Fracture of Wise Men"** (because it is easy to miss but difficult to treat). * **Milch Classification:** Used to categorize these fractures based on the fracture line relative to the trochlear groove. * **Tardy Ulnar Nerve Palsy:** Most commonly associated with non-union of the lateral condyle. Treatment involves ulnar nerve transposition. * **Cubitus Varus:** Most common deformity after supracondylar fractures; primarily a cosmetic issue rather than a functional one.

Q: Vertebral plana is a finding in a child with which of the following conditions?

Eosinophilic granuloma. **Explanation:** **Vertebra Plana** (also known as Calvé disease) refers to the uniform collapse of a vertebral body, resulting in a thin, wafer-like or "pancake" appearance on a lateral X-ray, while the adjacent intervertebral discs remain preserved. **1. Why Eosinophilic Granuloma (EG) is correct:** Eosinophilic Granuloma is the most common cause of vertebra plana in children. It is the localized form of **Langerhans Cell Histiocytosis (LCH)**. The pathology involves the infiltration of the vertebral body by histiocytes, leading to focal bone destruction and subsequent collapse under physiological load. Despite the severe collapse, the neurological status usually remains intact, and the bone often has a remarkable capacity for partial reconstitution over time. **2. Why the other options are incorrect:** * **Hyperparathyroidism:** Typically presents with generalized osteopenia, subperiosteal bone resorption (classically in the phalanges), and "Brown tumors." It does not cause isolated, uniform vertebral collapse. * **Osteomalacia:** Characterized by defective mineralization of the osteoid. In the spine, it leads to "codfish vertebrae" (biconcave appearance due to pressure from the discs) rather than the flat, wafer-like collapse of vertebra plana. **3. High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad of Hand-Schüller-Christian disease (a form of LCH):** Exophthalmos, Diabetes Insipidus, and lytic bone lesions. * **Differential Diagnosis for Vertebra Plana:** Use the mnemonic **"COMPRESS"**: **C**alvé disease (EG), **O**steomyelitis (TB), **M**etastasis/Malignancy (Neuroblastoma/Leukemia), **P**seudotumor, **R**eticuloendotheliosis, **E**osinophilic Granuloma, **S**cheuermann's disease (rarely), **S**teroids. * **Radiological Sign:** The "Coin-on-edge" appearance is synonymous with vertebra plana in EG.

Q: A 13-year-old girl complains of backache and fatigue. Her mother has noticed that she is becoming increasingly round-shouldered. On examination, she has a smooth thoracic kyphosis. X-ray shows wedge-shaped vertebral bodies in the thoracic spine. What is the most likely diagnosis?

Scheuermann's disease. **Explanation:** The clinical presentation and radiological findings are classic for **Scheuermann’s Disease** (Juvenile Kyphosis). This condition typically affects adolescents (13–16 years) and presents with a "round-back" deformity, backache, and fatigue. **Why Scheuermann’s Disease is correct:** The hallmark of this condition is a structural thoracic kyphosis caused by anterior wedging of the vertebral bodies. The diagnosis is confirmed radiologically by **Sorensen’s Criteria**: 1. Anterior wedging of ≥5° in at least three adjacent vertebrae. 2. Kyphosis angle >40° (Cobb’s angle). 3. Presence of **Schmorl’s nodes** (herniation of the disc into the vertebral endplate) and irregular endplates. **Why other options are incorrect:** * **Ankylosing Spondylitis:** Typically presents in young adults (not 13-year-olds) with morning stiffness, sacroiliitis, and "bamboo spine" on X-ray. It is an inflammatory condition, not a structural wedging disorder. * **Intervertebral Disc Prolapse:** Presents with acute radicular pain (sciatica) and neurological deficits; it does not cause structural kyphosis or vertebral wedging. * **Spinal Stenosis:** A degenerative condition seen in the elderly, characterized by neurogenic claudication. It is extremely rare in a 13-year-old. **High-Yield Pearls for NEET-PG:** * **Clinical Sign:** Unlike postural kyphosis, Scheuermann’s is a **fixed** deformity; the curve does not disappear on hyperextension or Adam’s forward bend test. * **Site:** Most common in the thoracic spine (T7-T9). * **Management:** Bracing (Milwaukee brace) is indicated for curves between 50°–75° in skeletally immature patients. Surgery is considered if the curve exceeds 75°.

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

All of the above. **Explanation:** Epiphyseal enlargement (widening of the bone ends) is a clinical and radiological sign that can result from metabolic, inflammatory, or infectious processes affecting the growth plate and surrounding joint structures. 1. **Rickets:** This is the most common metabolic cause. Due to a deficiency in Vitamin D, calcium, or phosphorus, there is a failure of osteoid mineralization. This leads to an accumulation of non-mineralized hypertrophic chondrocytes, causing the growth plate to thicken and the metaphysis to widen (cupping, splaying, and fraying). Clinically, this manifests as **widened wrists** and **double malleoli**. 2. **Scurvy:** Although not listed as a primary option, it is a common differential. However, in the context of this question, **Septic Arthritis** is a critical inflammatory cause. 3. **Septic Arthritis:** Acute infection of the joint space leads to inflammatory exudate and increased intra-articular pressure. This causes soft tissue swelling and can lead to apparent epiphyseal enlargement on examination. If chronic or severe, the hyperemia associated with inflammation can cause premature enlargement of the epiphysis (overgrowth) due to increased blood flow to the growth plate. **Clinical Pearls for NEET-PG:** * **Rickets:** Look for "Wrist widening" as the earliest clinical sign. Radiologically, the distance between the epiphysis and metaphysis increases. * **Scurvy:** Characterized by "Ground glass" osteoporosis and Wimberger’s ring sign (dense rim around the epiphysis), but the epiphysis itself does not widen in the same hypertrophic manner as Rickets. * **Differential Diagnosis of Epiphyseal Enlargement:** Includes Rickets, Septic Arthritis, Juvenile Idiopathic Arthritis (JIA), and Hemophilia (due to chronic hemarthrosis causing hyperemia).

Q: Sabre tibia is associated with:

Congenital syphilis. **Explanation:** **Sabre Tibia** is a classic clinical sign characterized by a sharp, anterior bowing of the tibia. It is a hallmark feature of **Late Congenital Syphilis** (manifesting after 2 years of age). **Why Congenital Syphilis is correct:** The deformity results from chronic **periostitis**. In congenital syphilis, the *Treponema pallidum* infection causes persistent inflammation of the periosteum. This leads to the deposition of new subperiosteal bone specifically along the anterior aspect of the tibial shaft, making it appear thickened and convex (resembling a "sabre" or curved sword). **Analysis of Incorrect Options:** * **Gonorrhea:** This is primarily a cause of neonatal conjunctivitis (ophthalmia neonatorum) or acute septic arthritis in adults; it does not cause chronic periosteal bone remodeling. * **Renal Osteodystrophy:** This leads to "Rugger-Jersey spine" and general osteopenia due to secondary hyperparathyroidism, but not specific anterior tibial bowing. * **Rickets:** While Rickets causes bowing of long bones, it typically results in **lateral bowing** (Genu varum) due to softening of the osteoid (osteomalacia), rather than the anterior cortical thickening seen in syphilis. **High-Yield Clinical Pearls for NEET-PG:** * **Hutchinson’s Triad (Late Syphilis):** Interstitial keratitis, Sensorineural hearing loss (8th nerve deafness), and Hutchinson’s teeth (notched incisors). * **Clutton’s Joints:** Painless, symmetrical hydrarthrosis (usually of the knee) seen in late congenital syphilis. * **Wimberger’s Sign:** Radiographic finding in early syphilis showing focal erosion of the medial aspect of the proximal tibial metaphysis. * **Differential Diagnosis:** Sabre tibia can also be seen in **Paget’s disease**, but in the context of pediatric orthopaedics and standard NEET-PG patterns, Congenital Syphilis is the primary association.

Q: Which of the following is NOT true regarding osteogenesis imperfecta?

Metaphyseal fractures are common.. **Explanation:** Osteogenesis Imperfecta (OI), also known as "Brittle Bone Disease," is a genetic disorder primarily caused by mutations in the **COL1A1** and **COL1A2** genes, leading to defective Type 1 collagen synthesis. **Why Option B is correct (The False Statement):** In Osteogenesis Imperfecta, the primary pathology is generalized bone fragility. The most common site for fractures is the **diaphysis** (shaft) of long bones. **Metaphyseal fractures** (specifically "corner fractures" or "bucket-handle fractures") are highly characteristic of **Non-Accidental Injury (Child Abuse)**, not OI. While OI patients can have fractures anywhere, the predilection for the metaphysis is a classic "distractor" used to differentiate OI from child abuse in exams. **Analysis of Incorrect Options:** * **Option A:** Diaphyseal fractures are indeed the hallmark of OI due to the cortical thinning and bowing of long bones. * **Option C:** The **Sillence Classification** is the gold standard for categorizing OI. It originally described four types (Type I: Mild/Blue sclera; Type II: Perinatal lethal; Type III: Severe deforming; Type IV: Moderate/Normal sclera). * **Option D:** Type 1 collagen is found in the sclera and dentin. Deficiencies lead to **blue sclera** (due to uveal tissue showing through thin collagen) and **dentinogenesis imperfecta** (opalescent teeth). **High-Yield Clinical Pearls for NEET-PG:** * **Inheritance:** Most common types are Autosomal Dominant. * **Radiology:** Look for "Zebra stripe sign" (post-bisphosphonate therapy), "Popcorn calcifications" at metaphyses, and "Wormian bones" in the skull. * **Treatment:** Medical management involves **Bisphosphonates** (e.g., Pamidronate) to increase bone density; surgical management involves **Sofield-Millar procedure** (multiple osteotomies and intramedullary nailing).

Q: A 3-year-old child presents with a complaint of limp. What is the most likely diagnosis?

Developmental dysplasia of the hip (DDH). ***Developmental dysplasia of the hip (DDH)*** - Most common cause of **painless limp** in toddlers aged **1-3 years**, presenting with **leg length discrepancy** and **asymmetric hip abduction**. - Radiological findings include **shallow acetabulum**, **lateral displacement of femoral head**, **disrupted Shenton's line**, and **elevated acetabular index**. *Septic arthritis* - Presents as an **acute febrile illness** with **severe hip pain**, **inability to bear weight**, and **systemic toxicity**. - Patient would appear **unwell** with **raised inflammatory markers** (CRP, ESR, WCC), which is not described here. *Slipped capital femoral epiphysis* - Typically occurs in **adolescents** aged **10-16 years**, especially those who are **obese** or have **endocrine disorders**. - Presents with **hip or knee pain** that worsens with activity, not typically seen in **3-year-olds**. *Perthes' disease* - Most commonly affects children aged **4-8 years**, with peak incidence around **5-6 years**. - Involves **avascular necrosis of femoral head** causing **progressive hip pain** and **restricted range of motion**, rare in **3-year-olds**.

Question 1

Which of the following tests is useful in the diagnosis of congenital dislocation of the hip?

Accepted Answer

Barlow's test

Answer

Thomas test

Answer

Hibb's test

Answer

Laguerre's test

Question 2

A 10-year-old girl sustained an upper limb injury two years ago. She now presents with a valgus deformity of the elbow and paresthesias over the medial aspect of her hand. What is the most likely diagnosis?

Accepted Answer

Lateral condyle fracture of the humerus

Answer

Supracondylar fracture of the humerus

Answer

Medial condyle fracture of the humerus

Answer

Fracture of the proximal ulna

Question 3

Nail-patella syndrome is characterized by which of the following?

Accepted Answer

Absent patella

Answer

Iliac horn

Answer

Sacral horn

Answer

Knee deformity

Question 4

Vertebral plana is a finding in a child with which of the following conditions?

Accepted Answer

Eosinophilic granuloma

Answer

Hyperparathyroidism

Answer

Osteomalacia

Answer

None of the above

Question 5

A 13-year-old girl complains of backache and fatigue. Her mother has noticed that she is becoming increasingly round-shouldered. On examination, she has a smooth thoracic kyphosis. X-ray shows wedge-shaped vertebral bodies in the thoracic spine. What is the most likely diagnosis?

Accepted Answer

Scheuermann's disease

Answer

Ankylosing spondylitis

Answer

Intervertebral disc prolapse

Answer

Spinal stenosis

Question 6

Perthes disease is treated by which of the following methods?

Accepted Answer

Supervised containment of the femoral head in the acetabulum

Answer

High dose of calcium with steroids

Answer

Total hip replacement

Answer

Relieving weight bearing

Question 7

Epiphyseal enlargement is seen in which of the following conditions?

Accepted Answer

All of the above

Answer

Rickets

Answer

Rickets

Answer

Septic arthritis

Question 8

Sabre tibia is associated with:

Accepted Answer

Congenital syphilis

Answer

Gonorrhea

Answer

Renal osteodystrophy

Answer

Rickets

Question 9

Which of the following is NOT true regarding osteogenesis imperfecta?

Accepted Answer

Metaphyseal fractures are common.

Answer

Diaphyseal fractures are common.

Answer

It is classified by the Sillence classification.

Answer

Scleral and dental abnormalities are present.

Question 10

A 3-year-old child presents with a complaint of limp. What is the most likely diagnosis?

Accepted Answer

Developmental dysplasia of the hip (DDH)

Answer

Septic arthritis

Answer

Slipped capital femoral epiphysis

Answer

Perthes' disease

Pediatric Orthopaedics — MCQs

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