Pediatric Orthopaedics Practice Questions

Q: What is the ideal age for performing a Posterior Malleolar Stress Test (PMSTR)?

1 - 3 years. **Explanation:** The **Posterior Medial Soft Tissue Release (PMSTR)**, also known as the Turco procedure, is a comprehensive surgical intervention used for the management of **Congenital Talipes Equinovarus (CTEV)** or Clubfoot that has failed conservative management (Ponseti method). **Why 1–3 years is the ideal age:** The primary goal of PMSTR is to achieve a plantigrade foot by releasing tight ligaments, tendons, and joint capsules on the posterior and medial aspects of the foot. * **Before 1 year:** The tarsal bones are largely cartilaginous and small, making surgical stabilization difficult and increasing the risk of avascular necrosis or crush injuries to the cartilage. * **Between 1–3 years:** The bones have sufficient ossification to hold sutures and pins, yet the foot still possesses enough remodeling potential to adapt to the corrected position. This is the "sweet spot" for achieving a balanced, functional foot before significant adaptive bony changes occur. **Analysis of Incorrect Options:** * **A. Less than 1 year:** Conservative management (Ponseti casting) is the gold standard during this period. Surgery is avoided due to the small size of structures and the risk of damaging growth plates. * **C & D. 3–9 years:** Beyond the age of 3–4, the deformity becomes "neglected" or "relapsed" with significant bony changes. Soft tissue release alone is usually insufficient; these cases often require **bony procedures** (like Evans calcaneal osteotomy or Dwyer’s osteotomy) or salvage procedures (Triple Arthrodesis if >10–12 years). **High-Yield Clinical Pearls for NEET-PG:** * **Turco’s Incision:** A hockey-stick shaped incision used for PMSTR. * **Order of Correction in Ponseti:** CAVE (Cavus, Adduction, Varus, Equinus). * **Most common residual deformity:** Equinus (corrected by Percutaneous Achilles Tenotomy). * **Kite’s Angle:** Decreased in CTEV (on AP and Lateral X-rays).

Q: The Ortolani test is considered positive when the examiner hears which of the following?

Clunk of entry on abduction and flexion of the hip. The **Ortolani test** is a clinical maneuver used to identify a dislocated hip that is **reducible** in infants with Developmental Dysplasia of the Hip (DDH). ### Explanation of the Correct Answer **A. Clunk of entry on abduction and flexion of the hip:** The test is performed with the infant supine, hips flexed to 90°, and knees flexed. The examiner places their thumb on the inner thigh and fingers over the greater trochanter. As the hip is slowly **abducted**, the examiner applies upward pressure on the greater trochanter. If the hip is dislocated, this maneuver pushes the femoral head back into the acetabulum, resulting in a palpable (and sometimes audible) **"clunk" of entry**. ### Why Other Options are Incorrect * **B & D (Extension and Adduction):** These movements are associated with the **Barlow maneuver**, which is a provocative test used to dislocate a "dislocatable" but currently reduced hip. * **C & D (Click of exit):** A "click" is often a benign sound caused by ligamentous laxity or snapping tendons. The Ortolani sign is specifically a **"clunk"** representing the physical reduction of the joint. "Exit" refers to dislocation (Barlow), not reduction (Ortolani). ### High-Yield Clinical Pearls for NEET-PG * **Mnemonic:** **O**rtolani **O**ut to **I**n (Reduces the hip); **B**arlow **B**ack and **O**ut (Dislocates the hip). * **Age Limit:** These tests are most reliable from birth up to **2–3 months**. After this, soft tissue contractures develop, and the most reliable sign becomes **limited abduction** and **Galeazzi sign** (apparent femoral shortening). * **Gold Standard Investigation:** **Ultrasound** is the investigation of choice for DDH in infants <6 months (as the femoral head is not yet ossified). X-rays are used after 6 months. * **Treatment:** The initial treatment of choice for a positive Ortolani test in a newborn is the **Pavlik harness**.

Q: A 16-year-old obese female presents with a history of bilateral hip pain of long duration and a painful, limping gait. Endocrinology tests show hypothyroidism. Which of the following investigations is of no use in the diagnosis of this condition?

USG. **Explanation:** The clinical presentation of an **obese adolescent** with chronic hip pain, limping gait, and **hypothyroidism** is a classic "textbook" description of **Slipped Capital Femoral Epiphysis (SCFE)**. In SCFE, the femoral head slips posteriorly and inferiorly relative to the femoral neck through the growth plate. **Why USG is the correct answer (of no use):** While Ultrasonography (USG) can detect a joint effusion or a subtle step-off at the head-neck junction, it is **not a standard diagnostic tool** for SCFE. It lacks the sensitivity and specificity required to grade the slip or plan surgical management. In the context of NEET-PG, USG is the "least useful" investigation compared to radiographic imaging. **Analysis of other options:** * **X-ray (Option A):** This is the **initial and gold standard investigation**. AP and Frog-leg lateral views are essential. Key signs include **Klein’s Line** (which fails to intersect the femoral head) and the **Steel Sign** (double density). * **MRI (Option B):** Highly sensitive for diagnosing **"Pre-slip" SCFE** (where there is physeal widening and edema but no displacement yet) and for assessing femoral head vascularity (AVN). * **CT (Option C):** Useful for complex cases to accurately measure the degree of posterior tilt and for preoperative planning of corrective osteotomies. **Clinical Pearls for NEET-PG:** * **Associations:** SCFE is strongly associated with endocrine disorders like **Hypothyroidism** and Growth Hormone deficiency, especially when bilateral or presenting at an atypical age ( 16 years). * **Drehmann Sign:** Positive (obligate external rotation of the hip during passive flexion). * **Treatment:** The definitive management is **In-situ pinning** (usually with a single cannulated screw) to prevent further slippage.

Q: A 9-year-old child presents to your clinic with a deformity. Which is the most likely fracture leading to such a defect?

Supracondylar fracture. ***Supracondylar fracture*** - **Most common elbow fracture** in children aged **5-10 years**, typically resulting from a fall on outstretched hand with hyperextended elbow. - Malunion commonly leads to **cubitus varus** (gunstock deformity) due to **loss of Baumann's angle** and medial angulation of the distal fragment. *Colle's fracture* - This is a **distal radius fracture** that occurs primarily in **adults** following a fall on outstretched hand. - Results in **dinner fork deformity** at the wrist, not elbow deformity, and is uncommon in children due to their flexible bones. *Lateral epicondyle fracture* - Uncommon fracture that typically causes **cubitus valgus** (opposite of the described deformity) rather than cubitus varus. - Often associated with **posterolateral rotatory instability** of the elbow rather than angular deformity. *Medial epicondyle fracture* - Commonly causes **ulnar nerve palsy** with numbness in the little finger and weakness of intrinsic hand muscles. - Does **not typically cause cubitus varus deformity** and is less common than supracondylar fractures in this age group.

Q: Congenital talipes equinovarus (CTEV) is caused by all of the following except?

Cubitus varus. **Explanation:** The correct answer is **Cubitus varus** because it is a deformity of the **elbow**, not the foot. It typically occurs as a late complication of a malunited supracondylar fracture of the humerus (Gunstock deformity) and has no etiological link to Congenital Talipes Equinovarus (CTEV). **Analysis of Options:** * **Idiopathic factors (Option B):** This is the most common cause of CTEV. The exact etiology is unknown, though theories suggest primary germplasm defects or intrauterine packing. * **Neurological disorders & Spina bifida (Options A & C):** CTEV can be secondary to neuromuscular imbalances. Conditions like **Spina bifida** (specifically myelomeningocele), cerebral palsy, and arthrogryposis multiplex congenita are well-known causes of "teratological" or secondary clubfoot. In these cases, the deformity is often more rigid and difficult to treat than the idiopathic variety. **Clinical Pearls for NEET-PG:** * **Components of CTEV (CAVE):** **C**avus (midfoot), **A**dduction (forefoot), **V**arus (heel), and **E**quinus (ankle). * **Order of Correction:** Follows the acronym **PARE** (or reverse CAVE): 1. Cavus, 2. Adduction, 3. Varus, 4. Equinus. * **Treatment Gold Standard:** The **Ponseti Method** (serial casting). The Achilles tenotomy is the most common surgical procedure performed during this process. * **Radiology:** The **Kite’s angle** (talocalcaneal angle) is decreased in both AP and lateral views in CTEV.

Q: A child presents with hip pain. X-ray of the pelvis shows generalized osteopenia, thin cortices, gracile long bones, and proximal femoral deformity with evidence of healed fractures. What is the most likely clinical diagnosis?

Osteogenesis imperfecta. ***Osteogenesis imperfecta*** - X-ray findings of **osteopenia**, **thin cortices**, and **gracile bones** with possible **proximal femur deformity/fracture** in a child are pathognomonic for **osteogenesis imperfecta**. - This genetic disorder affects **COL1A1/COL1A2 genes** encoding type I collagen, presenting with the classic triad of **blue sclerae**, **hearing loss**, and **fragile bones** with multiple fractures. *Osteoporosis* - Primarily an **adult disease** associated with **postmenopausal** or **senile bone loss**, not typically seen in children. - Characterized by **decreased bone density** but normal bone architecture, unlike the **structural abnormalities** seen in osteogenesis imperfecta. *Osteopetrosis* - X-ray shows **dense, sclerotic bones** with **marble bone appearance** and **Erlenmeyer flask deformity**, opposite to the osteopenic findings described. - Associated with **bone marrow failure** and **cranial nerve compression** due to **excessive bone formation**. *Osteopoikilocytosis* - This term is incorrect as it refers to **red blood cell morphology** (spotted RBCs), not a bone condition. - The correct bone condition would be **osteopoikilosis**, which shows **punctate sclerotic lesions** throughout bones, not osteopenia or fractures.

Q: Which of the following is a musculoskeletal abnormality associated with neurofibromatosis?

All of the above. **Explanation:** Neurofibromatosis Type 1 (NF-1), also known as von Recklinghausen’s disease, is an autosomal dominant multisystem disorder caused by a mutation in the neurofibromin gene on chromosome 17. It has significant musculoskeletal manifestations that are frequently tested in NEET-PG. * **Scoliosis (Option B):** This is the **most common** skeletal abnormality in NF-1. It typically presents in two forms: a non-dystrophic type (similar to idiopathic scoliosis) and a **dystrophic type**, characterized by sharp, short-segment curves (usually involving 4-6 vertebrae) often associated with vertebral scalloping and rib penciling. * **Hypertrophy of limb (Option A):** This occurs due to **localized gigantism** resulting from plexiform neurofibromas and associated hemangiomatous or lymphatic overgrowth. This leads to limb length discrepancy and soft tissue hypertrophy. * **Cafe au lait spots (Option C):** While these are cutaneous markers (hyperpigmented macules), they are a cardinal diagnostic feature of NF-1. In the context of "musculoskeletal syndromes," they are often grouped with skeletal findings in clinical examinations. **Why "All of the above" is correct:** Since NF-1 is a generalized mesodermal dysplasia, it simultaneously affects the skin (Cafe au lait spots), the spine (Scoliosis), and the extremities (Limb hypertrophy/Pseudoarthrosis). **High-Yield Clinical Pearls for NEET-PG:** * **Anterolateral bowing of the tibia:** A pathognomonic skeletal finding in NF-1, often leading to **congenital pseudoarthrosis of the tibia**. * **Sphenoid wing dysplasia:** A characteristic skull deformity in NF-1. * **Diagnostic Criteria:** Remember the "Rule of 6": 6 or more Cafe au lait spots (>5mm in prepubertal, >15mm in postpubertal), 2 or more Lisch nodules (iris hamartomas), and 2 or more neurofibromas.

Q: How is a pulled elbow treated?

Reduction by supination. **Pulled Elbow (Nursemaid’s Elbow)** is a common pediatric injury occurring in children aged 1–4 years. It results from sudden longitudinal traction on an extended, pronated forearm (e.g., pulling a child’s hand to prevent a fall), causing the **annular ligament** to slip over the radial head and become trapped in the radio-capitellar joint. ### **Explanation of Options** * **Correct Answer (C): Reduction by Supination.** The standard management is closed reduction. The classic technique involves applying pressure over the radial head while **supinating the forearm**, followed by **flexion** of the elbow. Supination tightens the annular ligament, pulling it back to its anatomical position over the radial head. * **Option A & D:** Extension or simple flexion alone does not address the rotational displacement of the annular ligament. While flexion is the *second* step of the maneuver, supination is the critical corrective movement. * **Option B:** While some modern studies suggest that **Hyperpronation** is actually more successful than supination for reduction, "Supination and Flexion" remains the traditional, gold-standard textbook answer for NEET-PG. ### **Clinical Pearls for NEET-PG** * **Pathophysiology:** Subluxation of the radial head; the annular ligament is the structure interposed. * **Clinical Presentation:** The child holds the arm in a characteristic position—**slightly flexed and pronated**—and refuses to use it (pseudoparalysis). There is no swelling or deformity. * **Diagnosis:** Primarily clinical. X-rays are usually normal but are done only to rule out fractures if the history is atypical. * **Post-Reduction:** A palpable "click" is often felt during reduction. The child typically resumes normal arm use within minutes, and no immobilization is required.

Question 1

What is the ideal age for performing a Posterior Malleolar Stress Test (PMSTR)?

Accepted Answer

1 - 3 years

Answer

Less than 1 year

Answer

3 - 6 years

Answer

6 - 9 years

Question 2

What is the most common associated injury with a fracture of the medial epicondyle?

Accepted Answer

Elbow dislocation

Answer

Monteggia fracture-dislocation

Answer

Supracondylar humerus fracture

Answer

Vascular deficit

Question 3

The Ortolani test is considered positive when the examiner hears which of the following?

Accepted Answer

Clunk of entry on abduction and flexion of the hip

Answer

Clunk of entry on extension and adduction of the hip

Answer

Click of exit on abduction and flexion of the hip

Answer

Click of exit on extension and adduction of the hip

Question 4

A 16-year-old obese female presents with a history of bilateral hip pain of long duration and a painful, limping gait. Endocrinology tests show hypothyroidism. Which of the following investigations is of no use in the diagnosis of this condition?

Accepted Answer

USG

Answer

X-ray

Answer

MRI

Answer

CT

Question 5

Surgical excision is contraindicated in which of the following anatomical structures?

Accepted Answer

Lateral condyle humerus

Answer

Olecranon process

Answer

Patella

Answer

Head of radius

Question 6

A 9-year-old child presents to your clinic with a deformity. Which is the most likely fracture leading to such a defect?

Accepted Answer

Supracondylar fracture

Answer

Colle's fracture

Answer

Lateral epicondyle fracture

Answer

Medial epicondyle fracture

Question 7

Congenital talipes equinovarus (CTEV) is caused by all of the following except?

Accepted Answer

Cubitus varus

Answer

Neurological disorder

Answer

Idiopathic factors

Answer

Spina bifida

Question 8

A child presents with hip pain. X-ray of the pelvis shows generalized osteopenia, thin cortices, gracile long bones, and proximal femoral deformity with evidence of healed fractures. What is the most likely clinical diagnosis?

Accepted Answer

Osteogenesis imperfecta

Answer

Osteoporosis

Answer

Osteopetrosis

Answer

Osteopoikilocytosis

Question 9

Which of the following is a musculoskeletal abnormality associated with neurofibromatosis?

Accepted Answer

All of the above

Answer

Hypertrophy of limb

Answer

Scoliosis

Answer

Cafe au lait spots

Question 10

How is a pulled elbow treated?

Accepted Answer

Reduction by supination

Answer

Reduction by extension of the elbow

Answer

Reduction by pronation

Answer

Reduction by flexion

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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