Pediatric Orthopaedics Practice Questions

Q: What is the treatment of choice in a newborn with club foot?

Both manipulation and splinting. **Explanation:** The treatment of choice for a newborn with **Congenital Talipes Equinovarus (CTEV)**, commonly known as clubfoot, is the **Ponseti Method**. This method relies on the principle of biological plasticity in a newborn's tissues. **1. Why "Both manipulation and splinting" is correct:** The management must begin as early as possible (ideally within the first week of life). It involves a two-step serial process: * **Manipulation:** Gentle manual stretching of the ligaments and tendons to gradually correct the deformities. * **Splinting (Casting):** Immediate application of a long-leg toe-to-groin plaster cast to maintain the correction achieved during manipulation. This process is repeated weekly for 5–8 weeks. **2. Why other options are incorrect:** * **Observation and follow-up:** Clubfoot is a progressive deformity; delay in treatment leads to rigid soft tissues and bony changes, making future correction difficult. * **Manipulation only:** Without a cast or splint, the elastic recoil of the soft tissues would cause the foot to return to its original deformed position immediately. * **Splint application alone:** Applying a cast without prior manipulation is ineffective and can lead to "rocker-bottom" deformities by forcing the foot into a position it is not yet ready to assume. **Clinical Pearls for NEET-PG:** * **Order of Correction (CAVE):** **C**avus first, then **A**dduction, then **V**arus, and finally **E**quinus. * **Tenotomy:** About 85-90% of cases require a Percutaneous Achilles Tenotomy to correct the residual Equinus. * **Maintenance:** After casting, a **Dennis Browne Splint** (foot abduction brace) is used to prevent recurrence (23 hours/day for 3 months, then at night until age 4). * **Pirani Score:** Used to assess the severity and monitor progress during treatment.

Q: Apert syndrome is a disease of:

Bones and joints. **Explanation:** **Apert Syndrome** (Acrocephalosyndactyly Type I) is a rare genetic disorder characterized by multisystem involvement, primarily affecting the **bones and joints**. It is caused by a mutation in the **FGFR2 gene** (Fibroblast Growth Factor Receptor 2), which leads to the premature fusion of skull bones (**craniosynostosis**) and severe limb abnormalities. **Why the correct answer is right:** The hallmark of Apert syndrome is the fusion of skeletal elements. This includes **acrocephaly** (tower-shaped skull) due to coronal suture synostosis and **complex syndactyly** (fusion of fingers and toes), often referred to as "mitten hands" or "sock feet." Because the primary pathology involves skeletal development and joint formation, it is classified as a disease of the bones and joints. **Why other options are wrong:** * **Blood:** Apert syndrome is a genetic structural disorder; it does not involve hematological abnormalities or bone marrow failure. * **Skin:** While skin changes like acne or hyperhidrosis can occur, they are secondary features. The primary pathology is skeletal. * **Autoimmune disorder:** This is a congenital genetic mutation (autosomal dominant), not an immune-mediated attack on body tissues. **High-Yield Clinical Pearls for NEET-PG:** * **Genetics:** Autosomal Dominant; associated with **advanced paternal age**. * **Hand Finding:** Symmetrical "mitten hand" syndactyly involving the 2nd, 3rd, and 4th digits. * **Facial Features:** Midface hypoplasia, proptosis (bulging eyes), and a high arched palate. * **Intellectual Disability:** Often present due to increased intracranial pressure from craniosynostosis.

Q: Wading gait is seen in which of the following conditions?

Common peroneal nerve injury. **Explanation:** The correct answer is **Common peroneal nerve injury (Option C)**. **1. Why Common Peroneal Nerve Injury is Correct:** Common peroneal nerve (CPN) injury leads to paralysis of the muscles in the anterior and lateral compartments of the leg, resulting in **Foot Drop**. To prevent the toes from dragging on the ground during the swing phase of walking, the patient must lift the knee higher than normal. This compensatory mechanism is known as a **High Steppage Gait** or **Wading Gait** (resembling someone walking through shallow water). **2. Analysis of Incorrect Options:** * **Bilateral Dislocation of the Hip (Option A):** This condition typically presents with a **Waddling Gait**. Due to the loss of a stable fulcrum and ineffective abductor mechanism (Trendelenburg positive) on both sides, the patient shifts the trunk from side to side. * **Myopathies (Option B):** Proximal muscle weakness (e.g., Duchenne Muscular Dystrophy) also results in a **Waddling Gait** due to weakness of the gluteus medius and maximus. * **Unilateral Dislocation of the Hip (Option D):** This presents with a **Lurching Gait** (Trendelenburg gait) where the trunk tilts toward the affected side during the stance phase to maintain pelvic balance. **3. Clinical Pearls for NEET-PG:** * **Trendelenburg Test:** Positive in conditions with abductor mechanism failure (e.g., Polio, CDH, SCFE). * **Antalgic Gait:** A "pain-relieving" gait characterized by a shortened stance phase on the affected limb. * **Hand-to-Knee Gait:** Seen in **Quadriceps paralysis** (e.g., Polio), where the patient pushes the thigh back to lock the knee in extension. * **Stamping Gait:** Seen in **Sensory Ataxia** (Tabes Dorsalis) due to loss of proprioception.

Q: A 3-year-old girl has developed a painful elbow after being jerked by the forearm. What is the next step to be done?

Fully supinate the forearm.. ### Explanation **Underlying Medical Concept: Pulled Elbow (Nursemaid’s Elbow)** The clinical scenario describes a classic case of **Pulled Elbow** (Subluxation of the Radial Head). In children under 5 years, the annular ligament is relatively lax. Sudden longitudinal traction on an extended, pronated forearm causes the radial head to slip distally, allowing a portion of the **annular ligament** to become trapped between the radial head and the capitellum. **Why Option D is Correct:** The definitive management is **manual reduction**. The most common and successful technique involves **fully supinating the forearm** while the elbow is flexed to 90 degrees. A palpable "click" often signifies the ligament returning to its normal position, followed by a rapid return of limb function. **Why Other Options are Incorrect:** * **Option A & B:** Immobilization or elbow pads are unnecessary. Once reduced, the joint is stable, and the child usually resumes normal activity within minutes. * **Option C:** X-rays are typically **normal** in pulled elbow and are not required unless there is focal bony tenderness or a history of a direct fall (to rule out fractures). A posterior slab is contraindicated as it delays the simple curative maneuver. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Sudden upward pull (traction) on a pronated forearm. * **Clinical Presentation:** The child holds the arm in slight flexion and **pronation** (pseudoparalysis); they refuse to use the arm. * **Pathology:** Entrapment of the **annular ligament** in the radio-capitellar joint. * **Reduction Techniques:** 1. Supination-Flexion (Traditional) 2. Hyperpronation (Often more successful on the first attempt). * **Post-reduction:** No immobilization is needed; if the child uses the arm to reach for a toy, the reduction is successful.

Q: What is the usual treatment for a fresh case of Congenital Talipes Equinovarus (CTEV) in a newborn?

Ponseti technique. **Explanation:** **Congenital Talipes Equinovarus (CTEV)**, also known as clubfoot, is a complex deformity characterized by four components: **C**aveus, **A**dduction, **V**arus, and **E**quinus (CAVE). **1. Why Ponseti Technique is Correct:** The **Ponseti technique** is currently the "Gold Standard" and the most widely accepted treatment for fresh cases of CTEV in newborns. It is a non-operative method involving serial manipulation and long-leg casting. The core principle is the correction of deformities in a specific sequence (CAVE) while using the **lateral head of the talus** as the fulcrum. Most cases (approx. 90%) also require a percutaneous Achilles tenotomy to correct the residual equinus. **2. Why Other Options are Incorrect:** * **Kite’s Technique:** An older casting method. It is considered inferior because it uses the calcaneocuboid joint as a fulcrum, which often fails to correct the heel varus and can lead to "flat-top talus" or midfoot break. * **Kocher’s Technique:** This is a method used for the reduction of **Subaxial/Shoulder dislocations**, not clubfoot. * **Wilson’s Technique:** Refers to a specific osteotomy (V-shaped) used for the correction of **Hallux Valgus**, unrelated to pediatric CTEV. **High-Yield Clinical Pearls for NEET-PG:** * **Order of Correction:** **CAVE** (C-A-V-E). Cavus is corrected first by supinating the forefoot; Equinus is always corrected last. * **Fulcrum:** Lateral head of the talus (Ponseti) vs. Calcaneocuboid joint (Kite). * **Bracing:** After casting, a **Steenbeek or Denis Browne splint** is used (in abduction) to prevent recurrence until age 4–5. * **Pirani Score:** Used to assess the severity and progress of CTEV during Ponseti management.

Q: What is the characteristic attitude of the lower limb in post-polio residual paralysis?

Flexion, abduction, external rotation. In Post-Polio Residual Paralysis (PPRP), the characteristic attitude of the lower limb is **Flexion, Abduction, and External Rotation** at the hip. ### **Mechanism of Deformity** The primary driver of this deformity is the **contracture of the Iliotibial Band (ITB)**. In polio, there is often a significant imbalance between muscle groups. The ITB acts as a dense fibrous band that spans from the ilium to the tibia. When it undergoes contracture, it exerts a multi-planar pull on the hip joint: 1. **Flexion:** Due to the ITB's position anterior to the axis of the hip joint. 2. **Abduction:** Because the ITB is located on the lateral aspect of the thigh. 3. **External Rotation:** Due to the posterior attachment of the ITB relative to the greater trochanter. ### **Analysis of Options** * **Option A (Correct):** This triad (Flexion, Abduction, External Rotation) is the classic "Polio Attitude" caused by ITB tightness and tensor fasciae latae (TFL) contracture. * **Option B (Incorrect):** Flexion, adduction, and internal rotation is the characteristic deformity seen in **Posterior Dislocation of the Hip** or early stages of Tuberculosis of the hip. * **Option C (Incorrect):** Extension is rarely seen in PPRP as the hip flexors (Iliopsoas) are often spared or less affected than the extensors (Gluteus Maximus), leading to flexion contractures. ### **NEET-PG High-Yield Pearls** * **Ober’s Test:** Used clinically to assess for ITB contracture. * **Soutter’s Release / Yount’s Procedure:** Surgical interventions used to release the tight ITB and fascia in polio patients. * **Associated Deformities:** The ITB contracture also causes secondary deformities: **Valgus** at the knee, **Flexion** at the knee, and **External rotation** of the tibia on the femur. * **Muscle Involvement:** Polio typically affects the **quadriceps** (most common) and the **tibialis anterior**, leading to a "Foot Drop" or "Flail Limb."

Q: Which of the following statements is NOT true regarding talipes equinovarus?

The foot is everted.. **Explanation:** **Congenital Talipes Equinovarus (CTEV)**, commonly known as Clubfoot, is a complex three-dimensional deformity of the foot. The correct answer is **B** because, in CTEV, the foot is **inverted**, not everted. The underlying medical concept is based on the four classic components of the deformity, remembered by the mnemonic **CAVE**: 1. **C – Cavus:** High arch due to the drop of the first metatarsal. 2. **A – Adduction:** The forefoot is deviated toward the midline (Option C is true). 3. **V – Varus:** The hindfoot/heel is tilted inward (Inversion). 4. **E – Equinus:** The ankle is in plantar flexion due to a tight Achilles tendon (Option D is true). **Analysis of Options:** * **Option A:** True. CTEV is more common in males (ratio of 2:1) and is bilateral in 50% of cases. * **Option C:** True. Forefoot adduction occurs at the tarsometatarsal joints. * **Option D:** True. Equinus refers to the inability to dorsiflex the ankle, meaning it is fixed in plantar flexion. **Clinical Pearls for NEET-PG:** * **Gold Standard Treatment:** The **Ponseti Method** (serial casting). The sequence of correction is **C-A-V-E** (Cavus first, Equinus last). * **Radiology:** On X-ray, the **Kite’s angle** (talocalcaneal angle) is **decreased** (less than 20°). In a normal foot, these axes diverge; in CTEV, they are nearly parallel. * **Pirani Scoring:** Used to assess the severity of the deformity and monitor progress during casting. * **Surgery:** If conservative management fails, a **Posteromedial Soft Tissue Release (PMSTR)** may be required.

Q: Which muscle is involved in congenital muscular torticollis?

Sternocleidomastoid. ### Explanation **Correct Answer: B. Sternocleidomastoid** **Medical Concept:** Congenital Muscular Torticollis (CMT), also known as "Wry Neck," is a common pediatric condition caused by the shortening or fibrosis of the **Sternocleidomastoid (SCM)** muscle. Pathologically, there is an replacement of muscle fibers with fibrous tissue, often presenting as a firm, non-tender mass (pseudotumor) within the muscle belly shortly after birth. This leads to a characteristic deformity where the infant’s head is **tilted toward the affected side** and the **chin is rotated toward the opposite shoulder**. **Analysis of Incorrect Options:** * **A. Deltoid:** This muscle is involved in shoulder abduction and is frequently associated with Axillary nerve injuries or intramuscular injection fibrosis, but it plays no role in neck positioning. * **C. Digastric & D. Mylohyoid:** These are suprahyoid muscles involved in swallowing and depressing the mandible. They are not involved in the rotational or lateral flexion movements of the neck seen in torticollis. **Clinical Pearls for NEET-PG:** * **Associated Conditions:** Always screen for **Developmental Dysplasia of the Hip (DDH)**, as there is a 10–20% clinical association between CMT and DDH. * **Clinical Presentation:** "Cock-robin" appearance (Head tilt to the same side, chin rotation to the opposite side). * **Complications:** If left untreated, it can lead to **Plagiocephaly** (flattening of the skull) and facial asymmetry. * **Treatment:** Initial management is conservative (stretching exercises). Surgical intervention (SCM release) is indicated if the condition persists beyond 1 year of age.

Question 1

In congenital dislocation of the hip, which clinical sign shows that the affected thigh is at a lower level when the knees and hips are flexed to 90 degrees?

Accepted Answer

Galeazzi's sign

Answer

Oolani's sign

Answer

Barlow's sign

Answer

Von Rosen's sign

Question 2

What is the treatment of choice in a newborn with club foot?

Accepted Answer

Both manipulation and splinting

Answer

Observation and follow-up

Answer

Manipulation only

Answer

Splint application alone

Question 3

Apert syndrome is a disease of:

Accepted Answer

Bones and joints

Answer

Blood

Answer

Skin

Answer

Autoimmune disorder

Question 4

Wading gait is seen in which of the following conditions?

Accepted Answer

Common peroneal nerve injury

Answer

Bilateral dislocation of hip

Answer

Myopathies

Answer

Unilateral dislocation of the hip

Question 5

Ortolani's test is done in which condition?

Accepted Answer

Congenital Dysplasia of the Hip (CDH)

Answer

Perthes disease

Answer

Posterior dislocation of the hip

Answer

Septic arthritis

Question 6

A 3-year-old girl has developed a painful elbow after being jerked by the forearm. What is the next step to be done?

Accepted Answer

Fully supinate the forearm.

Answer

Cuff and collar sling immobilization.

Answer

Reduction, setting, and application of an elbow pad.

Answer

X-ray and elevation of the limb in a posterior slab.

Question 7

What is the usual treatment for a fresh case of Congenital Talipes Equinovarus (CTEV) in a newborn?

Accepted Answer

Ponseti technique

Answer

Kites technique

Answer

Kocher's technique

Answer

Wilson's technique

Question 8

What is the characteristic attitude of the lower limb in post-polio residual paralysis?

Accepted Answer

Flexion, abduction, external rotation

Answer

Flexion, adduction, internal rotation

Answer

Extension, abduction, internal rotation

Answer

None of the above

Question 9

Which of the following statements is NOT true regarding talipes equinovarus?

Accepted Answer

The foot is everted.

Answer

It is common in boys.

Answer

The forefoot is adducted.

Answer

The ankle is plantar flexed.

Question 10

Which muscle is involved in congenital muscular torticollis?

Accepted Answer

Sternocleidomastoid

Answer

Deltoid

Answer

Digastric

Answer

Mylohyoid

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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