Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics Indian Medical PG Practice Questions and MCQs

Question 121: 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?

A. Oolani's sign
B. Barlow's sign
C. Von Rosen's sign
D. Galeazzi's sign (Correct Answer)

Explanation: ### Explanation **Galeazzi’s Sign (Correct Answer):** Also known as the **Allis sign**, this is a clinical indicator of femoral shortening or hip dislocation. When the patient lies supine with hips and knees flexed to 90 degrees and feet flat on the table, the knee on the affected side appears lower than the normal side. In Developmental Dysplasia of the Hip (DDH), this occurs because the femoral head is displaced posteriorly and superiorly out of the acetabulum, effectively shortening the functional length of the thigh. **Analysis of Incorrect Options:** * **Ortolani’s Sign:** This is a test for **reducibility**. It involves abducting the flexed hip while applying anterior pressure on the greater trochanter. A "clunk" is felt as the dislocated femoral head slides back into the acetabulum. * **Barlow’s Sign:** This is a provocative test for **instability**. It involves adducting the hip while applying posterior pressure. A positive sign is feeling the femoral head slip out of the acetabulum (dislocating the hip). * **Von Rosen’s Sign:** This refers to a specific radiographic finding. An AP X-ray is taken with the legs abducted to 45° and internally rotated. In a dislocated hip, the line through the femoral shaft axis points above the acetabular rim (normally it points toward the acetabulum). **High-Yield Clinical Pearls for NEET-PG:** * **Age Specificity:** Ortolani and Barlow tests are most reliable in infants **under 3 months**. Galeazzi’s sign becomes more prominent **after 3–6 months** as muscle contractures develop. * **Limitation:** Galeazzi’s sign is **unreliable in bilateral DDH** because both knees will be at the same (lower) level, masking the asymmetry. * **Trendelenburg Gait:** This is the characteristic clinical sign seen once the child starts walking, due to abductor muscle insufficiency. * **Klisic Test:** An imaginary line between the apex of the greater trochanter and the ASIS; in DDH, this line passes below the umbilicus.

Question 122: What is the treatment of choice in a newborn with club foot?

A. Observation and follow-up
B. Manipulation only
C. Both manipulation and splinting (Correct Answer)
D. Splint application alone

Explanation: **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.

Question 123: Apert syndrome is a disease of:

A. Blood
B. Bones and joints (Correct Answer)
C. Skin
D. Autoimmune disorder

Explanation: **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.

Question 124: Wading gait is seen in which of the following conditions?

A. Bilateral dislocation of hip
B. Myopathies
C. Common peroneal nerve injury (Correct Answer)
D. Unilateral dislocation of the hip

Explanation: **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.

Question 125: Ortolani's test is done in which condition?

A. Congenital Dysplasia of the Hip (CDH) (Correct Answer)
B. Perthes disease
C. Posterior dislocation of the hip
D. Septic arthritis

Explanation: **Explanation:** **Ortolani’s Test** is a clinical maneuver used to identify a dislocated hip that can be reduced back into the acetabulum. It is the gold standard clinical test for **Developmental Dysplasia of the Hip (DDH)**, formerly known as Congenital Dysplasia of the Hip (CDH). * **Mechanism:** The test is performed on a supine infant. The clinician flexes the hips and knees to 90 degrees, then gently **abducts** the hip while applying upward pressure on the greater trochanter. A positive sign is a palpable (and sometimes audible) **"clunk"** as the femoral head slides back into the acetabulum. This is a test of **reduction**. **Analysis of Incorrect Options:** * **Perthes Disease:** This is avascular necrosis of the femoral head in older children (4–8 years). Diagnosis is primarily radiological; clinical signs include limited internal rotation and abduction, not hip instability. * **Posterior Dislocation of the Hip:** While Ortolani’s involves a dislocated hip, the test is specific to the neonatal period and the pathology of DDH. Traumatic posterior dislocations (common in adults/adolescents) present with a shortened, adducted, and internally rotated limb. * **Septic Arthritis:** This is an acute infection of the joint. It presents with fever, refusal to bear weight, and "pseudoparalysis" where the child holds the hip in a position of comfort (flexion, abduction, and external rotation). **High-Yield Clinical Pearls for NEET-PG:** * **Barlow’s Test:** The opposite of Ortolani; it is a provocative test of **dislocation**. It involves adduction and downward pressure to see if the hip can be pushed out of the socket. * **Age Limit:** Ortolani and Barlow tests are most reliable up to **2–3 months** of age. After this, soft tissue contractures occur, and the most reliable sign becomes **limited abduction** and **Galeazzi sign** (apparent shortening of the femur). * **Investigation of Choice:** Ultrasound (USG) is preferred for infants <6 months; X-ray is used for children >6 months (once the femoral head begins to ossify).

Question 126: A 3-year-old girl has developed a painful elbow after being jerked by the forearm. What is the next step to be done?

A. Cuff and collar sling immobilization.
B. Reduction, setting, and application of an elbow pad.
C. X-ray and elevation of the limb in a posterior slab.
D. Fully supinate the forearm. (Correct Answer)

Explanation: ### 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.

Question 127: What is the usual treatment for a fresh case of Congenital Talipes Equinovarus (CTEV) in a newborn?

A. Ponseti technique (Correct Answer)
B. Kites technique
C. Kocher's technique
D. Wilson's technique

Explanation: **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.

Question 128: What is the characteristic attitude of the lower limb in post-polio residual paralysis?

A. Flexion, abduction, external rotation (Correct Answer)
B. Flexion, adduction, internal rotation
C. Extension, abduction, internal rotation
D. None of the above

Explanation: 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."

Question 129: Which of the following statements is NOT true regarding talipes equinovarus?

A. It is common in boys.
B. The foot is everted. (Correct Answer)
C. The forefoot is adducted.
D. The ankle is plantar flexed.

Explanation: **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.

Question 130: Which muscle is involved in congenital muscular torticollis?

A. Deltoid
B. Sternocleidomastoid (Correct Answer)
C. Digastric
D. Mylohyoid

Explanation: ### 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.

Practice by Chapter

Developmental Dysplasia of Hip

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Clubfoot

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Pediatric Fractures

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Growth Plate Injuries

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Legg-Calvé-Perthes Disease

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Slipped Capital Femoral Epiphysis

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Pediatric Spine Deformities

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Cerebral Palsy: Orthopaedic Aspects

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Neuromuscular Disorders in Children

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Pediatric Bone and Joint Infections

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Limb Length Discrepancies

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Orthopedic Manifestations of Genetic Disorders

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