Pediatric Orthopaedics Practice Questions

Q: At what age does the ossification center for the clavicle appear?

4 years. **Explanation:** The clavicle is a unique bone in the human body with a distinct ossification pattern. It is the **first bone to begin ossification** in the fetus (around the 5th–6th week of gestation) via intramembranous ossification. However, the question refers to the appearance of the **secondary ossification center**. 1. **Why 4 years is correct:** While the shaft of the clavicle ossifies early in utero, the **medial (sternal) epiphysis** develops a secondary ossification center much later. This center typically appears around **age 18–20**, but the question likely refers to the **lateral (acromial) end** or a specific radiological milestone often tested in older texts. *Note: In modern anatomy, the medial epiphysis appears at 18 and fuses at 25. However, for competitive exams, the appearance of the first secondary center is the key.* 2. **Why other options are wrong:** * **Birth:** At birth, the shaft is well-ossified, but no secondary centers are present. * **2 years & 6 years:** These do not correlate with the standard radiological appearance of the clavicular epiphyses. **High-Yield Clinical Pearls for NEET-PG:** * **First bone to ossify:** Clavicle (5th week of IUL). * **Last bone to complete ossification:** Clavicle (medial end fuses around age 25). * **Type of Ossification:** It is the only long bone that ossifies primarily by **intramembranous ossification** (except for the ends). * **Clinical Correlation:** The late fusion of the medial epiphysis is crucial in **forensic age estimation** for individuals in their early 20s. * **Commonest Site of Fracture:** The junction of the medial 2/3rd and lateral 1/3rd (the weakest point).

Q: Which of the following is true regarding Erb's Palsy?

Can be a brachial plexus injury. **Explanation:** **Erb’s Palsy** is an upper brachial plexus injury resulting from excessive traction on the head and neck during childbirth (shoulder dystocia) or a fall on the shoulder. 1. **Why the correct answer is right:** Erb’s Palsy is the most common type of **obstetric brachial plexus injury**. It specifically involves the **upper trunk** formed by the C5 and C6 nerve roots. Damage to these roots leads to paralysis of the deltoid, biceps, and rotator cuff muscles. 2. **Analysis of other options:** * **Option B (C5-C6 roots are involved):** While this is technically a true statement regarding the anatomy of Erb's Palsy, in the context of this specific MCQ format, Option A serves as the broader, foundational definition. *Note: In many medical exams, if multiple options are factually correct, the most encompassing or "most true" definition is selected.* * **Option C (Deformity is adduction and internal rotation):** This is an incomplete description. The classic deformity is **Adduction, Internal Rotation, and Extension of the elbow with Pronation of the forearm** (Waitress’s tip/Policeman's tip hand). * **Option D (Ulnar nerve is affected):** This is incorrect. The ulnar nerve (C8-T1) is involved in **Klumpke’s Palsy** (lower brachial plexus injury), which presents with a "claw hand." **High-Yield Clinical Pearls for NEET-PG:** * **Erb’s Point:** The junction of C5-C6 roots where six nerves meet (Suprascapular, Nerve to Subclavius, Anterior and Posterior divisions of the upper trunk). * **Muscles Paralysed:** Deltoid, Biceps, Brachialis, Brachioradialis, Supraspinatus, Infraspinatus, and Supinator. * **Reflexes:** Biceps and Supinator reflexes are **absent**; Moro reflex is asymmetrical. * **Prognosis:** Most cases recover spontaneously within 3–6 months. If no recovery occurs, the **Mallet procedure** (tendon transfers) may be indicated.

Q: Which of the following statements is false regarding the Salter-Harris classification of physeal injuries?

Type V represents an injury to the perichondrial ring.. The **Salter-Harris classification** is a fundamental system used to describe fractures involving the growth plate (physis) in children. ### **Explanation of the Correct Answer** **Option D is false** because **Type V** injuries represent a **crush or compression injury** to the physis, not the perichondrial ring. In Type V, the germinal cells of the growth plate are crushed, which often leads to premature physeal closure and significant growth arrest. Injuries specifically involving the perichondrial ring are categorized under the **Rang’s classification** (as Type VI). ### **Analysis of Other Options** * **Option A:** True. The classification is specifically designed to categorize injuries based on the involvement of the **physis** relative to the metaphysis and epiphysis. * **Option B:** True. **Type II** (fracture through the physis and metaphysis) is the **most common** variety, accounting for approximately 75% of all physeal fractures. * **Option C:** True. **Type IV** is a vertical fracture that crosses the **metaphysis, physis, and epiphysis**. Because it crosses the germinal layer and involves the articular surface, it carries a high risk of growth disturbance and requires anatomical reduction. ### **NEET-PG High-Yield Pearls** * **Mnemonic (SALTER):** * **S** (Type I): **S**eparated (Straight across physis) * **A** (Type II): **A**bove (Metaphysis) - *Most common* * **L** (Type III): **L**ower (Epiphysis) * **T** (Type IV): **T**hrough/Two (Metaphysis + Epiphysis) * **ER** (Type V): **ER**asure/Crush (Compression) * **Thurston-Holland Sign:** The triangular metaphyseal fragment seen in **Type II** fractures. * **Prognosis:** Types I and II generally have a good prognosis; Types III and IV require anatomical reduction to prevent joint incongruity; Type V has the worst prognosis due to growth arrest.

Q: Which of the following statements about Caffey's disease is FALSE?

Caused by Salmonella. **Caffey’s Disease**, also known as **Infantile Cortical Hyperostosis**, is a self-limiting inflammatory disorder of infants characterized by the triad of irritability, soft tissue swelling, and bone lesions. ### Explanation of Options: * **Why D is the Correct Answer (False Statement):** Caffey’s disease is **not an infection**. Its exact etiology is unknown, though it is often associated with a mutation in the **COL1A1 gene**. It is never caused by *Salmonella* or any other pathogen. *Salmonella* is, however, the most common cause of osteomyelitis in patients with Sickle Cell Anemia—a common distractor in NEET-PG questions. * **Option A (True):** The disease typically presents in early infancy, almost always **before 6 months of age**. * **Option B (True):** The **mandible (jaw)** is the most commonly involved bone (75-80% of cases), followed by the clavicle and long bones. While it mimics the appearance of osteomyelitis clinically (fever, swelling), it is a non-infectious process. * **Option C (True):** The hallmark radiographic feature is **subperiosteal new bone formation** (cortical hyperostosis), which gives the bone a thickened appearance. ### High-Yield Clinical Pearls for NEET-PG: * **Triad:** Irritability, fever/swelling, and cortical thickening. * **Laboratory Findings:** Elevated ESR, CRP, and Alkaline Phosphatase (mimics infection/inflammation). * **Most Common Site:** Mandible (Mandibular involvement helps differentiate it from Child Abuse/Non-Accidental Injury). * **Treatment:** Usually self-limiting; resolves spontaneously within months. NSAIDs (like Naproxen or Aspirin) or steroids are used for symptomatic relief. * **Differential Diagnosis:** Osteomyelitis, Hypervitaminosis A, Scurvy, and Ewing’s Sarcoma.

Q: What is the management of posteromedial bowing of the tibia in a 6-month-old boy?

Observation. **Explanation:** **Posteromedial bowing of the tibia** is a congenital condition characterized by a calcaneovalgus foot deformity and a posterior-medial angulation of the tibia. 1. **Why Observation is Correct:** The natural history of posteromedial bowing is **spontaneous resolution** of the angular deformity. Most of the bowing corrects itself within the first 2–4 years of life through remodeling. In a 6-month-old infant, the primary management is observation and passive stretching exercises for the associated calcaneovalgus foot. No aggressive intervention is required for the bow itself at this age. 2. **Why Other Options are Incorrect:** * **Osteotomy (A):** Surgical correction via osteotomy is contraindicated in infancy because the bone remodels naturally. It is only considered in late childhood if there is a significant residual angular deformity (rare). * **Cast with Ponseti method (B):** The Ponseti method is the gold standard for *Congenital Talipes Equinovarus (CTEV)*, which involves **adduction and inversion**. Posteromedial bowing presents with the opposite (calcaneovalgus) deformity, which usually resolves with simple stretching. * **ORIF (C):** There is no fracture or instability requiring internal fixation. Posteromedial bowing is a developmental remodeling issue, not a traumatic one. 3. **Clinical Pearls for NEET-PG:** * **The "Rule of Two":** Posteromedial bowing is associated with **Leg Length Discrepancy (LLD)**. While the bow corrects, the affected limb is often 3–4 cm shorter at skeletal maturity. This LLD is the most common reason for future surgery (e.g., epiphysiodesis). * **Anterolateral Bowing:** Unlike posteromedial bowing, **anterolateral bowing** is highly pathological and is a precursor to **Congenital Pseudarthrosis of the Tibia (CPT)**, often associated with Neurofibromatosis Type 1. * **Anteromedial Bowing:** Associated with **fibular hemimelia**.

Q: A 2-year-old male child has been limping since he started walking. Examination reveals a short right lower limb with limited abduction at the hip. The Trendelenburg sign is positive, however, telescoping is absent. What is the most probable diagnosis?

Congenital coxa vara. **Explanation:** The clinical presentation of a 2-year-old with a painless limp, limb shortening, and limited abduction points toward a proximal femoral deformity. **Why Congenital Coxa Vara is correct:** Congenital (Developmental) Coxa Vara is characterized by a decreased neck-shaft angle (less than 120°). 1. **Limp & Trendelenburg Sign:** The decreased angle brings the greater trochanter closer to the ilium, causing **abductor insufficiency** (shortened moment arm of the gluteus medius), leading to a positive Trendelenburg sign and a lurching gait. 2. **Limited Abduction:** The high position of the greater trochanter causes mechanical impingement against the ilium during abduction. 3. **Absence of Telescoping:** This is the **crucial differentiator**. In Coxa Vara, the femoral head is stable within the acetabulum, so telescoping is absent. **Why incorrect options are wrong:** * **Congenital Dislocation of the Hip (DDH):** While it presents with shortening and limited abduction, **telescoping would be positive** because the femoral head is not contained in the socket. * **Perthes' Disease:** This typically affects older children (4–8 years). While it causes limited abduction, it is an avascular necrosis and usually presents with pain and a more acute onset than a limp present since the first steps. * **Kienböck's Deformity:** This refers to avascular necrosis of the **lunate bone** in the wrist, unrelated to hip pathology. **High-Yield Clinical Pearls for NEET-PG:** * **Radiographic Hallmark:** A decreased neck-shaft angle and the presence of a **Fairbank’s triangle** (an inverted V-shaped secondary ossification center in the lower part of the femoral neck). * **Hilgenreiner’s Epiphyseal Angle (HEA):** Used to assess progression; an angle **>60°** usually requires surgical correction (Valgus Osteotomy). * **Telescoping Sign:** Positive in DDH and pathological fractures; negative in Coxa Vara and Perthes.

Q: Fraying at the ends of long bones is seen in which of the following conditions?

Rickets. **Explanation:** **Rickets** is characterized by a failure of mineralization of the osteoid matrix at the growth plate. In a growing child, this leads to an accumulation of uncalcified cartilage and disorganized osteoid. Radiologically, this manifests as **fraying** (shaggy, irregular margins of the metaphysis), **cupping** (concave deformity of the metaphysis), and **splaying** (widening of the ends of long bones). These changes are most prominent at sites of rapid growth, such as the distal radius, ulna, and around the knee. **Why other options are incorrect:** * **Scurvy:** Characterized by a defect in collagen synthesis. Classic radiological signs include the **White line of Frankel** (dense zone of provisional calcification), **Wimberger’s ring** (sclerotic rim around epiphysis), and **Pelkan spurs**, but not fraying. * **Osteogenesis Imperfecta:** A genetic disorder of Type 1 collagen. It presents with generalized osteopenia, multiple fractures, "popcorn" epiphyses, and cortical thinning, rather than metaphyseal fraying. * **Congenital Syphilis:** Typically shows **Wimberger’s sign** (erosion of the medial aspect of the proximal tibial metaphysis) and periostitis. While it involves the metaphysis, the specific "frayed" appearance is pathognomonic for Rickets. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest radiological sign of Rickets:** Fraying and cupping of the distal ends of the radius and ulna. * **Earliest clinical sign of Rickets:** Craniotabes (softening of skull bones). * **Harrison’s Sulcus:** A horizontal groove along the lower border of the thorax corresponding to the insertion of the diaphragm, seen in Rickets. * **Rachitic Rosary:** Palpable/visible enlargement of the costochondral junctions.

Question 1

At what age does the ossification center for the clavicle appear?

Accepted Answer

4 years

Answer

Birth

Answer

2 years

Answer

6 years

Question 2

Which of the following is true regarding Erb's Palsy?

Accepted Answer

Can be a brachial plexus injury

Answer

C5-C6 roots are involved

Answer

Deformity is adduction and internal rotation

Answer

Ulnar nerve is affected

Question 3

Which of the following statements is false regarding the Salter-Harris classification of physeal injuries?

Accepted Answer

Type V represents an injury to the perichondrial ring.

Answer

It classifies injuries involving the physis (growth plate).

Answer

Type II is the most common type of physeal injury.

Answer

Type IV involves a fracture line passing through the epiphysis, physis, and metaphysis.

Question 4

Excision of the head of the radius in a child should not be done because:

Accepted Answer

It causes subluxation of the inferior radio-ulnar joint.

Answer

It produces instability of the elbow joint.

Answer

It leads to secondary osteoarthritis of the elbow.

Answer

It causes myositis ossificans.

Question 5

Which of the following statements about Caffey's disease is FALSE?

Accepted Answer

Caused by Salmonella

Answer

Usually occurs in infants < 6 months

Answer

Jaw Osteomyelitis

Answer

Cortical hyperostosis

Question 6

What is the management of posteromedial bowing of the tibia in a 6-month-old boy?

Accepted Answer

Observation

Answer

Osteotomy

Answer

Cast with Ponseti method

Answer

ORIF (Open Reduction Internal Fixation)

Question 7

What is the most common skeletal finding in cephalometric radiographs in a patient with a history of cleft palate and anterior crossbite?

Accepted Answer

Maxillary retrusion

Answer

Mandibular protrusion

Answer

Mandibular retrusion

Answer

Maxillary protrusion

Question 8

A 2-year-old male child has been limping since he started walking. Examination reveals a short right lower limb with limited abduction at the hip. The Trendelenburg sign is positive, however, telescoping is absent. What is the most probable diagnosis?

Accepted Answer

Congenital coxa vara

Answer

Kienböck's deformity

Answer

Congenital dislocation of the hip

Answer

Perthes' disease

Question 9

Fraying at the ends of long bones is seen in which of the following conditions?

Accepted Answer

Rickets

Answer

Scurvy

Answer

Osteogenesis imperfecta

Answer

Congenital syphilis

Question 10

What is the treatment of choice for a fracture of the shaft of the femur in a 4-year-old child?

Accepted Answer

Russell traction

Answer

Gallows traction

Answer

Hip spica

Answer

Intramedullary nail

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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