Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics Indian Medical PG Practice Questions and MCQs

Question 131: At what age does the ossification center for the clavicle appear?

A. Birth
B. 2 years
C. 4 years (Correct Answer)
D. 6 years

Explanation: **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).

Question 132: Which of the following is true regarding Erb's Palsy?

A. Can be a brachial plexus injury (Correct Answer)
B. C5-C6 roots are involved
C. Deformity is adduction and internal rotation
D. Ulnar nerve is affected

Explanation: **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.

Question 133: Which of the following statements is false regarding the Salter-Harris classification of physeal injuries?

A. It classifies injuries involving the physis (growth plate).
B. Type II is the most common type of physeal injury.
C. Type IV involves a fracture line passing through the epiphysis, physis, and metaphysis.
D. Type V represents an injury to the perichondrial ring. (Correct Answer)

Explanation: 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.

Question 134: Excision of the head of the radius in a child should not be done because:

A. It produces instability of the elbow joint.
B. It leads to secondary osteoarthritis of the elbow.
C. It causes subluxation of the inferior radio-ulnar joint. (Correct Answer)
D. It causes myositis ossificans.

Explanation: **Explanation:** The radial head plays a critical role in the longitudinal stability of the forearm, especially in children whose skeletal structures are still developing. **Why Option C is Correct:** The radius and ulna are linked as a closed kinematic chain. The radial head acts as a "spacer" that maintains the length of the radius relative to the ulna. If the radial head is excised in a growing child, the radius loses its proximal support and migrates proximally (cephalad) due to the pull of the forearm muscles. This proximal migration results in a **positive ulnar variance**, which disrupts the **inferior (distal) radio-ulnar joint (DRUJ)**, leading to subluxation, wrist pain, and decreased grip strength. **Analysis of Incorrect Options:** * **Option A:** While the radial head is a secondary stabilizer against valgus stress, its excision in children is avoided primarily due to growth-related longitudinal instability rather than simple elbow joint laxity. * **Option B:** While joint incongruity can eventually lead to arthritis, the most immediate and characteristic complication in a pediatric patient is the disruption of the distal joint due to radial shortening. * **Option D:** Myositis ossificans is a complication of trauma (like elbow dislocation) or aggressive passive stretching, not a direct consequence of radial head excision. **High-Yield Clinical Pearls for NEET-PG:** * **Management Rule:** In children, radial head fractures should be managed conservatively or via closed/open reduction. **Excision is contraindicated** until skeletal maturity. * **Essex-Lopresti Fracture-Dislocation:** This involves a radial head fracture, interosseous membrane tear, and DRUJ disruption. It highlights the importance of the radial head in longitudinal stability. * **Mason Classification:** Used to grade radial head fractures (Type I-IV). * **Safe Zone for Hardware:** The "safe zone" for placing screws in the radial head is a 90-degree arc (non-articulating portion) to avoid limiting pronation/supination.

Question 135: Which of the following statements about Caffey's disease is FALSE?

A. Usually occurs in infants < 6 months
B. Jaw Osteomyelitis
C. Cortical hyperostosis
D. Caused by Salmonella (Correct Answer)

Explanation: **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.

Question 136: What is the management of posteromedial bowing of the tibia in a 6-month-old boy?

A. Osteotomy
B. Cast with Ponseti method
C. ORIF (Open Reduction Internal Fixation)
D. Observation (Correct Answer)

Explanation: **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**.

Question 137: What is the most common skeletal finding in cephalometric radiographs in a patient with a history of cleft palate and anterior crossbite?

A. Maxillary retrusion (Correct Answer)
B. Mandibular protrusion
C. Mandibular retrusion
D. Maxillary protrusion

Explanation: **Explanation:** The correct answer is **Maxillary retrusion**. **1. Why Maxillary Retrusion is Correct:** In patients with a history of cleft palate, the primary cause of an anterior crossbite is **midface hypoplasia** or **maxillary retrusion**. This occurs due to two main factors: * **Surgical Scarring:** The most significant factor is the scar tissue formed following palatoplasty (cleft palate repair). This fibrous tissue restricts the forward and lateral growth of the maxilla. * **Intrinsic Growth Deficiency:** There is often an inherent deficiency in the growth potential of the maxillary complex associated with the cleft deformity itself. On a cephalometric radiograph, this manifests as a decreased **SNA angle** (Sella-Nasion-A point), indicating that the maxilla is positioned posteriorly relative to the cranial base. **2. Why Other Options are Incorrect:** * **Mandibular Protrusion (B):** While the patient may appear to have a "prognathic" look (Relative Mandibular Prognathism), the mandible is usually of normal size. The discrepancy is "pseudo-Class III" caused by the small maxilla, not an overgrowth of the mandible. * **Mandibular Retrusion (C):** This would result in an overjet (buck teeth), which is the opposite of an anterior crossbite. * **Maxillary Protrusion (D):** This is the opposite of what is observed in cleft patients; protrusion is more common in Class II malocclusions. **3. Clinical Pearls for NEET-PG:** * **SNA Angle:** Measures maxillary position (Decreased in cleft patients). * **SNB Angle:** Measures mandibular position (Usually normal in cleft patients). * **ANB Angle:** Represents the relationship between the maxilla and mandible. In cleft patients, this is often negative, indicating a Class III skeletal relationship. * **Management:** Anterior crossbite in these patients often requires maxillary expansion and protraction (e.g., Face mask therapy) or orthognathic surgery (LeFort I osteotomy) after growth is complete.

Question 138: 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?

A. Kienböck's deformity
B. Congenital dislocation of the hip
C. Congenital coxa vara (Correct Answer)
D. Perthes' disease

Explanation: **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.

Question 139: Fraying at the ends of long bones is seen in which of the following conditions?

A. Rickets (Correct Answer)
B. Scurvy
C. Osteogenesis imperfecta
D. Congenital syphilis

Explanation: **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 140: What is the treatment of choice for a fracture of the shaft of the femur in a 4-year-old child?

A. Gallows traction
B. Hip spica
C. Russell traction (Correct Answer)
D. Intramedullary nail

Explanation: **Explanation:** The management of pediatric femoral shaft fractures is primarily determined by the **age and weight** of the child. For a **4-year-old child**, the treatment of choice is **Russell traction**. **1. Why Russell Traction is Correct:** Russell traction is a type of skin traction that uses a sling under the knee and a single pulley system to provide both longitudinal and upward pull. It is specifically indicated for children aged **2 to 10 years**. It helps in maintaining alignment and neutralizing the muscle forces (quadriceps and hamstrings) that cause shortening, acting as a definitive treatment or a bridge to casting. **2. Analysis of Incorrect Options:** * **Gallows Traction (Overhead Traction):** This is used for infants and children **under 2 years of age** (or weighing <12-15 kg). Both legs are suspended vertically to lift the buttocks off the bed. * **Hip Spica:** While often used as definitive treatment, it is typically applied immediately (Immediate Spica) in children **under 6 months** or after a period of traction (once the callus starts forming) in older children. In a 4-year-old, traction is usually the initial step to ensure length. * **Intramedullary (IM) Nail:** Rigid IM nails are contraindicated in children due to the risk of damaging the trochanteric epiphysis and causing avascular necrosis. **Elastic Stable Intramedullary Nailing (ESIN/TENS)** is an option for older children (6–12 years), but Russell traction remains the classic textbook answer for the 2–10 age group in NEET-PG contexts. **Clinical Pearls for NEET-PG:** * **0–6 months:** Pavlik harness or Immediate Hip Spica. * **6 months – 2 years:** Gallows traction. * **2–10 years:** Russell traction (followed by Spica). * **>10 years/Adolescents:** Titanium Elastic Nailing System (TENS). * **Complication:** The most common complication of pediatric femur fractures is **malunion**, but children have excellent remodeling potential. **Overgrowth** (1-2 cm) is common due to hyperemia, so 1 cm of shortening in traction is often acceptable.

Practice by Chapter

Developmental Dysplasia of Hip

Practice Questions

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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