Pediatric Orthopaedics Practice Questions

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.

Q: Cubitus valgus is typically associated with which anatomical variation?

Lateral condyle of humerus. **Explanation:** The correct answer is **Lateral condyle of humerus**. **Why it is correct:** Cubitus valgus (an increase in the carrying angle of the elbow) is a classic late complication of a **non-union of the lateral condyle of the humerus**. When a fracture of the lateral condyle fails to unite, there is a progressive arrest or retardation of growth on the lateral side of the distal humeral epiphysis. Meanwhile, the medial side (trochlea) continues to grow normally. This asymmetrical growth leads to a progressive outward deviation of the forearm, resulting in a valgus deformity. **Why the other options are incorrect:** * **Intercondylar region:** Fractures here (T or Y-shaped) usually lead to stiffness or osteoarthritis rather than a specific angular deformity like cubitus valgus. * **Olecranon process:** Fractures of the olecranon typically result in loss of active extension or triceps weakness, not a change in the carrying angle. * **Head of the radius:** Injuries here (like radial head fractures or dislocations) may cause restricted rotation (pronation/supination) or cubitus valgus only if associated with significant medial collateral ligament injury, but it is not the "typical" association. **High-Yield Clinical Pearls for NEET-PG:** * **Tardy Ulnar Nerve Palsy:** This is the most important complication of cubitus valgus. As the valgus deformity increases, the ulnar nerve is stretched around the medial epicondyle, leading to delayed (tardy) paralysis. * **Supracondylar Fracture:** Most commonly leads to **Cubitus Varus** (Gunstock deformity) due to malunion. * **Milch Classification:** Used for lateral condyle fractures; Type II is more unstable and prone to non-union. * **Treatment:** If the deformity is severe or symptomatic (ulnar nerve involvement), a **supracondylar osteotomy** may be required.

Q: Which is the least important risk factor associated with developmental dysplasia of the hip?

Gestational diabetes. **Explanation:** Developmental Dysplasia of the Hip (DDH) is a condition characterized by an abnormal relationship between the femoral head and the acetabulum. Its etiology is multifactorial, involving both mechanical and genetic factors. **Why Gestational Diabetes is the correct answer:** Gestational diabetes (Option D) is not a recognized risk factor for DDH. While it may lead to macrosomia (large baby), it does not directly influence the ligamentous laxity or mechanical positioning required to cause hip dysplasia. **Analysis of Incorrect Options (Major Risk Factors):** * **Female Sex (Option A):** This is a major risk factor (F:M ratio is 6:1). It is attributed to the increased sensitivity of the female fetus to maternal **relaxin**, which increases ligamentous laxity. * **Breech Position (Option B):** This is the **strongest mechanical risk factor**. The "frank breech" position (hips flexed, knees extended) places significant stress on the hip joint, potentially leading to dislocation. * **Positive Family History (Option C):** There is a strong genetic component; a sibling with DDH increases the risk significantly, suggesting an inherited tendency toward joint laxity or acetabular morphology. **High-Yield Clinical Pearls for NEET-PG:** * **The "6 Fs" of DDH:** **F**emale, **F**irst-born, **F**oot first (Breech), **F**amily history, **F**luid (Oligohydramnios), and **F**lexibility (Ligamentous laxity). * **Left Hip Predominance:** The left hip is more commonly involved (60%) because the left hip usually abuts the mother’s sacrum in the standard intrauterine position (LOA), causing adduction. * **Associated Conditions:** Always check for **Congenital Muscular Torticollis** and **Metatarsus Adductus**, as they frequently coexist with DDH ("Packaging defects"). * **Screening:** Ultrasound is the investigation of choice before 4–6 months; X-rays are used after 6 months once the femoral head ossifies.

Q: Kohler's disease involves which of the following bones?

Navicular bone. **Explanation:** **Kohler’s disease** is a self-limiting osteochondrosis of the **tarsal navicular bone**. It typically occurs in children aged 2 to 9 years (more common in boys) and is caused by a temporary disruption of the blood supply to the navicular bone. As the navicular is the last bone of the foot to ossify, it is susceptible to compression between the already ossified talus and cuneiforms, leading to avascular necrosis (AVN). **Analysis of Options:** * **Option B (Navicular bone):** This is the correct site. Radiologically, it presents with a flattened, sclerotic ("wafer-like"), and fragmented navicular bone. * **Option A (Femoral head):** AVN of the femoral head in children is known as **Legg-Calvé-Perthes disease**. * **Option C (Tibial tubercle):** Traction apophysitis of the tibial tubercle is known as **Osgood-Schlatter disease**. * **Option D (Lunate bone):** AVN of the lunate bone (usually in adults) is known as **Kienböck's disease**. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** A child presenting with an antalgic gait and localized pain/tenderness over the medial aspect of the midfoot. * **Prognosis:** Excellent. Unlike Perthes disease, Kohler’s disease has a remarkable capacity for bony reconstitution. * **Management:** Conservative (symptomatic relief, activity modification, or a short-leg walking cast for 4–6 weeks). * **Mnemonic for Osteochondrosis:** * **K**ohler = **K**id's Navicular * **F**reiberg = **F**oot (2nd Metatarsal head) * **P**anner = **P**roximal (Capitellum of humerus) * **S**ever = **S**tep (Calcaneum)

Q: What is the most common elbow injury in adolescents?

Physeal injury. **Explanation:** In adolescents, the **physeal (growth) plate** is the weakest link in the musculoskeletal system. While ligaments and tendons are relatively strong, the hypertrophic zone of the physis is structurally vulnerable to shear and tension forces. During the adolescent growth spurt, the physis is particularly susceptible to injury before it undergoes complete ossification. Therefore, trauma that would cause a ligamentous sprain in an adult or a greenstick fracture in a younger child typically results in a **physeal injury** (often classified by the Salter-Harris system) in adolescents. **Analysis of Incorrect Options:** * **A. Dislocation:** While elbow dislocations do occur, they are more common in young adults after the growth plates have fused. In adolescents, the bone usually fails at the physis before the joint capsule or ligaments give way. * **C. Supracondylar fracture:** This is the most common elbow fracture in **children** (peak age 5–8 years). By adolescence, the distal humerus has remodeled and strengthened, making this injury less frequent than physeal disruptions. * **D. Olecranon fracture:** These are relatively rare in the pediatric and adolescent population, usually associated with direct trauma or underlying conditions like osteogenesis imperfecta. **Clinical Pearls for NEET-PG:** * **CRITOE:** Remember the order of ossification center appearance: **C**apitellum (1y), **R**adial head (3y), **I**nternal/Medial epicondyle (5y), **T**rochlea (7y), **O**lecranon (9y), **E**xternal/Lateral epicondyle (11y). * **Little League Elbow:** A common adolescent overuse injury involving the medial epicondyle physis. * **Salter-Harris Type II** is the most common type of physeal injury overall.

Q: Gallows traction is used in the management of fracture of which bone shaft?

Femur. **Explanation:** **Gallows traction** (also known as Bryant’s traction) is a specific type of skin traction used primarily for the management of **femur shaft fractures** in young children. **Why Femur is Correct:** The underlying principle involves suspending the child’s lower limbs vertically using skin traction applied to both legs. The legs are hoisted such that the **buttocks are just lifted off the bed**. This uses the child’s own body weight as counter-traction to align the femoral fragments. It is specifically indicated for children **under 2 years of age** (or weighing less than 12–15 kg) because their light body weight allows for effective traction without compromising peripheral circulation. **Why Other Options are Incorrect:** * **Tibia:** Fractures here in children are usually managed with closed reduction and casting (above-knee or below-knee casts). * **Humerus:** Pediatric humeral shaft fractures are typically treated with U-slabs, hanging casts, or simple immobilization. * **Ulna:** Forearm fractures are managed via closed reduction and "well-molded" POP casts. Traction is not a standard modality for upper limb shaft fractures in this age group. **High-Yield Clinical Pearls for NEET-PG:** 1. **Age/Weight Limit:** Crucial for the exam—used for children <2 years or <15 kg. 2. **Position:** Both legs are suspended, even if only one is fractured, to maintain stability and prevent rotation. 3. **Complication:** The most serious risk is **vascular compromise** (ischemia). Frequent checks of the dorsalis pedis pulse and capillary refill are mandatory. 4. **Alternative:** For children older than 2 years with femur fractures, **Thomas Splint** or immediate spica casting is preferred.

Question 1

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 2

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 3

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

Question 4

Cubitus valgus is typically associated with which anatomical variation?

Accepted Answer

Lateral condyle of humerus

Answer

Intercondylar region of humerus

Answer

Olecranon process

Answer

Head of the radius

Question 5

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 6

Which is the least important risk factor associated with developmental dysplasia of the hip?

Accepted Answer

Gestational diabetes

Answer

Female sex

Answer

Breech position

Answer

Positive family history

Question 7

Kohler's disease involves which of the following bones?

Accepted Answer

Navicular bone

Answer

Femoral head

Answer

Tibial tubercle

Answer

Lunate bone

Question 8

What is the most common elbow injury in adolescents?

Accepted Answer

Physeal injury

Answer

Dislocation

Answer

Supracondylar fracture

Answer

Olecranon fracture

Question 9

Gallows traction is used in the management of fracture of which bone shaft?

Accepted Answer

Femur

Answer

Tibia

Answer

Humerus

Answer

Ulna

Question 10

Which of the following is FALSE regarding Developmental Dysplasia of the Hip?

Accepted Answer

Associated with polyhydramnios

Answer

Ortolani Test

Answer

Sailor's gait

Answer

Non-positive Trendelenburg sign

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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