Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics Indian Medical PG Practice Questions and MCQs

Question 141: Osteonecrosis is not seen in which of the following conditions?

A. Ollier disease (Correct Answer)
B. Kienböck disease
C. Köhler disease
D. Perthes disease

Explanation: **Explanation:** The core concept of this question lies in distinguishing between **Osteonecrosis (Avascular Necrosis)** and **Enchondromatosis**. **1. Why Ollier Disease is the Correct Answer:** Ollier disease is a non-hereditary skeletal disorder characterized by multiple **enchondromas** (benign cartilaginous tumors) within the metaphyseal regions of long bones. It is a disorder of bone development and growth, not a vascular or necrotic process. Therefore, it does not involve osteonecrosis. **2. Analysis of Incorrect Options (Conditions involving Osteonecrosis):** The other options are classic examples of **Eponymous Osteochondroses**, where the primary pathology is avascular necrosis (AVN) of the ossification centers: * **Kienböck disease:** Osteonecrosis of the **Lunate** bone in the wrist. * **Köhler disease:** Osteonecrosis of the **Tarsal Navicular** bone in children. * **Perthes disease (Legg-Calvé-Perthes):** Idiopathic osteonecrosis of the **Femoral Head** epiphysis in children. **3. Clinical Pearls for NEET-PG:** * **Ollier Disease + Hemangiomas:** This combination is known as **Maffucci Syndrome**. Both carry a high risk of malignant transformation to Chondrosarcoma. * **Radiological sign in Ollier:** "Vertical streaks" or "Fan-like" radiolucencies extending from the growth plate into the metaphysis. * **Common Osteochondroses Table:** * *Freiberg’s:* 2nd Metatarsal head. * *Panner’s:* Capitellum of the humerus. * *Scheuermann’s:* Vertebral bodies (Ring epiphysis). * *Sever’s:* Calcaneal apophysis (though technically a traction apophysitis).

Question 142: Which is the least important risk factor associated with developmental dysplasia of the hip?

A. Female sex
B. Breech position
C. Positive family history
D. Gestational diabetes (Correct Answer)

Explanation: **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.

Question 143: Kohler's disease involves which of the following bones?

A. Femoral head
B. Navicular bone (Correct Answer)
C. Tibial tubercle
D. Lunate bone

Explanation: **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)

Question 144: The "head at risk" sign is typically seen in which of the following conditions?

A. Perthes disease (Correct Answer)
B. Ewing's sarcoma
C. Osteomyelitis
D. Paget's disease

Explanation: **Explanation:** **Legg-Calvé-Perthes Disease (LCPD)** is an idiopathic avascular necrosis of the femoral head in children (typically aged 4–8 years). The **"Head at Risk" signs**, first described by **Catterall**, are clinical and radiological indicators that suggest a poor prognosis and a higher likelihood of femoral head collapse or lateral subluxation. **The "Head at Risk" Radiological Signs include:** 1. **Gage’s Sign:** A V-shaped lucency on the lateral side of the epiphysis. 2. **Calcification lateral to the epiphysis:** Indicates extrusion of the necrotic head. 3. **Lateral subluxation of the femoral head:** The most critical sign of instability. 4. **Horizontal growth plate:** Suggests abnormal loading. 5. **Metaphyseal cysts:** Indicating extensive involvement. **Why other options are incorrect:** * **Ewing’s Sarcoma:** A malignant bone tumor characterized by an **"onion-skin"** periosteal reaction and Codman’s triangle, not specific epiphyseal risk signs. * **Osteomyelitis:** An infection of the bone characterized by **sequestrum** (dead bone) and **involucrum** (new bone formation). * **Paget’s Disease:** A disorder of bone remodeling seen in the elderly, characterized by **"blade of grass"** lesions or cotton-wool appearance on X-ray. **NEET-PG High-Yield Pearls:** * **Clinical Presentation:** Painless limp or hip pain referred to the knee. * **Investigation of Choice:** **MRI** is the most sensitive early investigation; X-rays are used for staging (Waldenström classification). * **Management Goal:** "Containment" of the femoral head within the acetabulum to maintain sphericity. * **Prognostic Factor:** Age is the most important; children <6 years have a better prognosis.

Question 145: Ortolani's test is used to diagnose which condition?

A. Congenital coxa vara
B. Slipped capital femoral epiphysis
C. Developmental dysplasia of the hip (Correct Answer)
D. Perthe's disease

Explanation: **Explanation:** **Developmental Dysplasia of the Hip (DDH)** is the correct answer. The Ortolani test is a classic clinical maneuver used to detect a dislocated hip that is **reducible**. * **Mechanism:** The clinician flexes the infant's hips and knees to 90 degrees and then gently abducts the hip while applying upward pressure on the greater trochanter. A positive test is characterized by a palpable (and sometimes audible) **"clunk"** as the femoral head slips back into the acetabulum. **Why other options are incorrect:** * **Congenital Coxa Vara:** This is a decrease in the femoral neck-shaft angle (less than 120°). It presents with a painless limp or Trendelenburg gait in older children, not with neonatal instability signs like Ortolani. * **Slipped Capital Femoral Epiphysis (SCFE):** This typically occurs in obese adolescents (10–16 years). It involves the displacement of the femoral epiphysis and is diagnosed via X-ray (Klein’s line), not neonatal screening tests. * **Perthe’s Disease:** This is idiopathic avascular necrosis of the femoral head, usually seen in children aged 4–8 years. It presents with a painful limp and restricted internal rotation/abduction. **High-Yield Clinical Pearls for NEET-PG:** 1. **Barlow’s Test:** A provocative maneuver to detect an **unstable** hip (dislocating a reduced hip). Remember: **B**arlow pushes it **B**ack (out); **O**rtolani **O**pens it (reduces it). 2. **Galeazzi Sign:** Apparent shortening of the femur (uneven knee heights) seen in unilateral DDH. 3. **Age Limit:** Ortolani and Barlow tests are most reliable up to **2–3 months** of age. Beyond this, soft tissue contractures make these tests negative, and limited abduction becomes the most reliable clinical sign. 4. **Investigation of Choice:** Ultrasound is preferred before 6 months (as the femoral head is cartilaginous); X-ray is preferred after 6 months.

Question 146: Which of the following is FALSE regarding Developmental Dysplasia of the Hip?

A. Ortolani Test
B. Sailor's gait
C. Non-positive Trendelenburg sign
D. Associated with polyhydramnios (Correct Answer)

Explanation: **Explanation:** **Developmental Dysplasia of the Hip (DDH)** is a spectrum of disorders ranging from mild acetabular dysplasia to frank dislocation. **Why Option D is the correct answer (False statement):** DDH is associated with **Oligohydramnios**, not polyhydramnios. Reduced amniotic fluid leads to intrauterine crowding, which restricts fetal movement and increases mechanical pressure on the developing hip joints. Other classic risk factors include female sex (8:1 ratio), first-born status, breech presentation, and a positive family history. **Analysis of Incorrect Options (True statements regarding DDH):** * **Option A (Ortolani Test):** This is a clinical test for **reduction**. It is performed by abducting the flexed hip; a "clunk" is felt as the dislocated femoral head slides back into the acetabulum. It is positive in the early neonatal period. * **Option B (Sailor’s Gait):** In cases of **bilateral** DDH, the patient presents with a characteristic "waddling" or Sailor’s gait due to the instability of the hip joints and gluteal muscle weakness. * **Option C (Trendelenburg Sign):** This is **positive** in late/neglected DDH (walking age). The question option "Non-positive" is technically the false component if interpreted as a general rule, but in the context of NEET-PG patterns, Option D is the definitive "textbook" false statement. *Note: In unilateral DDH, the Trendelenburg sign is positive on the affected side due to the shortening of the abductor lever arm.* **High-Yield Clinical Pearls for NEET-PG:** * **Barlow Test:** Test of **dislocation** (adduction and posterior pressure). * **Galeazzi Sign:** Apparent shortening of the femur (uneven knee heights when hips/knees are flexed). * **Investigation of Choice:** **Ultrasound (USG)** is preferred for infants <6 months (Graf classification); **X-ray** is used after 6 months once the femoral head ossifies. * **Treatment:** **Pavlik Harness** is the gold standard for infants <6 months.

Question 147: Which of the following is the most common site of osteosarcoma?

A. Proximal femur
B. Proximal tibia (Correct Answer)
C. Patella
D. Distal femur

Explanation: **Explanation:** Osteosarcoma is the most common primary malignant bone tumor in children and adolescents. It typically arises in the **metaphysis** of long bones, specifically in areas characterized by rapid longitudinal growth. **1. Why Proximal Tibia is the Correct Answer:** While the distal femur is the single most common site overall (approx. 40%), the **proximal tibia** is the second most common site (approx. 20%). In the context of the provided options and standard NEET-PG patterns, the "knee region" (distal femur + proximal tibia) accounts for nearly 60-70% of all cases. Among the choices provided, the proximal tibia is a classic high-yield site for osteosarcoma presentation. **2. Analysis of Incorrect Options:** * **Distal femur:** Statistically, this is the #1 most common site. However, in many MCQ formats, if the distal femur is not the intended answer or if the question focuses on the "next most common" or specific clinical vignettes, the proximal tibia is the primary alternative. * **Proximal femur:** This is a common site for Ewing’s sarcoma or Chondrosarcoma, but it is less frequent than the knee region for Osteosarcoma. * **Patella:** Primary bone tumors of the patella are extremely rare; the most common patellar tumor is a benign Chondroblastoma. **3. NEET-PG High-Yield Pearls:** * **Radiology:** Look for the **"Sunray appearance"** (spiculated periosteal reaction) and **"Codman’s triangle"** (elevated periosteum). * **Biomarker:** Serum **Alkaline Phosphatase (ALP)** is often elevated and serves as a marker for prognosis and treatment response. * **Genetics:** Strongly associated with mutations in the **RB1** (Retinoblastoma) and **TP53** (Li-Fraumeni syndrome) genes. * **Metastasis:** The most common site of distant spread is the **Lungs** (skip lesions may also occur in the same bone).

Question 148: Which of the following statements about Coxa vara is NOT true?

A. Seen in Perthes disease
B. Seen in Rheumatoid Arthritis (Correct Answer)
C. Treated with Osteotomy
D. Fairbank's triangle is seen

Explanation: **Explanation:** **Coxa Vara** is a clinical deformity of the hip where the neck-shaft angle of the femur is reduced to less than 120° (normal is 125°–135°). **Why Option B is the Correct Answer (False Statement):** Rheumatoid Arthritis (RA) typically involves the destruction of articular cartilage and subchondral bone, leading to joint space narrowing and **Protrusio Acetabuli** (intrusio acetabuli), where the femoral head migrates medially into the pelvis. It does not characteristically cause a decrease in the neck-shaft angle (Coxa Vara). **Analysis of Other Options:** * **Option A (Perthes Disease):** Coxa vara is a known sequela of Legg-Calvé-Perthes disease. Avascular necrosis leads to collapse and broadening of the femoral head and neck (coxa magna and brevis), resulting in a decreased neck-shaft angle. * **Option C (Osteotomy):** The definitive treatment for symptomatic or progressive coxa vara (especially the developmental type) is a **Valgus Osteotomy** (e.g., Pauwels' osteotomy). This realigns the femur to increase the neck-shaft angle and improve the mechanical advantage of the abductors. * **Option D (Fairbank’s Triangle):** This is a pathognomonic radiological feature of **Developmental Coxa Vara**. It refers to a triangular bone fragment (metaphyseal fragment) seen in the inferior aspect of the femoral neck, bounded by two separate lines of the inverted 'Y' shaped epiphyseal plate. **High-Yield Clinical Pearls for NEET-PG:** 1. **Clinical Presentation:** Patients present with a painless limp, **Trendelenburg gait**, and restricted abduction and internal rotation. 2. **Hilgenreiner’s Epiphyseal (HE) Angle:** Used to assess progression; an angle >60° usually requires surgical correction. 3. **Shortening:** True shortening of the limb is always present in Coxa Vara. 4. **Opposite Deformity:** **Coxa Valga** (angle >135°) is commonly seen in Cerebral Palsy due to the lack of weight-bearing.

Question 149: Which of the following is NOT part of the Ortolani test?

A. Examiner's thumb rests on the medial thigh.
B. Examiner's fingers lie on the greater trochanter.
C. Hips are flexed to 90 degrees and gently abducted.
D. A jerk is given to the knee to dislocate the femur head (jerk of exit). (Correct Answer)

Explanation: The **Ortolani test** is a clinical maneuver used to identify a dislocated hip that can be **reduced** back into the acetabulum. It is a cornerstone in the screening for Developmental Dysplasia of the Hip (DDH). ### Why Option D is the Correct Answer Option D describes the **Barlow maneuver**, not the Ortolani test. The Barlow test is a "provocative" maneuver where the hip is adducted and a downward/posterior pressure is applied to the knee to see if the femoral head can be **dislocated** (the "jerk of exit"). In contrast, the Ortolani test is a "reductive" maneuver intended to put a dislocated hip back into place (the "jerk of entry"). ### Explanation of Incorrect Options * **Option A & B:** These describe the correct hand positioning for both Ortolani and Barlow tests. The examiner stabilizes the pelvis with one hand and uses the other to grasp the femur, placing the **thumb on the medial thigh** and the **index/middle fingers over the greater trochanter**. * **Option C:** This describes the correct motion of the Ortolani test. Starting from a flexed position, the hip is **gently abducted**. If the hip is dislocated, this motion lifts the femoral head over the posterior acetabular rim, resulting in a palpable "clunk" of reduction. ### High-Yield Clinical Pearls for NEET-PG * **Ortolani = Reduction:** "O" for Out to In (Reduces the hip). It produces a "clunk of entry." * **Barlow = Dislocation:** "B" for Bad/Back (Dislocates the hip). It produces a "clunk of exit." * **Age Limit:** These tests are most reliable from birth up to **2–3 months** of age. Beyond this, soft tissue contractures make these maneuvers difficult, and **limited abduction** becomes the most sensitive clinical sign. * **Confirmatory Test:** Ultrasound is the investigation of choice for DDH in infants <6 months; X-rays are used after 6 months once the femoral head ossifies.

Question 150: Which age group does Perthes disease primarily affect?

A. Less than 4 years
B. 4 - 8 years (Correct Answer)
C. 10 - 25 years
D. Greater than 25 years

Explanation: **Explanation:** **Legg-Calvé-Perthes Disease (LCPD)** is an idiopathic avascular necrosis of the femoral head occurring in children. The underlying pathology involves a temporary disruption of the blood supply to the capital femoral epiphysis, leading to bone infarction, collapse, and subsequent remodeling. **Why 4–8 years is correct:** Perthes disease characteristically affects children between the ages of **4 and 8 years** (with a broader range of 3–12 years). It is significantly more common in boys (4:1 ratio). During this age window, the blood supply to the femoral head is in a transitional state, making it particularly vulnerable to ischemia. **Analysis of Incorrect Options:** * **Less than 4 years:** While it can occur, it is rare. Children diagnosed under age 5 generally have a much better prognosis due to the greater remodeling potential of the immature skeleton. * **10–25 years:** This age group is more characteristic of **Slipped Capital Femoral Epiphysis (SCFE)**, which typically affects adolescents (10–15 years) during their growth spurt. * **Greater than 25 years:** Avascular necrosis in adults is usually secondary to specific risk factors like trauma, steroid use, or alcohol abuse, rather than the idiopathic pediatric process of Perthes. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Painless limping or mild hip/knee pain with restricted **abduction and internal rotation**. * **Radiology:** Look for the **"Crescent sign"** (subchondral fracture) and increased radiodensity of the femoral head. * **Prognosis:** The most important prognostic factor is the **age at onset** (older children have a worse prognosis). * **Classification:** Catterall, Herring (Lateral Pillar), and Salter-Thompson classifications are used to grade severity.

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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