Pediatric Orthopaedics Practice Questions

Q: A child presented with a fall on an outstretched hand with the elbow in full extension. On examination there is pain and swelling over his right elbow. What is the probable diagnosis?

Supracondylar fracture of the humerus. ### Explanation **Correct Option: C. Supracondylar fracture of the humerus** **Mechanism and Concept:** Supracondylar fracture of the humerus is the most common elbow fracture in children (peak age 5–8 years). The classic mechanism is a **fall on an outstretched hand (FOOSH) with the elbow in extension**. In this position, the olecranon process is forced into the olecranon fossa, acting as a fulcrum that causes the thin supracondylar bone to snap. This results in an **extension-type** fracture (95% of cases), where the distal fragment is displaced posteriorly. **Analysis of Incorrect Options:** * **A. Fracture of the olecranon:** Rare in children; usually occurs due to a direct blow to the point of the elbow or a forceful contraction of the triceps. * **B. Posterior dislocation of the elbow:** While the mechanism (FOOSH) is similar, dislocations are much more common in **adults**. In children, the supracondylar area is physiologically weaker than the joint ligaments, making a fracture far more likely than a dislocation. * **D. Fracture of both bones of the forearm:** While FOOSH can cause forearm fractures, the clinical presentation specifically mentions pain and swelling **over the elbow**, pointing toward a periarticular injury. **NEET-PG High-Yield Pearls:** * **Clinical Sign:** On examination, the **three-point bony relationship** (medial epicondyle, lateral epicondyle, and olecranon) is **maintained** in supracondylar fractures but **disturbed** in elbow dislocations. * **Complications:** The most serious acute complication is injury to the **Brachial artery** or **Median nerve** (specifically the Anterior Interosseous Nerve). * **Late Sequel:** **Gunstock deformity** (Cubitus varus) is the most common late complication due to malunion. * **Emergency:** Always check the radial pulse to rule out **Volkmann’s Ischemic Contracture**.

Q: Fracture of the lateral condyle of the humerus is typically seen in which age group?

5-15 years. Fracture of the lateral condyle of the humerus is the **second most common elbow fracture** in children (after supracondylar fractures). **1. Why 5-15 years is correct:** This injury is primarily a pediatric fracture. The peak incidence occurs between **5 and 10 years of age**. During this period, the lateral condyle is largely cartilaginous and represents a weak point in the elbow's structural integrity. The mechanism usually involves a fall on an outstretched hand with the forearm in supination (pull-off injury by the extensor muscles) or a varus force (push-off injury by the radius) [1]. Because it involves the growth plate, it is classified as a **Salter-Harris Type IV injury** [1]. **2. Why other options are incorrect:** * **2-3 years:** While possible, the ossification center of the capitellum (which forms the lateral condyle) is just beginning to appear, and the mechanism of high-energy falls is less common in toddlers compared to school-aged children. * **15-25 years & 35-45 years:** In adolescents and adults, the growth plates have fused. Trauma to the elbow in these age groups more commonly results in radial head fractures, olecranon fractures, or elbow dislocations rather than isolated physeal condylar fractures. **Clinical Pearls for NEET-PG:** * **Milch Classification:** Used to categorize these fractures based on whether the fracture line passes lateral (Type I) or medial (Type II) to the trochlear groove. * **"The Fracture of Wise Men":** It is notoriously difficult to diagnose on X-ray because the fragment is often largely cartilaginous and appears smaller than it actually is [1]. * **Complications:** If missed or inadequately treated, it leads to **Non-union**, which causes **Cubitus Valgus** deformity. This deformity can result in delayed **Tardy Ulnar Nerve Palsy** years later.

Q: A young child presents with abnormal development of membranous bones, characterized by a broad skull and associated facial and dental anomalies. Which other bones are most likely to be affected?

Clavicles. ### Explanation The clinical presentation described—abnormal development of membranous bones, broad skull (delayed closure of fontanelles), and dental anomalies—is a classic description of **Cleidocranial Dysplasia (CCD)**. **Why Clavicles are the Correct Answer:** Cleidocranial Dysplasia is an autosomal dominant disorder caused by a mutation in the **RUNX2 gene**, which is essential for osteoblast differentiation. It primarily affects bones formed via **intramembranous ossification**. The **clavicle** is the first bone in the body to ossify and does so primarily through intramembranous ossification. In CCD, the clavicles are typically hypoplastic or entirely absent (aplastic), allowing the patient to abnormally approximate their shoulders in the midline. **Why Other Options are Incorrect:** * **B, C, and D (Femurs, Metatarsals, Phalanges):** These are long or short tubular bones that develop primarily through **endochondral ossification** (cartilage template replaced by bone). While CCD can show minor secondary effects in these bones (like pseudoepiphyses in metacarpals), the hallmark of the disease is the failure of membranous bone formation, making the clavicle the most characteristic site of involvement. **High-Yield Clinical Pearls for NEET-PG:** * **Genetics:** Mutation in **RUNX2** (CBFA1) on Chromosome 6p21. * **Skull Findings:** Delayed closure of sutures/fontanelles, presence of multiple **Wormian bones**, and frontal bossing. * **Dental Findings:** Supernumerary (extra) teeth and delayed eruption of permanent teeth. * **Clinical Sign:** Ability to touch shoulders together in front of the chest. * **Stature:** Patients often have moderately short stature but normal intelligence.

Q: Contracture of the iliotibial band can contribute to which of the following deformities?

Abduction contracture at the hip.. ### Explanation **Correct Option: C. Abduction contracture at the hip.** The Iliotibial Band (ITB) is a thickened lateral portion of the fascia lata. It originates from the iliac crest and inserts into Gerdy’s tubercle on the lateral condyle of the tibia. Because it lies lateral to the hip joint axis, its primary action when contracted is **abduction of the hip**. In conditions like poliomyelitis or ITB syndrome, fibrosis and shortening of this band lead to a fixed abduction deformity. This is clinically assessed using **Ober’s Test**. **Analysis of Incorrect Options:** * **Option A:** While ITB contracture contributes to abduction, a full "Flexion, abduction, and external rotation" (FABER) deformity is more characteristic of a **Sartorius** contracture or advanced hip joint pathology (like early TB hip). * **Option B:** While chronic ITB contracture can pull the knee into valgus over time, it is primarily associated with **flexion** at the knee (as the ITB passes posterior to the knee axis when flexed). However, isolated "Abduction contracture at the hip" is the most direct and classic orthopedic manifestation. * **Option D:** External tibial torsion can occur as a secondary complication in severe, chronic cases, but it is a late sequela rather than the primary deformity defined by the contracture itself. **High-Yield Clinical Pearls for NEET-PG:** * **Ober’s Test:** Used to detect ITB contracture. A positive test is the inability of the elevated thigh to adduct past the midline when the knee is flexed. * **Yount’s Test:** Specifically identifies ITB tightness contributing to hip and knee deformities. * **Poliomyelitis:** ITB contracture is a classic feature in polio patients due to muscle imbalances. * **Snapping Hip Syndrome:** The ITB sliding over the greater trochanter is the most common cause of "external" snapping hip.

Q: A newborn child presents with an inverted foot and the dorsum of the foot cannot touch the anterior tibia. What is the most probable diagnosis?

Congenital talipes equinovarus (CTEV). **Explanation:** The clinical presentation of an **inverted foot** where the **dorsum cannot touch the anterior tibia** is a classic description of **Congenital Talipes Equinovarus (CTEV)**, also known as Clubfoot. **1. Why CTEV is correct:** CTEV is characterized by four primary deformities (mnemonic: **CAVE**): **C**avus, **A**dduction, **V**arus, and **E**quinus. The "inverted foot" refers to the **Varus** (hindfoot) and **Adduction** (forefoot) components. The inability to touch the dorsum of the foot to the anterior tibia indicates a fixed **Equinus** deformity (plantarflexion at the ankle), which prevents normal dorsiflexion. **2. Why other options are incorrect:** * **Congenital Vertical Talus (CVT):** Also known as "Rocker-bottom foot." In CVT, the foot is **everted** (valgus) and the midfoot is prominent plantarly. The dorsum of the foot *can* often touch the anterior tibia due to severe calcaneovalgus positioning. * **Arthrogryposis Multiplex:** While this condition often presents with severe CTEV, it involves multiple joint contractures (e.g., knees, elbows) and muscle wasting. The question describes an isolated foot deformity in a newborn. * **Flat foot (Pes Planus):** This involves the loss of the medial longitudinal arch. It does not present with inversion or fixed equinus; in fact, the foot is typically mobile and everted. **Clinical Pearls for NEET-PG:** * **Standard Treatment:** The **Ponseti Method** (serial casting) is the gold standard. The sequence of correction is **CAVE** (Cavus first, then Adduction and Varus, and finally Equinus via tenotomy). * **Radiology:** The **Kite’s Angle** (talocalcaneal angle) is decreased (<20°) in both AP and lateral views in CTEV. * **Pirani Scoring:** Used to assess the severity of CTEV and monitor progress during casting.

Q: A 10-year-old male presents with pain in the left hip and limping. Examination reveals restricted abduction and internal rotation. What is the probable diagnosis?

Perthes disease. ### Explanation **Correct Option: D. Perthes Disease** Perthes disease (Legg-Calvé-Perthes disease) is idiopathic avascular necrosis of the femoral head, typically occurring in boys aged 4–10 years. The hallmark clinical presentation is an **antalgic limp** and hip pain (often referred to the knee). On examination, the classic finding is a **limitation of abduction and internal rotation** due to muscle spasm and femoral head deformity. This matches the patient's age and clinical profile perfectly. **Why Incorrect Options are Wrong:** * **A. Septic Arthritis:** This is an acute emergency characterized by high-grade fever, severe pain, and an inability to bear weight. The patient would appear toxic, and all ranges of motion (not just abduction/rotation) would be severely restricted and painful. * **B. Tuberculous Arthritis:** While it causes restricted movements, it usually presents with a more chronic, constitutional picture (weight loss, night sweats) and follows a specific sequence of stages (Synovitis, Arthritis, Erosion). * **C. Congenital Dislocation of the Hip (DDH):** This is typically diagnosed in infancy or early childhood. By age 10, an untreated dislocation would present with significant limb length discrepancy and a Trendelenburg gait, rather than an acute onset of restricted internal rotation. **High-Yield Clinical Pearls for NEET-PG:** * **Age Groups:** 0–3 years (Septic Arthritis/DDH), 4–10 years (Perthes), 10–15 years (Slipped Capital Femoral Epiphysis - SCFE). * **Radiology of Perthes:** Look for increased density of the femoral head, fragmentation (Catterall classification), and the **"Crescent sign"** (subchondral fracture). * **Gage’s Sign:** A V-shaped lucency on the lateral side of the epiphysis (a poor prognostic sign). * **Management:** The primary goal is "containment" of the femoral head within the acetabulum using braces or osteotomy.

Q: A 9-year-old child with a high arched palate has shoulders meeting in front of his chest. What condition does he likely have?

Cleidocranial dysostosis. **Explanation:** The clinical presentation of a child whose **shoulders can meet in the midline** (front of the chest) is a classic hallmark of **Cleidocranial Dysostosis (CCD)**. This occurs due to the partial or complete **absence (aplasia/hypoplasia) of the clavicles**, which normally act as a strut to keep the shoulders apart. **Why the Correct Answer is Right:** Cleidocranial Dysostosis is an autosomal dominant skeletal dysplasia caused by a mutation in the **RUNX2 gene**. Key features include: * **Clavicular hypoplasia:** Allows hypermobility of the shoulders. * **Craniofacial features:** Delayed closure of fontanelles (open sutures), frontal bossing, and a **high arched palate**. * **Dental anomalies:** Presence of multiple supernumerary teeth and delayed eruption of permanent teeth. **Why Other Options are Incorrect:** * **Erb’s Palsy:** A brachial plexus injury (C5-C6) resulting in a "waiter's tip" deformity. It affects limb movement but does not cause clavicular absence or midline shoulder approximation. * **Chondro-osteodystrophy (Morquio Syndrome):** A mucopolysaccharidosis characterized by short stature, spinal deformities (platyspondyly), and ligamentous laxity, but not the specific clavicular findings of CCD. * **Cortical Hyperostosis (Caffey’s Disease):** Characterized by subperiosteal new bone formation, typically in the mandible, causing pain and swelling in infants; it does not cause shoulder hypermobility. **NEET-PG High-Yield Pearls:** * **Gene Mutation:** RUNX2 (CBFA1) on Chromosome 6p21. * **Radiological Sign:** Widening of the pubic symphysis (delayed ossification of pelvic bones) is a common co-finding. * **Wormian Bones:** Often seen on skull X-rays due to delayed suture closure. * **Key Differentiator:** If a question mentions "supernumerary teeth" + "shoulder mobility," always think Cleidocranial Dysostosis.

Question 1

Post poliomyelitis, a patient has grade H power in Gastrocnemius, grade HI in Peroneus, and grade IV in Tibialis Anterior. What is the resulting deformity?

Accepted Answer

Calcaneovarus

Answer

Calcaneovalgus

Answer

Equinovarus

Answer

Genu valgus

Question 2

A child presented with a fall on an outstretched hand with the elbow in full extension. On examination there is pain and swelling over his right elbow. What is the probable diagnosis?

Accepted Answer

Supracondylar fracture of the humerus

Answer

Fracture of the olecranon

Answer

Posterior dislocation of the elbow

Answer

Fracture of both bones of the forearm

Question 3

Fracture of the lateral condyle of the humerus is typically seen in which age group?

Accepted Answer

5-15 years

Answer

2-3 years

Answer

15-25 years

Answer

35-45 years

Question 4

A young child presents with abnormal development of membranous bones, characterized by a broad skull and associated facial and dental anomalies. Which other bones are most likely to be affected?

Accepted Answer

Clavicles

Answer

Femurs

Answer

Metatarsals

Answer

Phalanges

Question 5

Contracture of the iliotibial band can contribute to which of the following deformities?

Accepted Answer

Abduction contracture at the hip.

Answer

Flexion, abduction, and external rotation deformity of the hip.

Answer

Genu valgum and flexion contracture at the knee joint.

Answer

External tibial torsion with or without knee subluxation.

Question 6

A newborn child presents with an inverted foot and the dorsum of the foot cannot touch the anterior tibia. What is the most probable diagnosis?

Accepted Answer

Congenital talipes equinovarus (CTEV)

Answer

Congenital vertical talus

Answer

Arthrogryposis multiplex

Answer

Flat foot

Question 7

A 10-year-old male presents with pain in the left hip and limping. Examination reveals restricted abduction and internal rotation. What is the probable diagnosis?

Accepted Answer

Perthes disease

Answer

Septic arthritis of the hip

Answer

Tuberculous arthritis of the hip

Answer

Congenital dislocation of the hip

Question 8

A 9-year-old child with a high arched palate has shoulders meeting in front of his chest. What condition does he likely have?

Accepted Answer

Cleidocranial dysostosis

Answer

Erb's palsy

Answer

Chondro-osteodystrophy

Answer

Cornical hyperostosis

Question 9

Arrange the following steps in the sequence as part of surgical intervention for Developmental Dysplasia of the Hip (DDH):

Accepted Answer

Perform capsulotomy

Answer

Locate the acetabulum by tracing the ligament of teres

Answer

Relocate the femoral head in the acetabulum

Answer

Perform derotation femoral osteotomy

Question 10

A 14-year-old boy presents with a 3-month history of gradually developing right hip pain and a limp. What is the most likely diagnosis?

Accepted Answer

Slipped capital femoral epiphysis

Answer

Volkmann's ischemia

Answer

Congenital dislocation of the hip

Answer

Fracture of the proximal end of the fibula

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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