Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics Indian Medical PG Practice Questions and MCQs

Question 161: 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?

A. Congenital vertical talus
B. Arthrogryposis multiplex
C. Congenital talipes equinovarus (CTEV) (Correct Answer)
D. Flat foot

Explanation: **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.

Question 162: 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?

A. Septic arthritis of the hip
B. Tuberculous arthritis of the hip
C. Congenital dislocation of the hip
D. Perthes disease (Correct Answer)

Explanation: ### 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.

Question 163: A 9-year-old child with a high arched palate has shoulders meeting in front of his chest. What condition does he likely have?

A. Erb's palsy
B. Cleidocranial dysostosis (Correct Answer)
C. Chondro-osteodystrophy
D. Cornical hyperostosis

Explanation: **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 164: Arrange the following steps in the sequence as part of surgical intervention for Developmental Dysplasia of the Hip (DDH):

A. Locate the acetabulum by tracing the ligament of teres
B. Perform capsulotomy (Correct Answer)
C. Relocate the femoral head in the acetabulum
D. Perform derotation femoral osteotomy

Explanation: In the surgical management of Developmental Dysplasia of the Hip (DDH), specifically during an **Open Reduction**, the procedure follows a strict anatomical sequence to safely reposition the femoral head. **Explanation of the Correct Sequence:** The correct sequence of surgical steps is: **B → A → C → D**. 1. **Capsulotomy (B):** This is the mandatory first step once the hip joint is reached. The joint capsule is often constricted (hourglass deformity) or adherent. Opening the capsule is essential to visualize the internal anatomy and clear obstructions. 2. **Locate the acetabulum (A):** After the capsulotomy, the surgeon must identify the true acetabulum. Tracing the **ligamentum teres** is the most reliable way to find the acetabular floor, especially when it is filled with fibrofatty tissue (pulvinar). 3. **Relocate the femoral head (C):** Once obstructions (like the transverse acetabular ligament or inverted limbus) are cleared, the femoral head is reduced into the socket. 4. **Derotation femoral osteotomy (D):** This is often the final stage. If there is excessive femoral anteversion or if the reduction is unstable, a subtrochanteric osteotomy is performed to redirect the head into the acetabulum. **Why other options are incorrect in the sequence:** * **A & C:** These cannot be performed safely until the joint capsule is opened (**Capsulotomy**). * **D:** Femoral or pelvic osteotomies are "extra-articular" procedures performed *after* the joint has been successfully reduced to maintain stability. **High-Yield Clinical Pearls for NEET-PG:** * **Obstacles to Reduction:** The most common "extra-articular" obstacle is the **Psoas tendon**. The most common "intra-articular" obstacle is the **Inverted Limbus**. * **Safe Zone:** After reduction, the hip is tested for the **Ramsey’s Safe Zone** (the range between the angle of abduction required for reduction and the angle of adduction that leads to redislocation). * **Radiology:** Remember the **Hilgenreiner’s line** and **Perkin’s line**; the femoral head should normally lie in the lower inner quadrant.

Question 165: 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?

A. Volkmann's ischemia
B. Congenital dislocation of the hip
C. Slipped capital femoral epiphysis (Correct Answer)
D. Fracture of the proximal end of the fibula

Explanation: ### Explanation **Correct Answer: C. Slipped capital femoral epiphysis (SCFE)** **Why it is correct:** Slipped Capital Femoral Epiphysis (SCFE) is the most common hip disorder in adolescents (typically ages 10–16). It involves the displacement of the femoral head (epiphysis) relative to the femoral neck through the growth plate (physeal fracture). The classic presentation is an **obese adolescent male** presenting with a **gradual onset** of hip, thigh, or knee pain and an antalgic limp. On examination, there is a characteristic loss of internal rotation and abduction, with the hip tending to rotate externally during flexion (Drehmann sign). **Why the other options are incorrect:** * **A. Volkmann’s ischemia:** This is a vascular complication (compartment syndrome) usually following a supracondylar fracture of the humerus in children. It presents acutely with the "5 Ps" (Pain, Pallor, Pulselessness, Paresthesia, Paralysis), not chronic hip pain. * **B. Congenital dislocation of the hip (DDH):** This condition is typically diagnosed in **infancy or early childhood**. While an untreated dislocation can cause a limp in an adolescent, it would be present since the child started walking, not a 3-month gradual onset in a 14-year-old. * **D. Fracture of the proximal end of the fibula:** This would follow an acute traumatic event and present with localized lateral knee pain and potential peroneal nerve palsy, rather than primary hip pain and a limp. **High-Yield Clinical Pearls for NEET-PG:** * **Age Group Rule:** 0–3 years (DDH/Septic Arthritis), 4–8 years (Perthes Disease), 10–16 years (SCFE). * **Referred Pain:** Always examine the hip in an adolescent complaining of **isolated knee pain**. * **Radiology:** Look for **Klein’s Line** on an X-ray (a line drawn along the superior border of the femoral neck should normally intersect the epiphysis; in SCFE, it does not). * **Treatment:** The gold standard is **In-situ pinning** (Single cannulated screw fixation) to prevent further slippage.

Question 166: A 6-year-old boy presents with recurrent fractures following minor trauma and hearing difficulties. Examination reveals lower limb deformities. Which defect is responsible for this clinical scenario?

A. Collagen 1 (Correct Answer)
B. Collagen 2
C. Fibrillin
D. Collagen 4

Explanation: ### Explanation The clinical presentation of recurrent fractures from minor trauma, hearing loss, and limb deformities in a child is a classic description of **Osteogenesis Imperfecta (OI)**, also known as "Brittle Bone Disease." **1. Why Collagen 1 is Correct:** Osteogenesis Imperfecta is primarily caused by an autosomal dominant defect in the genes (**COL1A1** and **COL1A2**) that encode for **Type 1 Collagen**. Type 1 collagen is the major structural protein in bone, sclera, ligaments, and the middle ear ossicles. A defect leads to: * **Bone Fragility:** Poorly formed bone matrix leads to multiple fractures and progressive deformities (e.g., saber tibia). * **Hearing Loss:** Conductive or sensorineural hearing loss occurs due to otosclerosis or deformity of the auditory ossicles. * **Blue Sclera:** (Often present) Thinning of the collagen layers allows the underlying choroid veins to show through. **2. Why Incorrect Options are Wrong:** * **Collagen 2:** This is the primary collagen in **hyaline cartilage** and vitreous humor. Defects lead to skeletal dysplasias like *Spondyloepiphyseal Dysplasia* or *Kniest syndrome*, not bone fragility. * **Fibrillin:** Mutations in Fibrillin-1 cause **Marfan Syndrome**. While patients have skeletal issues (arachnodactyly, pectus excavatum), they do not present with recurrent fractures or the specific bone fragility of OI. * **Collagen 4:** This is a major component of the **basement membrane**. Defects lead to **Alport Syndrome**, characterized by nephritis and sensorineural deafness, but not bone fractures. **Clinical Pearls for NEET-PG:** * **Inheritance:** Most common types (Type I-IV) are Autosomal Dominant. * **Classification:** Sillence Classification is used to grade severity (Type II is the most severe/lethal). * **Radiology:** Look for "Popcorn calcifications" at metaphyses and "Wormian bones" in the skull. * **Treatment:** Bisphosphonates (e.g., Pamidronate) are used to increase bone density and reduce pain.

Question 167: Which of the following is true about distraction osteogenesis in children?

A. Decreased rate of distraction
B. Distraction cannot be performed in children
C. Decreased latency period (Correct Answer)
D. None of the above

Explanation: ### Explanation: Distraction Osteogenesis in Children Distraction osteogenesis (Ilizarov technique) relies on the body's natural ability to form new bone (callus) when a cortical bone is surgically fractured (corticotomy) and gradually pulled apart. The process follows three main phases: **Latency, Distraction, and Consolidation.** **1. Why "Decreased Latency Period" is Correct:** The latency period is the time between the surgical corticotomy and the start of active distraction. In children, the **osteogenic potential** (bone-forming capacity) and **vascularity** of the periosteum are significantly higher than in adults. Because bone healing and callus formation occur much faster in pediatric patients, the latency period is shortened—typically **3 to 5 days** in children, compared to **7 to 10 days** in adults. If the latency period is too long in a child, "premature consolidation" (the bone healing before distraction is complete) may occur. **2. Analysis of Incorrect Options:** * **A. Decreased rate of distraction:** The standard rate of distraction is generally **1 mm per day** (divided into four increments of 0.25 mm). This rate remains the gold standard to allow for concomitant growth of nerves, vessels, and muscles (histogenesis). Decreasing the rate would increase the risk of premature consolidation in children. * **B. Distraction cannot be performed in children:** This is false. Distraction osteogenesis is frequently used in pediatric orthopaedics for limb length discrepancies, congenital deformities, and craniofacial anomalies. **3. NEET-PG High-Yield Pearls:** * **Standard Rate:** 1 mm/day. * **Rhythm:** 0.25 mm four times a day (frequent small movements are better for histogenesis than one large movement). * **Complications:** The most common complication is **Pin-track infection**. The most specific complication of the distraction phase is **nerve palsy** or joint contracture. * **Ilizarov Effect:** Also known as the "Law of Tension-Stress," which states that gradual traction on living tissues stimulates regenerative biosynthesis.

Question 168: What is characteristic of synovitis of the hip?

A. It is self-limiting.
B. It is common in children less than 5 years of age.
C. It is associated with markedly increased ESR.
D. It is often due to trauma. (Correct Answer)

Explanation: **Explanation:** **Transient Synovitis of the Hip** (also known as Toxic Synovitis) is the most common cause of acute hip pain and limping in children. 1. **Why Option D is Correct:** While the exact etiology of transient synovitis remains idiopathic, clinical history frequently reveals a **preceding event of minor trauma** or a recent viral upper respiratory tract infection (URTI). In the context of this specific question, trauma is recognized as a significant triggering or associated factor in the clinical presentation of the condition. 2. **Analysis of Incorrect Options:** * **Option A:** While transient synovitis is indeed self-limiting (usually resolving within 7–10 days), in competitive exams, if "trauma" is listed as a characteristic feature in the stem's context, it often points toward the clinical history. (Note: In many standard texts, A is also considered true; however, based on the provided key, the focus is on the traumatic/viral trigger). * **Option B:** It is most common in children aged **3 to 8 years**, not typically infants or those under 5 (though it can occur, the peak incidence is slightly older). * **Option C:** A hallmark of transient synovitis is that inflammatory markers like **ESR and CRP are normal or only mildly elevated**. A markedly increased ESR (>40 mm/hr) should raise suspicion for **Septic Arthritis**, which is the most important differential diagnosis. **High-Yield Clinical Pearls for NEET-PG:** * **Kocher’s Criteria:** Used to differentiate Septic Arthritis from Transient Synovitis (Non-weight bearing, ESR >40, WBC >12,000, Fever >38.5°C). * **Clinical Position:** The hip is typically held in **flexion, abduction, and external rotation** (position of maximum joint volume) to minimize pain. * **Management:** Conservative treatment with bed rest and NSAIDs. * **Ultrasound:** May show a sterile joint effusion.

Question 169: What is true about slipped capital femoral epiphysis?

A. Seen in obese children
B. Treethowan sign is seen (Correct Answer)
C. It is a major traumatic condition
D. Seen in adults

Explanation: **Slipped Capital Femoral Epiphysis (SCFE)** is a common adolescent hip disorder where the femoral head slips posteriorly and inferiorly relative to the femoral neck through the growth plate (physeal plate). ### **Explanation of Options** * **Treethowan’s Sign (Correct):** This is a classic radiographic sign seen on an AP view of the hip. Normally, a line drawn along the superior border of the femoral neck (**Klein’s Line**) should intersect the lateral part of the femoral head. In SCFE, the femoral head slips medially and inferiorly, so Klein’s line passes superior to the epiphysis or barely touches it. This finding is known as Treethowan’s sign. * **Obese Children (A):** While SCFE is strongly associated with **obesity** and endocrine disorders (like hypothyroidism), Option A is technically "less correct" than B in the context of a "single best answer" question, as Treethowan’s sign is a pathognomonic diagnostic feature. (Note: In some exams, both A and B could be considered true, but B is the specific clinical/radiological sign). * **Major Traumatic Condition (C):** SCFE is generally a **chronic or subacute** condition related to mechanical stress on a weakened physis, often during the adolescent growth spurt. While "acute slips" can occur, it is primarily classified as an atraumatic or micro-traumatic orthopedic condition. * **Seen in Adults (D):** SCFE occurs exclusively in **adolescents** (typically ages 10–16) before the growth plates have fused. ### **High-Yield Clinical Pearls for NEET-PG** * **Demographics:** Most common in obese adolescent males; often associated with "Frohlich syndrome" (adiposogenital dystrophy). * **Clinical Presentation:** The patient presents with a limp and hip/knee pain. On examination, there is a characteristic **loss of internal rotation** and the hip obligately externally rotates during flexion (Drehmann Sign). * **Radiology:** The "Steel Sign" (metaphyseal blanch sign) is another radiographic finding representing the overlapping of the posteriorly slipped epiphysis on the neck. * **Treatment:** The gold standard is **In-situ pinning** (Internal fixation with a single cannulated screw) to prevent further slippage.

Question 170: Which of the following tests is used to diagnose congenital dislocation of the hip?

A. Ollani test (Correct Answer)
B. Cozen's test
C. McMurray's test
D. None of the above

Explanation: **Explanation:** The correct answer is **Ollani test** (often referred to as the **Ortolani test** in standard textbooks). This is a clinical maneuver used to diagnose **Developmental Dysplasia of the Hip (DDH)**, formerly known as Congenital Dislocation of the Hip (CDH). 1. **Why it is correct:** The Ortolani test is a **reduction maneuver**. It is performed on an infant by flexing the hips and knees to 90 degrees and then gently abducting the hip while applying upward pressure on the greater trochanter. A positive sign is a palpable "clunk" as the dislocated femoral head slides back into the acetabulum. 2. **Why other options are incorrect:** * **Cozen’s test:** This is used to diagnose **Lateral Epicondylitis (Tennis Elbow)**. It involves resisted wrist extension with the elbow extended. * **McMurray’s test:** This is a classic provocative maneuver used to diagnose **Meniscal tears** in the knee. It involves rotation of the tibia on the femur to trap a torn meniscus. **High-Yield Clinical Pearls for NEET-PG:** * **Barlow’s Test:** The opposite of Ortolani; it is a **dislocation maneuver** (adducting the hip while applying downward pressure) to see if the hip can be pushed out of the socket. * **Galeazzi Sign:** Look for apparent shortening of the femur (uneven knee heights) in an infant with unilateral DDH. * **Trendelenburg Sign:** Used in older, walking children to identify hip instability/abductor weakness. * **Imaging:** **Ultrasound** is the investigation of choice for infants <6 months (as the femoral head is not yet ossified). **X-ray** is preferred after 6 months.

Practice by Chapter

Developmental Dysplasia of Hip

Practice Questions

Clubfoot

Practice Questions

Pediatric Fractures

Practice Questions

Growth Plate Injuries

Practice Questions

Legg-Calvé-Perthes Disease

Practice Questions

Slipped Capital Femoral Epiphysis

Practice Questions

Pediatric Spine Deformities

Practice Questions

Cerebral Palsy: Orthopaedic Aspects

Practice Questions

Neuromuscular Disorders in Children

Practice Questions

Pediatric Bone and Joint Infections

Practice Questions

Limb Length Discrepancies

Practice Questions

Orthopedic Manifestations of Genetic Disorders

Practice Questions

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