Pediatric Orthopaedics Practice Questions

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

Calcaneum. **Explanation:** **Sever’s disease**, also known as **calcaneal apophysitis**, is a common cause of heel pain in physically active children (typically aged 8–14 years). It is a traction-overuse injury caused by repetitive microtrauma from the Achilles tendon pulling on the unossified calcaneal apophysis. * **Why Calcaneum is correct:** The disease specifically involves the posterior growth plate (apophysis) of the **calcaneum**. During growth spurts, the heel bone grows faster than the surrounding tendons, leading to increased tension. Clinical signs include tenderness over the posterior aspect of the calcaneum and a positive "squeeze test" (pain on mediolateral compression of the heel). **Analysis of Incorrect Options:** * **Lunate:** Involvement of the lunate bone is seen in **Kienböck’s disease** (avascular necrosis), which typically presents in adults with wrist pain. * **Tibial Tubercle:** Inflammation of the tibial tubercle apophysis is known as **Osgood-Schlatter disease**, the most common cause of knee pain in adolescents. * **Navicular:** Osteochondritis of the tarsal navicular bone is called **Köhler’s disease**, usually seen in younger children (3–7 years). **High-Yield Clinical Pearls for NEET-PG:** * **Radiological sign:** Increased density and fragmentation of the calcaneal apophysis (though diagnosis is primarily clinical). * **Management:** Conservative treatment including rest, ice, heel cups/inserts, and stretching of the gastrocnemius-soleus complex. * **Mnemonic for Osteochondroses:** * **S**ever’s = **S**hoe (Heel/Calcaneum) * **F**reiberg’s = **F**oot (2nd Metatarsal head) * **P**erthes = **P**elvis (Femoral head) * **P**anner’s = **P**unch (Capitellum of humerus)

Q: What is the least common complication of a closed supracondylar fracture in an 8-year-old child?

Nonunion. **Explanation:** Supracondylar fractures of the humerus are the most common pediatric elbow fractures. Understanding the complication profile is critical for NEET-PG. **Why Nonunion is the Correct Answer:** Nonunion is extremely rare in pediatric supracondylar fractures. This is due to the **thick, osteogenic periosteum** in children and the fact that the fracture occurs through cancellous bone, which has an excellent blood supply and high remodeling potential. These fractures typically heal rapidly, often within 3–4 weeks. **Analysis of Incorrect Options:** * **Cubitus Varus (Gunstock Deformity):** This is the **most common late complication**. It usually results from malreduction (medial tilt or rotation) rather than growth arrest. While functionally acceptable, it is cosmetically distressing. * **Cubitus Valgus:** This is much less common than varus but can occur. It is clinically significant because it may lead to **tardy ulnar nerve palsy** years later. * **Vessel Injury:** The brachial artery is at significant risk, especially in Gartland Type III (displaced) posterolateral fractures, where the proximal fragment pierces the brachialis muscle and injures the artery. **High-Yield Clinical Pearls for NEET-PG:** * **Most common nerve injured:** Anterior Interosseous Nerve (AIN) — test by asking the child to make an "OK" sign. * **Most common nerve injured in flexion type:** Ulnar nerve. * **Volkmann’s Ischemic Contracture:** The most dreaded acute complication resulting from unrecognized compartment syndrome. * **Management Gold Standard:** Closed reduction and percutaneous pinning (CRPP) for displaced fractures.

Q: Which of the following is NOT a feature of clubfoot?

Eversion at sub-talar joint. ### Explanation **Congenital Talipes Equinovarus (CTEV)**, commonly known as clubfoot, is a complex congenital deformity characterized by four specific anatomical components. The correct answer is **B (Eversion at sub-talar joint)** because clubfoot involves **Inversion**, not eversion. #### Why Option B is Correct: The core deformity in CTEV is remembered by the mnemonic **CAVE**: 1. **C**avus (High medial longitudinal arch) 2. **A**dduction (Forefoot moving toward the midline) 3. **V**arus (**Inversion** at the subtalar and midtarsal joints) 4. **E**quinus (Plantar flexion at the ankle joint) In CTEV, the heel is tilted inward (Varus/Inversion). Eversion is the corrective movement, not a feature of the pathology. #### Analysis of Other Options: * **Option A & C:** Forefoot adduction occurs at the mid-tarsal joints (specifically the talonavicular and calcaneocuboid joints). This is a hallmark feature where the front of the foot deviates medially. * **Option D:** Plantar flexion of the ankle (Equinus) is caused by the contracture of the Tendo-Achilles and is typically the last component to be corrected during treatment. #### High-Yield Clinical Pearls for NEET-PG: * **Treatment Gold Standard:** The **Ponseti Method** (serial casting). * **Order of Correction (Ponseti):** Remember **CAVE** in reverse—**C**avus first, then **A**dduction and **V**arus simultaneously, and finally **E**quinus (often requiring a percutaneous Achilles tenotomy). * **Radiology:** On X-ray, the **Kite’s Angle** (talocalcaneal angle) is **decreased** (less than 20°) in both AP and lateral views, as the talus and calcaneus become more parallel. * **Pirani Score:** Used to assess the severity of the deformity and monitor progress during casting.

Q: Which of the following are clinical tests used in the diagnosis of congenital dislocation of the hip (CDH)?

Both of the above. ### Explanation The diagnosis of **Developmental Dysplasia of the Hip (DDH)**, formerly known as Congenital Dislocation of the Hip (CDH), in neonates relies primarily on clinical provocative maneuvers that assess hip stability. **1. Why the correct answer is "Both of the above":** * **Barlow Test (Provocative Test):** This test identifies a "dislocatable" hip. The clinician adducts the hip and applies a gentle posterior force. If the femoral head slides out of the acetabulum, the test is positive. Think: **B**arlow = **B**ack (pushing the hip back/out). * **Ortolani Test (Reductive Test):** This test identifies a "dislocated" hip that is reducible. The clinician abducts the hip while applying an anterior pressure on the greater trochanter. A positive test is a palpable "clunk" as the femoral head slips back into the acetabulum. Think: **O**rtolani = **O**ut to **I**n (reducing the hip). **2. Why other options are incorrect:** Since both Barlow and Ortolani are the gold-standard clinical maneuvers for screening newborns (up to 2–3 months of age), selecting only one would be incomplete. **3. High-Yield Clinical Pearls for NEET-PG:** * **Age Limit:** Barlow and Ortolani tests are most reliable in the first **2–3 months**. After this, soft tissue contractures develop, and the most sensitive sign becomes **limited hip abduction**. * **Galeazzi Sign:** Used in older infants; it involves flexing the knees and hips to look for unequal knee heights (indicating femoral shortening/dislocation). * **Imaging of Choice:** * 6 months: **X-ray** (Look for Shenton’s line disruption and Perkins' line). * **Treatment:** The **Pavlik Harness** is the initial treatment of choice for infants under 6 months.

Q: Bavarian cast is used in which of the following conditions?

Developmental dysplasia of the hip (DDH). ### Explanation The **Bavarian cast** (also known as a Lorenz cast or a "frog-leg" cast) is a specialized type of hip spica cast used in the management of **Developmental Dysplasia of the Hip (DDH)**. **Why it is correct:** In the treatment of DDH, once a closed or open reduction of the femoral head into the acetabulum is achieved, the hip must be immobilized to maintain stability and allow the joint capsule to tighten. The Bavarian cast holds the hips in the **"Frog-leg position"**—characterized by 90° of flexion and 60–70° of abduction. This position ensures maximum congruency between the femoral head and the acetabulum, promoting normal joint development. **Analysis of Incorrect Options:** * **A. Fracture of the radius:** These are typically managed with Colles' casts, sugar-tong splints, or above-elbow/below-elbow casts depending on the site. * **B. Club foot (CTEV):** The gold standard is the **Ponseti technique**, which utilizes serial long-leg corrective casts, followed by a Denis Browne splint. * **C. Fracture of the calcaneus:** These are managed with non-weight-bearing below-knee casts or specific orthotics like the Essex-Lopresti reduction. **High-Yield Clinical Pearls for NEET-PG:** * **Safe Zone of Ramsey:** When applying a cast for DDH, abduction should not exceed 60–70° to avoid **Avascular Necrosis (AVN)** of the femoral head due to compression of the medial circumflex femoral artery. * **Pavlik Harness:** The most common initial treatment for DDH in infants <6 months (dynamic splint). * **Von Rosen Splint:** Another rigid splint used for neonatal DDH. * **Batchelor Cast:** A variation of the hip spica used in older children where the hips are abducted but internally rotated.

Q: A 10-year-old obese child presents with a painful limp and hip pain. Which of the following investigations is not required?

CT scan of the hip. **Explanation:** The clinical presentation of an **obese 10-year-old child** with a painful limp and hip pain is a classic "spotter" for **Slipped Capital Femoral Epiphysis (SCFE)**. In SCFE, the femoral head slips posteriorly and inferiorly relative to the femoral neck through the growth plate. **Why CT scan is the correct answer (Not Required):** A CT scan provides excellent bony detail but is **not** part of the standard diagnostic protocol for SCFE. It involves significant radiation exposure and rarely changes the management plan, which is primarily based on clinical findings and plain radiographs. **Analysis of other options:** * **X-ray of the hip (A):** This is the **initial and gold-standard investigation**. AP and Frog-leg lateral views are essential. Key signs include **Klein’s line** (which fails to intersect the femoral head) and the **Steel sign** (metaphyseal blanch). * **MRI of the hip (B):** MRI is the most sensitive tool for detecting **"Pre-slip" SCFE** (where clinical symptoms exist but X-rays are normal) by showing marrow edema and physeal widening. * **USG of the hip (C):** Ultrasound is useful for detecting a **joint effusion**, which is common in acute or acute-on-chronic slips, and can sometimes visualize the step-off at the physeal-metaphyseal junction. **NEET-PG High-Yield Pearls:** * **Demographics:** Most common in obese adolescent males (10–16 years). * **Referred Pain:** Hip pathology in children often presents as **isolated knee pain** (obturator nerve distribution). Always examine the hip in a child with a knee limp. * **Clinical Sign:** **Drehmann Sign** (obligate external rotation of the hip during passive flexion). * **Management:** Emergency stabilization with **In-situ Percutaneous Pinning/Screwing** to prevent further slip and Avascular Necrosis (AVN).

Q: In a patient with post-polio syndrome, iliotibial tract contracture is most likely to result in which of the following?

Flexion at the knee. **Explanation:** The **Iliotibial Tract (ITT)** is a thickened lateral portion of the fascia lata. Its anatomical path and attachments are crucial to understanding the deformities it causes when contracted, particularly in post-polio residual paralysis (PPRP). **Why Flexion at the Knee is Correct:** The ITT originates from the iliac crest and inserts into **Gerdy’s tubercle** on the lateral condyle of the tibia. Because its insertion point lies **posterior to the axis of the knee joint** when the knee is flexed, a tight ITT acts as a powerful flexor. Furthermore, it often causes a characteristic **triad of deformities** at the knee: flexion, abduction, and external rotation of the tibia. **Analysis of Incorrect Options:** * **B & C (Extension at the hip/knee):** A contracted ITT does not cause extension. At the hip, the ITT passes anterior to the joint axis, meaning contracture leads to **flexion**, abduction, and external rotation (Ober’s sign positive), not extension. * **D (Flexion at the hip and the knee):** While ITT contracture *can* contribute to hip flexion, the question asks what it is **most likely** to result in regarding the options provided. In the context of classic orthopedic teaching for ITT contracture (Yount’s procedure), the primary distal manifestation emphasized is knee flexion and valgus deformity. **NEET-PG High-Yield Pearls:** * **Yount’s Tenotomy:** This is the surgical procedure used to release a contracted ITT by excising a segment of the tract and lateral intermuscular septum just proximal to the knee. * **Ober’s Test:** Used to clinically assess ITT contracture. A positive test is the inability of the abducted hip to adduct past the midline. * **Deformity Pattern:** ITT contracture classically results in the "Frog-leg" position: Hip (Flexion, Abduction, External Rotation) and Knee (Flexion, Valgus, External Rotation of Tibia).

Question 1

Sever's disease involves which of the following bones?

Accepted Answer

Calcaneum

Answer

Lunate

Answer

Tibial tubercle

Answer

Navicular

Question 2

What is the least common complication of a closed supracondylar fracture in an 8-year-old child?

Accepted Answer

Nonunion

Answer

Cubitus valgus

Answer

Cubitus varus

Answer

Vessel injury

Question 3

Which of the following is NOT a feature of clubfoot?

Accepted Answer

Eversion at sub-talar joint

Answer

Forefoot adduction

Answer

Forefoot adduction at mid-tarsal joint

Answer

Plantar flexion of the ankle

Question 4

A 4-year-old boy presents with recurrent fractures, hyperextensible joints, and hearing problems. What is your diagnosis?

Accepted Answer

Osteogenesis imperfecta

Answer

Achondroplasia

Answer

Osteopetrosis

Answer

Ehlers-Danlos syndrome

Question 5

Which of the following are clinical tests used in the diagnosis of congenital dislocation of the hip (CDH)?

Accepted Answer

Both of the above

Answer

Barlow test

Answer

Ortolani test

Answer

None of the above

Question 6

Bavarian cast is used in which of the following conditions?

Accepted Answer

Developmental dysplasia of the hip (DDH)

Answer

Fracture of the radius

Answer

Club foot

Answer

Fracture of the calcaneus

Question 7

A 10-year-old obese child presents with a painful limp and hip pain. Which of the following investigations is not required?

Accepted Answer

CT scan of the hip

Answer

X-ray of the hip

Answer

MRI of the hip

Answer

USG of the hip

Question 8

In a patient with post-polio syndrome, iliotibial tract contracture is most likely to result in which of the following?

Accepted Answer

Flexion at the knee

Answer

Extension at the hip

Answer

Extension at the hip and knee

Answer

Flexion at the hip and the knee

Question 9

Transient synovitis of the hip is characterized by all of the following, except?

Accepted Answer

The hip is typically held in abduction and external rotation

Answer

May follow upper respiratory infection

Answer

ESR and white blood cell counts are usually normal

Answer

Ultrasound of the joint reveals widening of the joint space

Question 10

Waddling gait is seen in which of the following conditions?

Accepted Answer

Bilateral developmental dysplasia of the hip

Answer

Unilateral developmental dysplasia of the hip

Answer

Slipped capital femoral epiphysis

Answer

Perthes disease

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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