Pediatric Orthopaedics Practice Questions

Q: What is the most common mode of inheritance for Achondroplasia?

Autosomal dominant. **Explanation:** **Achondroplasia** is the most common cause of disproportionate short-limb dwarfism. The correct answer is **Autosomal Dominant (B)** because the condition is caused by a gain-of-function mutation in the **FGFR3 gene** (Fibroblast Growth Factor Receptor 3) located on chromosome 4p. This mutation leads to constant inhibition of chondrocyte proliferation at the epiphyseal growth plate, resulting in impaired endochondral ossification. **Why other options are incorrect:** * **Sporadic (A):** While approximately **80% of cases** arise from *de novo* (new) mutations—often associated with advanced paternal age—the **mode of inheritance** itself is classified as Autosomal Dominant. If an affected individual has children, the trait follows a dominant pattern. * **Autosomal Recessive (C) & X-linked Recessive (D):** These do not apply to Achondroplasia. However, it is important to note that homozygous inheritance (two dominant alleles) is lethal in the neonatal period. **High-Yield Clinical Pearls for NEET-PG:** * **Genetics:** Specifically, a point mutation (G380R) in the FGFR3 gene. * **Clinical Features:** Rhizomelic shortening (proximal limb segments), "Trident hand" (persistent space between 3rd and 4th fingers), frontal bossing, and lumbar lordosis. * **Radiology:** Narrowing of the interpedicular distance (caudally), "Champagne glass" pelvis, and "Square" iliac wings. * **Intelligence:** Patients typically have normal intelligence and a normal lifespan. * **Complication:** Foramen magnum stenosis is a critical risk in infancy, potentially leading to sudden death or hydrocephalus.

Q: In a 2-year-old child, gallows traction is applied. The child is suffering from a fracture of which bone?

Fracture shaft of femur. ### Explanation **Correct Option: C. Fracture shaft of femur** **Gallows traction** (also known as **Bryant’s traction**) is a specific type of skin traction used primarily for the management of **femoral shaft fractures** in children. The underlying medical concept involves suspending the child’s lower limbs vertically using skin traction. The weight of the child’s body acts as the counter-traction. For this to be effective and safe, the child must weigh **less than 12–15 kg** and be **under 2 years of age**. The traction is applied such that the buttocks are just lifted off the bed (enough to pass a hand underneath), ensuring constant traction on the femur to maintain alignment and length. **Why other options are incorrect:** * **Neck of femur (A):** Pediatric femoral neck fractures are rare and are orthopedic emergencies usually requiring internal fixation (e.g., cannulated screws) due to the high risk of avascular necrosis (AVN). * **Greater trochanter (B):** Isolated fractures of the trochanter are usually avulsion injuries and do not require vertical suspension traction. * **Shaft of tibia (D):** Tibial fractures in toddlers are typically managed with an above-knee cast (e.g., Toddler’s fracture). Gallows traction is biomechanically designed for the femur. **High-Yield Clinical Pearls for NEET-PG:** * **Age/Weight Limit:** Strictly for children <2 years and <15 kg. * **Vascular Warning:** The most critical complication to monitor is **ischemia** of the feet. Frequent neurovascular checks are mandatory to prevent compartment syndrome or peroneal nerve palsy. * **Alternative:** For children older than 2 years with femur fractures, **Thomas splint** or **Spica casting** is preferred. * **Counter-traction:** Provided by the child's own body weight.

Q: Growth disturbance, nonunion, elbow instability, and late ulnar nerve palsy are commonly seen in which type of fracture?

Fracture of the lateral condyle. **Explanation:** Fracture of the **lateral condyle of the humerus** is the correct answer because it is an **intra-articular fracture** that often involves the growth plate (Salter-Harris Type IV). 1. **Why it is correct:** The lateral condyle is a "fracture of necessity" (usually requiring ORIF) because the fragment is pulled by the extensor muscles, leading to displacement. * **Nonunion:** Synovial fluid inhibits callus formation, and the pull of extensors causes constant motion. * **Growth Disturbance:** Damage to the physis leads to **Cubitus Valgus** deformity. * **Late Ulnar Nerve Palsy (Tardy Ulnar Nerve Palsy):** As the cubitus valgus deformity progresses, the ulnar nerve is chronically stretched over the medial epicondyle, leading to delayed palsy years after the injury. 2. **Why other options are wrong:** * **Supracondylar Humerus:** Most common pediatric elbow fracture. Complications include Volkmann’s Ischemic Contracture and **Cubitus Varus** (Gunstock deformity), but nonunion is rare as it is extra-articular. * **Medial Condyle:** Rare injury. While it can cause ulnar nerve issues, it does not typically result in the classic triad of nonunion, cubitus valgus, and tardy palsy associated with lateral condyle fractures. * **Radial Head:** Common in adults; usually results in restricted forearm rotation (pronation/supination) rather than late ulnar nerve palsy. **Clinical Pearls for NEET-PG:** * **Milch Classification** is used for lateral condyle fractures. * **Tardy Ulnar Nerve Palsy** is most classically associated with **Lateral Condyle Nonunion**. * **Cubitus Varus** = Supracondylar fracture; **Cubitus Valgus** = Lateral condyle fracture.

Q: Sprengel's deformity is a defect of?

Congenital elevation of scapula. ### Explanation **Correct Answer: C. Congenital elevation of scapula** **Understanding Sprengel’s Deformity** Sprengel’s deformity is the most common congenital anomaly of the shoulder girdle. It results from a **failure of the scapula to descend** from its embryonic position in the neck (where it originates at the level of C5-T1) to its normal thoracic position during the 9th to 12th week of gestation. Consequently, the scapula remains high, hypoplastic, and medially rotated. **Analysis of Options:** * **Option A (Absence of clavicle):** This is characteristic of **Cleidocranial Dysplasia**, a condition involving defective intramembranous ossification, often associated with dental anomalies and patent fontanelles. * **Option B & D (AC dislocation / Recurrent shoulder dislocation):** These are typically traumatic or instability-related conditions seen in adults or adolescents, not congenital developmental defects. **High-Yield Clinical Pearls for NEET-PG:** * **Omovertebral Bone:** Present in about 30% of cases. It is a fibrous, cartilaginous, or bony connection between the superior angle of the scapula and the cervical spine (usually C4-C7). * **Associated Anomalies:** Frequently associated with **Klippel-Feil Syndrome** (fused cervical vertebrae), scoliosis, and rib anomalies. * **Clinical Presentation:** Restricted shoulder abduction (due to scapulothoracic tethering) and cosmetic deformity (short neck appearance). * **Treatment:** Mild cases are managed conservatively. Severe cases (Green’s classification) require surgical procedures like the **Woodward procedure** or **Green’s procedure** to surgically lower the scapula.

Q: Osgood-Schlatter's disease is typically seen in which anatomical location?

Proximal tibia. **Explanation:** **Osgood-Schlatter’s disease** is a common cause of knee pain in active adolescents. It is characterized as an **osteochondritis** or traction apophysitis resulting from repetitive microtrauma at the insertion of the patellar tendon. 1. **Why Proximal Tibia is Correct:** The patellar tendon attaches to the **tibial tuberosity**, which is located on the anterior aspect of the **proximal tibia**. During growth spurts, repetitive contraction of the quadriceps muscle pulls on this immature ossification center, leading to inflammation, pain, and characteristic bony prominence. 2. **Why Incorrect Options are Wrong:** * **Proximal Femur:** Common pediatric pathologies here include Slipped Capital Femoral Epiphysis (SCFE) or Legg-Calvé-Perthes disease, not traction apophysitis of the knee. * **Distal Femur:** While the distal femur is a site for Osgood-Schlatter-like conditions (e.g., Sinding-Larsen-Johansson syndrome occurs at the inferior pole of the patella), it is not the site of the tibial tuberosity. * **Distal Tibia:** Pathologies here include Tillaux fractures or Pilon fractures; it is anatomically distant from the knee extensor mechanism. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Typically affects boys (12–15 years) and girls (8–12 years) involved in jumping or sprinting sports. * **Clinical Feature:** Exquisite tenderness and swelling over the tibial tuberosity; pain is aggravated by resisted knee extension. * **Radiology:** Lateral X-ray may show fragmentation or "ossicles" within the patellar tendon at the tuberosity. * **Management:** Primarily conservative (RICE, NSAIDs, and activity modification). It is self-limiting and resolves with skeletal maturity (closure of the apophysis). * **Differential:** **Sinding-Larsen-Johansson syndrome** is a similar traction apophysitis but occurs at the **inferior pole of the patella**.

Q: A child is swung around by holding his hand. While doing this, the child started crying and does not allow his father to touch his elbow. What is the most likely diagnosis?

Pulled elbow. **Explanation:** The clinical scenario describes a classic case of **Pulled Elbow**, also known as **Nursemaid’s Elbow**. This condition typically occurs in children aged 1–4 years when a sudden upward pull is applied to an extended, pronated arm (e.g., swinging a child or pulling them up a curb). **1. Why "Pulled Elbow" is correct:** The underlying anatomical mechanism is the **subluxation of the radial head**. In young children, the radial head is relatively small and the **annular ligament** is lax. Sudden traction causes the radial head to slip out from under the annular ligament, which then becomes trapped between the radial head and the capitellum. The child typically holds the arm in a pronated, slightly flexed position and refuses to move it due to pain. **2. Analysis of Incorrect Options:** * **B. Radial head subluxation:** While this is the actual pathological process, "Pulled Elbow" is the specific clinical diagnosis/syndrome name. In many exams, the clinical term is preferred over the anatomical description. * **C. Annular ligament tear:** The ligament is usually displaced or entrapped, not torn. A complete tear would require much higher energy trauma. * **D. Fracture of olecranon process:** This usually results from a direct fall on the elbow or a forceful contraction of the triceps. It would present with significant swelling and bruising, which are absent in a pulled elbow. **Clinical Pearls for NEET-PG:** * **Anatomy:** The **annular ligament** stabilizes the proximal radioulnar joint. * **Management:** Reduction is performed by **supination** of the forearm followed by **flexion** at the elbow (a "click" is often felt). * **Radiology:** X-rays are usually normal and are only indicated if a fracture is suspected (e.g., focal bone tenderness or swelling). * **High-Yield Fact:** The condition becomes rare after age 5 because the annular ligament becomes thicker and the radial head becomes more bulbous.

Q: Which of the following is not a typical deformity seen in congenital talipes equinovarus?

Forefoot pronation.. ### Explanation Congenital Talipes Equinovarus (CTEV), or clubfoot, is characterized by a specific sequence of four anatomical deformities. The correct answer is **Forefoot pronation** because, in CTEV, the forefoot is actually in **supination** relative to the hindfoot. #### The CAVE Acronym To remember the components of CTEV in the order they are typically corrected (Ponseti method), use the acronym **CAVE**: 1. **C - Cavus (Midfoot):** Caused by the drop of the first metatarsal (plantarflexion). This is the first deformity addressed during casting. 2. **A - Adduction (Forefoot):** The forefoot is deviated medially at the Tarsometatarsal joints. 3. **V - Varus (Hindfoot):** The heel is tilted inward (inverted) due to the alignment of the calcaneus under the talus. 4. **E - Equinus (Ankle):** Plantarflexion at the ankle joint due to a tight Achilles tendon. This is the last deformity to be corrected, often requiring a tenotomy. #### Why the other options are incorrect: * **Forefoot adduction (A), Midfoot cavus (C), and Hindfoot varus (D)** are all cardinal features of the CTEV deformity. In clubfoot, the foot is "twisted" inward and downward; therefore, any "valgus" or "pronation" component is clinically inconsistent with the diagnosis. #### NEET-PG High-Yield Pearls: * **Ponseti Method:** The gold standard treatment involving serial casting. The order of correction is **C $\rightarrow$ A $\rightarrow$ V $\rightarrow$ E**. * **Pirani Score:** Used to assess the severity of CTEV (0 to 6 scale). * **Radiology:** On X-ray, the **Kite’s angle** (talocalcaneal angle) is **decreased** (<20°) in both AP and lateral views. * **Associated Condition:** Always screen for Developmental Dysplasia of the Hip (DDH) and Spina Bifida in children with clubfoot.

Q: Pirani scoring of CTEV includes all except?

Curvature of the medial border of the foot. The **Pirani Scoring System** is a clinical tool used to assess the severity of Congenital Talipes Equinovarus (CTEV) and monitor progress during Ponseti casting. It consists of **6 clinical signs**, each scored 0, 0.5, or 1 (Total score: 0 to 6). ### Why Option A is the Correct Answer The correct term used in the Pirani score is the **Curvature of the Lateral Border** of the foot, not the medial border. In CTEV, the lateral border is convex due to the adduction of the forefoot. Assessing the degree of this convexity is a key component of the Midfoot Score. ### Analysis of Other Options The Pirani score is divided into two sub-categories: **1. Midfoot Score (MS):** * **Curvature of the lateral border (Option A - Incorrectly phrased):** Assesses forefoot adduction. * **Medial Crease (Option B):** A deep crease indicates more severe deformity. * **Lateral Head of Talus (Option C):** In a deformed foot, the talar head is prominent laterally; as correction occurs, it is covered by the navicular. **2. Hindfoot Score (HS):** * **Posterior Crease:** Assesses the severity of equinus. * **Empty Heel (Option D):** In severe equinus, the calcaneus is felt high up, leaving the heel pad "empty." * **Rigid Equinus:** Assesses the flexibility of the ankle dorsiflexion. ### High-Yield Clinical Pearls for NEET-PG * **Dimeglio Score:** Another common scoring system for CTEV, but it uses a 20-point scale based on four parameters of reducibility. * **Ponseti Method:** The gold standard treatment. The sequence of correction is **C-A-V-E** (Cavus, Adduction, Varus, Equinus). * **Tenotomy:** A Pirani Hindfoot Score > 1 with a Midfoot Score < 0.5 often indicates the need for a Percutaneous Achilles Tenotomy to correct residual equinus.

Question 1

Which of the following statements is NOT true about Perthes disease?

Accepted Answer

Femoral valgus derotation osteotomy

Answer

Chiari osteotomy

Answer

Coxa plana

Answer

More common in females

Question 2

What is the most common mode of inheritance for Achondroplasia?

Accepted Answer

Autosomal dominant

Answer

Sporadic

Answer

Autosomal recessive

Answer

X-linked recessive

Question 3

In a 2-year-old child, gallows traction is applied. The child is suffering from a fracture of which bone?

Accepted Answer

Fracture shaft of femur

Answer

Neck of femur

Answer

Greater trochanter of femur

Answer

Shaft of tibia

Question 4

Growth disturbance, nonunion, elbow instability, and late ulnar nerve palsy are commonly seen in which type of fracture?

Accepted Answer

Fracture of the lateral condyle

Answer

Fracture of the supracondylar humerus

Answer

Fracture of the medial condyle

Answer

Fracture of the head of the radius

Question 5

Sprengel's deformity is a defect of?

Accepted Answer

Congenital elevation of scapula

Answer

Absence of clavicle

Answer

Acromioclavicular dislocation

Answer

Recurrent dislocation of shoulder

Question 6

Osgood-Schlatter's disease is typically seen in which anatomical location?

Accepted Answer

Proximal tibia

Answer

Proximal femur

Answer

Distal tibia

Answer

Distal femur

Question 7

A child is swung around by holding his hand. While doing this, the child started crying and does not allow his father to touch his elbow. What is the most likely diagnosis?

Accepted Answer

Pulled elbow

Answer

Radial head subluxation

Answer

Annular ligament tear

Answer

Fracture of olecranon process

Question 8

Patients with bilateral CDH walk with which type of gait?

Accepted Answer

Waddling gait

Answer

Antalgic gait

Answer

Stumbling gait

Answer

Knock knee gait

Question 9

Which of the following is not a typical deformity seen in congenital talipes equinovarus?

Accepted Answer

Forefoot pronation.

Answer

Forefoot adduction.

Answer

Midfoot cavus.

Answer

Hindfoot varus.

Question 10

Pirani scoring of CTEV includes all except?

Accepted Answer

Curvature of the medial border of the foot

Answer

Severity of the medial crease

Answer

Position of the lateral aspect of the head of the talus

Answer

Emptiness of the heel

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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