Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics Indian Medical PG Practice Questions and MCQs

Question 181: Sever's disease involves which of the following bones?

A. Lunate
B. Tibial tubercle
C. Calcaneum (Correct Answer)
D. Navicular

Explanation: **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)

Question 182: What is the least common complication of a closed supracondylar fracture in an 8-year-old child?

A. Cubitus valgus
B. Cubitus varus
C. Nonunion (Correct Answer)
D. Vessel injury

Explanation: **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.

Question 183: Which of the following is NOT a feature of clubfoot?

A. Forefoot adduction
B. Eversion at sub-talar joint (Correct Answer)
C. Forefoot adduction at mid-tarsal joint
D. Plantar flexion of the ankle

Explanation: ### 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.

Question 184: A 4-year-old boy presents with recurrent fractures, hyperextensible joints, and hearing problems. What is your diagnosis?

A. Achondroplasia
B. Osteogenesis imperfecta (Correct Answer)
C. Osteopetrosis
D. Ehlers-Danlos syndrome

Explanation: **Explanation:** The clinical triad of **recurrent fractures**, **joint hypermobility**, and **hearing loss** in a young child is a classic presentation of **Osteogenesis Imperfecta (OI)**. 1. **Why Osteogenesis Imperfecta is correct:** OI is a genetic disorder (most commonly Autosomal Dominant) caused by a defect in **Type I collagen** synthesis (COL1A1 or COL1A2 genes). Since Type I collagen is a primary component of bone matrix, tendons, and the middle ear ossicles, its deficiency leads to: * **Bone Fragility:** Recurrent fractures with minimal trauma. * **Joint Laxity:** Hyperextensibility due to weak connective tissue. * **Hearing Loss:** Conductive or sensorineural loss due to otosclerosis or ossicle deformity. * **Blue Sclera:** (Often present) due to thinning of the scleral collagen, allowing the underlying choroid to show through. 2. **Why other options are incorrect:** * **Achondroplasia:** A defect in FGF-R3 causing rhizomelic dwarfism and trident hands; it does not present with recurrent fractures or joint laxity. * **Osteopetrosis:** Characterized by "marble bones" due to defective osteoclast function. While bones are prone to fractures, they are dense/sclerotic on X-ray, and joint hyperextensibility is not a feature. * **Ehlers-Danlos Syndrome:** Primarily affects Type III or V collagen. While it features joint hypermobility and skin hyperextensibility, **recurrent fractures** are not a hallmark. **High-Yield Clinical Pearls for NEET-PG:** * **Radiology:** Look for "Popcorn calcifications" at metaphyses and "Codfish vertebrae" (biconcave). * **Classification:** **Sillence Classification** is used. Type II is the most severe (lethal in utero); Type I is the mildest and most common. * **Treatment:** **Bisphosphonates** (e.g., Pamidronate) are the mainstay to increase bone mineral density and reduce pain. * **Surgery:** "Sofield-Millar" procedure (multiple osteotomies and intramedullary nailing).

Question 185: Which of the following are clinical tests used in the diagnosis of congenital dislocation of the hip (CDH)?

A. Barlow test
B. Ortolani test
C. Both of the above (Correct Answer)
D. None of the above

Explanation: ### 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:** * < 4–6 months: **Ultrasonography (Graf’s classification)** because the femoral head is not yet ossified. * \> 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.

Question 186: Bavarian cast is used in which of the following conditions?

A. Fracture of the radius
B. Club foot
C. Developmental dysplasia of the hip (DDH) (Correct Answer)
D. Fracture of the calcaneus

Explanation: ### 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.

Question 187: A 10-year-old obese child presents with a painful limp and hip pain. Which of the following investigations is not required?

A. X-ray of the hip
B. MRI of the hip
C. CT scan of the hip (Correct Answer)
D. USG of the hip

Explanation: **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).

Question 188: In a patient with post-polio syndrome, iliotibial tract contracture is most likely to result in which of the following?

A. Flexion at the knee (Correct Answer)
B. Extension at the hip
C. Extension at the hip and knee
D. Flexion at the hip and the knee

Explanation: **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 189: Transient synovitis of the hip is characterized by all of the following, except?

A. May follow upper respiratory infection
B. ESR and white blood cell counts are usually normal
C. Ultrasound of the joint reveals widening of the joint space
D. The hip is typically held in abduction and external rotation (Correct Answer)

Explanation: **Explanation:** Transient Synovitis (Toxic Synovitis) is the most common cause of acute hip pain in children aged 3–10 years. It is a self-limiting, non-specific inflammatory condition. **Why Option D is the Correct Answer (The "Except"):** In Transient Synovitis, the hip is typically held in **flexion, abduction, and external rotation** (the position of maximum joint volume/capacity) to minimize intra-articular pressure and pain. Option D is technically incomplete or misleading in the context of standard orthopedic teaching, as the classic deformity involves **flexion** as the primary component. However, in many competitive exams, this question tests the distinction between Transient Synovitis and Septic Arthritis; while both share this "position of comfort," the clinical hallmark of Transient Synovitis is the *absence* of systemic toxicity. **Analysis of Other Options:** * **Option A:** It is frequently preceded by a viral **upper respiratory tract infection** (70% of cases) or trauma, suggesting an immune-mediated response. * **Option B:** Characteristically, inflammatory markers like **ESR, CRP, and WBC counts are normal** or only minimally elevated. This is a key differentiator from Septic Arthritis (where markers are significantly high). * **Option C:** Ultrasound is the investigation of choice. It reveals a **joint effusion** (widening of the joint space), which confirms the presence of fluid but does not differentiate the type of fluid. **NEET-PG High-Yield Pearls:** * **Kocher’s Criteria:** Used to differentiate Septic Arthritis from Transient Synovitis. Points include: Non-weight bearing, ESR >40 mm/hr, Fever >38.5°C, and WBC >12,000/mm³. * **Management:** Conservative treatment with bed rest and NSAIDs. Symptoms usually resolve within 7–10 days. * **Radiology:** X-rays are usually normal but may show "Waldenström’s sign" (increased medial joint space).

Question 190: Waddling gait is seen in which of the following conditions?

A. Unilateral developmental dysplasia of the hip
B. Bilateral developmental dysplasia of the hip (Correct Answer)
C. Slipped capital femoral epiphysis
D. Perthes disease

Explanation: ### Explanation **Correct Answer: B. Bilateral developmental dysplasia of the hip** **Underlying Concept:** Waddling gait (also known as a **Bilateral Trendelenburg gait**) occurs due to the functional weakness of the hip abductors (Gluteus medius and minimus). In Developmental Dysplasia of the Hip (DDH), the femoral head is displaced out of the acetabulum, which brings the origin and insertion of the abductor muscles closer together. This leads to **muscle slackness** (shortening of the lever arm), making the muscles unable to stabilize the pelvis during the stance phase. When this occurs on both sides, the patient compensates by shifting the trunk toward the weight-bearing side alternately, creating a "waddle." **Analysis of Incorrect Options:** * **A. Unilateral DDH:** This presents with a **Trendelenburg gait** (lurching to one side) rather than a waddling gait. It is also characterized by limb length discrepancy and a positive Galeazzi sign. * **C. Slipped Capital Femoral Epiphysis (SCFE):** Typically presents in obese adolescents with an **antalgic gait** or an externally rotated limb. While a Trendelenburg sign can be positive in chronic cases, "waddling" is not the classic description. * **D. Perthes Disease:** This usually presents with an **antalgic gait** (painful limp) due to avascular necrosis of the femoral head, often accompanied by a limitation of internal rotation and abduction. **High-Yield Clinical Pearls for NEET-PG:** * **Trendelenburg Sign:** Positive when the pelvis drops on the unsupported side (swing leg) due to weak abductors on the supported side (stance leg). * **Waddling Gait Differential:** Apart from Bilateral DDH, it is classically seen in **Duchenne Muscular Dystrophy (DMD)** and **Coxa Vara**. * **DDH Screening:** Remember the **Barlow test** (dislocates a stable hip) and **Ortolani test** (reduces a dislocated hip). Ultrasound is the investigation of choice before 6 months of age.

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

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free