Pediatric Orthopaedics Practice Questions

Q: Gallow's traction is used in children for which type of fracture?

Shaft of femur. **Explanation:** **Gallow’s traction** (also known as Bryant’s traction) is a form of skin traction specifically designed for the management of **fractures of the shaft of the femur** in children. **Why it is the correct answer:** The underlying principle involves suspending the child’s lower limbs vertically using skin traction. The legs are hoisted such that the **buttocks are just lifted off the bed**. This uses the child’s own body weight as counter-traction to maintain alignment and reduce the femoral fracture. It is typically indicated for children **under 2 years of age** (or weighing less than 12–15 kg) because their light body weight allows for effective traction without compromising peripheral circulation. **Why other options are incorrect:** * **Neck of femur:** These are rare in children and usually require internal fixation (e.g., cannulated screws) due to the high risk of avascular necrosis (AVN). * **Shaft of tibia:** These are generally managed with closed reduction and an above-knee (AK) cast. * **Tibial plafond:** These involve the articular surface (Pilon fractures) and require precise anatomical reduction, usually via surgery or specialized casting, not vertical suspension traction. **High-Yield Clinical Pearls for NEET-PG:** * **Age/Weight Limit:** Crucial for the exam—only used if the child is <2 years old and <15 kg. * **Complication:** The most serious risk is **vascular compromise** (ischemia). Frequent checks of dorsal pedis pulses and capillary refill are mandatory. * **Alternative:** For children older than 2 years with femoral fractures, **Thomas splint** (traction) or **Spica casting** is preferred.

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: 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: A 10-year-old child presents with anemia and recurrent fractures. The X-ray shows diffuse hyper density of bone. What is the most likely diagnosis?

Osteopetrosis. ### **Explanation** The clinical presentation of recurrent fractures, anemia, and diffuse hyperdensity on X-ray is classic for **Osteopetrosis** (also known as Marble Bone Disease or Albers-Schönberg disease). **1. Why Osteopetrosis is Correct:** The underlying pathology is **defective osteoclast function** (failure of bone resorption). While bones appear dense ("marble-like") on X-ray, they are structurally weak, brittle, and prone to fractures. The excessive bone formation encroaches upon the medullary cavity, leading to **bone marrow failure**, which manifests as **anemia**, thrombocytopenia, and hepatosplenomegaly (due to extramedullary hematopoiesis). **2. Why Other Options are Incorrect:** * **Osteogenesis Imperfecta:** Characterized by defective Type I collagen. While it presents with recurrent fractures and "brittle bones," the X-ray typically shows **osteopenia** (radiolucent/thin bones) rather than hyperdensity. Blue sclera is a common associated finding. * **Osteochondroma:** This is a benign bone tumor (exostosis) presenting as a bony outgrowth near the growth plate. It does not cause diffuse hyperdensity or systemic anemia. * **Hyperparathyroidism:** Increased PTH leads to excessive osteoclast activity, resulting in **osteopenia**, subperiosteal resorption, and "Brown tumors." It is characterized by decreased bone density, not hyperdensity. **3. High-Yield Clinical Pearls for NEET-PG:** * **X-ray Signs:** "Bone-within-a-bone" appearance and "Sandwich vertebrae" (sclerosis of endplates). * **Erlenmeyer Flask Deformity:** Seen at the distal femur due to defective remodeling. * **Cranial Nerve Palsies:** Narrowing of cranial foramina can lead to blindness or deafness. * **Treatment:** Bone Marrow Transplant is the definitive treatment for the infantile (malignant) form to provide functional osteoclasts.

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.

Q: A six-year-old boy presents to the emergency department with a painful limp. Clinical examination reveals tenderness in the femoral triangle and some limitation of hip movements. An X-ray was normal. What is the next appropriate investigation?

MRI Scan. ### Explanation The clinical presentation of a 6-year-old with a painful limp, femoral triangle tenderness, and restricted hip motion—coupled with a **normal X-ray**—is highly suspicious for early-stage **Perthes disease (Legg-Calvé-Perthes)** or **Septic Arthritis**. **Why MRI Scan is the correct answer:** In pediatric hip pathologies, X-rays often remain normal during the early stages (Stage I of Perthes or early infection). **MRI is the most sensitive imaging modality** for detecting early marrow edema, ischemia (avascular necrosis), or joint effusions that are not visible on plain radiographs. It allows for early diagnosis before irreversible bony changes occur. **Analysis of Incorrect Options:** * **Observation (A):** This is inappropriate in a symptomatic child with limited range of motion. Delaying diagnosis in conditions like Septic Arthritis or Perthes can lead to permanent joint destruction. * **Ultrasonography (B):** While excellent for detecting a joint effusion (Transient Synovitis), it cannot evaluate the bone marrow or confirm ischemia, making MRI superior for a definitive diagnosis when X-rays are negative. * **Aspiration (C):** This is an invasive procedure. It is indicated only if there is a high suspicion of Septic Arthritis (based on Kocher’s criteria: fever, non-weight bearing, elevated ESR/CRP). MRI is a better non-invasive next step to differentiate between various pathologies. **NEET-PG High-Yield Pearls:** * **Perthes Disease:** Most common in boys aged 4–8 years. Earliest X-ray sign is the "Caffey’s Silver Lining" or "Gage’s sign," but MRI is the earliest diagnostic tool overall. * **Transient Synovitis:** The most common cause of hip pain in children; usually follows a viral URI. Diagnosis of exclusion. * **Kocher’s Criteria:** Used to differentiate Septic Arthritis from Transient Synovitis (WBC >12k, ESR >40, Fever >38.5°C, Inability to bear weight).

Q: What is the most common cause of congenital talipes equinovarus (CTEV) deformity?

Idiopathic. **Explanation:** **Congenital Talipes Equinovarus (CTEV)**, also known as clubfoot, is a complex deformity involving four components: Hindfoot **E**quinus, Midfoot **V**arus, Forefoot **A**dductus, and Midfoot **C**avus (Mnemonic: **CAVE**). 1. **Why Idiopathic is Correct:** In approximately **80% of cases**, CTEV occurs as an isolated birth defect without any identifiable systemic or syndromic cause. This is termed **Idiopathic CTEV**. While the exact etiology remains unknown, theories suggest a combination of genetic predisposition and environmental factors (multifactorial inheritance) leading to abnormal collagen distribution and muscle contractures. 2. **Why Other Options are Incorrect:** * **Achondroplasia multiplex congenita (Arthrogryposis):** This is a rare syndrome characterized by multiple joint contractures. While CTEV is a common feature of this condition, it represents a "syndromic" or "secondary" cause, which is far less common than the idiopathic variety. * **Spina Bifida & Neural Tube Defects:** These are **neuropathic** causes of CTEV. In these cases, the foot deformity is secondary to muscle imbalance caused by spinal cord lesions. While important to rule out during clinical examination (by checking the spine for tufts of hair or dimples), they account for a minority of cases. **High-Yield Clinical Pearls for NEET-PG:** * **Incidence:** 1 in 1000 live births; more common in males (2:1); bilateral in 50% of cases. * **Pathology:** The primary deformity lies in the **Talus** (it is smaller with a medially deviated neck). * **Treatment Gold Standard:** **Ponseti Method** (Serial casting). The order of correction is **C-A-V-E** (Cavus first, then Adductus and Varus, and finally Equinus). * **First muscle to be released** (if surgery is needed): Abductor Hallucis. * **Last deformity to be corrected:** Equinus (often requires a percutaneous Achilles Tenotomy).

Question 1

Gallow's traction is used in children for which type of fracture?

Accepted Answer

Shaft of femur

Answer

Neck of femur

Answer

Shaft of tibia

Answer

Tibial plafond

Question 2

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 3

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 4

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 5

A 10-year-old child presents with anemia and recurrent fractures. The X-ray shows diffuse hyper density of bone. What is the most likely diagnosis?

Accepted Answer

Osteopetrosis

Answer

Osteogenesis imperfecta

Answer

Osteochondroma

Answer

Hyperparathyroidism

Question 6

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

Question 7

Which of the following are seen in bilateral congenital hip dislocation?

Accepted Answer

Short stature, lumbar lordosis, and waddling gait

Answer

Short stature and lumbar lordosis

Answer

Wandering acetabulum and waddling gait

Answer

Wandering acetabulum, waddling gait, and decreased femoral neck anteversion

Question 8

Which of the following is NOT true about developmental dysplasia of the hip?

Accepted Answer

When the ossification center is in the lower medial quadrant, the hip is dislocated.

Answer

It is more common in females.

Answer

Oligohydramnios is associated with a higher risk of developmental dysplasia of the hip.

Answer

The hourglass appearance of the joint capsule may prevent a successful closed reduction.

Question 9

A six-year-old boy presents to the emergency department with a painful limp. Clinical examination reveals tenderness in the femoral triangle and some limitation of hip movements. An X-ray was normal. What is the next appropriate investigation?

Accepted Answer

MRI Scan

Answer

Observation

Answer

Ultrasonography

Answer

Aspiration

Question 10

What is the most common cause of congenital talipes equinovarus (CTEV) deformity?

Accepted Answer

Idiopathic

Answer

Achondroplasia multiplex congenita

Answer

Spina bifida

Answer

Neural tube defect

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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