Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics Indian Medical PG Practice Questions and MCQs

Question 211: What is the most common cause of genu valgum in children?

A. Osteoarthritis
B. Rickets (Correct Answer)
C. Paget disease
D. Rheumatoid arthritis

Explanation: **Explanation:** **Genu valgum** (knock-knees) is a common pediatric orthopedic deformity where the knees angle in and touch each other while the ankles remain apart. In the context of pediatric populations, **Rickets** is the most common pathological cause. Rickets leads to defective mineralization of the osteoid matrix at the growth plates due to Vitamin D, calcium, or phosphate deficiency. This results in "soft" bones that succumb to mechanical loading, leading to characteristic angular deformities like genu valgum or genu varum (bow-legs). **Analysis of Options:** * **Rickets (Correct):** It is the leading cause of metabolic bone disease in children, frequently presenting with physeal widening and metaphyseal fraying/cupping, which manifests clinically as limb deformities. * **Osteoarthritis (Incorrect):** This is a degenerative joint disease primarily affecting the elderly. While it can cause valgus deformity in adults (lateral compartment OA), it is not a pediatric condition. * **Paget Disease (Incorrect):** This is a disease of increased bone remodeling seen in older adults (typically >50 years). It causes bone enlargement and bowing (usually genu varum), not pediatric genu valgum. * **Rheumatoid Arthritis (Incorrect):** This is an autoimmune inflammatory synovitis. While Juvenile Idiopathic Arthritis (JIA) exists in children, it is less common than Rickets as a cause of isolated genu valgum. **High-Yield Clinical Pearls for NEET-PG:** * **Physiological Genu Valgum:** It is normal for children to have a valgus alignment between ages **3 to 4 years**, which typically self-corrects by age 7. * **Radiological Signs of Rickets:** Look for "Cupping, Fraying, and Splaying" of the metaphysis. * **Measurement:** Genu valgum is clinically assessed by measuring the **inter-malleolar distance** (IMD). If IMD >8 cm after age 10, it is considered pathological. * **Treatment:** If pathological and severe, "Guided Growth" using **hemiepiphysiodesis** (e.g., 8-plate) is the surgical treatment of choice.

Question 212: An 11-year-old, 70 kg child presents with limitation of abduction and internal rotation of the hip. There is tenderness in Scarpa's triangle. On flexing the hip, the limb is abducted. What is the diagnosis?

A. Perthes disease
B. Slipped capital femoral epiphyses (Correct Answer)
C. Observation hip
D. Tuberculosis of the hip

Explanation: ### Explanation **Diagnosis: Slipped Capital Femoral Epiphysis (SCFE)** The clinical presentation is classic for **Slipped Capital Femoral Epiphysis (SCFE)**. The key diagnostic features in this scenario are: 1. **Demographics:** An 11-year-old child weighing 70 kg (obesity is a major risk factor). 2. **Clinical Sign:** The pathognomonic finding is **obligate external rotation during hip flexion** (Drehmann sign). This occurs because the femoral neck slips anteriorly and superiorly relative to the epiphysis, causing the limb to abduct and rotate externally when flexed. 3. **Range of Motion:** Limitation of internal rotation and abduction is a hallmark of the deformity. --- ### Differential Diagnosis * **Perthes Disease:** Typically affects younger children (4–8 years) who are usually of small stature. While it limits internal rotation and abduction, it does not present with the obligate external rotation/abduction on flexion seen in SCFE. * **Observation Hip (Transient Synovitis):** This is an acute, self-limiting condition usually following a viral infection in younger children (3–6 years). It presents with an acute limp but lacks the chronic weight-related associations and specific mechanical signs of SCFE. * **Tuberculosis of the Hip:** This would typically present with systemic symptoms (fever, weight loss), night cries, and a "pancytopenia" of hip movements (limitation in all planes), often with a more chronic, wasting clinical picture. --- ### High-Yield Pearls for NEET-PG * **Most Common Age:** 10–16 years (Adolescent growth spurt). * **Associations:** Obesity, Hypothyroidism, and Growth hormone abnormalities. * **Radiology:** Look for **Trethowan’s Sign** (Klein’s line does not intersect the femoral head) and the **Steel Metaphyseal Blanch Sign**. * **Management:** Emergency stabilization with **In-situ pinning** (Single cannulated screw) to prevent further slip and Avascular Necrosis (AVN).

Question 213: Sprengel's shoulder is associated with which of the following congenital anomalies?

A. Hemivertebra
B. Klippel-Feil anomaly
C. Cervical spina bifida
D. All of the above (Correct Answer)

Explanation: **Explanation:** **Sprengel’s deformity** is the most common congenital anomaly of the shoulder, characterized by a **high-lying, undescended scapula**. During the 9th to 12th week of gestation, the scapula normally migrates from the cervical level to its permanent thoracic position (T2–T7). Failure of this descent results in Sprengel’s shoulder. **Why "All of the above" is correct:** Because the insult occurs during early embryogenesis, it is frequently associated with other regional musculoskeletal and midline defects: * **Klippel-Feil Anomaly:** This is the most common association (seen in up to 30% of cases), characterized by the triad of a short neck, low posterior hairline, and restricted neck motion due to fused cervical vertebrae. * **Hemivertebra & Scoliosis:** Failure of proper vertebral formation often accompanies the failure of scapular descent. * **Cervical Spina Bifida:** Midline fusion defects of the neural arch are common associated findings. * **Omovertebral Bone:** A high-yield finding where a fibrous, cartilaginous, or bony connection exists between the superior angle of the scapula and the cervical spine (C4–C7). **Clinical Pearls for NEET-PG:** 1. **Clinical Presentation:** The affected shoulder is higher, the scapula is hypoplastic and rotated, and there is a significant **restriction of shoulder abduction**. 2. **Gender Predominance:** More common in **females** and usually unilateral (left side more common). 3. **Surgery:** Indicated for cosmetic improvement or functional limitation. The **Green’s procedure** or **Woodward’s procedure** are the classic surgical techniques used to relocate the scapula inferiorly. 4. **Associated Muscles:** The trapezius, levator scapulae, and rhomboids are often hypoplastic or fibrotic.

Question 214: Which of the following statements is false with respect to Pes planus?

A. Obliterated/lost medial longitudinal arch leads to Pes planus.
B. If the heel goes into lateral deviation, it is called plano valgus.
C. Rigid type on Jack's test often requires conservative intervention. (Correct Answer)
D. The most common cause is idiopathic.

Explanation: ### **Explanation** **Pes Planus (Flat Foot)** is characterized by the collapse or loss of the **medial longitudinal arch**. Understanding the distinction between flexible and rigid types is crucial for NEET-PG. **1. Why Option C is the Correct (False) Statement:** The **Jack’s Test (Great Toe Extension Test)** is used to differentiate between flexible and rigid flat feet. * **Flexible Pes Planus:** The arch reappears when the great toe is dorsiflexed (positive test). This type is usually asymptomatic and managed **conservatively**. * **Rigid Pes Planus:** The arch remains flat despite toe extension (negative test). This is often due to underlying structural pathologies like **tarsal coalition** or **vertical talus**. Unlike the flexible type, rigid pes planus is pathological and frequently requires **surgical intervention**, not just conservative management. **2. Analysis of Other Options:** * **Option A:** This is the anatomical definition of Pes planus. The medial longitudinal arch (formed by the calcaneus, talus, navicular, cuneiforms, and first three metatarsals) is flattened. * **Option B:** In flat feet, the hindfoot often compensates by tilting outward. This lateral deviation of the heel is termed **valgus**. When combined with a flat arch, it is called **Planovalgus**. * **Option D:** Most cases of pediatric flat foot are **idiopathic (flexible)**, related to ligamentous laxity, and resolve spontaneously as the child grows. **3. Clinical Pearls for NEET-PG:** * **Flexible Flat Foot:** Most common; arch seen when standing on tiptoes or during Jack's test. * **Congenital Vertical Talus (CVT):** Also known as "Rocker Bottom Foot"; it is a cause of **rigid** flat foot where the talus is vertically oriented. * **Tarsal Coalition:** A common cause of **spastic/rigid** flat foot in adolescents, most frequently involving the calcaneonavicular or talocalcaneal joints. * **Treatment:** Asymptomatic flexible flat foot requires **no treatment**. Orthotics (arch supports) are only used if the child is symptomatic.

Question 215: What is the ideal treatment of bilateral idiopathic clubfoot in a newborn?

A. Manipulation by mother
B. Manipulation and Dennis Brown splint
C. Manipulation and casts (Correct Answer)
D. Surgical release

Explanation: **Explanation:** The gold standard for the management of idiopathic congenital talipes equinovarus (CTEV/Clubfoot) in a newborn is the **Ponseti Method**, which consists of serial **manipulation and casting**. **Why Option C is Correct:** In a newborn, the bones and soft tissues are highly malleable. The Ponseti technique involves specific weekly manipulations to stretch the contracted tissues, followed by the application of long-leg plaster casts to maintain the correction. The sequence of correction follows the mnemonic **CAVE**: **C**avus is corrected first, followed by **A**dduction, **V**arus, and finally **E**quinus (often requiring a percutaneous Achilles tenotomy). **Why Other Options are Incorrect:** * **Option A:** Manipulation by the mother is insufficient to achieve the precise anatomical realignment required and cannot maintain the correction without immobilization. * **Option B:** The Denis Browne splint is a **maintenance tool**, not a primary treatment. It is used *after* the deformity has been fully corrected by casts to prevent recurrence. * **Option C:** Surgical release (e.g., Turco’s procedure) was common in the past but is now reserved for resistant cases or late presentations (usually after 6–12 months of age) due to the risk of long-term stiffness and scarring. **NEET-PG High-Yield Pearls:** * **Ideal time to start:** Within the first week of life. * **Order of correction:** Cavus → Adduction → Varus → Equinus. * **Achilles Tenotomy:** Required in ~80-90% of cases to correct the residual equinus. * **Maintenance:** After the final cast, the child wears a Foot Abduction Orthosis (FAO/Denis Browne Splint) for 23 hours a day for 3 months, then at night until age 4. * **Pirani Score:** Used to assess the severity and progress of clubfoot.

Question 216: What is the most likely diagnosis in a neonate presenting with multiple, healed fractures of long bones?

A. Osteomalacia
B. Osteopetrosis
C. Osteogenesis imperfecta (Correct Answer)
D. Congenital rickets

Explanation: **Explanation:** The presence of multiple, healed fractures in a neonate (at birth) is a classic presentation of **Osteogenesis Imperfecta (OI)**, specifically **Type II** (the perinatal lethal form). **1. Why Osteogenesis Imperfecta is correct:** OI is a genetic disorder caused by mutations in the **COL1A1 or COL1A2** genes, leading to defective synthesis of **Type 1 Collagen**. Since Type 1 collagen is the primary structural protein in the bone matrix (osteoid), its deficiency results in extreme bone fragility. In severe cases, the fetus sustains multiple fractures *in utero* due to normal fetal movements or during the birth process. Radiologically, these appear as "crumpled" long bones with exuberant callus formation from healed fractures. **2. Why other options are incorrect:** * **Osteomalacia:** This is a disorder of bone mineralization in adults (after epiphyseal closure), usually due to Vitamin D deficiency. It does not present at birth. * **Osteopetrosis:** Also known as "Marble Bone Disease," this involves defective osteoclast function leading to excessively dense but brittle bones. While it can cause fractures, it typically presents later in infancy with anemia and hepatosplenomegaly; it does not typically present with multiple *healed* fractures at birth. * **Congenital Rickets:** True rickets is rare in neonates because maternal Vitamin D transfer usually suffices. Even when present, it manifests as widening of growth plates and rachitic rosary, not multiple intrauterine fractures. **Clinical Pearls for NEET-PG:** * **Blue Sclera:** A hallmark of OI (due to thinning of the sclera, allowing the underlying choroid to show through). * **Dentinogenesis Imperfecta:** "Opalescent teeth" are often seen in OI patients. * **Wormian Bones:** Multiple small sutural bones in the skull are a characteristic radiological finding in OI. * **Classification:** Sillence Classification is used to grade the severity of OI.

Question 217: Which splint is used in the management of a fracture of the shaft of the femur in the age group of 2 to 10 years?

A. Split Russell's traction (Correct Answer)
B. Gallows traction
C. Buck's traction
D. Brandon traction

Explanation: **Explanation:** The management of femoral shaft fractures in children is primarily determined by the patient's age and weight. For the **2 to 10-year age group**, **Split Russell’s traction** is the preferred conservative management. **1. Why Split Russell’s Traction is Correct:** Split Russell’s traction is a form of skin traction that utilizes a sling under the knee and a longitudinal pull on the leg. It employs a system of pulleys to create a resultant force that aligns with the long axis of the femur. This "double-pull" mechanism allows for hip flexion and knee stabilization, which helps neutralize the muscle forces (iliopsoas and hamstrings) that typically cause displacement in this age group. **2. Analysis of Incorrect Options:** * **Gallows Traction (Bryant’s Traction):** Used for children **under 2 years** of age (or weighing less than 12-15 kg). Both legs are suspended vertically so that the buttocks are just cleared off the bed. * **Buck’s Traction:** A simple longitudinal skin traction without a knee sling. It is generally used for temporary immobilization of hip fractures or femoral shaft fractures in **adults** before surgery, but it does not provide the necessary angular control for pediatric femoral shafts. * **Brandon Traction:** This is not a standard orthopedic term used in the management of femoral fractures; it is likely a distractor. **Clinical Pearls for NEET-PG:** * **Age <2 years:** Gallows (Bryant) traction. * **Age 2–10 years:** Split Russell’s traction or immediate Spica casting (if shortening is <2cm). * **Age >10 years:** Flexible Intramedullary Nails (TENS - Titanium Elastic Nailing System) is the treatment of choice. * **Complication:** The most common complication of pediatric femoral shaft fractures treated conservatively is **malunion** (specifically, limb length discrepancy due to overgrowth/hyperemia).

Question 218: Congenital elevation of the scapula is called?

A. Sprengel deformity (Correct Answer)
B. Bouchard node
C. Boutonniere deformity
D. None of the above

Explanation: **Explanation:** **Sprengel Deformity (Correct Answer):** Sprengel deformity is the most common congenital anomaly of the scapula. It results from the failure of the scapula to descend from its embryonic position in the neck to its normal posterior thoracic position during the 9th to 12th week of gestation. Clinically, the scapula is elevated, hypoplastic, and medially rotated. In about 30% of cases, an **omovertebral bone** (a fibrous, cartilaginous, or bony connection) exists between the superior angle of the scapula and the cervical spine, further restricting shoulder abduction. **Why other options are incorrect:** * **Bouchard nodes:** These are bony outgrowths (osteophytes) at the **Proximal Interphalangeal (PIP) joints**, typically seen in Osteoarthritis. * **Boutonniere deformity:** This is a hand deformity characterized by flexion of the PIP joint and hyperextension of the Distal Interphalangeal (DIP) joint, caused by a rupture of the central slip of the extensor tendon. **High-Yield Clinical Pearls for NEET-PG:** * **Associations:** Sprengel deformity is frequently associated with **Klippel-Feil Syndrome** (congenital fusion of cervical vertebrae), scoliosis, and rib anomalies. * **Clinical Feature:** The most significant functional deficit is the limitation of shoulder abduction. * **Radiology:** Look for a high-riding, small, and rotated scapula on a chest or shoulder X-ray. * **Treatment:** Mild cases are managed with physical therapy. Severe cases (Green’s classification) require surgical procedures like the **Woodward procedure** or **Green’s procedure** to lower the scapula.

Question 219: The characteristic triad of Klippel-Feil syndrome includes all of the following, except?

A. Short neck
B. Low hairline
C. Limited neck movements
D. Elevated scapula (Correct Answer)

Explanation: **Explanation:** **Klippel-Feil Syndrome (KFS)** is a congenital skeletal condition characterized by the failure of normal segmentation of cervical vertebrae, leading to fused cervical segments. **Why "Elevated Scapula" is the correct answer (the exception):** The classic clinical triad of KFS, as originally described by Maurice Klippel and André Feil, consists of: 1. **Short neck** 2. **Low posterior hairline** 3. **Limited neck range of motion** (due to fused vertebrae) While **Sprengel’s deformity** (congenital elevation of the scapula) is the most common associated orthopedic anomaly in KFS (occurring in about 25–35% of cases), it is **not** part of the defining diagnostic triad. **Analysis of Incorrect Options:** * **Short neck (A):** A direct result of cervical vertebral fusion and a core component of the triad. * **Low hairline (B):** A classic physical finding where the hairline extends down to the upper back/neck area. * **Limited neck movements (C):** The most common clinical finding, specifically affecting lateral bending and rotation more than flexion/extension. **High-Yield Clinical Pearls for NEET-PG:** * **Most common association:** Scoliosis is frequently seen; however, Sprengel’s deformity is the most characteristic associated scapular finding. * **Systemic Associations:** Renal anomalies (most common non-skeletal anomaly, e.g., unilateral renal agenesis) and sensorineural hearing loss. * **Wildervanck Syndrome:** KFS associated with Duane retraction syndrome and deafness. * **Radiology:** Lateral X-ray of the cervical spine is the gold standard for diagnosis, showing "wasp-waist" appearance of fused vertebrae.

Question 220: Genu valgum deformity is seen in all except?

A. Rickets
B. Bone Dysplasia
C. Rheumatoid arthritis
D. Medial compartment osteoarthritis (Correct Answer)

Explanation: **Explanation:** The correct answer is **Medial compartment osteoarthritis**. **1. Why Medial Compartment Osteoarthritis is the correct answer:** In the knee, the mechanical axis normally passes slightly medial to the center. In osteoarthritis (OA), the medial compartment is the most common site of primary degeneration. As the medial articular cartilage wears down, the joint space narrows, leading to a **Genu Varum (Bow-legs)** deformity. Conversely, Genu Valgum (Knock-knees) is typically associated with *lateral* compartment osteoarthritis. **2. Analysis of Incorrect Options:** * **Rickets:** Nutritional or metabolic bone disease leads to softened osteoid. While Genu Varum is more common in early childhood rickets, **Genu Valgum** is frequently seen in the "healing" phase or in specific types like Vitamin D-resistant rickets (X-linked hypophosphatemia). * **Bone Dysplasia:** Various skeletal dysplasias (e.g., Morquio syndrome, Multiple Epiphyseal Dysplasia) interfere with normal physeal growth. Asymmetrical growth at the distal femoral or proximal tibial epiphysis often results in **Genu Valgum**. * **Rheumatoid Arthritis (RA):** Unlike primary OA, RA is a symmetric inflammatory pan-arthritis. It often leads to the destruction of the lateral compartment and laxity of the medial collateral ligament, characteristically resulting in a **Genu Valgum** deformity. **High-Yield Clinical Pearls for NEET-PG:** * **Physiological Development:** Genu Varum is normal up to 2 years; Genu Valgum is physiological between ages 3–6 years. * **Q-Angle:** Increased in Genu Valgum; decreased in Genu Varum. * **Mnemonic for OA:** **M**edial compartment = **M**edial deviation of the knee (Varus). * **Cozen’s Phenomenon:** Post-traumatic Genu Valgum following a proximal tibial metaphyseal fracture in children.

Practice by Chapter

Developmental Dysplasia of Hip

Practice Questions

Clubfoot

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Pediatric Fractures

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Growth Plate Injuries

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Legg-Calvé-Perthes Disease

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Slipped Capital Femoral Epiphysis

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Pediatric Spine Deformities

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Cerebral Palsy: Orthopaedic Aspects

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Neuromuscular Disorders in Children

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Pediatric Bone and Joint Infections

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Limb Length Discrepancies

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Orthopedic Manifestations of Genetic Disorders

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