Pediatric Orthopaedics Practice Questions

Q: In children, acute osteomyelitis most commonly affects which part of the long bone?

Metaphysis. **Explanation:** Acute Hematogenous Osteomyelitis (AHO) is most common in children, and the **metaphysis** is the site of predilection due to its unique vascular anatomy. **Why Metaphysis is the correct answer:** 1. **Hairpin Loops:** The nutrient arteries end in sharp "hairpin" loops at the growth plate before entering large venous sinusoids. This sudden change in direction causes turbulent blood flow and stasis. 2. **Sluggish Circulation:** The slow blood flow in these sinusoids allows bacteria (most commonly *Staphylococcus aureus*) to settle and proliferate. 3. **Deficient Phagocytosis:** The capillary loops in this region lack a robust population of functioning phagocytic cells (macrophages), making it an ideal environment for infection to take root. **Why other options are incorrect:** * **Diaphysis:** While it can be involved in conditions like Ewing’s Sarcoma or Sickle Cell-related *Salmonella* osteomyelitis, it is not the primary site for AHO due to faster blood flow. * **Epiphysis:** This area is generally protected by the physis (growth plate), which acts as a mechanical barrier to the spread of infection. It is only commonly involved in infants (where trans-physeal vessels exist) or in septic arthritis. * **Physis:** The growth plate consists of dense cartilage and is relatively avascular; it acts as a barrier rather than a site of primary infection. **High-Yield Clinical Pearls for NEET-PG:** * **Most common organism:** *Staphylococcus aureus* (overall); *Salmonella* (in Sickle Cell Disease). * **Most common site:** Distal femur and proximal tibia (areas of rapid growth). * **Infant Exception:** In children <1 year, trans-physeal vessels allow infection to spread from the metaphysis to the epiphysis, frequently leading to **septic arthritis**. * **Diagnosis:** MRI is the most sensitive early imaging modality; X-rays may remain normal for the first 10–14 days.

Q: Which of the following features defines a toddler's fracture?

Spiral fracture of the tibia. **Explanation:** **Toddler’s fracture** is a classic pediatric injury typically seen in children aged **9 months to 3 years** who have recently started walking. It is defined as a **non-displaced spiral or oblique fracture of the distal one-third of the tibial shaft.** 1. **Why Option D is correct:** The injury occurs due to a low-energy **rotational (twisting) force** on the tibia while the foot is planted. Because the periosteum in children is thick and tough, the fracture remains stable and non-displaced. Clinically, the child presents with a sudden refusal to bear weight or a limp, often without a clear history of significant trauma. 2. **Why other options are incorrect:** * **Option A:** Subluxation of the radial head is known as **Nursemaid’s Elbow**, caused by sudden traction on an extended arm. * **Option B:** Salter-Harris Type 3 fractures of the distal tibia (not fibula) are more common in adolescents (e.g., Tillaux fracture), not toddlers. * **Option C:** Distal radius fractures (like Buckle or Greenstick fractures) are common in older children following a fall on an outstretched hand (FOOSH). **High-Yield Clinical Pearls for NEET-PG:** * **Radiology:** The fracture line is often faint and may be **invisible on initial X-rays**. If clinical suspicion is high, repeat X-rays after 7–10 days will show periosteal reaction/callus formation. * **Differential Diagnosis:** Must be distinguished from **Child Abuse (Non-Accidental Injury)**. However, a toddler’s fracture is a common accidental injury and, in isolation, is not typically a sign of abuse. * **Management:** Immobilization in a long-leg or short-leg cast for 3–4 weeks; prognosis is excellent.

Q: What is the commonest presentation of congenital dislocation of the knee?

Hyperextension. **Explanation:** **Congenital Dislocation of the Knee (CDK)** is a rare neonatal deformity characterized by a spectrum of hyperextension deformities. **1. Why Hyperextension is Correct:** The hallmark of CDK is a **hyperextension** deformity present at birth. It occurs due to a malalignment of the quadriceps mechanism, where the quadriceps acts as a primary deforming force, pulling the tibia anteriorly relative to the femur. This results in a range of severity: from simple congenital hyperextension (recurvatum) to subluxation, and finally, true dislocation where the tibia is displaced anterior to the femoral condyles. **2. Why Other Options are Incorrect:** * **Flexion:** This is the opposite of the clinical presentation. While many neonatal conditions (like Breech presentation) involve hip flexion, the knee in CDK is locked in extension or hyperextension. * **Varus/Valgus:** These refer to coronal plane angulations (bow-legs or knock-knees). While they may coexist with other syndromes, they are not the primary or defining presentation of a knee dislocation. **3. High-Yield Clinical Pearls for NEET-PG:** * **Associations:** CDK is frequently associated with **Developmental Dysplasia of the Hip (DDH)** (up to 70% of cases) and **Clubfoot (CTEV)**. Always screen the hips in a child with CDK. * **Etiology:** Often linked to intrauterine packaging (breech position) or genetic conditions like **Larsen Syndrome** (multiple joint dislocations). * **Management:** The priority in a child with multiple deformities is: **Knee first, then Hip, then Foot.** * **Treatment:** Initial management is serial casting (in flexion). Refractory cases require surgical quadricepsplasty.

Q: What anatomical structure is most commonly affected in Osgood-Schlatter disease?

Tibial tuberosity. **Explanation:** **Osgood-Schlatter disease** is a common cause of knee pain in active adolescents. It is a traction-induced **apophysitis** (inflammation of the growth plate) of the **tibial tuberosity**. 1. **Why Tibial Tuberosity is Correct:** The condition is caused by repetitive microtrauma from the forceful contraction of the quadriceps muscle. This force is transmitted through the patellar tendon to its insertion point at the tibial tuberosity. In skeletally immature patients, this repetitive stress leads to inflammation, micro-avulsion, and sometimes bony hypertrophy at the tuberosity, resulting in a characteristic painful bump. 2. **Analysis of Incorrect Options:** * **B. Femur head:** Affected in **Legg-Calvé-Perthes disease** (avascular necrosis) or Slipped Capital Femoral Epiphysis (SCFE). * **C. Navicular bone:** Affected in **Kohler’s disease** (osteochondritis of the tarsal navicular). * **D. Calcaneum:** Affected in **Sever’s disease** (calcaneal apophysitis), which causes heel pain in children. **NEET-PG High-Yield Pearls:** * **Clinical Presentation:** Typically an adolescent athlete (10–15 years) complaining of activity-related anterior knee pain and localized swelling over the tibial tubercle. * **Radiology:** Lateral X-ray may show fragmentation or prominence of the tibial tuberosity and soft tissue swelling. * **Management:** Primarily conservative (Rest, Ice, NSAIDs, and activity modification). It is self-limiting and resolves once the growth plate closes. * **Sinding-Larsen-Johansson Syndrome:** A similar traction apophysitis occurring at the **inferior pole of the patella** (proximal end of the patellar tendon).

Q: An orthopedician adducts the flexed hip and gently pushes the thigh posteriorly in an effort to dislocate the femoral head of a neonate. What is this maneuver called?

Barlow test. ### Explanation The correct answer is **Barlow test**. This maneuver is a provocative test used to identify an unstable hip that is currently "in" but can be "dislocated." **1. Why Barlow test is correct:** The Barlow maneuver is performed by adducting the hip (bringing the thigh toward the midline) and applying a gentle posterior force through the femur. If the hip is unstable, this action pushes the femoral head out of the acetabulum, resulting in a palpable "clunk" of dislocation. A simple mnemonic to remember this is: **B**arlow **B**acks it out. **2. Analysis of Incorrect Options:** * **Ortolani test:** This is the reverse of the Barlow test. It is used to "reduce" a hip that is already dislocated. The hip is abducted while the greater trochanter is elevated anteriorly. A positive test is a "clunk" of reduction. Mnemonic: **O**rtolani **O**pens/puts it back in. * **Galeazzi sign:** This is a sign of apparent limb length discrepancy. With the infant supine, hips and knees flexed, and feet flat on the table, one knee appears lower than the other due to posterior displacement of the femoral head. * **Telescopic sign:** This involves pushing and pulling the femur along its long axis; excessive mobility (like a telescope) indicates a dislocated hip with no stable contact between the femur and acetabulum. **3. Clinical Pearls for NEET-PG:** * **Screening:** Barlow and Ortolani tests are most reliable from birth up to **2–3 months** of age. After this, soft tissue contractures make these tests difficult, and limited abduction becomes the most reliable clinical sign. * **Gold Standard Investigation:** For infants <6 months, **Ultrasound (Graf classification)** is the investigation of choice because the femoral head is not yet ossified. * **Treatment:** The **Pavlik Harness** is the initial treatment of choice for Developmental Dysplasia of the Hip (DDH) in neonates.

Q: Which of the following can cause a painless limp in infancy?

All of the above. **Explanation:** The hallmark of a **painless limp** in a child is a structural or mechanical abnormality that affects the stability or length of the limb without causing acute inflammation or joint destruction. 1. **Congenital Dislocation of the Hip (DDH):** In the walking age, an unreduced dislocation leads to a **Trendelenburg gait** (due to abductor insufficiency) or a **short-limb gait**. Since there is no active inflammation, the child walks without pain. 2. **Infantile Coxa Vara:** This condition involves a decreased neck-shaft angle (less than 120°). This results in a shortening of the limb and a prominent greater trochanter, which moves superiorly, causing abductor weakness. Like DDH, this presents as a painless "waddling" or Trendelenburg gait. 3. **Poliomyelitis:** This is a lower motor neuron (LMN) disorder causing flaccid paralysis. While the initial viral prodrome may be painful, the residual stage presents with muscle wasting and weakness (e.g., foot drop or quadriceps weakness), leading to a painless, compensatory limp. **Clinical Pearls for NEET-PG:** * **Trendelenburg Test:** Positive in all three conditions mentioned above due to the failure of the hip abductor mechanism (Gluteus medius and minimus). * **Painful vs. Painless Limp:** Always differentiate. **Painful limps** (Antalgic gait) are seen in Septic Arthritis, Transient Synovitis, and Perthes disease (early stage). **Painless limps** are typically mechanical (DDH, Coxa Vara, LLD). * **Bilateral DDH:** Presents with a characteristic **"Waddling Gait"** and increased lumbar lordosis. * **Coxa Vara Radiographic Sign:** Look for **Fairbank’s triangle** (an inverted Y-shaped fragment of bone in the inferior neck).

Q: Open reduction is indicated in which of the following conditions?

Lateral condyle humerus fractures. **Explanation:** **Lateral condyle humerus fractures** are the correct answer because they are **intra-articular fractures** that are notoriously unstable. Due to the pull of the common extensor origin, these fractures often undergo displacement and rotation. Even a displacement of >2mm necessitates **Open Reduction and Internal Fixation (ORIF)** to ensure anatomical restoration of the joint surface and to prevent complications like non-union or cubitus valgus. **Why the other options are incorrect:** * **Clavicle fractures:** Most clavicle fractures (especially mid-shaft) are managed conservatively with a figure-of-eight bandage or a triangular sling. Surgery is reserved only for specific indications like neurovascular injury or skin tenting. * **Both bone forearm fractures in children:** Children have a thick periosteum and high remodeling potential. Most of these fractures are managed by **Closed Reduction and casting**. Surgery is usually reserved for older children or failed closed reductions. * **Supracondylar humerus fractures:** These are extra-articular. The standard of care for displaced fractures (Gartland Type II/III) is **Closed Reduction and Percutaneous Pinning (CRPP)**. Open reduction is only indicated if closed reduction fails or if there is an associated vascular injury. **High-Yield Clinical Pearls for NEET-PG:** * **Lateral Condyle Fracture:** Known as the "Fracture of Necessity" (requires surgery) and the "Milch Fracture." * **Complication:** If left untreated, it leads to **Non-union**, which causes **Cubitus Valgus** deformity, eventually leading to **Tardy Ulnar Nerve Palsy**. * **Absolute Indications for Open Reduction:** Intra-articular fractures (displaced), failed closed reduction, fractures with neurovascular compromise, and "unstable" fractures (e.g., femoral neck).

Q: A child, after being spun around by his father while holding his hand, begins crying and resists touching his elbow. What is the most likely diagnosis?

Pulled elbow. **Explanation:** **1. Why "Pulled Elbow" is correct:** The clinical scenario describes a classic case of **Pulled Elbow** (also known as **Nursemaid’s Elbow** or Subluxation of the Radial Head). It typically occurs in children aged 1–4 years when sudden longitudinal traction is applied to an extended, pronated arm (e.g., swinging a child or pulling them up a curb). * **Pathophysiology:** In young children, the radial head is relatively small and the annular ligament is lax. Sudden traction causes the **annular ligament to slip over the radial head**, becoming trapped in the radio-capitellar joint. * **Clinical Presentation:** The child holds the arm in a fixed position of **extension and pronation**, refusing to use it. There is no significant swelling or bruising. **2. Why other options are incorrect:** * **Radial head dislocation:** This is usually associated with high-energy trauma or a Monteggia fracture-dislocation (ulnar fracture). It presents with significant deformity and swelling, unlike the subtle presentation of a pulled elbow. * **Annular ligament tear:** While the ligament is displaced/interposed, it is rarely actually "torn" in this mechanism. The pathology is displacement, not a structural rupture. * **Fracture of the olecranon process:** This would result from a direct fall on the elbow or a forceful contraction of the triceps. It would present with localized bony tenderness, swelling, and often a palpable gap, which are absent here. **3. NEET-PG High-Yield Pearls:** * **Management:** Reduction is performed by **Supination followed by Flexion** (or the hyperpronation technique). A "click" is often felt, and the child usually begins using the arm within minutes. * **X-ray:** Usually normal; not required unless a fracture is suspected. * **Age Group:** Rare after age 5 because the annular ligament becomes thicker and the radial head becomes more bulbous.

Question 1

In children, acute osteomyelitis most commonly affects which part of the long bone?

Accepted Answer

Metaphysis

Answer

Diaphysis

Answer

Epiphysis

Answer

Physis

Question 2

An eight-year-old child is suffering from transient synovitis of the hip joint. Which of the following statements is false?

Accepted Answer

The hip is typically held in adduction and internal rotation.

Answer

May follow upper respiratory tract infection.

Answer

WBC count and ESR are usually normal.

Answer

Widening of the joint space will be seen on ultrasound.

Question 3

Which of the following features defines a toddler's fracture?

Accepted Answer

Spiral fracture of the tibia

Answer

Subluxation of the radial head

Answer

Salter Harris type 3 fracture of the distal fibular epiphysis

Answer

Fracture of the distal radius

Question 4

What is the commonest presentation of congenital dislocation of the knee?

Accepted Answer

Hyperextension

Answer

Varus

Answer

Valgus

Answer

Flexion

Question 5

What anatomical structure is most commonly affected in Osgood-Schlatter disease?

Accepted Answer

Tibial tuberosity

Answer

Femur head

Answer

Navicular bone

Answer

Calcaneum

Question 6

An orthopedician adducts the flexed hip and gently pushes the thigh posteriorly in an effort to dislocate the femoral head of a neonate. What is this maneuver called?

Accepted Answer

Barlow test

Answer

Galeazzi sign

Answer

Ortolani test

Answer

Telescopic sign

Question 7

Which of the following can cause a painless limp in infancy?

Accepted Answer

All of the above

Answer

Congenital dislocation of the hip

Answer

Infantile coxa vara

Answer

Poliomyelitis

Question 8

Open reduction is indicated in which of the following conditions?

Accepted Answer

Lateral condyle humerus fractures

Answer

Clavicle fractures

Answer

Both bone forearm fractures in children

Answer

Supracondylar humerus fractures

Question 9

A child, after being spun around by his father while holding his hand, begins crying and resists touching his elbow. What is the most likely diagnosis?

Accepted Answer

Pulled elbow

Answer

Radial head dislocation

Answer

Annular ligament tear

Answer

Fracture of the olecranon process

Question 10

Rocker bottom foot is typically associated with which condition?

Accepted Answer

Congenital talipes equinovarus (CTEV)

Answer

Malunited fracture of the calcaneum

Answer

Horizontal talus

Answer

Neural tube defect

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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