Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics Indian Medical PG Practice Questions and MCQs

Question 241: A 4-year-old child complains of a painful limb. What is the most likely cause?

A. Poliomyelitis
B. Infantile coxa vara
C. Perthe's disease (Correct Answer)
D. Congenital talipes equinovarus (CTEV)

Explanation: ***Perthe's disease*** - **Avascular necrosis** of the femoral head typically presents in children aged **4-8 years** with painful limping, matching this case perfectly. - The hallmark presentation is a **painful limp** with hip pain that may radiate to the knee, often worse with activity. *Poliomyelitis* - This is a **viral infection** affecting the anterior horn cells of the spinal cord, causing **flaccid paralysis** rather than limb pain. - The condition is now extremely rare due to **vaccination programs** and would present with weakness, not isolated pain. *Infantile coxa vara* - This is a **developmental deformity** of the hip that typically presents in **infancy to early childhood** (under 3 years). - The condition is usually **painless** and presents with limping due to limb length discrepancy, not pain. *Congenital talipes equinovarus (CTEV)* - This is a **congenital foot deformity** present at birth, characterized by inward and downward turning of the foot. - The condition affects the **foot and ankle**, not causing limb pain, and would be evident from birth rather than presenting at age 4.

Question 242: What is the most commonly accepted etiology for Perthes disease?

A. Pyogenic infection
B. Tubercular infection
C. Trauma (Correct Answer)
D. Unknown

Explanation: ### Explanation **Legg-Calvé-Perthes Disease (LCPD)** is an idiopathic avascular necrosis (AVN) of the proximal femoral epiphysis in children. While the exact primary trigger remains a subject of debate, **Trauma** is the most commonly accepted etiology in the context of competitive exams like NEET-PG. **Why Trauma is the Correct Answer:** The underlying pathophysiology of Perthes disease involves an interruption of the blood supply to the femoral head. Recurrent **micro-trauma** or a single traumatic event is believed to increase intra-articular pressure or directly damage the fragile subsynovial vessels (the primary blood supply to the developing femoral head). This mechanical disruption leads to ischemia, bone infarction, and subsequent collapse. **Why Other Options are Incorrect:** * **Pyogenic & Tubercular Infection (A & B):** These cause Septic Arthritis or Osteomyelitis. While infection can lead to joint destruction, Perthes is strictly a non-infectious, aseptic process. * **Unknown (D):** Although often termed "idiopathic," the mechanical/vascular theory triggered by trauma is the most widely accepted academic explanation for the initiation of the ischemic process. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in boys (4:1 ratio) aged 4–8 years. * **Clinical Feature:** Painless limp or hip/knee pain with restricted **abduction and internal rotation**. * **Radiological Sign:** **Crescent Sign** (subchondral fracture) is an early finding; "Mushroom-shaped head" is a late finding. * **Classification:** Catterall (extent of involvement) and Herring (Lateral Pillar height) are used for prognosis. * **Management:** The goal is "Containment" of the femoral head within the acetabulum.

Question 243: All of the following are seen in Rickets except –

A. Bow legs
B. Gunstock deformity (Correct Answer)
C. Pot belly
D. Craniotabes

Explanation: **Explanation:** The correct answer is **Gunstock deformity** (Cubitus varus). This deformity is a classic late complication of a **Supracondylar fracture of the humerus** in children, usually resulting from malunion. It is not a feature of Rickets. **Why the other options are seen in Rickets:** * **Bow legs (Genu varum):** Rickets causes defective mineralization of the osteoid matrix, leading to "soft" bones. When a child starts weight-bearing, the softened long bones of the lower limbs bend under gravity, resulting in bow legs. * **Pot belly:** This occurs due to generalized muscular hypotonia (low muscle tone) and weakness of the abdominal wall muscles, which is a systemic manifestation of Vitamin D deficiency. * **Craniotabes:** This is often the earliest clinical sign of Rickets (seen in infants <6 months). it refers to the softening of the skull bones (occipital and parietal), which give a "ping-pong ball" sensation upon pressure. **High-Yield Clinical Pearls for NEET-PG:** * **Radiological Signs of Rickets:** Cupping, fraying, and splaying of the metaphysis (best seen at the distal radius and ulna). * **Rachitic Rosary:** Palpable enlargement of the costochondral junctions (rounded beads). In contrast, **Scorbutic rosary** (Scurvy) is sharp/angular due to subluxation of the sternum. * **Harrison’s Sulcus:** A horizontal groove along the lower margin of the thorax at the insertion of the diaphragm. * **Biochemical profile:** Low/Normal Calcium, Low Phosphate, and **Elevated Alkaline Phosphatase (ALP)**—ALP is the most sensitive marker for disease activity.

Question 244: Posterior iliac horns are seen in which of the following conditions?

A. Fisher's syndrome
B. Crouzan syndrome
C. Nail patella syndrome (Correct Answer)
D. Pierre Robbins syndrome

Explanation: **Explanation:** **Nail-Patella Syndrome (NPS)**, also known as **Fong’s Disease** or Hereditary Osteo-onychodysplasia (HOOD), is an autosomal dominant disorder caused by a mutation in the **LMX1B gene**. The presence of **posterior iliac horns** is considered a **pathognomonic** radiological feature of this condition, occurring in approximately 80% of cases. These are bilateral, symmetrical bony outgrowths arising from the posterior aspect of the iliac bones. **Why the other options are incorrect:** * **Fisher’s Syndrome:** A variant of Guillain-Barré syndrome characterized by the triad of ataxia, areflexia, and ophthalmoplegia. It is a neurological condition with no specific orthopedic bony outgrowths. * **Crouzon Syndrome:** A branchial arch syndrome involving craniosynostosis (premature fusion of skull bones), resulting in midface hypoplasia and proptosis, but not iliac abnormalities. * **Pierre Robin Sequence:** Characterized by the triad of micrognathia, glossoptosis, and cleft palate. It affects the craniofacial structures rather than the pelvic girdle. **High-Yield Clinical Pearls for NEET-PG:** * **Tetrad of NPS:** 1. **Nails:** Hypoplastic or absent (especially the thumb). 2. **Patella:** Hypoplastic or absent (leads to recurrent dislocations). 3. **Elbows:** Limited extension/supination due to radial head hypoplasia. 4. **Iliac Horns:** Pathognomonic radiological sign. * **Systemic Involvement:** Up to 40% of patients develop **nephropathy** (resembling glomerulonephritis), which is the most serious complication and can lead to renal failure. * **Lester’s Sign:** Hyperpigmentation of the pupillary margin of the iris (seen in some NPS patients).

Question 245: Which of the following characteristics are TRUE or FALSE about osteopetrosis in a child? 1. Growth retardation 2. Mental retardation 3. Multiple fractures 4. Cataract 5. Hepatosplenomegaly

A. 1, 3, 5 True & 2, 4 False (Correct Answer)
B. 1, 3, 4 True & 2, 5 False
C. 1, 3, 4 True & 5, 2 False
D. 2, 3 False & 1, 4, 5 True

Explanation: **Explanation:** **Osteopetrosis** (Albers-Schönberg disease or Marble Bone Disease) is a rare genetic disorder characterized by **defective osteoclast function**. This leads to a failure of bone resorption, resulting in excessively dense but brittle bones. **Why Option A is correct:** 1. **Growth Retardation (True):** Defective remodeling of the primary spongiosa into lamellar bone interferes with longitudinal growth, leading to short stature. 2. **Mental Retardation (False):** Intelligence is typically **normal** in osteopetrosis. Neurological deficits are usually mechanical (e.g., cranial nerve compression due to bony overgrowth of foramina), not cognitive. 3. **Multiple Fractures (True):** Despite increased bone density on X-ray ("chalky bones"), the lack of a proper trabecular pattern makes the bones extremely brittle and prone to pathological fractures. 4. **Cataract (False):** Cataracts are not a feature of this disease. However, **optic atrophy** and blindness are common due to compression of the optic nerve in the optic canal. 5. **Hepatosplenomegaly (True):** As the marrow cavity is obliterated by dense bone, the body resorts to **extramedullary hematopoiesis** in the liver and spleen to compensate for life-threatening anemia and thrombocytopenia. **High-Yield NEET-PG Pearls:** * **Radiological Signs:** "Bone-within-a-bone" appearance, "Sandwich vertebrae" (Rugger-Jersey spine), and "Erlenmeyer flask deformity" of the distal femur. * **Complications:** Pancytopenia (leading to infections and bleeding), cranial nerve palsies (II, VII, and VIII), and osteomyelitis (especially of the mandible). * **Treatment:** Bone marrow transplant is the mainstay for the infantile (malignant) form to provide functional osteoclasts.

Question 246: All of the following are true about a pulled elbow except?

A. The elbow is fully flexed (Correct Answer)
B. The forearm lies in pronation
C. It is treated by fully supinating the forearm
D. It is a dislocation of the radial head

Explanation: ### Explanation: Pulled Elbow (Nursemaid’s Elbow) **Pulled Elbow** (Subluxation of the radial head) is a common pediatric injury occurring typically in children aged 1–4 years. It results from sudden longitudinal traction on an extended, pronated arm (e.g., pulling a child up a curb). #### 1. Why Option A is the Correct Answer (The False Statement) In a pulled elbow, the child typically presents with the **elbow in slight flexion (semi-flexed)** or extended, and the **forearm in a pronated position**. The child refuses to move the arm (pseudoparalysis) and holds it close to the body. **Full flexion is not the presenting posture**; in fact, the child will resist any movement of the elbow due to pain. #### 2. Analysis of Other Options * **Option B (Forearm lies in pronation):** This is a classic clinical feature. The injury occurs because the annular ligament is torn from its attachment to the radial neck and becomes trapped between the radial head and the capitellum during pronation. * **Option C (Treated by fully supinating):** The standard reduction technique involves **supination of the forearm** followed by flexion of the elbow while applying pressure over the radial head. A "click" is often felt upon successful reduction. * **Option D (Dislocation of the radial head):** While technically a **subluxation**, the annular ligament slips over the head of the radius. In the context of undergraduate exams, it is categorized under radial head displacements. #### Clinical Pearls for NEET-PG * **Pathophysiology:** The annular ligament is thin and weak in children; it slips over the radial head and becomes incarcerated in the radio-capitellar joint. * **X-ray Findings:** Usually normal. X-rays are only indicated if there is focal bone tenderness or a history of a fall (to rule out fractures). * **Post-Reduction:** Relief is almost instantaneous. The child usually begins using the arm within 5–10 minutes. No immobilization is required for a first-time episode. * **Hyperpronation Technique:** Recent studies suggest that forced hyperpronation is often more successful and less painful than the traditional supination-flexion method.

Question 247: Which of the following is not a component of Kocher's criteria when diagnosing septic arthritis of the hip?

A. Non-weight-bearing on the affected side.
B. Erythrocyte sedimentation rate (ESR) greater than 40mm/hr.
C. White blood cell (WBC) count of >12000/mm³.
D. C-reactive protein (CRP) > 20 mg/L. (Correct Answer)

Explanation: **Explanation:** Kocher’s criteria is a high-yield clinical prediction tool used to differentiate **Septic Arthritis** from Transient Synovitis in a child with a painful hip. The diagnosis is critical because septic arthritis is a surgical emergency. **Why Option D is the correct answer:** While C-reactive protein (CRP) is a highly sensitive marker for inflammation and is often used in clinical practice to monitor treatment response, it was **not** part of the original four criteria described by Kocher et al. Later studies (Cady et al.) suggested adding CRP >20 mg/L as a fifth independent predictor, but it remains excluded from the classic "Kocher’s Criteria." **Analysis of Incorrect Options (The 4 Original Criteria):** 1. **Non-weight-bearing (Option A):** Inability to bear weight on the affected side is a primary clinical indicator. 2. **ESR > 40 mm/hr (Option B):** An elevated Erythrocyte Sedimentation Rate indicates systemic inflammation. 3. **WBC Count > 12,000/mm³ (Option C):** Peripheral leukocytosis is the third laboratory component. 4. **Fever > 38.5°C (101.3°F):** (Not listed in options but is the 4th criterion). **Clinical Pearls for NEET-PG:** * **Probability of Septic Arthritis:** * 1/4 criteria: 3% * 2/4 criteria: 40% * 3/4 criteria: 93% * 4/4 criteria: **99%** * **Gold Standard Diagnosis:** Joint aspiration (Arthrocentesis) showing a synovial WBC count >50,000/mm³ (predominantly neutrophils). * **Most Common Organism:** *Staphylococcus aureus*. * **Management:** Emergency incision and drainage (Arthrotomy) + intravenous antibiotics.

Question 248: What is the most common complication of a lateral condylar fracture in children?

A. Valgus deformity (Correct Answer)
B. Cubitus varus
C. Malunion
D. Hyperextension

Explanation: **Explanation:** Lateral condylar fractures are the second most common elbow fractures in children (after supracondylar fractures). They are **Salter-Harris Type IV** injuries, meaning they involve the joint surface and the growth plate. **Why Valgus Deformity is Correct:** The lateral condyle includes the growth center for the lateral part of the distal humerus. A fracture here often leads to **lateral physeal arrest** (premature closure of the growth plate) or a **non-union**. While the lateral side stops growing, the medial side (trochlea) continues to grow normally. This asymmetrical growth results in an increasing outward angulation of the forearm, known as **Cubitus Valgus**. **Analysis of Incorrect Options:** * **Cubitus Varus (B):** This is the most common complication of **Supracondylar fractures** of the humerus (due to malunion), not lateral condyle fractures. * **Malunion (C):** While malunion can occur, **Non-union** is actually a more notorious and frequent complication of lateral condyle fractures due to the bathing of the fracture line in synovial fluid and the pull of the extensor muscles. * **Hyperextension (D):** This is not a typical complication of this fracture; it is more commonly associated with ligamentous laxity or malaligned supracondylar fractures. **High-Yield Clinical Pearls for NEET-PG:** * **Tardy Ulnar Nerve Palsy:** This is a classic late complication of lateral condyle fractures. The progressive **Cubitus Valgus** stretches the ulnar nerve as it rounds the medial epicondyle, leading to delayed paralysis (often years later). * **Milch Classification:** Used to categorize these fractures based on whether the fracture line passes lateral (Type I) or medial (Type II) to the trochlear groove. * **Management:** Because they are intra-articular, even minimally displaced fractures (>2mm) require **Open Reduction and Internal Fixation (ORIF)** to prevent non-union and subsequent deformity.

Question 249: French osteotomy is used in the treatment of which condition?

A. Cubitus varus (Correct Answer)
B. Cubitus valgus
C. Coxa vara
D. Coxa valga

Explanation: **Explanation:** **French osteotomy** is a specific surgical procedure used to correct **Cubitus varus** deformity, commonly known as "Gunstock deformity." This deformity most frequently occurs as a late complication of a malunited supracondylar fracture of the humerus in children. 1. **Why Cubitus Varus is Correct:** The French osteotomy is a **lateral closing wedge osteotomy** of the distal humerus. It involves removing a wedge of bone from the lateral side and fixing it with two screws and a tension-band wire (or a small plate). This procedure corrects the triplanar deformity (primarily the varus angulation and internal rotation) to restore the normal carrying angle of the elbow. 2. **Why Other Options are Incorrect:** * **Cubitus valgus:** While osteotomies can treat this (often caused by lateral condyle non-union), the French technique is specifically described for varus correction. * **Coxa vara:** This is a hip deformity (decreased neck-shaft angle). It is treated with proximal femoral osteotomies, such as the **Pauwel’s osteotomy** or **Borden’s osteotomy**, not the French osteotomy. * **Coxa valga:** This is an increased neck-shaft angle of the femur, usually managed with a **Varus Derotation Osteotomy (VDRO)**. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of Cubitus varus:** Malunited supracondylar fracture (due to inadequate reduction of the medial tilt/rotation). * **Deformity components:** It is a triplanar deformity (Varus + Internal rotation + Hyperextension). * **Indication for surgery:** Primarily cosmetic; it rarely affects elbow function or range of motion. * **Other osteotomies for Cubitus varus:** King’s osteotomy, Amspacher and Fowler osteotomy.

Question 250: Which of the following statements is FALSE regarding radial club hand?

A. Caused by deficiency of the radius and thumb.
B. Hand is deviated to the ulnar side. (Correct Answer)
C. Associated conditions include Holt-Oram syndrome and VACTERL association.
D. Preferred management includes pollicization and centralization of the ulna.

Explanation: ***Hand is deviated to the ulnar side*** - This statement is **FALSE** - in radial club hand, the hand deviates toward the **radial side** (thumb side), not the ulnar side. - The deviation occurs due to **absent or hypoplastic radius**, causing the hand to bend toward the deficient radial side. *Caused by deficiency of the radius and thumb* - This statement is **TRUE** - radial club hand results from **congenital absence or hypoplasia** of the radius bone. - Often associated with **thumb aplasia or hypoplasia**, as the thumb development is closely linked to radial formation. *Associated conditions include Holt-Oram syndrome and VACTERL association* - This statement is **TRUE** - radial club hand is frequently seen with **Holt-Oram syndrome** (cardiac and upper limb defects). - Also associated with **VACTERL association**, **TAR syndrome**, and **Fanconi anemia**. *Preferred management includes pollicization and centralization of the ulna* - This statement is **TRUE** - **centralization** involves positioning the carpus over the distal ulna for better alignment. - **Pollicization** converts the index finger into a functional thumb when the thumb is absent or severely hypoplastic.

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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