Pediatric Orthopaedics Practice Questions

Q: A 6-year-old child sustained an elbow injury. Four years later, the child presents with tingling and numbness on the ulnar side of the fingers. What type of fracture is most likely associated with these symptoms?

Lateral condylar humerus fracture. **Explanation:** The clinical presentation describes **Tardy Ulnar Nerve Palsy**, a classic late complication of a **Lateral Condylar Humerus Fracture**. **1. Why Lateral Condylar Fracture is Correct:** Lateral condyle fractures are "fractures of necessity" (often requiring ORIF) because they are intra-articular and prone to non-union. If the fracture fails to unite or develops a growth arrest, it leads to a progressive **Cubitus Valgus** (increased carrying angle) deformity. As the valgus deformity increases over years, the ulnar nerve is chronically stretched as it passes behind the medial epicondyle. This "tardy" (delayed) stretching results in ulnar neuropathy, manifesting as tingling and numbness in the ulnar 1.5 fingers. **2. Why Incorrect Options are Wrong:** * **Supracondylar Humerus Fracture:** While this is the most common elbow fracture in children, its most common nerve injury is the **Anterior Interosseous Nerve (AIN)**. Late complications usually involve **Cubitus Varus** (Gunstock deformity), which rarely causes ulnar nerve symptoms. * **Olecranon Fracture:** These are less common in children and typically do not result in significant remodeling deformities that stretch the ulnar nerve over a 4-year period. * **Dislocation of the Elbow:** Acute ulnar nerve injury can occur during the trauma, but it does not typically present with a delayed (tardy) onset years later due to progressive deformity. **Clinical Pearls for NEET-PG:** * **Milch Classification** is used for lateral condyle fractures. * **Tardy Ulnar Nerve Palsy** treatment: Anterior transposition of the ulnar nerve. * **Lateral Condyle Fracture** is the second most common elbow fracture in children and is known as the "Fracture of Wise Men" (as it requires surgical judgment).

Q: Cubitus varus deformity in supracondylar fracture of humerus is usually due to which of the following?

Coronal tilt. **Explanation:** **Cubitus Varus (Gunstock Deformity)** is the most common late complication of a supracondylar fracture of the humerus. While this fracture involves several planes of displacement (posterior, medial, and rotational), the development of the varus deformity is specifically attributed to the **Coronal Tilt** (medial tilt) of the distal fragment. 1. **Why Coronal Tilt is Correct:** In a supracondylar fracture, if the distal fragment tilts medially in the coronal plane, it alters the alignment of the humeral axis relative to the forearm. This tilt leads to a decrease in the carrying angle, resulting in a permanent varus deformity. Unlike rotational or sagittal displacements, which may undergo some remodeling in children, coronal tilt does not remodel and must be corrected during initial reduction. 2. **Why Other Options are Incorrect:** * **Posterior Displacement/Angulation:** These occur in the sagittal plane. They primarily lead to a loss of flexion or extension range of motion but do not influence the lateral/medial (varus/valgus) alignment of the elbow. * **Malunion vs. Growth Arrest:** It is important to note that Cubitus Varus is almost always due to **malunion** (poor reduction of the coronal tilt) rather than an injury to the growth plate (epiphyseal arrest), as the distal humeral epiphysis contributes only 20% to longitudinal growth. **Clinical Pearls for NEET-PG:** * **Most common complication:** Cubitus Varus (Gunstock Deformity). * **Most common nerve injured:** Median nerve (specifically the Anterior Interosseous Nerve/AIN); however, in extension-type fractures with posterolateral displacement, the Radial nerve is at risk. * **Most serious complication:** Volkmann’s Ischemic Contracture (VIC) due to brachial artery injury or compartment syndrome. * **Treatment of choice for Cubitus Varus:** French Osteotomy (Modified Step-cut Osteotomy).

Q: What is meant by a 'pulled elbow'?

Subluxation of the head of the radius. ### Explanation **Pulled Elbow (Nursemaid’s Elbow)** is a common pediatric injury occurring typically in children aged 1–4 years. **Why Option B is Correct:** The injury is a **subluxation of the radial head** caused by sudden longitudinal traction (pulling) on an extended, pronated arm. Because the **annular ligament** is relatively lax and the radial head is not yet fully developed (bulbous) in young children, the ligament slips over the head of the radius and becomes trapped within the radio-capitellar joint. **Why Other Options are Incorrect:** * **Option A & D:** Pulled elbow is a soft-tissue/ligamentous displacement, not a bony fracture. While fractures (like Supracondylar or Monteggia) are common in children, they involve different mechanisms and present with significant swelling and deformity, which are absent in a pulled elbow. * **Option C:** A fracture-dislocation (e.g., Monteggia fracture-dislocation) involves a complete disruption of the joint along with a fracture, requiring urgent surgical or formal orthopedic intervention, unlike the simple manual reduction used for a pulled elbow. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** The child holds the arm in a fixed position of **flexion and pronation**, refusing to use it (pseudoparalysis). There is no significant swelling or bruising. * **Management:** Reduction is performed via **supination and flexion** (most common) or hyperpronation. A characteristic "click" is felt, and the child usually begins using the arm within minutes. * **Radiology:** X-rays are typically normal and are only indicated if a fracture is suspected (e.g., history of a fall rather than a pull). * **Anatomy:** The specific structure involved is the **annular ligament**.

Q: Ortolani's test is done for which condition?

Congenital dislocation of the hip joints. **Explanation:** **Ortolani’s Test** is a classic clinical maneuver used to diagnose **Developmental Dysplasia of the Hip (DDH)**, formerly known as Congenital Dislocation of the Hip (CDH). **Why the correct answer is right:** The test is designed to identify a hip that is currently dislocated but is **reducible**. To perform the test, the clinician flexes the infant's hips and knees to 90 degrees and then gently **abducts** the hip while applying upward pressure on the greater trochanter. A positive test is indicated by a palpable (and sometimes audible) **"clunk"** as the femoral head slips back into the acetabulum. This "clunk of entry" confirms the reduction of a dislocated hip. **Why the incorrect options are wrong:** * **Options A, C, and D:** While congenital dislocations can occur in the knee, shoulder, or elbow, they are significantly rarer than DDH. There are no specific eponymously named "reduction maneuvers" like Ortolani’s used as standard screening tools for these joints in the neonatal period. **High-Yield Clinical Pearls for NEET-PG:** * **Barlow’s Test:** The opposite of Ortolani; it is a **provocative maneuver** used to detect a "dislocatable" hip. It involves adduction and downward pressure to push the femoral head out of the acetabulum ("clunk of exit"). * **Age Limit:** These tests are most reliable in the first **2–3 months** of life. After this, soft tissue contractures develop, and **limited abduction** becomes the most sensitive clinical sign. * **Galeazzi Sign:** Used in older infants; it identifies apparent shortening of the femur when hips and knees are flexed. * **Investigation of Choice:** **Ultrasound** is preferred for infants 6 months.

Q: Which of the following splints is shown in the image?

Craig splint and von Rosen splint. ***Craig splint and von Rosen splint*** - Both splints are used for treating **developmental dysplasia of the hip (DDH)** in newborns and infants, maintaining hip **abduction** and **flexion**. - **Craig splint** is a rigid metal splint while **von Rosen splint** is a malleable aluminum splint, both keeping hips in the optimal position for acetabular development. *Pavlik harness and Frejka pillow* - **Pavlik harness** is used for DDH in infants aged **0-6 months** with dynamic movement control, not shown as rigid splints in the image. - **Frejka pillow** is a soft abduction device for DDH treatment in older infants, appearing as a padded cushion rather than rigid splinting. *Denis Browne splint and Thomas splint* - **Denis Browne splint** is specifically designed for **clubfoot correction** with shoes connected by a metal bar, not for hip positioning. - **Thomas splint** is used for **femoral fractures** providing longitudinal traction, completely different from hip abduction devices. *Bohler-Braun frame and hip spica cast* - **Bohler-Braun frame** is a bed attachment for **lower limb traction** in fracture management, not a wearable splint. - **Hip spica cast** is a large **plaster cast** covering the torso and affected leg for fracture immobilization, not the flexible splinting devices shown.

Q: Which is correct about the image shown below?

Hip spica and von Rosen splint. ***Hip spica and von Rosen splint*** - The image displays a **hip spica cast** on the left child, characterized by its wide abduction of the hips and stabilization across the trunk and both thighs. - The right child is wearing a **von Rosen splint**, indicated by the rigid, H-shaped metal brace that holds the hips in abduction and external rotation. *Craig splint and von Rosen splint* - A **Craig splint** involves holding the hips in 90 degrees of flexion and maximal internal rotation using a bar between the knees, which is not shown. - While the von Rosen splint is correctly identified, the other brace is a hip spica, not a Craig splint. *Bohler-Braun splint and von Rosen splint* - A **Bohler-Braun splint** is a traction frame typically used for lower limb fractures, which is very different from the hip bracing devices shown. - The von Rosen splint is correct, but the first device is not a Bohler-Braun splint. *Hip spica and Craig splint* - The hip spica is correctly identified on the left, but the brace on the right is a **von Rosen splint**, not a Craig splint. - A Craig splint positions the hips differently, as described above.

Q: A 3-year-child fell from the roof and landed on his feet. What is the Salter and Harris grading of the fracture in distal tibia as shown below?

Grade II. ***Grade II*** - This fracture involves the **epiphysis, physis, and metaphysis**, specifically a fracture through the growth plate and extending into the metaphysis but sparing the epiphysis. - Grade II fractures are characterized by a fragment of the metaphysis remaining attached to the epiphyseal fragment, often described as a **"corner sign" or "Thurston Holland fragment."** *Grade I* - A Grade I fracture involves a **transverse fracture through the physis (growth plate)**, with no involvement of the metaphysis or epiphysis. - This type of fracture is often difficult to detect on X-ray, as there is no displacement of bone fragments. *Grade V* - A Grade V fracture is a **crush injury to the physis (growth plate)**, resulting in complete compression and potential growth arrest. - This is the most severe type of Salter-Harris fracture and carries the **worst prognosis** for disturbed growth. *Grade III* - A Grade III fracture involves a **fracture through the physis and extending into the epiphysis**, but not involving the metaphysis. - This fracture type is intra-articular and often requires **anatomical reduction** to prevent long-term complications like arthritis.

Q: A 7-year-old child presents to the emergency department after a fall on an outstretched hand. The following X-ray of the elbow shows:

Supracondylar fracture humerus. ***Supracondylar fracture humerus*** - The image displays a clear **fracture of the distal humerus**, specifically above the condyles, with significant displacement of the distal fragment. - This type of fracture commonly occurs in children due to a fall on an outstretched hand and carries a risk of neurovascular compromise due to its proximity to vital structures like the **brachial artery** and **median nerve**. *Fracture tibia* - The image shows bones of the arm, specifically around the elbow joint, not the lower leg. - Fractures of the tibia would appear in an X-ray of the lower leg, typically involving the shaft or ends of the **shin bone**. *Fracture radius* - While the **radius** is visible in the image as one of the forearm bones, the primary fracture site is clearly in the **humerus** above the elbow joint, not the radius itself. - A radial fracture would involve the bone on the thumb side of the forearm. *Colles fracture* - A **Colles fracture** is a specific type of fracture of the **distal radius**, characterized by dorsal displacement of the distal fragment and typically occurs near the wrist joint. - The image clearly depicts a fracture localized to the **elbow region**, not the wrist, and involves the humerus.

Q: A 12-year-old boy while playing football falls over a goalpost and hurts his arm. X-ray forearm was performed. What is the most likely diagnosis?

Greenstick fracture. ***Greenstick fracture*** - The X-ray image shows an **incomplete fracture** where one side of the bone is broken and the other side is bent, which is characteristic of a greenstick fracture. - This type of fracture is common in children because their bones are **more flexible** and less brittle than adult bones. *Nonunion* - **Nonunion** refers to the failure of a fractured bone to heal after a sufficient period, typically presenting with persistent pain and mobility at the fracture site long after the injury. - This image shows an **acute fracture** with no signs of attempted or failed healing. *Malunion* - **Malunion** occurs when a fractured bone heals in an anatomically incorrect or deformed position. - The image depicts an **acute fracture** immediately following injury, not a healed but malaligned fracture. *Torus fracture* - A **torus (buckle) fracture** is a subtle fracture where the bone cortex buckles but does not break through completely. - This image clearly shows a **distinct break** in one cortex and bending of the other, which is beyond a simple buckle.

Question 1

What is true about Salter-Harris type IV epiphyseal injury?

Accepted Answer

Fracture occurs through the growth plate, metaphysis, and epiphysis.

Answer

Fracture occurs through the growth plate only.

Answer

Fracture occurs through the growth plate and metaphysis only.

Answer

Fracture occurs through the epiphysis only.

Question 2

A 6-year-old child sustained an elbow injury. Four years later, the child presents with tingling and numbness on the ulnar side of the fingers. What type of fracture is most likely associated with these symptoms?

Accepted Answer

Lateral condylar humerus fracture

Answer

Supracondylar humerus fracture

Answer

Olecranon fracture

Answer

Dislocation of the elbow

Question 3

Cubitus varus deformity in supracondylar fracture of humerus is usually due to which of the following?

Accepted Answer

Coronal tilt

Answer

Posterior displacement

Answer

Posterior angulation

Answer

All of the above

Question 4

What is meant by a 'pulled elbow'?

Accepted Answer

Subluxation of the head of the radius

Answer

Fracture of the head of the radius

Answer

Fracture-dislocation of the elbow

Answer

Fracture of the ulna

Question 5

Ortolani's test is done for which condition?

Accepted Answer

Congenital dislocation of the hip joints

Answer

Congenital dislocation of the knee joints

Answer

Congenital dislocation of the shoulder joints

Answer

Congenital dislocation of the elbow joints

Question 6

Which of the following splints is shown in the image?

Accepted Answer

Craig splint and von Rosen splint

Answer

Pavlik harness and Frejka pillow

Answer

Denis Browne splint and Thomas splint

Answer

Bohler-Braun frame and hip spica cast

Question 7

Which is correct about the image shown below?

Accepted Answer

Hip spica and von Rosen splint

Answer

Craig splint and von Rosen splint

Answer

Bohler-Braun splint and von Rosen splint

Answer

Hip spica and Craig splint

Question 8

A 3-year-child fell from the roof and landed on his feet. What is the Salter and Harris grading of the fracture in distal tibia as shown below?

Accepted Answer

Grade II

Answer

Grade I

Answer

Grade V

Answer

Grade III

Question 9

A 7-year-old child presents to the emergency department after a fall on an outstretched hand. The following X-ray of the elbow shows:

Accepted Answer

Supracondylar fracture humerus

Answer

Fracture tibia

Answer

Fracture radius

Answer

Colles fracture

Question 10

A 12-year-old boy while playing football falls over a goalpost and hurts his arm. X-ray forearm was performed. What is the most likely diagnosis?

Accepted Answer

Greenstick fracture

Answer

Nonunion

Answer

Malunion

Answer

Torus fracture

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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