Pediatric Orthopaedics Practice Questions

Q: Image shown below depicts:

Salter and Harris growth plate injury. ***Salter and Harris growth plate injury*** - The image clearly shows a **fracture through the growth plate** (physis) of a long bone, indicated by the red arrows pointing to a disruption at the metaphyseal-epiphyseal junction. This type of injury is classified by the Salter-Harris system. - Specifically, this appears to be a **Salter-Harris type II fracture**, where the fracture line extends through the physis and then exits through the metaphysis, leaving the epiphysis intact. *Morel-Lavallee lesion* - A Morel-Lavallee lesion is a **closed degloving injury** resulting from shearing forces that separate the skin and subcutaneous tissue from the underlying fascia. - It presents as a **seroma or hematoma** and is typically identified on MRI or ultrasound rather than a plain radiograph of bone. *Ulnar fovea sign* - The ulnar fovea sign is a clinical finding associated with **triangular fibrocartilage complex (TFCC) injuries** in the wrist. - It refers to localized tenderness upon palpation of the fovea, which is felt just distal to the ulnar styloid process, and is not a radiographic finding. *Rickets* - Rickets is a condition caused by a **deficiency of vitamin D, calcium, or phosphate**, leading to impaired mineralization of growing bone. - Radiographic features include **widened, cupped, and frayed growth plates**, bowing of long bones, and osteopenia, which are not the primary abnormalities depicted here.

Q: Incorrect about the image is:

Circumduction gait. ***Circumduction gait*** - The image depicts **genu valgum** (knock-knees), which is typically associated with a **waddling or scissoring gait**, not circumduction. - **Circumduction gait** is characterized by swinging the leg in a semicircle to clear the ground, commonly seen in conditions causing limb weakness or stiffness like **hemiplegia**. *Distal femur is most common site* - This statement is **correct**. **Genu valgum** most commonly results from an angular deformity originating at the **distal femur**, which causes the knees to come together. - Less commonly, the deformity can originate in the **proximal tibia**. *Hemiepiphysiodesis* - This statement is **correct** as **hemiepiphysiodesis**, a procedure that temporarily arrests growth on one side of a growth plate, is a common surgical treatment for **genu valgum** in growing children. - It aims to correct the angular deformity by allowing the unchained side of the physis to continue growing, thus straightening the limb. *Bracing is preferred* - This statement is **correct** for managing **mild physiological genu valgum** in younger children, especially if the deformity is not severe. - **Bracing** can help guide bone growth and prevent progression of the deformity, often used before considering surgical intervention.

Q: All are true about the test being performed except:

Barlow's test is followed by Ortolani's test. ***Barlow's test is followed by Ortolani's test*** - This statement is incorrect as it reverses the usual examination sequence. Generally, the **Ortolani maneuver** is performed first to reduce a dislocated hip, followed by the **Barlow maneuver** to check for hip instability. - While both tests assess for developmental dysplasia of the hip (DDH), their intended purposes and typical order are distinct. *Ortolani's test is followed by Barlow's test* - This statement accurately describes the typical sequence: the **Ortolani maneuver** first attempts to reduce a hip that is already dislocated. - Following a successful Ortolani reduction, the **Barlow maneuver** is then performed to assess if the now-reduced hip is stable and not easily dislocatable. *Barlow's test positive implies hip is dislocatable* - A positive **Barlow's test** indicates that the hip is **dislocatable**, meaning the femoral head can be made to slip out of the acetabulum with gentle pressure. - This test is used to assess for hip instability in an otherwise reduced hip. *Ortolani positive implies hip is reducible* - A positive **Ortolani's test** implies that the hip is **dislocated** but **reducible**, meaning the femoral head can be gently maneuvered back into the acetabulum. - The sensation of a "clunk" or "thud" is felt as the femoral head re-enters the socket.

Q: The following gait is due to:

Bilateral congenital dysplasia of hip. ***Bilateral congenital dysplasia of hip*** - The image shows a **waddling gait**, characterized by swaying from side to side, which is typical of **bilateral hip abductor muscle weakness**. This weakness often results from the femoral heads being poorly seated in the acetabulum, as seen in bilateral congenital dysplasia of the hip. - In this condition, the instability of both hips leads to an exaggerated side-to-side trunk movement during walking as the body attempts to maintain balance over the stance leg. *Coxa vara* - **Coxa vara** is a deformity where the angle between the head and shaft of the femur is decreased, leading to **shortening of the leg** and a **limp**. - While it can manifest as a Trendelenburg gait if unilateral, it typically does not present with the prominent bilateral waddling seen in the image. *Charcot-Marie-Tooth disease* - **Charcot-Marie-Tooth disease** is a neurological disorder affecting peripheral nerves, causing muscle weakness and atrophy, particularly in the lower legs and feet. - This often results in a **steppage gait** or **foot drop**, not the characteristic waddling gait depicted. *Bilateral coxa valgum* - **Coxa valga** is a deformity where the angle between the femoral head and shaft is increased. - This condition generally causes a **less stable hip joint** and potentially a slight limp, but does not typically lead to the pronounced waddling gait that is characteristic of severe bilateral hip abductor insufficiency.

Q: Comment on the diagnosis on the case presentation shown:

Sprengel's shoulder. ***Sprengel's shoulder*** - The image shows an **elevated and abducted scapula**, which is characteristic of Sprengel's deformity. This is often associated with a short, webbed neck and restricted shoulder movement. - The elevated scapula is typically due to a failure of descent during embryonic development, and it may be connected to the cervical spine by an **omovertebral bone** or cartilaginous bar. *Klippel-Feil syndrome* - This syndrome is characterized by the **congenital fusion of two or more cervical vertebrae**, leading to a short neck, low hairline, and restricted neck movement. - While it can be associated with Sprengel's deformity, the primary feature in the image is the elevated scapula, not explicitly fused cervical vertebrae. *Winging of scapula* - **Scapular winging** occurs when the scapula protrudes posteriorly from the back, often due to weakness or paralysis of the serratus anterior muscle (long thoracic nerve palsy). - The image depicts an abnormally high and rotated scapula, not a posterior protrusion. *Madelung deformity* - This condition involves an abnormal growth of the **distal radius**, leading to volar and ulnar deviation of the wrist. - It affects the wrist and forearm, and is not related to the elevated shoulder and scapular abnormalities seen in the image.

Q: A 10-year-old obese boy has pain in the left groin after slipping during a basketball match 4 weeks back. On examination he has limitation of internal rotation. What does the given X-ray bilateral hip joint show?

Slipped capital femoral epiphysis. ***Slipped capital femoral epiphysis*** - The X-ray image (indicated by the arrow) shows **posterior and medial displacement of the capital femoral epiphysis** relative to the metaphysis, which is characteristic of SCFE. - The patient's age (10-year-old), obesity, groin pain, and **limitation of internal rotation** are classic clinical features of SCFE. *Developmental dysplasia of hip* - This condition involves abnormal development of the hip socket and femoral head, typically diagnosed in **infancy** or early childhood. - Radiographically, it presents as a **shallow acetabulum**, a small or abnormally positioned femoral head, and sometimes subluxation or dislocation, which are not seen here. *Septic arthritis* - Septic arthritis is an ** EMERGENCY** condition characterized by acute joint pain, swelling, warmth, and systemic signs of infection (fever, elevated inflammatory markers). - Radiographs may show **joint effusions** and eventually joint space narrowing and bone erosion, but not the specific epiphyseal displacement seen in the image. *TB hip joint* - **Tuberculosis of the hip joint** is a chronic infection that typically presents with gradual onset of pain, stiffness, and antalgic gait, often with systemic symptoms like weight loss and night sweats. - Radiographic features include **osteopenia**, joint space narrowing, and bony erosion, particularly in the weight-bearing areas, without the characteristic slip seen here.

Q: What does X-ray pelvis show?

Coxa Vara. ***Coxa Vara*** - The image clearly shows a **decreased angle between the neck and shaft of the femur** on the left side, indicated by the red lines, which is characteristic of coxa vara. - Specifically, this typically means the **neck-shaft angle is less than 120 degrees**, causing the femoral head to be lower relative to the greater trochanter. *Coxa Valgum* - This condition is characterized by an **increased angle** between the neck and shaft of the femur (typically greater than 135 degrees), which is the opposite of what is seen here. - In coxa valga, the femoral head is positioned **higher** relative to the greater trochanter. *TB hip* - Tuberculosis of the hip would typically show signs of **joint destruction, osteopenia, or abscess formation**, none of which are evident in this image. - While TB can cause bone deformities over time, the primary finding here is a specific angular deformity, not infectious changes. *Developmental dysplasia of the hip* - Developmental dysplasia of the hip (DDH) involves **abnormal development of the hip joint**, leading to instability or dislocation of the femoral head from the acetabulum. - Common radiographic signs of DDH include an **underdeveloped acetabulum**, a high-riding femoral head, or increased acetabular index, which are not the primary findings demonstrated by the marked lines in this X-ray.

Q: What does the image given below show?

Congenital vertical talus. ***Congenital vertical talus*** - The clinical image shows a severe **rocker-bottom foot deformity** with a prominent talar head plantarly and a dorsiflexed foot. - The radiograph confirms the diagnosis by showing the **vertical position of the talus**, which is characteristic of this condition. *CTEV* - **CTEV (Congenital Talipes Equinovarus)**, or clubfoot, presents with a foot that is *plantarflexed, varus, adductus, and cavus*, which is distinctly different from the rocker-bottom foot seen. - The talus in CTEV is typically *plantarflexed*, not vertical, and the foot is *adducted* and *inverted*. *Calcaneovalgus foot* - A **calcaneovalgus foot** is characterized by excessive *dorsiflexion* and *eversion* of the foot, where the ankle is significantly bent upwards and outwards. - This condition is generally *flexible* and can often be corrected passively, unlike the rigid deformity seen in the image. *Spinal muscular atrophy* - **Spinal muscular atrophy (SMA)** is a *neuromuscular disorder* causing muscle weakness and atrophy, which can lead to foot deformities such as clubfoot or pes cavus. - However, SMA is a systemic condition, and the image specifically depicts a *structural foot deformity* that is congenital, not primarily a neuromuscular one, although severe foot deformities can occur secondary to SMA.

Q: A 3-year-old obese child presents with a leg deformity as shown. On work up, the plasma ascorbate levels are normal. Serum calcium, phosphate and serum alkaline phosphatase are normal. X-ray of bilateral knee joint is shown below. What is the diagnosis?

Blount's disease. ***Blount's disease*** - The image shows **bowing of the legs** (genu varum) in an obese 3-year-old child, along with X-ray findings consistent with **medial tibial growth plate disturbance**, which are classic features of Blount's disease. - The normal plasma ascorbate, serum calcium, phosphate, and alkaline phosphatase levels rule out other metabolic causes of bowed legs like rickets. *Congenital knee dislocation* - This condition involves an **abnormal position of the tibia relative to the femur** at birth, and typically presents with a severely hyperextended or dislocated knee joint, which would be evident immediately after birth. - The clinical presentation and X-ray findings of bowed legs are not characteristic of congenital knee dislocation. *Resistant rickets* - Rickets, including resistant forms, is primarily characterized by **defective mineralization of growing bone** often due to vitamin D deficiency or genetic defects in phosphate metabolism. - This would typically present with **abnormal serum calcium, phosphate, or alkaline phosphatase levels**, which are explicitly stated as normal in this case. *Albright hereditary osteodystrophy* - This is a complex genetic disorder associated with resistance to parathyroid hormone causing **short stature, brachydactyly**, and **ectopic ossification**, along with specific facial features. - It does not typically present with isolated bowing of the legs (genu varum) as the primary orthopaedic manifestation, and the imaging and lab findings do not support this diagnosis.

Question 1

Image shown below depicts:

Accepted Answer

Salter and Harris growth plate injury

Answer

Morel-Lavallee lesion

Answer

Ulnar fovea sign

Answer

Rickets

Question 2

All are correct about the image shown except:

Accepted Answer

Highest incidence seen with type 1 supracondylar fracture of humerus

Answer

Gun stock deformity

Answer

Cubitus varus

Answer

Tardy ulnar nerve palsy

Question 3

Incorrect about the image is:

Accepted Answer

Circumduction gait

Answer

Distal femur is most common site

Answer

Hemiepiphysiodesis

Answer

Bracing is preferred

Question 4

All are true about the test being performed except:

Accepted Answer

Barlow's test is followed by Ortolani's test

Answer

Ortolani's test is followed by Barlow's test

Answer

Barlow's test positive implies hip is dislocatable

Answer

Ortolani positive implies hip is reducible

Question 5

The following gait is due to:

Accepted Answer

Bilateral congenital dysplasia of hip

Answer

Coxa vara

Answer

Charcot-Marie-Tooth disease

Answer

Bilateral coxa valgum

Question 6

Comment on the diagnosis on the case presentation shown:

Accepted Answer

Sprengel's shoulder

Answer

Klippel-Feil syndrome

Answer

Winging of scapula

Answer

Madelung deformity

Question 7

A 10-year-old obese boy has pain in the left groin after slipping during a basketball match 4 weeks back. On examination he has limitation of internal rotation. What does the given X-ray bilateral hip joint show?

Accepted Answer

Slipped capital femoral epiphysis

Answer

Developmental dysplasia of hip

Answer

Septic arthritis

Answer

TB hip joint

Question 8

What does X-ray pelvis show?

Accepted Answer

Coxa Vara

Answer

Coxa Valgum

Answer

TB hip

Answer

Developmental dysplasia of the hip

Question 9

What does the image given below show?

Accepted Answer

Congenital vertical talus

Answer

CTEV

Answer

Calcaneovalgus foot

Answer

Spinal muscular atrophy

Question 10

A 3-year-old obese child presents with a leg deformity as shown. On work up, the plasma ascorbate levels are normal. Serum calcium, phosphate and serum alkaline phosphatase are normal. X-ray of bilateral knee joint is shown below. What is the diagnosis?

Accepted Answer

Blount's disease

Answer

Congenital knee dislocation

Answer

Resistant rickets

Answer

Albright hereditary osteodystrophy

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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