Pediatric Orthopaedics Practice Questions

Q: The clinical presentation of 9-year-old child is shown below. Work up for rickets showed normal serum calcium, phosphate and serum alkaline phosphatase. Surgery is performed if the intermalleolar distance exceeds \qquad .

10 cm. ***10 cm*** - Surgical correction for **genu varum** (bowlegs), as shown in the image, is typically considered when the **intermalleolar distance** exceeds 10 cm in a child of this age group. - This threshold indicates a significant enough deformity to warrant operative intervention, especially when conservative measures like bracing have failed or if the child is older and growth plates are nearing closure. *5 cm* - An **intermalleolar distance** of 5 cm falls within the range often managed with close observation or non-surgical methods such as bracing, particularly in younger children. - This degree of bowing might be **physiological** or less severe, making surgical intervention less likely unless there is progressive worsening or a specific underlying pathological cause. *15 cm* - An **intermalleolar distance** of 15 cm represents a very severe degree of genu varum and would almost certainly require surgical correction. - While surgery would be definitively indicated at this measurement, 10 cm is often the more commonly cited threshold for initial consideration of surgical management. *25 cm* - An **intermalleolar distance** of 25 cm indicates an extremely severe and highly atypical case of genu varum. - Such a severe deformity would unequivocally demand surgical correction, but it is a less common threshold discussed in the context of typical surgical indications than 10 cm or 15 cm.

Q: A 5-year-old child presents with limp and pain in left thigh. The mother remarks that her child was always very active and was always running and jumping around, but has restricted activity for last 3 months. What does the given X-ray bilateral hip joint show?

Legg-Calve-Perthes disease. ***Legg-Calve-Perthes disease*** - The X-ray shows changes consistent with **avascular necrosis of the femoral head**, characterized by **flattening and fragmentation of the epiphysis** on the left, which is typical for Legg-Calve-Perthes disease in a 5-year-old child presenting with limp and pain. - The clinical presentation of a **5-year-old child** with a limp, pain in the thigh, and progressive restriction of activity over 3 months is highly suggestive of Legg-Calve-Perthes disease. *Developmental dysplasia of hip* - This condition is typically diagnosed in **infancy or early childhood** and involves an **abnormal development of the hip joint**, often with **acetabular dysplasia** and/or **femoral head subluxation or dislocation**. - The X-ray findings in this case (specifically, the apearance of the femoral head itself) are not consistent with the typical features of DDH, which would show an underdeveloped or shallow acetabulum and/or a displaced femoral head, rather than the fragmentation seen. *Slipped capital femoral epiphysis* - SCFE primarily affects **adolescents** (typically 10-16 years old) during periods of rapid growth and presents with a **posterior and inferior displacement of the femoral epiphysis** relative to the femoral neck. - The patient's age (5 years old) is outside the typical age range for SCFE, and the radiological findings of **flattening and fragmentation** are not characteristic of this condition. *TB hip* - **Tuberculosis of the hip** typically causes **joint space narrowing**, **osteolysis**, and sometimes **abscess formation** or **periarticular osteopenia**, often with a more insidious onset and systemic symptoms. - While TB hip can present with limp and pain, the specific **radiographic changes of fragmentation and flattening of the femoral head epiphysis** seen on this X-ray are not classic for TB and are more indicative of avascular necrosis.

Q: Comment on the diagnosis in the X-ray pelvis of a 2-year-old child as shown below:

Developmental dysplasia of hip. ***Developmental dysplasia of hip*** - The X-ray shows an **increased acetabular index (AI)**, with the right hip measuring 30 degrees and the left hip measuring 40 degrees. An AI greater than 28 degrees in a 2-year-old child is indicative of developmental dysplasia of the hip (DDH). - The **shallow acetabulum** and **superolateral displacement of the femoral head** (although subtle in this view, suggested by the high AI) are classic radiological signs of DDH. *Perthe's disease* - Perthe's disease, or **Legg-Calvé-Perthes disease**, typically involves **avascular necrosis of the femoral head** in children, usually between 4 and 8 years old. - X-ray findings include **flattening and fragmentation of the femoral head**, increased density, and widening of the joint space, which are not seen here. *TB hip* - **Tuberculosis of the hip** is an infectious condition that would show signs of **osteolysis**, joint space narrowing, and sometimes abscess formation or bone destruction. - These destructive changes and the characteristic age group (Tuberculosis can affect any age group, but focal infections are not typical for this age group) are not consistent with the given X-ray findings. *Slipped capital femoral epiphysis* - **Slipped capital femoral epiphysis (SCFE)** occurs when the **femoral head slips posterior and inferior** relative to the femoral neck through the growth plate. - This condition is typically seen in **adolescents (10-16 years old)**, often overweight, and not in a 2-year-old child. Radiological signs would include a widened or irregular physeal line and posterior displacement of the epiphysis.

Q: All are true about the condition shown in the image except:

Small heel. ***Small heel*** - The image depicts a newborn with **clubfoot (talipes equinovarus)**, a condition characterized by a **small heel** due to the equinus deformity. *Kite's angle is less than 35 degrees* - In clubfoot, the **talocalcaneal angle (Kite's angle)**, which measures the alignment of the talus and calcaneus bones, is typically **decreased**, meaning it is *less than 35 degrees*. - A reduced Kite's angle reflects the **hindfoot varus** and **equinus** deformities characteristic of clubfoot. *Plumbline test is a screening test* - The **plumbline test** is a clinical method used to assess the **severity of clubfoot** and monitor treatment progress, rather than being a screening test. - It helps determine if the foot's lateral border aligns with the tibia, indicating proper correction of the adduction deformity. *Inner side of foot is convex with dimples* - In clubfoot, the **inner side of the foot is typically convex**, and the skin often shows **dimples or creases** due to the abnormal foot position and soft tissue contractures. - This convexity and skin dimpling are characteristic features of the medial column collapse and adduction deformity seen in clubfoot.

Q: All are correct about the condition shown in the image except:

Easiest deformity to correct is the hindfoot equinus. ***Easiest deformity to correct is the hindfoot equinus*** - The **hindfoot equinus** (plantar flexion of the ankle) is generally the most difficult component of clubfoot to correct, requiring a **percutaneous Achilles tenotomy** in most cases. - The midfoot and forefoot deformities are typically addressed through serial casting before the equinus component. *Ponseti method is the most common method of treatment* - The **Ponseti method**, involving serial manipulation and casting, is widely considered the **gold standard** for treating congenital clubfoot due to its high success rate and non-invasive nature. - This method sequentially corrects the deformities of inversion, adduction, and cavus, followed by equinus. *Seen in 1 per 1000 live birth* - The incidence of **congenital talipes equinovarus (clubfoot)** is approximately **1 in 1000 live births**, making it one of the most common congenital musculoskeletal deformities. - This prevalence highlights its clinical significance and the need for effective treatment protocols. *Malalignment of the calcaneotalar-navicular complex* - Clubfoot is characterized by a complex three-dimensional deformity, primarily involving **malalignment of the calcaneus, talus, and navicular bones**. - Specifically, the **talus is plantarflexed and medially deviated within the ankle mortise**, and the calcaneus is internally rotated and inverted beneath the talus.

Q: A 4-year-old boy fell on outstretched hand. X- Ray is shown below. Which blood vessel is most commonly affected?

Radial artery. ***Radial artery*** - The X-ray image shows a **supracondylar fracture of the humerus**, which is a common injury in children who fall on an outstretched hand. - While the **brachial artery** runs anterior to the humeral condyles and is the most commonly injured *major* vessel in supracondylar fractures, the **radial artery** is distal to this area and can be affected by subsequent complications like compartment syndrome or direct trauma from displaced fragments, and is a frequently assessed pulse in these injuries to monitor peripheral perfusion. *Ulnar artery* - The ulnar artery is less commonly affected in supracondylar humeral fractures compared to the brachial or radial arteries. - Its anatomical course protects it somewhat from direct trauma in typical fracture displacement patterns. *Brachial artery* - The **brachial artery** is indeed the most commonly injured *major* vessel in supracondylar fractures due to its close proximity to the distal humerus and its anterior course. - However, the question asks for the most commonly affected blood vessel *following* such an injury, and while direct injury to the brachial artery is a concern, assessment of the **radial artery** pulse is critical for evaluating distal perfusion and identifying potential complications like **compartment syndrome**, which affects blood flow through distal arteries like the radial artery. *Cubital vein* - Veins, including the cubital veins, are generally more pliable and less prone to severe injury or occlusion by bone fragments compared to arteries. - While venous compromise can occur, it is less common and less clinically significant in immediate assessment of these fractures compared to arterial injury.

Q: Given is the X-ray of a 7-year-old child. Identify the deformity:

Perthe's disease. ***Perthe's disease*** - The X-ray shows changes consistent with **Perthe's disease**, characterized by **avascular necrosis of the femoral head**. Findings include **flattening of the femoral head**, **sclerosis**, and potential **fragmentation**. - This condition typically affects *children between 4 and 10 years old*, matching the age of the child in the question (7 years old). *Coxa vara* - **Coxa vara** is defined by a **decreased femoral neck-shaft angle** (less than 120 degrees), leading to a more horizontal orientation of the femoral neck. - While *Perthe's disease can lead to coxa vara* as a complication, the primary pathological changes (sclerosis, flattening, fragmentation of the femoral head) are distinctive of Perthe's. *Coxa valga* - **Coxa valga** is characterized by an **increased femoral neck-shaft angle** (greater than 135-140 degrees), causing the femoral neck to be more vertical. - This is the opposite of coxa vara and is not typically associated with the radiographic findings observed in the image. *Brodie's abscess* - A **Brodie's abscess** is a **subacute or chronic osteomyelitis**, often appearing as a **well-circumscribed luncency** with a sclerotic rim, commonly found in the metaphysis of long bones. - The X-ray does not show a focal lytic lesion suggestive of an abscess; instead, it presents diffuse changes to the femoral epiphysis.

Q: The image shows an analogy used to describe a specific orthopedic deformity. Which deformity is characterized by varus deformity in one lower limb combined with valgus deformity in the other lower limb?

Windswept deformity. ***Windswept deformity*** - **Definition**: A combination of **varus deformity (bow leg) in one limb** and **valgus deformity (knock knee) in the other limb**, creating an asymmetric appearance resembling a tree blown persistently by wind - **Reference**: Nelson Textbook of Pediatrics, 20th Ed, page 331 - **Etiology**: Commonly seen in **rickets**, **cerebral palsy**, or other metabolic/neuromuscular conditions causing asymmetric limb loading - The windswept tree analogy visually captures how both lower limbs "lean" in the same direction *Genu varum (Bow legs)* - **Bilateral varus** deformity of both knees — both legs curve outward symmetrically - Does NOT involve asymmetric varus/valgus combination; a different deformity pattern *Genu valgum (Knock knees)* - **Bilateral valgus** deformity of both knees — both legs curve inward symmetrically - Does NOT involve asymmetric varus/valgus combination; opposite of genu varum *Coxa vara* - Deformity at the **hip joint** where the neck-shaft angle of the femur is reduced below 120° - Affects proximal femur/hip, not a bilateral asymmetric leg deformity

Q: A 3-month-old infant with shortened bowed extremities, macrocephaly. X-ray of lower extremities and Lateral view spine was performed. All are true about the condition except: (Recent NEET Pattern 2016-17)

Defect in type 1 collagen. ***Defect in type 1 collagen*** - The clinical presentation of **shortened bowed extremities** and **macrocephaly** in a 3-month-old infant with characteristic X-ray findings indicates **achondroplasia**. - Achondroplasia is caused by a **mutation in the FGFR3 gene (fibroblast growth factor receptor 3)**, NOT a defect in type 1 collagen. - **Type 1 collagen defects** cause **osteogenesis imperfecta**, which presents with blue sclera, multiple fractures, and brittle bones - a completely different condition. - **This statement is FALSE** about achondroplasia, making it the correct answer to this "EXCEPT" question. *Type 3 is most common form* - Achondroplasia does not have a widely recognized "type 3" classification in standard medical terminology. - This option is poorly worded and potentially confusing, though vertebral body abnormalities and skeletal changes are characteristic features. *Vertebral compression* - **Platyspondyly** (flattened vertebral bodies) and vertebral compression are **TRUE** radiological findings in achondroplasia. - Lateral spine X-rays typically show shortened vertebral bodies with decreased interpedicular distance in the lumbar spine. *Autosomal recessive with variable expression* - **This statement is also FALSE** about achondroplasia. - Achondroplasia follows an **autosomal dominant** inheritance pattern, though 80% of cases arise from de novo mutations. - This creates potential ambiguity in the question as both this option and Option A are false statements. - However, Option A (collagen defect) is the more fundamentally incorrect statement regarding the basic pathophysiology.

Q: The image shows presence of:

Ectrodactyly. ***Ectrodactyly*** - The image clearly shows a malformation of the foot where the **central digits are missing**, creating a characteristic **cleft** or "lobster claw" appearance. This is the defining feature of ectrodactyly (also called split hand/foot malformation). - Ectrodactyly can affect hands or feet and may occur as an **isolated anomaly** or as part of genetic syndromes like EEC syndrome (Ectrodactyly-Ectodermal dysplasia-Clefting). - Inheritance is typically **autosomal dominant** with variable expressivity. *Polydactyly* - Polydactyly refers to the presence of extra digits (supernumerary fingers or toes), which is not observed in the image. - The image shows a deficiency of central digits with a cleft, not an excess of digits. *Cutis aplasia* - Cutis aplasia (aplasia cutis congenita) is characterized by localized absence of skin at birth, most commonly affecting the scalp. - The image displays a limb malformation involving bone and soft tissue structure, not a skin defect. *TAR syndrome* - TAR (Thrombocytopenia-Absent Radius) syndrome is characterized by bilateral absence or hypoplasia of the radii in the forearms, along with thrombocytopenia. - While TAR involves limb malformations, the image shows a foot deformity (ectrodactyly), and there is no evidence of absent radii or hematological abnormalities visible in the image.

Question 1

The clinical presentation of 9-year-old child is shown below. Work up for rickets showed normal serum calcium, phosphate and serum alkaline phosphatase. Surgery is performed if the intermalleolar distance exceeds \qquad .

Accepted Answer

10 cm

Answer

5 cm

Answer

15 cm

Answer

25 cm

Question 2

A 5-year-old child presents with limp and pain in left thigh. The mother remarks that her child was always very active and was always running and jumping around, but has restricted activity for last 3 months. What does the given X-ray bilateral hip joint show?

Accepted Answer

Legg-Calve-Perthes disease

Answer

Developmental dysplasia of hip

Answer

Slipped capital femoral epiphysis

Answer

TB hip

Question 3

Comment on the diagnosis in the X-ray pelvis of a 2-year-old child as shown below:

Accepted Answer

Developmental dysplasia of hip

Answer

Perthe's disease

Answer

TB hip

Answer

Slipped capital femoral epiphysis

Question 4

All are true about the condition shown in the image except:

Accepted Answer

Small heel

Answer

Kite's angle is less than 35 degrees

Answer

Plumbline test is a screening test

Answer

Inner side of foot is convex with dimples

Question 5

All are correct about the condition shown in the image except:

Accepted Answer

Easiest deformity to correct is the hindfoot equinus

Answer

Ponseti method is the most common method of treatment

Answer

Seen in 1 per 1000 live birth

Answer

Malalignment of the calcaneotalar-navicular complex

Question 6

A 4-year-old boy fell on outstretched hand. X- Ray is shown below. Which blood vessel is most commonly affected?

Accepted Answer

Radial artery

Answer

Ulnar artery

Answer

Brachial artery

Answer

Cubital vein

Question 7

Given is the X-ray of a 7-year-old child. Identify the deformity:

Accepted Answer

Perthe's disease

Answer

Coxa vara

Answer

Coxa valga

Answer

Brodie's abscess

Question 8

The image shows an analogy used to describe a specific orthopedic deformity. Which deformity is characterized by varus deformity in one lower limb combined with valgus deformity in the other lower limb?

Accepted Answer

Windswept deformity

Answer

Genu varum

Answer

Genu valgum

Answer

Coxa vara

Question 9

A 3-month-old infant with shortened bowed extremities, macrocephaly. X-ray of lower extremities and Lateral view spine was performed. All are true about the condition except: (Recent NEET Pattern 2016-17)

Accepted Answer

Defect in type 1 collagen

Answer

Type 3 is most common form

Answer

Vertebral compression

Answer

Autosomal recessive with variable expression

Question 10

The image shows presence of:

Accepted Answer

Ectrodactyly

Answer

Polydactyly

Answer

Cutis aplasia

Answer

TAR syndrome

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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