Pediatric Orthopaedics Practice Questions

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: A 10-year-old child presents with fever and wound with discharging pus from right thigh for 4 months. Given below is the X -ray of the patient. Identify the marked area:

Sequestrum. ***Sequestrum*** - The arrow points to a dense, isolated fragment of **necrotic bone** within the bone shaft, which is a classic radiographic finding of a **sequestrum** in chronic osteomyelitis. - In chronic osteomyelitis, the host immune system attempts to wall off the infection, leading to bone necrosis and the formation of this devitalized bone fragment. *Cloacae* - A cloaca is an opening or channel in the **involucrum** (new bone formation) through which pus and necrotic debris (sequestrum) can drain from the infected bone. - The image does not clearly show an opening for drainage; rather, it highlights an internal bone fragment. *Involucrum* - The involucrum is a sheath of **new bone formation** that encapsulates the infected, necrotic bone (sequestrum) in chronic osteomyelitis. - While new bone formation is likely present, the arrow specifically indicates the denser, dead bone fragment rather than the surrounding reactive new bone. *Woven bone* - **Woven bone** is immature, rapidly formed bone, often seen during bone development, fracture healing, or in certain pathological conditions like fibrous dysplasia or Paget's disease. - The marked area is a distinct fragment of necrotic cortical bone, not indicative of diffuse woven bone formation.

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: The priority in management of supracondylar fracture of humerus in a child is:

Assessment of neurovascular status. ***Assessment of neurovascular status*** - The **brachial artery** and **median, radial, and ulnar nerves** are at significant risk of injury in a supracondylar humerus fracture, necessitating immediate evaluation. - Undetected neurovascular compromise can lead to severe complications like **Volkmann's ischemic contracture**. *Immobilization* - While important for pain control and preventing further injury, **immobilization** follows the initial neurovascular assessment to ensure no acute circulatory or neurological threats exist. - Improper immobilization without prior neurovascular assessment could worsen an already compromised limb. *Antibiotics* - **Antibiotics** are primarily indicated for **open fractures** to prevent infection, but this question does not specify an open injury. - Their use is not a priority over emergent assessment of limb viability in a closed fracture. *Debridement of wound* - **Debridement** is a surgical procedure reserved for **open fractures** to remove contaminated or devitalized tissue. - It is not relevant in the initial management of a suspected closed supracondylar fracture, where neurovascular assessment is paramount.

Q: An 8 year old girl sustained a fall on the outstretched right hand 6 hours ago and was treated with egg albumen bandages by a village bone setter. She presented with gross swelling of the right elbow and forearm. The first essential intervention in this case would be to

completely remove all encircling bandages.. ***completely remove all encircling bandages.*** - An 8-year-old with a fall on an outstretched hand and gross swelling of the elbow and forearm points to a **supracondylar fracture of the humerus**, which can lead to **compartment syndrome**. - **Tight bandages** (like egg albumen) will exacerbate swelling, impede venous return, and compromise arterial inflow, making their immediate removal essential to prevent **ischemia** and potential **nerve damage**. *elevate the right hand.* - While elevation helps reduce swelling, it is **secondary** to relieving any constricting external pressure caused by the bandages, which are the more immediate threat. - Elevating a limb with compromised circulation due to external compression would be insufficient and could delay proper management. *immerse the hand in warm water to increase the circulation.* - Immersing an injured limb in warm water can **increase swelling** and potentially aggravate bleeding into the tissues, which is counterproductive in a situation with suspected compartment syndrome. - This intervention would **worsen the clinical picture** and is inappropriate for acute trauma with significant swelling. *order urgent radiographs of both elbows.* - While radiographs are crucial for diagnosing the underlying fracture, they are **not the first essential intervention** in a limb with gross swelling and potential vascular compromise from tight bandages. - Addressing the immediate threat of **compartment syndrome** and relieving external compression takes priority over diagnostic imaging.

Q: The prognosis in reduced or unreduced fractures involving epiphyseal plate is very poor if the fracture line:

Crushes the epiphyseal plate. ***Crushes the epiphyseal plate*** - A crushed epiphyseal plate (Salter-Harris Type V) leads to **irreversible damage to the growth plate**, resulting in almost certain growth arrest and significant limb length discrepancy. - This type of injury directly destroys the proliferative and hypertrophic zones responsible for longitudinal bone growth, making its prognosis exceptionally poor. *Runs along the epiphyseal plate* - This typically describes a Salter-Harris Type I or II fracture, where the fracture line separates the epiphysis from the metaphysis **without damaging the growth plate itself**. - While requiring careful reduction, the prognosis is generally good as long as there is no significant displacement or vascular compromise, and the **growth plate remains viable**. *Crosses the epiphyseal plate* - This description is vague but could refer to a Salter-Harris Type III or IV fracture, which involves **articular surface involvement** and crossing the physis. - While these types have a poorer prognosis than Type I and II due to potential for incongruity and **growth arrest**, they are not as universally dire as a crush injury, provided proper anatomical reduction is achieved. *Extends into epiphysis* - This describes a Salter-Harris Type III fracture, where the fracture line extends from the growth plate into the epiphysis and often involves the **articular cartilage**. - The prognosis is generally good if **anatomical reduction** and fixation are achieved, but there is a risk of growth disturbance and **arthrosis** if displacement is not corrected.

Question 1

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 2

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 3

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 4

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 5

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 6

A 10-year-old child presents with fever and wound with discharging pus from right thigh for 4 months. Given below is the X -ray of the patient. Identify the marked area:

Accepted Answer

Sequestrum

Answer

Cloacae

Answer

Involucrum

Answer

Woven bone

Question 7

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 8

The priority in management of supracondylar fracture of humerus in a child is:

Accepted Answer

Assessment of neurovascular status

Answer

Immobilization

Answer

Antibiotics

Answer

Debridement of wound

Question 9

An 8 year old girl sustained a fall on the outstretched right hand 6 hours ago and was treated with egg albumen bandages by a village bone setter. She presented with gross swelling of the right elbow and forearm. The first essential intervention in this case would be to

Accepted Answer

completely remove all encircling bandages.

Answer

elevate the right hand.

Answer

immerse the hand in warm water to increase the circulation.

Answer

order urgent radiographs of both elbows.

Question 10

The prognosis in reduced or unreduced fractures involving epiphyseal plate is very poor if the fracture line:

Accepted Answer

Crushes the epiphyseal plate

Answer

Runs along the epiphyseal plate

Answer

Crosses the epiphyseal plate

Answer

Extends into epiphysis

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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