Pediatric Orthopaedics Practice Questions

Q: Kohler's disease is avascular necrosis of :

Navicular. ***Navicular*** - **Kohler's disease** specifically refers to **osteochondrosis** or **avascular necrosis** of the **navicular bone** in the foot. - It primarily affects **children** and is characterized by pain and tenderness over the medial aspect of the foot. *First metatarsal head* - Avascular necrosis of the first metatarsal head is known as **Freiberg's infraction**. - This condition typically affects **adolescent girls** and causes pain in the forefoot, especially during weight-bearing. *Capitellum of humerus* - Avascular necrosis of the capitellum of the humerus is called **Panner's disease**. - It is an **osteochondrosis** that primarily affects **young athletes** involved in repetitive overhead activities, leading to elbow pain and stiffness. *Lunate* - Avascular necrosis of the lunate bone in the wrist is known as **Kienbock's disease**. - This condition typically affects **adults** and is associated with wrist pain, stiffness, and weakness.

Q: Fracture at which site affects the longitudinal growth of a bone?

Epiphyseal plate. ***Epiphyseal plate*** - The **epiphyseal plate**, also known as the **growth plate**, is a cartilaginous disc responsible for the **longitudinal growth** of long bones. - A fracture in this region can damage the **chondrocytes** and disrupt the normal ossification process, potentially leading to **growth arrest** or limb length discrepancies. *Diaphysis* - The **diaphysis** is the **shaft** or central part of a long bone. - While a fracture here can cause pain and instability, it typically does not directly affect the **longitudinal growth** potential of the bone. *Epiphysis* - The **epiphysis** is the end part of a long bone, initially separated from the main bone by cartilage but later fused with it. - Although it contains the epiphyseal plate in growing individuals, a fracture to the epiphysis itself (excluding the growth plate) primarily affects the **joint surface** and stability, rather than longitudinal growth directly. *Metaphysis* - The **metaphysis** is the transitional zone between the diaphysis and the epiphysis, adjacent to the growth plate. - While fractures in this area can be close to the growth plate, a metaphyseal fracture generally does not directly damage the **growth plate cartilage** to the same extent as a fracture through the plate itself, making its impact on longitudinal growth less direct or severe.

Q: A 10-year-old boy presents with the physical findings shown in the image, characterized by inward angulation of the elbows. What is the most likely diagnosis?

Cubitus varus deformity. ***Cubitus varus deformity*** - The image clearly illustrates an **inward angulation of the elbow** (gunstock deformity), which is characteristic of **cubitus varus**. This often occurs after a supracondylar fracture of the humerus that heals with malunion. - This deformity typically results in a decreased or reversed carrying angle of the elbow. *Madelung deformity* - This is a rare congenital anomaly characterized by **dorsal and radial bowing of the distal radius** and premature fusion of the ulnar physis. - It primarily affects the wrist, leading to a visible prominence of the distal ulna and carpal bone subluxation, which is not depicted in the elbow region in the image. *Nursemaid's elbow* - This is a common injury in young children where the **radial head is subluxated** from the annular ligament, often due to a sudden pull on the forearm. - It presents as acute pain and refusal to use the arm, but does not involve a chronic structural deformity or angulation of the elbow joint as shown in the image. *Klippel-Feil syndrome* - This is a rare congenital disorder characterized by the **fusion of two or more cervical vertebrae**. - Its primary manifestations are a short neck, low posterior hairline, and restricted neck movement, with no direct involvement or deformity of the elbow joint itself.

Q: The image shows a pediatric fracture involving the growth plate. Which classification system and stage best describes this fracture?

Salter Harris 3. ***Salter Harris 3*** - The image shows a **fracture extending from the epiphyseal surface down through the growth plate (physis) and exiting through the epiphysis** into the joint. This configuration is characteristic of a Salter-Harris type III fracture. - Salter-Harris Type III fractures disrupt the **articular cartilage** and can have a poorer prognosis due to potential joint incongruity and growth disturbance if not properly reduced. *Gartland 3* - The **Gartland classification** is specifically used for **supracondylar fractures of the humerus** in children, which is a different type of fracture involving the distal humerus metaphysis, not typically the growth plate itself in this manner. - Gartland type 3 refers to a **completely displaced supracondylar fracture** with no cortical contact, involving the metaphysis proximal to the growth plate. *Gartland 2* - **Gartland type 2** describes a **displaced supracondylar fracture** with an intact posterior cortex, also referring to a fracture of the distal humerus metaphysis, not a trans-growth plate fracture. - This classification is not applicable to the image which clearly depicts a fracture involving the epiphysis and physis. *Salter Harris 2* - A **Salter-Harris type II fracture** involves the **physis and extends into the metaphysis**, creating a triangular fragment known as the "Thurston Holland sign." - In the provided image, the fracture line clearly extends into the **epiphysis**, not just the metaphysis, distinguishing it from a Salter-Harris type II.

Q: Combination of appearance in CTEV

Equinus, inversion, forefoot adduction, cavus. ***Equinus, inversion, forefoot adduction, cavus*** - The classic presentation of **clubfoot** (CTEV) involves a characteristic combination of deformities: **equinus** (fixed plantarflexion of the ankle), **inversion** (tilting of the heel inward), **forefoot adduction** (inward turning of the front of the foot), and **cavus** (an abnormally high arch). - These four components are essential for the diagnosis and classification of CTEV. *Equinus, eversion, forefoot adduction, cavus* - This option incorrectly lists **eversion** instead of inversion. Eversion involves the outward tilting of the heel and is not a feature of CTEV. - While equinus, forefoot adduction, and cavus are typical, the presence of eversion rules out classic CTEV. *Equinus, inversion, forefoot adduction, planus* - This option incorrectly lists **planus** (pes planus or flatfoot) instead of cavus. Cavus (high arch) is a defining characteristic of CTEV, not a flatfoot. - While equinus, inversion, and forefoot adduction are correct, the presence of planus makes this option incorrect. *Equinus, eversion, forefoot abduction, cavus* - This option incorrectly lists both **eversion** and **forefoot abduction**. Eversion is the outward tilting of the heel, and forefoot abduction is the outward turning of the front of the foot. - Both eversion and forefoot abduction are opposite to the deformities seen in classical CTEV.

Q: A 13-year-old Hispanic boy is brought to the physician by his mother because of left groin pain for 1 month. The pain radiates to his left knee and is aggravated on walking. He fell during soccer practice 5 weeks ago but did not see a doctor about it and does not recall any immediate and persistent pain after the event. He has hypothyroidism. His only medication is levothyroxine. His immunizations are up-to-date. He appears uncomfortable. He is at the 50th percentile for height and at the 95th percentile for weight. His temperature is 37.1°C (98.9°F), pulse is 77/min, respirations are 14/min, and blood pressure is 100/70 mm Hg. The patient has a left-sided, antalgic gait. The left lower extremity is externally rotated. The left hip is tender to palpation and internal rotation is limited by pain. Laboratory studies show: Hemoglobin 13.1 g/dL Leukocyte count 9,100/mm3 Platelet count 250,000/mm3 Serum TSH 3.6 μU/mL Which of the following is the most likely diagnosis?

Slipped capital femoral epiphysis. ***Slipped capital femoral epiphysis*** - This condition is characterized by a **slippage of the femoral head** off the femoral neck, occurring through the growth plate. - Classic presentation includes **obesity**, male sex, **mild trauma**, pain radiating to the knee, and **external rotation** of the affected leg, all of which are present in this patient. **Hypothyroidism** is also a risk factor. *Osteomyelitis of the left hip* - **Osteomyelitis** is an infection of the bone, typically presenting with fever, localized tenderness, and elevated inflammatory markers (e.g., ESR, CRP). This patient is **afebrile** and has normal leukocyte count. - While pain and an antalgic gait can occur, the absence of systemic signs of infection and the characteristic external rotation point away from osteomyelitis. *Developmental dysplasia of the left hip* - **DDH** usually presents in infancy or early childhood with hip instability, limited abduction, or limb length discrepancy. - It is unlikely to present for the first time with pain and external rotation in a 13-year-old boy following a minor trauma. *Transient synovitis* - **Transient synovitis** is a self-limiting inflammatory condition of the hip, typically seen in younger children (3-8 years old) and often follows a viral illness. - It usually presents with sudden onset of hip pain and limp, but the chronic nature (1 month) and the characteristic physical exam findings (external rotation, obesity) make SCFE more likely. *Septic arthritis of the left hip* - Similar to osteomyelitis, **septic arthritis** is a serious infection of the joint space, presenting with acute onset of severe pain, fever, inability to bear weight, and elevated inflammatory markers. - This patient lacks systemic signs of infection (no fever, normal WBC count) and the chronic presentation further argues against septic arthritis.

Q: Blount Disease is involvement of

Proximal tibia. ***Proximal tibia*** - Blount disease, also known as **tibia vara**, is a growth disorder affecting the **tibia** (shin bone) in children. - It specifically involves the **medial physis of the proximal tibia**, leading to abnormal growth in this area and resulting in a **bow-legged** deformity. *Distal femur* - Malformations or growth disturbances of the **distal femur** are typically associated with conditions like genu valgum (**knock-knees**) or other angular deformities originating higher up in the leg. - Blount disease's primary pathology does not originate from the distal femur. *Distal tibia* - Conditions affecting the **distal tibia** can lead to ankle deformities or foot problems. - Blount disease is distinctly a problem of the knee region, not the ankle. *Proximal femur* - Problems in the **proximal femur** are commonly associated with conditions like Legg-Calvé-Perthes disease or developmental dysplasia of the hip. - While these can also cause gait abnormalities, Blount disease's characteristic bowing deformity originates from the tibia.

Q: A 6-year-old child is suspected with supracondylar fracture of right hand, complaining of pain and swelling. X-ray of right elbow was not significant. What is the next best step in this case?

Compare with X-ray of left hand. ***Compare with X-ray of left hand*** - In pediatric elbow injuries, a seemingly **normal X-ray** in the presence of strong clinical suspicion (pain, swelling, suspected supracondylar fracture) often warrants a comparison view of the contralateral unaffected limb. - This helps identify subtle findings like **epiphyseal separations** or **minimally displaced fractures** that might otherwise be missed due to the developing osseous structures in children. *Cast* - Applying a cast without definitive diagnosis or clear radiographic evidence of a fracture can lead to **unnecessary immobilization** and potential complications if no fracture is present, or inadequate treatment if a specific type of fracture requires reduction. - While immobilization is appropriate for confirmed fractures, it's not the **initial diagnostic step** when X-rays are inconclusive. *Closed reduction with K wire fixation* - This is an **invasive procedure** reserved for **displaced or unstable fractures** after a clear diagnosis has been established. - Performing this without a confirmed and characterized fracture is inappropriate and carries risks of **iatrogenic injury** and complications. *Closed reduction and slab* - Similar to casting, this is a treatment for **confirmed fractures**, typically for acute, stable, or minimally displaced fractures that can be managed non-surgically after a reduction. - It is not a diagnostic step and should not be performed when initial imaging is **inconclusive** and the exact nature of the injury is unknown.

Q: Most common site of osteomyelitis in children

Metaphysis. ***Metaphysis*** - The **metaphysis** is the most common site for osteomyelitis in children due to its rich, **slow-flowing sinusoidal blood supply**, which facilitates bacterial seeding. - The **nutrient arteries** in the metaphysis make sharp loops, creating a turbulent flow that slows circulation and allows bacteria to lodge more easily. *Epiphysis* - The **epiphysis** is less commonly affected in children because its separate blood supply is not as prone to bacterial seeding as the metaphysis. - In infants, however, infection can spread from the metaphysis to the epiphysis and joint space due to **transphyseal vessels**. *Growth plate* - The **growth plate** itself is generally resistant to infection due to its avascular nature. - However, infection in the adjacent metaphysis or epiphysis can potentially disrupt its function. *Diaphysis* - While the **diaphysis** has a blood supply, it is less common for osteomyelitis to originate here compared to the metaphysis. - It usually occurs as a secondary spread from a metaphyseal infection or in specific scenarios like in **sickle cell disease**.

Q: Charlie Chaplin gait is seen in?

Tibial torsion. ***Tibial torsion*** - **Tibial torsion** typically causes an out-toeing gait, where the feet are externally rotated, mimicking the classic Charlie Chaplin gait. - This condition involves a rotational deformity of the **tibial bone**, leading to an altered foot progression angle during walking. *DDH* - **Developmental dysplasia of the hip (DDH)** usually presents with a **Trendelenburg gait** if unilateral, or a waddling gait if bilateral, due to hip instability. - It involves abnormal development of the **hip joint**, leading to dislocation or subluxation, rather than an out-toeing pattern. *Genu valgus* - **Genu valgus** (knock-knees) causes the knees to touch or come very close together while the ankles remain apart. - This condition generally leads to an ungainly gait with the feet often wide apart to maintain balance, not an out-toeing characteristic. *Congenital coxa vara* - **Congenital coxa vara** is characterized by a decreased angle between the femoral neck and shaft, leading to a shortened leg and often a **Trendelenburg gait**. - It can result in a functionally shorter limb and a characteristic limp, but not typically the exaggerated out-toeing seen in Charlie Chaplin gait.

Question 1

Kohler's disease is avascular necrosis of :

Accepted Answer

Navicular

Answer

First metatarsal head

Answer

Capitellum of humerus

Answer

Lunate

Question 2

Fracture at which site affects the longitudinal growth of a bone?

Accepted Answer

Epiphyseal plate

Answer

Diaphysis

Answer

Epiphysis

Answer

Metaphysis

Question 3

A 10-year-old boy presents with the physical findings shown in the image, characterized by inward angulation of the elbows. What is the most likely diagnosis?

Accepted Answer

Cubitus varus deformity

Answer

Madelung deformity

Answer

Nursemaid's elbow

Answer

Klippel-Feil syndrome

Question 4

The image shows a pediatric fracture involving the growth plate. Which classification system and stage best describes this fracture?

Accepted Answer

Salter Harris 3

Answer

Gartland 3

Answer

Gartland 2

Answer

Salter Harris 2

Question 5

Combination of appearance in CTEV

Accepted Answer

Equinus, inversion, forefoot adduction, cavus

Answer

Equinus, eversion, forefoot adduction, cavus

Answer

Equinus, inversion, forefoot adduction, planus

Answer

Equinus, eversion, forefoot abduction, cavus

Question 6

A 13-year-old Hispanic boy is brought to the physician by his mother because of left groin pain for 1 month. The pain radiates to his left knee and is aggravated on walking. He fell during soccer practice 5 weeks ago but did not see a doctor about it and does not recall any immediate and persistent pain after the event. He has hypothyroidism. His only medication is levothyroxine. His immunizations are up-to-date. He appears uncomfortable. He is at the 50th percentile for height and at the 95th percentile for weight. His temperature is 37.1°C (98.9°F), pulse is 77/min, respirations are 14/min, and blood pressure is 100/70 mm Hg. The patient has a left-sided, antalgic gait. The left lower extremity is externally rotated. The left hip is tender to palpation and internal rotation is limited by pain. Laboratory studies show:
Hemoglobin 13.1 g/dL
Leukocyte count 9,100/mm3
Platelet count 250,000/mm3
Serum
TSH 3.6 μU/mL
Which of the following is the most likely diagnosis?

Accepted Answer

Slipped capital femoral epiphysis

Answer

Osteomyelitis of the left hip

Answer

Developmental dysplasia of the left hip

Answer

Transient synovitis

Answer

Septic arthritis of the left hip

Question 7

Blount Disease is involvement of

Accepted Answer

Proximal tibia

Answer

Distal femur

Answer

Distal tibia

Answer

Proximal femur

Question 8

A 6-year-old child is suspected with supracondylar fracture of right hand, complaining of pain and swelling. X-ray of right elbow was not significant. What is the next best step in this case?

Accepted Answer

Compare with X-ray of left hand

Answer

Cast

Answer

Closed reduction with K wire fixation

Answer

Closed reduction and slab

Question 9

Most common site of osteomyelitis in children

Accepted Answer

Metaphysis

Answer

Epiphysis

Answer

Growth plate

Answer

Diaphysis

Question 10

Charlie Chaplin gait is seen in?

Accepted Answer

Tibial torsion

Answer

DDH

Answer

Genu valgus

Answer

Congenital coxa vara

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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