Pediatric Orthopaedics Practice Questions

Q: A 14-year-old presents with knee pain and limping. X-ray shows widened irregular growth plate at distal femur. What is the diagnosis?

Physeal Bar. ***Physeal Bar*** - A **physeal bar**, or bony bridge, forms across the growth plate, leading to **asymmetric growth arrest** and often angular deformity. The **widened irregular growth plate** on X-ray in a 14-year-old with knee pain and limping is highly suggestive of a physeal bar due to its disruption of normal growth. - The **irregularity and widening** indicate that normal linear growth is being impeded or altered by a localized premature fusion or defect within the growth plate. *Osteochondritis Dissecans* - This condition involves a **vascular necrosis** of subchondral bone, leading to the formation of a loose fragment of cartilage and bone, typically affecting the **femoral condyles** in the knee. - X-rays would show a **discrete lesion** or fragment, not primarily a widened and irregular growth plate itself. *Slipped Capital Femoral Epiphysis* - **SCFE** involves the femoral head slipping posteriorly and inferiorly relative to the femoral neck through the **epiphyseal plate** of the proximal femur. - While it causes hip and knee pain and limping in adolescents, the characteristic X-ray finding is a **displacement of the capital femoral epiphysis** at the hip, not an abnormality of the distal femoral growth plate. *Osgood-Schlatter Disease* - This is an **apophysitis** of the tibial tubercle, caused by repetitive stress on the patellar tendon insertion during growth spurts in active adolescents. - X-rays typically show **fragmentation or prominence of the tibial tubercle**, not changes to the growth plate at the distal femur.

Q: Which of the following best indicates poor prognosis in Developmental Dysplasia of Hip?

Delayed Diagnosis > 3 years. ***Delayed Diagnosis > 3 years*** - A diagnosis of **Developmental Dysplasia of Hip (DDH)** beyond 3 years of age signifies a more advanced stage of the condition, often with significant secondary changes in the hip joint. - This delay leads to **less effective non-surgical treatments** and a higher likelihood of needing complex surgical interventions, with a greater risk of residual deformity, **osteoarthritis**, and long-term functional limitations. *Breech Presentation* - While **breech presentation** is a well-known risk factor for DDH, it is a factor in the *etiology* and *prevalence* of the condition, not directly an indicator of poor prognosis once DDH is diagnosed. - Many cases of DDH in infants born via breech presentation are detected early and managed successfully with **Pavlik harness** or other non-surgical methods. *Female Gender* - **Female gender** is also a significant risk factor for DDH, making females more susceptible to the condition. - However, being female itself does not imply a worse prognosis compared to males with DDH, assuming the diagnosis and treatment are initiated at a similar stage. *Bilateral Involvement* - **Bilateral involvement** indicates that both hips are affected, which can present greater challenges in management and require more extensive treatment. - While bilateral DDH can be more complex to treat, an early diagnosis and appropriate intervention for bilateral cases can still lead to a good prognosis, whereas a delayed diagnosis in a unilateral case can have a worse outcome.

Q: Fish tail deformity on X-ray in children is most commonly associated with fractures of?

Distal humerus. **Distal humerus** - **Fish-tail deformity** (also known as a **condylar growth disturbance**) is a classic delayed complication of **distal humeral fractures** in children, particularly **supracondylar fractures** and **lateral condyle fractures**. - This deformity results from **avascular necrosis** or growth arrest of the **trochlear ossification center**, leading to a characteristic inverted V-shape or fish-tail appearance of the **distal humerus** on X-ray. *Distal Radius* - Fractures of the **distal radius** in children, such as **Salter-Harris fractures**, can lead to growth arrest but typically result in characteristic angulation or shortening, not specifically a "fish-tail" deformity. - While growth disturbances can occur, the **physis** of the distal radius has a different anatomy and growth pattern than the **distal humerus**. *Distal Tibia* - Fractures involving the **distal tibia** growth plate (e.g., **Tillaux fractures**, **triplane fractures**) can cause angular deformities or leg length discrepancies. - "Fish-tail deformity" specifically refers to changes in the **distal humeral epiphysis/trochlea**, not to the **distal tibia**. *Distal Femur* - **Distal femoral physeal fractures** in children carry a high risk of growth arrest due to the vigorous growth at this physis. - However, the resulting deformities are typically **leg length discrepancies** or **angular deformities** such as genu recurvatum, not the distinct "fish-tail" appearance seen in the humerus.

Q: Which Salter-Harris fracture type involves a metaphyseal fragment?

Type II. **Type II** - **Type II Salter-Harris fractures** involve a fracture line that extends through the growth plate (physis) and then exits through the metaphysis, carrying a portion of the metaphysis with it. - This is the most common type of Salter-Harris fracture, characterized by the presence of a **metaphyseal fragment** attached to the epiphysis. *Type I* - **Type I Salter-Harris fractures** involve a complete separation of the epiphysis from the metaphysis through the physis, without any bone fracture. - There is no involvement of the metaphysis or epiphysis in the fracture line itself, making it difficult to detect on X-ray unless displacement is significant. *Type III* - **Type III Salter-Harris fractures** involve a fracture line that extends through the growth plate and then exits through the epiphysis, extending into the joint. - This type does not involve a metaphyseal fragment; instead, a portion of the **epiphysis is fractured**. *Type IV* - **Type IV Salter-Harris fractures** involve a fracture line that passes through the epiphysis, across the growth plate, and then through the metaphysis. - This type extends through all three components (epiphysis, physis, and metaphysis) as a single fracture line, but it does not specifically involve a detached metaphyseal fragment in the way Type II does.

Q: A teenage boy presents with a painful lump below his knee. Which condition involving inflammation of the tibial tuberosity is most likely?

Osgood-Schlatter disease. ***Osgood-Schlatter disease*** - This condition is characterized by **inflammation of the patellar tendon insertion** into the **tibial tuberosity**, causing **painful lumps** below the knee, especially in active adolescent boys. - It results from **repetitive stress** on the growth plate during periods of rapid growth and increased physical activity. *Septic arthritis* - This is a **bacterial infection** of a joint, presenting with severe pain, swelling, redness, and fever, and is typically in a joint capsule, not a bony prominence. - It would involve the knee joint itself, not specifically the tibial tuberosity, and is generally associated with systemic signs of infection. *Slipped capital femoral epiphysis* - This condition involves the **femoral head slipping off the femoral neck** during growth, typically presenting with hip or knee pain and a characteristic limp. - The pain is usually referred to the knee, but the pathology is in the hip, and it does not result in a lump below the knee. *Osteochondritis dissecans* - This involves a **segment of bone and cartilage detaching** from a joint surface, most commonly the knee, causing pain, clicking, and catching. - While it affects the knee, it doesn't typically present as a painful lump specifically at the tibial tuberosity.

Q: A 12-year-old boy presents with a limp and knee pain. X-rays reveal a slipped capital femoral epiphysis. What is the most appropriate initial management?

Immediate orthopedic referral. ***Immediate orthopedic referral*** - **Slipped capital femoral epiphysis (SCFE)** is an orthopedic emergency requiring urgent surgical stabilization to prevent further slippage and complications like **avascular necrosis**. - Delay in intervention can lead to increased severity of the slip, poorer outcomes, and long-term disability. *Physical therapy* - **Physical therapy** is not an initial management for SCFE as it can worsen the slip during the acute phase. - It may be considered later during rehabilitation after surgical stabilization, but only under orthopedic guidance. *Bed rest* - While activity restriction is important, **bed rest alone** is insufficient to prevent progression of SCFE. - It does not address the underlying mechanical instability of the femoral head. *NSAIDs* - **NSAIDs** can help manage pain associated with SCFE but do not treat the underlying mechanical problem. - Relying solely on pain relief without addressing the slip significantly increases the risk of serious complications.

Q: A 9-year-old with recent onset of limping, no history of trauma, and intermittent knee pain. Physical examination shows decreased hip range of motion and a normal knee exam. X-ray reveals a flattened femoral head. What is the next step in evaluation and management?

Physical therapy + non-weight bearing. ***Physical therapy + non-weight bearing*** - The presentation is highly suggestive of **Legg-Calvé-Perthes disease (LCPD)**, characterized by **avascular necrosis** of the femoral head in children. **Non-weight-bearing** and **containment** (often through bracing or casts directed by physical therapy) are crucial to prevent further collapse and promote healing. - The goal of conservative treatment is to maintain a spherical femoral head and a good range of motion, allowing for **revascularization** and remodeling of the femoral head. *Rest and NSAIDs* - While **NSAIDs** can help with pain, mere rest and pain relief are insufficient for managing LCPD, as the underlying process of avascular necrosis and potential collapse requires specific mechanical protection. - This approach does not address the need for **femoral head containment** or prevent further deformity, which is critical in LCPD. *MRI to assess soft tissue* - While an **MRI** can provide more detailed information on the extent of avascular necrosis, the plain X-ray showing a **flattened femoral head** is sufficient for initial diagnosis and guiding the immediate management strategy for LCPD. - The primary concern here is the **structural integrity of the femoral head** and not primarily soft tissue injury, so an MRI is not the immediate "next step" before instituting protective measures. *Orthopedic referral for surgery* - **Surgery** (osteotomy) is considered for LCPD when conservative measures fail or in cases with significant femoral head deformity and poor containment, but it is not the immediate first step for every patient. - The initial management for most children with LCPD involves aiming for **conservative containment** and non-weight bearing to optimize femoral head remodeling.

Q: In a pediatric patient with a displaced supracondylar fracture of the humerus, what is the most appropriate treatment?

Closed reduction and casting. **Closed reduction and casting** - For **displaced supracondylar fractures** in children, **closed reduction** is usually the preferred method to realign the bone fragments, followed by casting to stabilize the fracture. - This approach minimizes disruption to the tissues, preserves the blood supply, and reduces the risk of complications associated with more invasive procedures. *Open reduction and internal fixation* - **Open reduction and internal fixation (ORIF)** is generally reserved for **unstable, highly comminuted, or open fractures**, or when closed reduction attempts have failed. - It is more invasive and carries a higher risk of complications such as infection, neurovascular injury, and disruption of the physis (growth plate). *Observation* - **Observation** is only appropriate for **nondisplaced or minimally displaced** supracondylar fractures where the risk of neurovascular compromise or further displacement is low. - For a **displaced fracture**, observation would lead to malunion, functional impairment, and potential long-term complications. *Skeletal traction* - **Skeletal traction** was historically used for complex or highly unstable supracondylar fractures, but its use has largely been replaced by percutaneous pinning or ORIF due to the long duration of hospitalization required and the risk of complications such as pin site infection and joint stiffness. - It is not considered the most appropriate initial treatment for a typical displaced supracondylar fracture.

Q: A 6-year-old child presents with a limp and limited hip abduction. An X-ray reveals flattening of the femoral head. What is the most likely diagnosis?

Legg-Calvé-Perthes disease. ***Legg-Calvé-Perthes disease*** - Characterized by **avascular necrosis** of the femoral head, leading to **flattening** seen on X-ray and symptoms such as a limp and limited hip abduction. - Typically presents in children ages **4-8**, aligning with this child's age and symptoms. *Slipped capital femoral epiphysis* - Generally occurs in **older children** and adolescents, usually presenting with **hip pain** and not primarily limp or abduction issues. - X-ray findings typically show **displacement of the femoral head**, rather than **flattening**. *Developmental dysplasia of the hip* - This condition usually presents at **birth or early infancy**, characterized by a palpable **clunk** on physical examination rather than isolated limp in a 6-year-old. - X-ray would likely show **joint dislocation** or **shallow acetabulum**, not a **flattened femoral head**. *Osteomyelitis* - More commonly presenting with **fever** and localized pain, accompanied by **systemic signs of infection**, which are absent here. - X-ray typically shows **bone infection** signs, not exclusively **joint deformity** like flattening of the femoral head.

Q: What is the most common cause of scoliosis in pediatric patients?

Idiopathic scoliosis. ***Idiopathic scoliosis*** - This is the most common form of scoliosis, making up about 80% of all cases, particularly in pediatric and adolescent populations, with no identifiable cause. - It often progresses during periods of rapid growth, especially during adolescence. *Congenital spinal deformities* - These are present at birth due to **vertebral malformations** but account for a smaller percentage of scoliosis cases compared to idiopathic forms. - The severity and progression of congenital scoliosis are often linked to the specific type of vertebral anomaly. *Neuromuscular conditions* - Conditions such as **cerebral palsy**, **muscular dystrophy**, or **spinal muscular atrophy** can cause scoliosis due to muscle weakness or imbalance. - While significant in affected individuals, the overall prevalence of neuromuscular scoliosis is lower than that of idiopathic scoliosis in the general pediatric population. *Trauma* - **Spinal trauma** can lead to scoliosis, but this is a relatively rare cause, typically resulting from fractures or injuries to the vertebral growth plates. - The onset is usually acute and directly attributable to a specific injury, unlike the gradual progression often seen in idiopathic cases.

Question 1

A 14-year-old presents with knee pain and limping. X-ray shows widened irregular growth plate at distal femur. What is the diagnosis?

Accepted Answer

Physeal Bar

Answer

Osteochondritis Dissecans

Answer

Slipped Capital Femoral Epiphysis

Answer

Osgood-Schlatter Disease

Question 2

Which of the following best indicates poor prognosis in Developmental Dysplasia of Hip?

Accepted Answer

Delayed Diagnosis > 3 years

Answer

Breech Presentation

Answer

Female Gender

Answer

Bilateral Involvement

Question 3

Fish tail deformity on X-ray in children is most commonly associated with fractures of?

Accepted Answer

Distal humerus

Answer

Distal Radius

Answer

Distal Tibia

Answer

Distal Femur

Question 4

Which Salter-Harris fracture type involves a metaphyseal fragment?

Accepted Answer

Type II

Answer

Type I

Answer

Type III

Answer

Type IV

Question 5

A teenage boy presents with a painful lump below his knee. Which condition involving inflammation of the tibial tuberosity is most likely?

Accepted Answer

Osgood-Schlatter disease

Answer

Septic arthritis

Answer

Slipped capital femoral epiphysis

Answer

Osteochondritis dissecans

Question 6

A 12-year-old boy presents with a limp and knee pain. X-rays reveal a slipped capital femoral epiphysis. What is the most appropriate initial management?

Accepted Answer

Immediate orthopedic referral

Answer

Physical therapy

Answer

Bed rest

Answer

NSAIDs

Question 7

A 9-year-old with recent onset of limping, no history of trauma, and intermittent knee pain. Physical examination shows decreased hip range of motion and a normal knee exam. X-ray reveals a flattened femoral head. What is the next step in evaluation and management?

Accepted Answer

Physical therapy + non-weight bearing

Answer

Rest and NSAIDs

Answer

MRI to assess soft tissue

Answer

Orthopedic referral for surgery

Question 8

In a pediatric patient with a displaced supracondylar fracture of the humerus, what is the most appropriate treatment?

Accepted Answer

Closed reduction and casting

Answer

Observation

Answer

Skeletal traction

Answer

Open reduction and internal fixation

Question 9

A 6-year-old child presents with a limp and limited hip abduction. An X-ray reveals flattening of the femoral head. What is the most likely diagnosis?

Accepted Answer

Legg-Calvé-Perthes disease

Answer

Slipped capital femoral epiphysis

Answer

Developmental dysplasia of the hip

Answer

Osteomyelitis

Question 10

What is the most common cause of scoliosis in pediatric patients?

Accepted Answer

Idiopathic scoliosis

Answer

Congenital spinal deformities

Answer

Neuromuscular conditions

Answer

Trauma

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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