Pediatric Orthopaedics Practice Questions

Q: A 4-year-old child presents with fever and a mass in the thigh. An X-ray shows periosteal reaction and bone destruction. What is the next best step in diagnosis?

Bone biopsy. ***Bone biopsy*** - The combination of **fever**, a **mass**, and **X-ray findings of periosteal reaction and bone destruction** in a child is highly suspicious for **osteosarcoma** or an infectious process like **osteomyelitis**. - A **bone biopsy** is the definitive diagnostic step to differentiate between these conditions, allowing for histological examination and culture if indicated. *Bone scan* - A bone scan would show increased metabolic activity in the affected area, indicating bone pathology, but it is **not specific enough** to determine the exact nature (benign, malignant, or infectious) of the lesion. - It could help identify other areas of involvement but wouldn't provide a definitive diagnosis for the primary lesion. *Blood culture* - While **fever** could suggest an infectious process like osteomyelitis, a **blood culture** alone is often negative in bone infections, and it **cannot address the possibility of a malignant tumor**. - It would be part of the workup for infection but not the next best step for definitive diagnosis given the presence of a mass and destructive bone changes. *CT Scan* - A **CT scan** would provide more detailed anatomical information about the bone lesion, including its extent and involvement of surrounding tissues. - However, it is an **imaging modality** and cannot provide a definitive histological diagnosis, which is crucial for distinguishing between tumor and infection.

Q: What is the most common type of fracture in children?

Greenstick fracture. ***Greenstick fracture*** - **Greenstick fractures** are common in children because their bones are more flexible and softer than adult bones. - The bone **bends and cracks** but does not break completely through, similar to how a young tree branch would break. *Transverse fracture* - A **transverse fracture** involves a clean break straight across the bone, which is less common in the flexible bones of children. - This type of fracture often results from a **direct blow** perpendicular to the bone's long axis. *Comminuted fracture* - A **comminuted fracture** involves the bone breaking into three or more pieces, indicating a high-energy trauma. - These are **rare in children** due to the elasticity of their bones. *Oblique fracture* - An **oblique fracture** has an angled break across the bone, typically caused by a twisting force. - While possible, it is **less common** than a greenstick fracture in children.

Q: In pediatric patients, what is the most likely consequence of untreated developmental dysplasia of the hip?

Shortening of the limb. ***Shortening of the limb*** - Untreated **developmental dysplasia of the hip (DDH)** results in the femoral head not being properly seated in the acetabulum, leading to a **proximal migration** of the femur and thus a functional **shortening of the affected limb**. - This limb length discrepancy can lead to an **uneven gait** and compensatory mechanisms in the spine and pelvis. *Genu valgum* - **Genu valgum**, or "knock-knees," is an angular deformity primarily at the **knee joint**, where the knees touch while the ankles are apart. - It is not a direct or primary consequence of untreated DDH, which primarily affects the **hip joint**. *Increased lumbar lordosis* - While **increased lumbar lordosis** can be a compensatory mechanism for various postural imbalances, it is usually a consequence of bilateral hip flexion contractures or anterior pelvic tilt, not a direct result of unilateral DDH. - In unilateral DDH, **pelvic tilt** and compensatory scoliosis are more directly associated due to limb length discrepancy. *Pelvic tilt* - **Pelvic tilt** often occurs as a **compensatory mechanism** in response to a limb length discrepancy. - While it is a common finding with untreated DDH, the **shortening of the limb** is the fundamental structural problem directly caused by the unreduced hip.

Q: In a 12-year-old with a painless limp and limited hip abduction, an X-ray shows a crescent sign on the femoral head. What is the most likely diagnosis?

Legg-Calvé-Perthes disease. ***Legg-Calvé-Perthes disease*** - The classic presentation includes a **painless limp**, limited hip abduction, and the characteristic **crescent sign** (subchondral collapse) on the femoral head X-ray, all indicative of avascular necrosis. - This condition is most common in boys aged 4-10 years, though a 12-year-old is still within the broader range for presentation, and the radiological finding is definitive. *Septic arthritis* - Typically presents with **severe pain**, fever, and inability to bear weight, which is not consistent with a painless limp. - X-rays would show joint effusion and possibly signs of cartilage destruction, not a crescent sign. *Osteosarcoma* - An osteosarcoma would present with progressive pain, swelling, and **pathological fractures**, but not a painless limp. - X-rays would show sunburst or Codman's triangle patterns, characteristic of bone tumor, rather than a crescent sign. *Slipped capital femoral epiphysis* - This condition is also common in adolescents, often overweight, and presents with a limp and hip pain. However, the unique **crescent sign** is not characteristic of SCFE; instead, X-rays would show posterior and inferior displacement of the femoral epiphysis.

Q: Which of the following statements about manipulation methods for correcting clubfoot (CTEV) is true?

Ponseti's technique has success rate of 90 - 98%. ***Ponseti's technique has success rate of 90 - 98%*** - The **Ponseti method** is highly successful for treating congenital talipes equinovarus (CTEV), with reported success rates in correcting the deformity ranging from 90% to 98%. - This high success minimizes the need for extensive surgery and improves long-term functional outcomes. *Involves serial casting and above knee plaster casting for 6-8 weeks* - While **serial casting** is part of the Ponseti method, the typical duration for the initial casting phase is usually around 5-7 weeks, not strictly 6-8 weeks, and consists of weekly cast changes. - The casting is indeed typically **above-knee** to effectively control rotation and maintain correction, but this option alone doesn't differentiate it sufficiently. *In Kite's method deformities are corrected sequentially equinus → adduction → inversion* - In **Kite's method**, correction is usually attempted in the sequence of **adduction → varus → equinus**, which is the reverse of the sequence stated in the option. - Kite's method is generally considered less effective than the Ponseti method and carries a higher risk of producing a "rocker-bottom" foot due to forceful, incorrect manipulation. *Ponseti's method of correction involves equinus → cavus → adduction → heel varus* - The specific order of correction in **Ponseti's method** is *cavus* (first part of equinus) → *adduction* → *varus* → and finally the *equinus*, with a **percutaneous Achilles tenotomy** often performed to correct the residual equinus. - The goal is to correct the foot by abducting and dorsiflexing it, with the heel varus correcting as the forefoot adduction and varus are addressed.

Q: Iliotibial band contracture in patients of poliomyelitis will lead to

Flexion at hip, extension at knee. **Flexion at hip, extension at knee** - A tight **iliotibial band (ITB)**, in the context of poliomyelitis, causes **flexion and abduction of the hip** and **extension of the knee**. - This characteristic posture, sometimes called a **"paradoxical genu recurvatum"**, is due to the ITB's strong attachment to the **Gerdy's tubercle** on the tibia, creating an extensor moment at the knee when the hip is flexed. *Flexion at hip and knee* - While ITB contracture does cause hip flexion, it leads to **knee extension**, not flexion, due to its distal attachments and mechanical leverage. - **Flexion at both hip and knee** is typically seen in conditions like generalized hamstring contracture or crouch gait. *Extension at hip, flexion at knee* - ITB contracture primarily causes **hip flexion**, not extension, because its proximal attachments like the **tensor fasciae latae** and **gluteus maximus** contribute to hip flexion, especially when the hip is already in a flexed position. - Knee flexion with hip extension is characteristic of a 'calcaneal gait' or weakness of quadriceps rather than ITB contracture. *Extension at hip and knee* - The ITB causes **hip flexion**, not hip extension. - While it contributes to knee extension in this specific pathology, the hip response rules this option out.

Q: Which deformity is the last to be corrected by Ponseti's method for CTEV?

Equinus Deformity. ***Equinus Deformity*** - The **equinus deformity** (plantarflexion of the ankle) is the *last* component to be corrected in Ponseti's method. - This is because the other deformities (cavus, adduction, varus) must be corrected first to allow for proper manipulation of the ankle. *Heel Varus* - **Heel varus** (inward turning of the heel) is corrected after the cavus and forefoot adduction, but *before* the equinus. - Correction of varus typically precedes the final manipulation for equinus. *Foot Adduction* - **Foot adduction** (inward turning of the forefoot) is one of the *earlier* deformities addressed in the Ponseti method after the cavus. - It is typically corrected by abducting the forefoot relative to the hindfoot. *Cavus* - **Cavus** (high arch or midfoot pronation) is the *first* deformity to be corrected in the Ponseti method. - This is achieved by supinating the forefoot to flatten the arch.

Q: Which of the following features are characteristic of Sprengel's deformity?

Elevated shoulder on the affected side. ***Elevated shoulder on the affected side*** - An **elevated and abducted scapula** is the hallmark feature in Sprengel's deformity, occurring due to the scapula failing to descend during fetal development. - This anomalous position results in a noticeable **asymmetry of the shoulders**, with the affected side being higher than the unaffected side. *Hypoplastic scapula* - While often associated with the deformity, **hypoplasia (underdevelopment)** of the scapula itself is not the primary diagnostic criterion. - The main characteristic is the **malposition**, rather than the size, of the scapula. *Short neck appearance* - A **short neck appearance** is a common clinical finding in Sprengel's deformity, however, this is an *effect* of the elevated scapula, not a primary characteristic of the deformity itself. - The elevated scapula restricts cervical movement and obscures the natural contour, making the neck look shorter. *None of the options* - This option is incorrect because **elevated shoulder on the affected side** is a direct and characteristic feature of Sprengel's deformity.

Q: All of the following are true regarding fracture of lateral condyle of humerus except:

Results in gun stock deformity. ***Results in gun stock deformity*** - A **gunstock deformity** is also known as **cubitus varus**, where the forearm is angled inward when the elbow is extended. - This deformity is classically associated with a **malunited supracondylar fracture of the humerus**, not typically a lateral condyle fracture. *Usually seen at 6-10 years of age* - **Lateral condyle fractures** are common in **children**, particularly between the ages of 6 and 10 years, as this is when the secondary ossification center for the lateral condyle is still largely cartilaginous and vulnerable to trauma. - The **ossification center** for the lateral condyle appears around age 1 and fuses around age 16, making the bone susceptible during this growing period. *Cubitus valgus occurs* - **Lateral condyle fractures** can lead to **cubitus valgus** (increased carrying angle) if the fracture heals with lateral displacement or nonunion, causing the elbow to angle away from the body. - The **physis (growth plate)** of the lateral condyle contributes to the normal growth of the elbow joint, and damage can disrupt this alignment. *Tardy ulnar nerve palsy is seen* - **Cubitus valgus** (a common complication of lateral condyle fractures) stretches the **ulnar nerve** behind the medial epicondyle over time, leading to **tardy ulnar nerve palsy**. - This chronic stretching can cause **neuropathic symptoms** such as numbness, tingling, and weakness in the distribution of the ulnar nerve years after the initial injury.

Question 1

A 4-year-old child presents with fever and a mass in the thigh. An X-ray shows periosteal reaction and bone destruction. What is the next best step in diagnosis?

Accepted Answer

Bone biopsy

Answer

Bone scan

Answer

Blood culture

Answer

CT Scan

Question 2

What is the most common type of fracture in children?

Accepted Answer

Greenstick fracture

Answer

Transverse fracture

Answer

Comminuted fracture

Answer

Oblique fracture

Question 3

In pediatric patients, what is the most likely consequence of untreated developmental dysplasia of the hip?

Accepted Answer

Shortening of the limb

Answer

Genu valgum

Answer

Increased lumbar lordosis

Answer

Pelvic tilt

Question 4

In a 12-year-old with a painless limp and limited hip abduction, an X-ray shows a crescent sign on the femoral head. What is the most likely diagnosis?

Accepted Answer

Legg-Calvé-Perthes disease

Answer

Osteosarcoma

Answer

Septic arthritis

Answer

Slipped capital femoral epiphysis

Question 5

Which of the following statements about manipulation methods for correcting clubfoot (CTEV) is true?

Accepted Answer

Ponseti's technique has success rate of 90 - 98%

Answer

Involves serial casting and above knee plaster casting for 6-8 weeks

Answer

In Kite's method deformities are corrected sequentially equinus → adduction → inversion

Answer

Ponseti's method of correction involves equinus → cavus → adduction → heel varus

Question 6

Iliotibial band contracture in patients of poliomyelitis will lead to

Accepted Answer

Flexion at hip, extension at knee

Answer

Extension at hip, flexion at knee

Answer

Flexion at hip and knee

Answer

Extension at hip and knee

Question 7

Which deformity is the last to be corrected by Ponseti's method for CTEV?

Accepted Answer

Equinus Deformity

Answer

Heel Varus

Answer

Foot Adduction

Answer

Cavus

Question 8

Which of the following features are characteristic of Sprengel's deformity?

Accepted Answer

Elevated shoulder on the affected side

Answer

Short neck appearance

Answer

None of the options

Answer

Hypoplastic scapula

Question 9

Which of the following statements about the tests for hip instability in neonates is not true?

Accepted Answer

Ortolani's test is a single maneuver.

Answer

They are performed at 2 - 3 days of birth.

Answer

In Ortolani's test, the examiner's fingers rest on the greater trochanter.

Answer

In Barlow's test, the examiner's thumb is placed in the groin.

Question 10

All of the following are true regarding fracture of lateral condyle of humerus except:

Accepted Answer

Results in gun stock deformity

Answer

Tardy ulnar nerve palsy is seen

Answer

Usually seen at 6-10 years of age

Answer

Cubitus valgus occurs

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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