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 fracture from femoral-head osteonecrosis) on the femoral head X-ray. In this clinical context, the crescent sign supports the diagnosis of avascular necrosis, though it is not uniquely definitive for Perthes disease alone. - 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 overall clinical and radiographic context makes Perthes the best option. *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 Congenital Talipes Equinovarus (CTEV) is correct?

The talus is displaced medially and plantarwards.. ***The talus is displaced medially and plantarwards.*** - In **Congenital Talipes Equinovarus (CTEV)**, the **talus** is typically displaced relative to the calcaneus,navicular, and cuboid, leading to its characteristic position. - This displacement contributes to the foot's **equinus (plantarflexion)**, **varus (inversion)**, **adduction**, and **cavus (high arch)** deformities. *It can occur in both males and females equally.* - **CTEV** has a higher incidence in **males** than in females, with a male-to-female ratio of about 2:1. - While it can affect both sexes, it is not an equally distributed condition. *It can affect either foot equally.* - **CTEV** can be **bilateral** (affecting both feet) in approximately 30-50% of cases. - When unilateral, there is no significant predilection for the left or right foot. *The tibia may show normal alignment.* - In most cases of **idiopathic talipes equinovarus**, the **tibia** itself is structurally normal. - The deformity primarily involves the foot and ankle joints, not the proximal long bones.

Q: Which of the following is the management for neglected case of CTEV in a patient > 10 years of age?

Triple arthrodesis. ***Triple arthrodesis*** - In neglected cases of **CTEV** (congenital talipes equinovarus, or clubfoot) in patients older than 10 years, the deformity is often **rigid and severe**, making soft tissue releases or less invasive procedures ineffective. - **Triple arthrodesis** involves **fusion of the talocalcaneal, talonavicular, and calcaneocuboid joints**, which corrects the hindfoot and midfoot deformities, providing a stable, plantigrade foot for weight-bearing. *Ankle arthrodesis* - **Ankle arthrodesis** fuses the **tibiotalar joint**, primarily addressing severe **ankle arthritis or instability**, rather than the complex multi-joint deformities of neglected CTEV. - While it creates a stable ankle, it does not correct the **forefoot and hindfoot deformities** inherent in long-standing clubfoot cases. *Jess fixation* - **JESS fixation** (Joshi's External Stabilisation System) is a type of **external fixator** used for gradual correction, particularly in cases with significant bone deformities or for lengthening procedures. - It is typically used for **limb reconstruction** or gradual correction of deformities in younger patients or less severe cases, but less effective for the significant, rigid deformities seen in older neglected CTEV. *Ponseti casting* - The **Ponseti method** is the gold standard for initial treatment of CTEV in **infants and young children**, using a series of plaster casts to gradually correct the deformity through manipulation. - It is highly effective when started early, but **not suitable for rigid, neglected clubfoot in older children or adults** where soft tissues and bones have adapted to the severe deformity.

Q: Which of the following statements about SCFE is incorrect?

Extension is restricted. ***Extension is restricted*** - In **slipped capital femoral epiphysis (SCFE)**, the femoral head slips posteriorly and medially relative to the femoral neck. - This posterior displacement leads to a characteristic limitation in **internal rotation**, **abduction**, and **flexion**, while **extension** is often preserved or even increased due to compensatory mechanisms. *Males are affected more frequently* - **SCFE** is indeed more prevalent in **males** than in females, with a male-to-female ratio of about 2:1. - This demographic difference may be attributed to hormonal influences and differing growth patterns during adolescence. *Commonly occurs during adolescence* - **SCFE** typically occurs during periods of rapid growth, most commonly in **preadolescent** and **adolescent children**, generally between the ages of 10 and 16 years. - This timing coincides with the weakening of the growth plate before its closure. *Varus, abduction and external rotation deformities are present* - This statement is incorrect. The characteristic deformity in **SCFE** is typically **valgus (coxa valga)**, not varus, due to the posterior and medial slip of the epiphysis. - The hip tends to be held in **external rotation** and **adduction**, with limited internal rotation and abduction range of motion.

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 of the following conditions is most commonly associated with genu recurvatum?

Cerebral palsy. ***Cerebral palsy*** - **Cerebral palsy** is frequently associated with **genu recurvatum** due to muscle imbalances, particularly spasticity of the quadriceps and weakness of the hamstrings or calf muscles. - The abnormal muscle tone and motor control can lead to hyperextension of the knee joint during gait. *Rheumatoid arthritis* - While rheumatoid arthritis can cause joint deformities, **genu recurvatum** is not a typical or most common presentation; it's more associated with flexion deformities or valgus/varus deformities. - Joint damage and inflammation in RA usually lead to **decreased range of motion** and stability rather than hyperextension. *Poliomyelitis* - Poliomyelitis can cause muscle weakness and paralysis, which might lead to altered gait and joint instability. - However, **genu recurvatum** is less commonly seen as the primary knee deformity compared to conditions involving spasticity or congenital factors. *Rickets* - Rickets primarily affects **bone mineralization**, leading to soft and weakened bones. - It commonly causes bowing of the legs (**genu varum**) or knock-knees (**genu valgum**), but not typically **genu recurvatum**. *Congenital recurvatum* - While **congenital recurvatum** can cause genu recurvatum, making it a direct cause, it refers to the condition itself, rather than an underlying disease or neurological disorder associated often with it. - Cases of isolated congenital recurvatum are less common than recurvatum seen secondary to broader neuromuscular conditions. *Lax ligaments* - **Lax ligaments** alone can contribute to joint instability and potentially **genu recurvatum**. - However, it's often a contributing factor or a consequence of underlying conditions, rather than being the single most common associated condition in a broad context.

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

Septic arthritis

Answer

Osteosarcoma

Answer

Slipped capital femoral epiphysis

Question 5

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 6

Which of the following statements about Congenital Talipes Equinovarus (CTEV) is correct?

Accepted Answer

The talus is displaced medially and plantarwards.

Answer

It can occur in both males and females equally.

Answer

It can affect either foot equally.

Answer

The tibia may show normal alignment.

Question 7

Which of the following is the management for neglected case of CTEV in a patient > 10 years of age?

Accepted Answer

Triple arthrodesis

Answer

Ankle arthrodesis

Answer

Jess fixation

Answer

Ponseti casting

Question 8

Which of the following statements about SCFE is incorrect?

Accepted Answer

Extension is restricted

Answer

Commonly occurs during adolescence

Answer

Males are affected more frequently

Answer

Varus, abduction and external rotation deformities are present

Question 9

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 10

Which of the following conditions is most commonly associated with genu recurvatum?

Accepted Answer

Cerebral palsy

Answer

Poliomyelitis

Answer

Rickets

Answer

Rheumatoid arthritis

Answer

Congenital recurvatum

Answer

Lax ligaments

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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