Pediatric Orthopaedics Practice Questions

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 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 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.

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: What is the usual first deformity to be seen in Charcot-Marie-Tooth (CMT) disease?

Pes cavus (high arch). ***Pes cavus (high arch)*** - **Pes cavus**, or a high arch, is the **most characteristic and often the first foot deformity** to develop in individuals with Charcot-Marie-Tooth disease due to muscular imbalances. - This deformity results from weakness in the **peroneal and intrinisic foot muscles**, leading to an overpull of strong opposing muscles and a characteristic foot shape. *Hammer toes* - **Hammer toes** are a common secondary deformity that can develop in CMT, but they typically occur **after the development of pes cavus**. - They are characterized by a bend in the middle joint of the toe (proximal interphalangeal joint) and are not usually the initial sign. *Flatfoot* - **Flatfoot (pes planus)** is characterized by a collapsed arch and is generally **not associated with CMT disease**. - CMT typically causes muscle weakness that leads to an overly high arch, making flatfoot a rare and atypical presentation. *Claw toes* - **Claw toes** are another toe deformity seen in CMT, involving hyper-extension of the metatarsophalangeal joint and flexion of the interphalangeal joints. - While common in CMT, they usually develop **concurrently with or after pes cavus**, rather than being the very first deformity.

Q: The primary diagnostic evaluation for developmental dysplasia of hip is -

USG. ***USG*** - **Ultrasound** is the gold standard for diagnosing **developmental dysplasia of the hip (DDH)** in infants younger than 4-6 months. - It allows for dynamic assessment of hip stability and provides detailed imaging of the unossified cartilaginous femoral head and acetabulum. *Clinical examination* - While initial screening involves clinical examination (e.g., **Ortolani** and **Barlow maneuvers**), it can have false negatives and is less reliable than imaging for definitive diagnosis. - It's a crucial first step but not the primary diagnostic evaluation for confirmation. *X-ray* - **X-rays** are primarily used for DDH diagnosis in infants older than 4-6 months, once the femoral head and acetabulum have begun to ossify significantly. - In younger infants, the cartilaginous structures are not well-visualized on X-ray, limiting its diagnostic utility. *CT Scan* - **CT scans** are generally reserved for complex cases of DDH, typically before or after surgical intervention, or when assessing femoral head reduction in a cast. - It involves radiation exposure and is not the preferred initial or primary diagnostic tool for routine DDH evaluation.

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

Posteromedial extension. ***Posteromedial extension*** - The vast majority of supracondylar humerus fractures in children are **extension-type fractures** (about 95-98%), and among these, **posteromedial displacement** is the most common pattern. - This type typically results from a **fall on an outstretched hand** with the elbow extended, causing the distal fragment to displace posteriorly and medially relative to the proximal fragment. *Anteromedial flexion* - **Flexion-type supracondylar fractures** are much less common (2-5%) and involve the distal fragment displacing anteriorly. - While medial displacement can occur with flexion, it's not the predominant type of supracondylar fracture. *Anterolateral flexion* - This describes a **flexion-type fracture** with anterior and lateral displacement of the distal fragment, which is rare. - Flexion fractures themselves are uncommon, and specific lateral displacement patterns are even less frequent. *Posterolateral extension* - While part of the common **extension-type fractures**, **posterolateral displacement** is less common than posteromedial displacement. - In extension fractures, the distal fragment typically displaces either posteromedially or posterolaterally, with posteromedial being seen more frequently.

Q: What sound does the examiner hear when the Ortolani test is positive?

Clunk of entry on abduction and flexion of the hip. ***Clunk of entry on abduction and flexion of the hip*** - A positive **Ortolani test** involves hearing a distinct "clunk" as the **femoral head** reduces back into the acetabulum. - This maneuver is performed by **abducting and flexing** the hip from an adducted position in an infant with a dislocated hip. *Clunk of entry on extension and adduction of the hip* - This description is incorrect; the Ortolani test is performed with hip **flexion and abduction**, not extension and adduction. - **Reduction** of the femoral head typically occurs with abduction, not adduction. *Click of exit on abduction and flexion of the hip* - The Ortolani test indicates **reduction** of a dislocated hip, which is characterized by a "clunk" of entry, not a "click of exit." - A "click of exit" when abducting and flexing the hip is more characteristic of the **Barlow maneuver's** results, which tests for reducibility and dislocation. *Click of exit on extension and adduction of the hip* - This describes neither the correct maneuver nor the characteristic sound of a positive Ortolani test. - The Ortolani test focuses on **reducing a dislocated hip** with a distinct "clunk" during a flexion and abduction maneuver.

Q: A 4-year-old child while playing suddenly had his elbow pulled by his servant maid's hand and is now continuously crying, not allowing anyone to touch his elbow. He is keeping his elbow extended. What is the most likely diagnosis?

Pulled elbow. ***Pulled elbow*** - This classic presentation involves a sudden pull on the extended arm, causing the **annular ligament** to slip over the **radial head**, characteristic of a pulled elbow (Nursemaid's elbow). - The child holds the arm in a pronated-extended position, refusing to use it due to pain, and cries when the elbow is touched, which aligns with the clinical picture. *Radial head fracture* - While a fracture can occur with trauma, a history of a distinct pulling mechanism and the absence of swelling or deformity make a **pulled elbow** more likely. - A radial head fracture would typically present with more localized pain and potentially **crepitus** or obvious swelling upon examination. *Supracondylar fracture* - This fracture usually results from a fall onto an outstretched hand, a different mechanism than described. - A supracondylar fracture would typically involve significant swelling, **ecchymosis**, and potential neurovascular compromise, which are not mentioned here. *Elbow dislocation* - Elbow dislocations usually result from high-energy trauma and present with obvious deformity and severe pain. - The history of a "pull" and the child holding the arm in an **extended, pronated position** are more consistent with a pulled elbow than a full dislocation.

Q: 4 year old child presented to the clinic with a history of fall on outstretched hand. Radiographs revealed a broken anterior cortex with an intact posterior cortex of the radius with an exaggerated bowing of the radius. The fracture sustained is known as -

Greenstick fracture. ***Greenstick fracture*** - This fracture type involves a **broken anterior cortex** but an **intact posterior cortex**, leading to an exaggerated bowing of the bone, characteristic of a greenstick fracture. - It occurs predominantly in **children** due to their softer, more flexible bones, which tend to bend rather than fully break when subjected to force like a fall on an outstretched hand. *Torus Fracture* - A torus fracture, or **buckle fracture**, involves compression of the bone leading to a bulging or buckling of the cortex, usually on one side, without a complete break in the bone. - While it occurs in children, it presents as a compression injury and not with a broken cortex and intact posterior cortex with bowing. *Galleazi Fracture* - A Galleazi fracture is a fracture of the **distal radius** with **dislocation of the distal radioulnar joint (DRUJ)**. - This fracture pattern involves two bones and two distinct injuries (fracture and dislocation), which is fundamentally different from the described single-bone incomplete fracture. *Monteggia Fracture Dislocation* - A Monteggia fracture involves a fracture of the **proximal ulna** with **dislocation of the radial head** at the elbow. - This injury also involves two bones and two distinct components (fracture and dislocation) and affects a different anatomical location (ulna and elbow) than described.

Question 1

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 2

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 3

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

Question 4

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 5

What is the usual first deformity to be seen in Charcot-Marie-Tooth (CMT) disease?

Accepted Answer

Pes cavus (high arch)

Answer

Hammer toes

Answer

Flatfoot

Answer

Claw toes

Question 6

The primary diagnostic evaluation for developmental dysplasia of hip is -

Accepted Answer

USG

Answer

Clinical examination

Answer

X-ray

Answer

CT Scan

Question 7

What is the most common type of supracondylar fracture in children?

Accepted Answer

Posteromedial extension

Answer

Anteromedial flexion

Answer

Anterolateral flexion

Answer

Posterolateral extension

Question 8

What sound does the examiner hear when the Ortolani test is positive?

Accepted Answer

Clunk of entry on abduction and flexion of the hip

Answer

Clunk of entry on extension and adduction of the hip

Answer

Click of exit on abduction and flexion of the hip

Answer

Click of exit on extension and adduction of the hip

Question 9

A 4-year-old child while playing suddenly had his elbow pulled by his servant maid's hand and is now continuously crying, not allowing anyone to touch his elbow. He is keeping his elbow extended. What is the most likely diagnosis?

Accepted Answer

Pulled elbow

Answer

Radial head fracture

Answer

Elbow dislocation

Answer

Supracondylar fracture

Question 10

4 year old child presented to the clinic with a history of fall on outstretched hand. Radiographs revealed a broken anterior cortex with an intact posterior cortex of the radius with an exaggerated bowing of the radius. The fracture sustained is known as -

Accepted Answer

Greenstick fracture

Answer

Torus Fracture

Answer

Galleazi Fracture

Answer

Monteggia Fracture Dislocation

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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