Pediatric Orthopaedics Practice Questions

Q: Osgood-Schlatter disease primarily affects which joint?

The knee joint. ***The knee joint*** - **Osgood-Schlatter disease** is characterized by inflammation of the **patellar tendon** at its insertion on the **tibial tuberosity**, which is located just below the knee joint. - It results from repetitive stress and microtrauma to the growth plate in growing adolescents, leading to pain and swelling around the **knee**. *Pelvis* - Conditions affecting the pelvis typically involve the **hip joint** or **sacroiliac joints**, such as **apophysitis of the iliac crest** or **ischial tuberosity**. - These conditions present with pain in the respective pelvic regions, distinct from the anterior knee pain seen in Osgood-Schlatter disease. *Wrist joint* - The wrist joint is composed of the distal radius and ulna articulating with the carpal bones; conditions here include **ganglion cysts**, **carpal tunnel syndrome**, or **distal radial fractures**. - Symptoms would be localized to the hand and wrist, completely separate from the knee. *Cervical spine* - The cervical spine involves the neck vertebrae and is associated with conditions like **cervical spondylosis**, **whiplash injuries**, or **herniated discs**. - These conditions manifest as neck pain, stiffness, or radiating symptoms down the arms, which are unrelated to the lower limb.

Q: All of the following are true regarding congenital dislocation of the hip except which of the following?

It is always bilateral. ***It is always bilateral*** - **Congenital dislocation of the hip (CDH)** is more commonly **unilateral**, with a predilection for the left hip. - While it can be bilateral, stating it is *always* bilateral is incorrect. - **Bilateral CDH** occurs in only about 20% of cases. *Asymmetric thigh folds may be seen* - **Asymmetric thigh folds** are a common soft sign of **developmental dysplasia of the hip (DDH)**, though they can also be seen in normal infants. - This asymmetry is due to the femoral head's abnormal position, leading to unequal skin fold distribution on the affected side. *Galeazzi sign and Ortolani's test may be positive* - The **Galeazzi sign** (also known as the Allis sign) indicates limb length discrepancy, often seen in unilateral hip dislocation when the knees are flexed. - **Ortolani's test** is a specific maneuver used to reduce a dislocated hip, producing a characteristic *clunk* as the femoral head re-enters the acetabulum. *Oligohydramnios is a known risk factor for congenital dislocation of the hip* - **Oligohydramnios** (decreased amniotic fluid) is a well-established risk factor for CDH due to restricted fetal movement and abnormal intrauterine positioning. - Other risk factors include **breech presentation**, **female sex**, **firstborn child**, and **family history**. - **Polyhydramnios** (excess amniotic fluid) is NOT associated with increased risk of CDH.

Q: A 10-year-old obese boy was referred to the emergency department with a history of hip pain. He was observed to be limping and complained of severe pain. Which of the following investigations is least appropriate for this condition?

USG of hip. ***USG of hip*** - An **ultrasound (USG)** of the hip is generally not the primary imaging modality for diagnosing conditions like **slipped capital femoral epiphysis (SCFE)**, which is suggested by the patient's presentation. - While USG can detect effusions or synovitis, it provides poor visualization of bony structures and the physeal plate, which are crucial for diagnosing SCFE. *X-ray of the hip* - **X-rays** (AP and frog-leg lateral views) are the **initial and most important imaging study** for diagnosing SCFE. - They effectively visualize the **epiphyseal displacement** relative to the metaphysis and are sufficient for diagnosis in most cases. *MRI of the hip* - **MRI** is highly sensitive for detecting early or subtle SCFE, especially when X-rays are inconclusive. - It can evaluate the **physeal edema**, chondral changes, and avascular necrosis, providing more detailed information than X-rays. *CT scan of hip* - A **CT scan** provides excellent bony detail and can precisely assess the **degree of physeal slip** and femoral head deformity. - It may be used for surgical planning, especially in complex cases or when the slip is difficult to assess with X-rays.

Q: Cubitus varus is most commonly seen in:

Fracture of the lateral condyle of the humerus. ***Fracture of the lateral condyle of the humerus*** - A fracture of the **lateral condyle of the humerus** that goes untreated or is improperly treated is a common cause of **cubitus varus** due to growth disturbance of the lateral physis. - This type of fracture often leads to **growth arrest** or **asymmetrical growth** of the distal humerus, resulting in an angular deformity. *Rickets* - **Rickets** is a metabolic bone disease characterized by defective bone mineralization, primarily affecting rapidly growing bones. - While rickets can cause various bone deformities, including bowing of the legs (genu varum), it does not directly lead to **cubitus varus** in the elbow through a specific mechanism. *Malunited supracondylar fracture* - A **malunited supracondylar fracture** of the humerus is the most common cause of **cubitus varus** deformity. - This occurs due to rotational or angular malalignment causing the distal fragment to unite in an altered position. *Post-inflammatory epiphyseal damage* - **Post-inflammatory epiphyseal damage** can lead to altered growth and angular deformities, but it is a less common and less specific cause of **cubitus varus** compared to a malunited supracondylar fracture or lateral condyle fracture. - This type of damage can result from conditions like **septic arthritis**, but its association with cubitus varus is secondary to growth plate disruption.

Q: Which one of the following is the most ideal treatment for a displaced fracture of the lateral condyle of the humerus in a 7-year-old child?

Open reduction and internal fixation. ***Open reduction and internal fixation*** - **Displaced lateral condyle fractures** in children require **anatomical reduction** and stable fixation to prevent complications like **non-union** and **cubitus valgus deformity**. - **Internal fixation** provides the necessary stability for healing and allows for earlier mobilization, which is crucial for elbow joint function. *Open reduction with plaster immobilization* - While it achieves open reduction, relying solely on **plaster immobilization** after reducing a displaced fracture of the lateral humeral condyle in a child often leads to **loss of reduction**. - This method does not provide adequate stability for this type of fracture, increasing the risk of **displacement** and **malunion**. *Closed reduction with plaster immobilization* - **Closed reduction** is typically attempted only for **minimally displaced** or **undisplaced fractures** of the lateral condyle. - Given that the fracture is described as **displaced**, closed reduction is unlikely to achieve and maintain an adequate anatomical alignment.

Q: The most common presenting feature of bilateral congenital hip dislocation in children is:

Waddling. ***Waddling*** - **Bilateral congenital hip dislocation** leads to an unstable gait where the body sways from side to side to maintain balance over the affected hip. - This characteristic gait is known as a **waddling gait** or **Trendelenburg gait**, making it the most common presenting feature when the child begins to walk. - Occurs due to bilateral hip instability causing the pelvis to tilt to the unsupported side during walking. *Stumbling* - **Stumbling** is generally associated with difficulties in coordination, muscle weakness, or neurological issues, rather than a primary presentation of hip dislocation. - It does not specifically describe the compensatory gait seen in bilateral congenital hip dislocation. *Knock knee* - **Knock knee** (genu valgum) is an angular deformity of the knees where they touch while the ankles are apart, which is unrelated to hip dislocation. - It is a lower limb alignment issue, distinct from hip joint instability. *Antalgic* - An **antalgic gait** is adopted to reduce pain in a limb or joint, often involving a shortened stance phase on the affected side. - While hip dislocation can cause pain, the specific and most common gait pattern in bilateral congenital hip dislocation is **waddling**, not merely an antalgic response. - Antalgic gait is more typical of unilateral painful conditions.

Q: A 3-year-old patient reports painless progressive bilateral facial swellings. The tentative diagnosis is

Cherubism. ***Cherubism*** - This genetic condition characteristically presents in **early childhood** (age 2-5 years) with **painless, bilateral swelling of the jaws**. - The distinctive clinical feature is the **"cherubic" facial appearance** due to bilateral expansion of the mandible and maxilla. *Monostotic fibrous dysplasia* - This condition is typically **unilateral** and affects a **single bone**, presenting as a localized swelling rather than bilateral facial involvement. - While it can manifest in childhood, its presentation of a solitary bone lesion doesn't match the described bilateral facial swellings. *Polyostotic fibrous dysplasia* - This form of fibrous dysplasia involves **multiple bones** and may present with facial asymmetry or swelling, often accompanied by **pathological fractures** and **skin pigmentation (café-au-lait spots)**. - While it can affect facial bones, the classic **bilateral, symmetrical, progressive facial swelling** described is more indicative of Cherubism. *Central giant cell granuloma* - This is a **benign intraosseous lesion** that can occur in the jaws but is typically **unilateral** and presents as a localized swelling, often causing **pain** or paresthesia. - It does not usually present with the **bilateral, progressive facial swelling** characteristic of Cherubism.

Q: A 10-year-old boy presenting with cubitus varus deformity and a history of trauma 3 months prior, on clinical examination, has preserved the normal relationship of the three bony points of the elbow. What is the most probable diagnosis?

Malunited supracondylar fracture of the humerus. ***Malunited supracondylar fracture of the humerus*** - A malunited **supracondylar fracture** is the most common cause of **cubitus varus** deformity, also known as gunstock deformity, in children, which results from the medial displacement and internal rotation of the distal fragment. - The **normal relationship of the three bony points** (medial epicondyle, lateral epicondyle, and olecranon) is preserved because the fracture is usually extra-articular and the trochlea and capitellum maintain their normal relationship with the ulna and radius. *Old unreduced elbow dislocation* - An **elbow dislocation** would disrupt the normal anatomical relationship between the radius, ulna, and humerus, leading to an **abnormal relationship of the three bony points** of the elbow. - While it can cause deformity, it typically presents with obvious joint incongruity and significant functional limitations that would be evident on examination. *Malunited intercondylar fracture of the humerus* - An **intercondylar fracture** involves the articular surface of the humerus, suggesting an intra-articular injury. - Such a fracture, even if malunited, would likely disrupt the **normal alignment of the trochlea and capitellum** with the olecranon and radial head, thus altering the relationship of the three bony points. *Non-union of lateral condylar fracture of the humerus* - A **non-union of a lateral condylar fracture** can lead to progressive valgus deformity (cubitus valgus) or instability, not typically cubitus varus. - While it affects the elbow joint, the primary issue is joint instability and changes in the carrying angle, not the varus deformity described with preserved bony point relationships.

Q: Clavicle is absent in which of the following conditions?

Cleidocranial dysostosis. ***Cleidocranial dysostosis*** [1] - Characterized by the **absence of clavicles**, leading to wide-set shoulders, which is a hallmark feature of this condition. - It is a genetic disorder due to mutations in the **RUNX2** gene [1], impacting bone development. *Osteogenesis imperfecta* - Known as "brittle bone disease," primarily affecting **collagen production**, leading to fragile bones. - Does not typically involve **clavicular absence**; clavicles are usually present, though they may be brittle. *Osteopetrosis* - A condition marked by **abnormal bone density** due to osteoclast dysfunction, leading to dense yet fragile bones. - The clavicles remain intact, although may show **thickening** rather than absence. *Fibrous dysplasia* - Characterized by **replacement of normal bone with fibrous tissue**, leading to bone deformities or fractures. - The clavicle is usually preserved, although it can be affected by **expansile lesions** in some cases. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, p. 1186.

Q: All are true regarding congenital talipes equinovarus (CTEV) except:

Increased dorsiflexion. ***Increased dorsiflexion*** - Congenital talipes equinovarus (CTEV), or **clubfoot**, is characterized by an **equinus deformity**, meaning the foot is pointing downwards, thus having significantly **reduced dorsiflexion**. - **Increased dorsiflexion** would imply the foot can be brought closer to the shin, which is directly opposite to the characteristic presentation of CTEV. *Hindfoot varus* - **Hindfoot varus** is a characteristic component of CTEV, where the heel is turned inward. - This inward turning of the heel contributes to the overall deformity and is one of the four main components of a clubfoot. *Cavus* - **Cavus** refers to a high arch in the foot, which is another defining feature of CTEV. - This exaggerated arch contributes to the rigidity and complex nature of the deformity. *Forefoot adduction* - **Forefoot adduction** means the front part of the foot is turned inward towards the body's midline, which is a key component of CTEV. - This inward deviation contributes to the 'club' shape of the foot and is often described as metatarsus adductus within the overall deformity.

Question 1

Osgood-Schlatter disease primarily affects which joint?

Accepted Answer

The knee joint

Answer

Pelvis

Answer

Wrist joint

Answer

Cervical spine

Question 2

All of the following are true regarding congenital dislocation of the hip except which of the following?

Accepted Answer

It is always bilateral

Answer

Asymmetric thigh folds may be seen

Answer

Galeazzi sign and Ortolani's test may be positive

Answer

Oligohydramnios is a known risk factor for congenital dislocation of the hip

Question 3

A 10-year-old obese boy was referred to the emergency department with a history of hip pain. He was observed to be limping and complained of severe pain. Which of the following investigations is least appropriate for this condition?

Accepted Answer

USG of hip

Answer

MRI of the hip

Answer

CT scan of hip

Answer

X-ray of the hip

Question 4

Cubitus varus is most commonly seen in:

Accepted Answer

Fracture of the lateral condyle of the humerus

Answer

Rickets

Answer

Malunited supracondylar fracture

Answer

Post-inflammatory epiphyseal damage

Question 5

Which one of the following is the most ideal treatment for a displaced fracture of the lateral condyle of the humerus in a 7-year-old child?

Accepted Answer

Open reduction and internal fixation

Answer

Open reduction with plaster immobilization

Answer

Closed reduction with plaster immobilization

Answer

All of the above

Question 6

The most common presenting feature of bilateral congenital hip dislocation in children is:

Accepted Answer

Waddling

Answer

Knock knee

Answer

Antalgic

Answer

Stumbling

Question 7

A 3-year-old patient reports painless progressive bilateral facial swellings. The tentative diagnosis is

Accepted Answer

Cherubism

Answer

Monostotic fibrous dysplasia

Answer

Polyostotic fibrous dysplasia

Answer

Central giant cell granuloma

Question 8

A 10-year-old boy presenting with cubitus varus deformity and a history of trauma 3 months prior, on clinical examination, has preserved the normal relationship of the three bony points of the elbow. What is the most probable diagnosis?

Accepted Answer

Malunited supracondylar fracture of the humerus

Answer

Old unreduced elbow dislocation

Answer

Malunited intercondylar fracture of the humerus

Answer

Non-union of lateral condylar fracture of the humerus

Question 9

Clavicle is absent in which of the following conditions?

Accepted Answer

Cleidocranial dysostosis

Answer

Osteogenesis imperfecta

Answer

Fibrous dysplasia

Answer

Osteopetrosis

Question 10

All are true regarding congenital talipes equinovarus (CTEV) except:

Accepted Answer

Increased dorsiflexion

Answer

Hindfoot varus

Answer

Cavus

Answer

Forefoot adduction

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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