Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics Indian Medical PG Practice Questions and MCQs

Question 31: Pavlic harness is used to treat which of the following conditions?

A. Developmental dysplasia of the hip (Correct Answer)
B. Perthes disease
C. Slipped capital femoral epiphysis
D. Congenital coxa vara

Explanation: **Explanation:** **Pavlik harness** is the gold standard, first-line treatment for **Developmental Dysplasia of the Hip (DDH)** in infants from birth up to 6 months of age. It is a dynamic functional brace that maintains the hip in a position of **flexion (above 90°)** and **abduction**. This position centers the femoral head into the acetabulum (the "human position"), promoting stable hip development while allowing active movement. **Why other options are incorrect:** * **Perthes Disease:** This is an idiopathic avascular necrosis of the femoral head in children (4–8 years). Management involves observation or containment using braces like the **Atlanta (Scottish Rite) brace**, but not the Pavlik harness. * **Slipped Capital Femoral Epiphysis (SCFE):** This occurs in adolescents (obese males). The definitive treatment is surgical stabilization with **in-situ percutaneous screw fixation**. * **Congenital Coxa Vara:** This is characterized by a decreased neck-shaft angle (less than 120°). It usually requires surgical correction via **Valgus Osteotomy** if the deformity is progressive. **High-Yield Clinical Pearls for NEET-PG:** * **Age Limit:** Pavlik harness is effective only up to **6 months**. Beyond this, closed or open reduction is usually required. * **Complication:** The most serious complication of a Pavlik harness is **Avascular Necrosis (AVN)** of the femoral head (due to excessive abduction) and **Femoral Nerve Palsy** (due to excessive flexion). * **Screening:** Clinical tests for DDH include **Barlow’s** (dislocatable) and **Ortolani’s** (reducible) maneuvers. Ultrasound is the investigation of choice for infants <6 months.

Question 32: A child was born with a deformity of the foot. The foot is severely internally rotated and inverted such that the sole faces superiorly. When should the treatment of this deformity begin?

A. As soon as possible after birth (Correct Answer)
B. 1 month after birth
C. 1 year after birth
D. None of the above

Explanation: **Explanation:** The clinical presentation described—severe internal rotation, inversion, and the sole facing superiorly—is characteristic of **Congenital Talipes Equinovarus (CTEV)**, also known as Clubfoot. **1. Why Option A is correct:** The gold standard for CTEV management is the **Ponseti Method**. Treatment should ideally begin **as soon as possible after birth** (typically within the first week). In neonates, the connective tissues (ligaments, tendons, and joint capsules) are highly elastic due to the presence of maternal hormones like relaxin. Early serial casting exploits this biological plasticity, allowing for easier remodeling of the tarsal bones and correction of the deformity without extensive surgery. **2. Why other options are incorrect:** * **Option B (1 month):** While treatment can still be successful at one month, delaying it unnecessarily allows the soft tissues to become stiffer and the bony deformities to become more fixed, potentially increasing the duration of treatment or the need for surgical intervention. * **Option C (1 year):** By one year, the child begins weight-bearing, which further hardens the deformed anatomy. Neglected clubfoot at this stage often requires complex surgical releases or bony procedures (like osteotomies) rather than simple casting. **Clinical Pearls for NEET-PG:** * **Components of CTEV (CAVE):** **C**avus, **A**dduction (forefoot), **V**arus (heel), and **E**quinus (ankle). * **Correction Order:** The Ponseti method follows the mnemonic **"CAV"** (Cavus first, then Adduction and Varus together). Equinus is always corrected last. * **Tenotomy:** About 80-90% of cases require a **Percutaneous Achilles Tenotomy** to correct the residual equinus. * **Maintenance:** After correction, a **Steenbeek or Denis Browne splint** (foot abduction brace) is used to prevent recurrence, worn 23 hours a day initially.

Question 33: What is the cause of coxa vera?

A. Congenital
B. Perthe's disease
C. SCFE
D. All of the above (Correct Answer)

Explanation: **Explanation:** **Coxa Vara** is defined as a clinical condition where the neck-shaft angle of the femur is reduced to **less than 120°** (normal range is 120°–135°). This reduction in angle leads to a shortened limb, a prominent greater trochanter, and a characteristic waddling gait (Trendelenburg gait). The correct answer is **"All of the above"** because Coxa Vara is a morphological finding that can result from various underlying etiologies: 1. **Congenital (Developmental):** This is often due to a primary defect in the ossification of the femoral neck (cervical coxa vara). It is usually noticed when the child starts walking and is characterized by a vertical growth plate and a "Fairbank’s triangle" on X-ray. 2. **Perthes Disease:** Avascular necrosis of the femoral head leads to flattening and broadening of the head (coxa magna) and shortening of the neck, resulting in a secondary coxa vara deformity. 3. **Slipped Capital Femoral Epiphysis (SCFE):** In SCFE, the femoral head slips posteriorly and inferiorly relative to the neck. This "downward" displacement effectively reduces the neck-shaft angle, causing a varus deformity. **Clinical Pearls for NEET-PG:** * **Normal Neck-Shaft Angle:** At birth (~150°), Adult (~125°–135°). * **Radiographic Hallmark:** In developmental coxa vara, look for **Hilgenreiner’s Epiphyseal (HE) angle**; an angle >60° usually requires surgical correction (Valgus Osteotomy). * **Clinical Sign:** Positive **Trendelenburg sign** due to the shortening of the distance between the origin and insertion of the abductor muscles (gluteus medius), leading to muscle slackness. * **Other causes:** Rickets (metabolic), trauma (malunited intertrochanteric fractures), and skeletal dysplasias (e.g., Cleidocranial dysplasia).

Question 34: Which of the following are features of cleidocranial dysplasia?

A. Clavicle is small or absent.
B. Wormian bones are present.
C. Air sinuses are absent.
D. All of the above. (Correct Answer)

Explanation: **Explanation:** Cleidocranial Dysplasia (CCD) is an autosomal dominant skeletal dysplasia caused by a mutation in the **RUNX2 gene** (located on chromosome 6p21), which is essential for osteoblast differentiation and intramembranous ossification. **Why Option D is Correct:** The clinical features of CCD primarily affect bones formed via intramembranous ossification (skull and clavicle). * **Clavicle (Option A):** The clavicles are characteristically hypoplastic or completely absent (aplasia). This allows the patient to abnormally approximate their shoulders in the midline. * **Skull & Wormian Bones (Option B):** There is delayed closure of cranial sutures and fontanelles. This leads to the formation of multiple **Wormian bones** (small, irregular bones within sutures) and a "hot cross bun" appearance of the skull. * **Air Sinuses (Option C):** There is significant hypoplasia or complete absence of the paranasal air sinuses (especially the frontal and maxillary sinuses) and the mastoid air cells. **High-Yield Clinical Pearls for NEET-PG:** * **Dental Findings:** This is a frequent exam favorite. Patients often have **supernumerary teeth** (extra teeth), delayed eruption of permanent teeth, and a high-arched palate. * **Stature:** Patients usually have moderately short stature. * **Pelvis:** Widening of the symphysis pubis (delayed ossification) is a classic radiological sign. * **Hand:** Long second metacarpals and tapering distal phalanges. **Summary for Revision:** Remember the triad: **Absent clavicles + Wormian bones + Supernumerary teeth.** If these three are present, the diagnosis is invariably Cleidocranial Dysplasia.

Question 35: Which of the following is NOT an X-ray feature of child abuse?

A. Metaphyseal corner fracture
B. Metaphyseal bucket handle fracture
C. Metaphyseal fragment displacement
D. Subepiphyseal microfractures (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Subepiphyseal microfractures.** In pediatric orthopaedics, the hallmark of Non-Accidental Injury (NAI) or child abuse is the **Classic Metaphyseal Lesion (CML)**. This occurs due to violent shaking or pulling of the limbs, which creates shearing forces across the fragile primary spongiosa of the metaphysis. * **Why D is correct:** The term "subepiphyseal microfractures" is not a standard radiological description of child abuse. The actual pathology involves **transverse microfractures through the primary spongiosa of the metaphysis**, not the subepiphyseal region. * **Why A and B are incorrect:** **Metaphyseal corner fractures** and **Bucket handle fractures** are two different radiographic views of the same injury (CML). When the avulsed metaphyseal fragment is viewed at an angle, it appears as a "corner" chip; when viewed head-on, it appears as a "bucket handle" arc. These are considered **highly specific (pathognomonic)** for child abuse. * **Why C is incorrect:** **Metaphyseal fragment displacement** is a direct consequence of the shearing forces in CML, where a thin planar fragment of the metaphysis is separated from the shaft. **Clinical Pearls for NEET-PG:** 1. **High Specificity Lesions:** CML (Corner/Bucket handle), posterior rib fractures (due to squeezing), scapular fractures, and sternal fractures. 2. **Dating Fractures:** Presence of fractures in different stages of healing is a major red flag. 3. **Commonest Bone Involved:** Long bones (Femur/Humerus), but the *pattern* (e.g., spiral fracture in a non-ambulatory infant) is more suspicious than the location. 4. **Initial Investigation:** A **Skeletal Survey** (not a bone scan) is the gold standard for suspected child abuse in children under 2 years.

Question 36: The Ponseti method is primarily used for the treatment of which condition?

A. Rickets
B. Blount's disease
C. Congenital Talipes Equinovarus (CTEV) (Correct Answer)
D. Congenital vertical talus

Explanation: **Explanation:** The **Ponseti method** is the gold-standard conservative treatment for **Congenital Talipes Equinovarus (CTEV)**, also known as clubfoot. The underlying medical concept involves the manipulation of the foot to correct the three-dimensional deformity by rotating the foot around the head of the talus (the "pivot"). This is followed by serial long-leg casting to maintain the correction. **Why the correct answer is right:** CTEV is characterized by the mnemonic **CAVE**: **C**avirus, **A**dductus, **V**arus, and **E**quinus. The Ponseti method corrects these in a specific sequence (CAV first, then E). A key component is the **Percutaneous Achilles Tenotomy**, required in about 80-90% of cases to correct the residual equinus after the other components are addressed. **Why the incorrect options are wrong:** * **Rickets:** This is a metabolic bone disease treated primarily with Vitamin D and Calcium supplementation, not serial casting. * **Blount's disease:** This involves disordered ossification of the medial proximal tibial phalanx (tibia vara). Treatment ranges from bracing to corrective osteotomy. * **Congenital Vertical Talus (CVT):** While CVT is also a foot deformity ("Rocker-bottom foot"), it is treated using the **Reverse Ponseti method**, where the foot is manipulated into equinus and varus (the opposite of CTEV). **High-Yield Clinical Pearls for NEET-PG:** * **Order of correction:** C $\rightarrow$ A $\rightarrow$ V $\rightarrow$ E. * **The Pivot Point:** The head of the talus (never touch the calcaneus during manipulation). * **Maintenance:** After casting, a **Steenbeek or Denis Browne splint** is used (70° external rotation) to prevent recurrence. * **Pirani Score:** Used to assess the severity and progress of CTEV during Ponseti treatment.

Question 37: Which of the following are true about Congenital Hip Dysplasia (CDH)?

A. Genu valgum, Wadding gait, Shenton's line broken
B. Genu valgum, Wadding gait, Spine lordosis present
C. Wadding gait, Shenton's line broken, Spine lordosis present (Correct Answer)
D. Usually unilateral, Wadding gait, Shenton's line broken, Spine lordosis present

Explanation: **Explanation:** Developmental Dysplasia of the Hip (DDH), formerly known as CDH, involves a spectrum of disorders ranging from neonatal instability to total dislocation of the femoral head from the acetabulum. **Why Option C is Correct:** 1. **Waddling Gait:** In bilateral dislocation, the patient exhibits a "duck-like" waddling gait due to the ineffective action of the gluteus medius (Trendelenburg gait) on both sides. 2. **Shenton’s Line Broken:** This is a radiological landmark formed by the continuous arc of the inferior border of the femoral neck and the superior margin of the obturator foramen. In DDH, the femoral head moves superiorly and laterally, disrupting this smooth curve. 3. **Spinal Lordosis:** To compensate for the posterior displacement of the center of gravity (as the femoral heads sit posterior to the acetabulum), the patient develops an exaggerated lumbar lordosis to maintain balance. **Analysis of Incorrect Options:** * **Options A & B:** These include **Genu Valgum** (knock-knees). DDH does not typically cause genu valgum; if any knee deformity is associated with hip pathology, it is more commonly secondary to gait changes, but it is not a cardinal sign of DDH. * **Option D:** While it includes the correct clinical signs, it states DDH is **"Usually unilateral."** While DDH can be unilateral (more common on the left side), the classic presentation of a "Waddling gait" and "Spinal lordosis" is most pronounced and characteristically described in **bilateral** cases. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** First-born, Female (8:1 ratio), Frank breech presentation, Family history (The "4 F's"). * **Clinical Tests:** **Barlow’s** (Provocative/Dislocating) and **Ortolani’s** (Reductive/Relocating) are used in neonates. **Galeazzi sign** (uneven knee heights) and **Trendelenburg sign** are used in older children. * **Radiology:** Look for **Putti’s Triad**: 1. Absent/small epiphysis, 2. Lateral displacement of femur, 3. Increased acetabular index. * **Treatment:** **Pavlik Harness** is the gold standard for infants <6 months.

Question 38: A 4-year-old boy complains of pain around the elbow with the hand held in pronation and extension. Radiographs of the elbow joint are normal. What is the most probable diagnosis?

A. Pulled elbow (Correct Answer)
B. Monteggia fracture
C. Cellulitis
D. None of the above

Explanation: ### Explanation **Correct Option: A. Pulled elbow** Pulled elbow, also known as **Nursemaid’s elbow** or **Subluxation of the Radial Head**, is a common pediatric injury occurring typically between ages 1–4 years. It is caused by sudden longitudinal traction on an extended, pronated arm (e.g., pulling a child up a curb). * **Pathophysiology:** The annular ligament, which is relatively lax in toddlers, slips over the head of the radius and becomes trapped in the radio-capitellar joint. * **Clinical Presentation:** The child holds the arm in a characteristic position of **pronation and slight flexion/extension**, refusing to use it. Crucially, **radiographs are typically normal** because it is a subluxation, not a fracture. **Why other options are incorrect:** * **B. Monteggia fracture:** This involves a fracture of the proximal third of the ulna associated with a dislocation of the radial head. It would show obvious bony deformity and significant findings on an X-ray. * **C. Cellulitis:** This is an inflammatory/infectious condition presenting with localized redness, warmth, swelling, and fever, rather than a sudden mechanical injury. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Sudden traction on a pronated forearm. * **Pathology:** Interposition of the **annular ligament**. * **Management:** Reduction is performed via **supination** of the forearm followed by **flexion** at the elbow (a "click" is often felt). No immobilization is required once the child starts using the arm. * **Radiology:** Always normal; X-rays are only indicated if a fracture is suspected (e.g., history of a fall or focal bony tenderness).

Question 39: What is the characteristic deformity in Blount's disease?

A. Genu valgum
B. Genu varus (Correct Answer)
C. Coxa vara
D. Coxa valgus

Explanation: **Explanation:** **Blount’s Disease (Tibia Vara)** is a developmental disorder characterized by disordered endochondral ossification of the **medial aspect of the proximal tibial physis**. This leads to a progressive growth suppression of the medial tibial plateau, resulting in **Genu Varus** (bow-legs). 1. **Why Genu Varus is Correct:** In Blount’s disease, the posteromedial part of the proximal tibia fails to grow normally. As the lateral side continues to grow at a standard rate while the medial side lags, the tibia angles inward toward the midline, creating a varus deformity. It is distinguished from physiological bowing by its progressive nature and specific radiographic findings (e.g., Langenskiöld classification). 2. **Why Incorrect Options are Wrong:** * **Genu Valgum:** Also known as "knock-knees," this is the opposite of the deformity seen in Blount’s. It is commonly seen in conditions like renal rickets or as a physiological stage in children aged 3–5 years. * **Coxa Vara/Valgus:** These refer to the neck-shaft angle of the **femur** at the hip joint (normal is ~120°–135°). While they are common orthopedic distractors, Blount’s disease specifically affects the proximal **tibia**, not the hip. **Clinical Pearls for NEET-PG:** * **Radiographic Hallmark:** Increased **Metaphyseal-Diaphyseal Angle (Drennan’s Angle)** >16° is highly suggestive of Blount’s. * **Classification:** The **Langenskiöld Classification** (Stages I-VI) is used to assess severity based on the depression of the medial tibial beak. * **Types:** Infantile (early onset, 0–3 years, often bilateral) and Adolescent (late onset, >10 years, often unilateral and associated with obesity). * **Treatment:** Bracing (KAFO) is effective in early stages (Stage I-II); surgical osteotomy is required for advanced stages or persistent deformity.

Question 40: Which of the following statements is true regarding skeletal tuberculosis in children?

A. The most common sites are the hip (40%), spine (20%), and knee (10%).
B. The most common site affected is the upper limb.
C. The dorsolumbar spine is the most commonly affected site.
D. Progression to kyphosis deformity is least likely with lumbar lesions. (Correct Answer)

Explanation: **Explanation:** **1. Why Option D is Correct:** In Spinal Tuberculosis (Pott’s disease), the development of **kyphosis** (gibbus deformity) depends on the anatomical level of the lesion and the physiological curvature of the spine. * **Lumbar Spine:** The lumbar region has a natural **lordosis** (inward curve). For a kyphotic deformity to appear, the disease must first neutralize this lordosis before it can create a posterior angulation. Additionally, the vertebral bodies in the lumbar region are larger, and the center of gravity falls posterior to the vertebral bodies, reducing the "crushing" force. Thus, kyphosis is least likely or least severe in lumbar lesions. * **Thoracic Spine:** Conversely, the thoracic spine has a natural **kyphosis**. The center of gravity falls anterior to the vertebrae, leading to rapid collapse and severe angulation. **2. Why Other Options are Incorrect:** * **Option A & B:** These are epidemiologically incorrect. The **Spine** is the most common site of skeletal TB (approx. 50%), followed by the hip and knee. The lower limb is affected far more frequently than the upper limb due to weight-bearing stresses. * **Option C:** While the spine is the most common site, the **Thoracic spine** (specifically the lower thoracic) is the most frequently involved segment in children, followed by the thoracolumbar junction. **3. High-Yield NEET-PG Pearls:** * **Paradiscal Lesion:** The most common type of spinal TB (affects the disc space and adjacent vertebrae). * **Cold Abscess:** Characterized by a lack of traditional signs of inflammation (heat, redness). In the lumbar spine, it often tracks down the psoas sheath (**Psoas Abscess**). * **Deformity Formula:** The degree of kyphosis can be predicted using **Rajasekaran’s formula**. * **Triple Displacement of Shands:** Seen in TB Hip (Flexion, Abduction, and External Rotation in the early stage).

Practice by Chapter

Developmental Dysplasia of Hip

Practice Questions

Clubfoot

Practice Questions

Pediatric Fractures

Practice Questions

Growth Plate Injuries

Practice Questions

Legg-Calvé-Perthes Disease

Practice Questions

Slipped Capital Femoral Epiphysis

Practice Questions

Pediatric Spine Deformities

Practice Questions

Cerebral Palsy: Orthopaedic Aspects

Practice Questions

Neuromuscular Disorders in Children

Practice Questions

Pediatric Bone and Joint Infections

Practice Questions

Limb Length Discrepancies

Practice Questions

Orthopedic Manifestations of Genetic Disorders

Practice Questions

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free