Pediatric Orthopaedics Practice Questions

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

Developmental dysplasia of the hip. **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.

Q: 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?

As soon as possible after birth. **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.

Q: What is the cause of coxa vera?

All of the above. **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).

Q: Which of the following are features of cleidocranial dysplasia?

All of the above.. **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.

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

Subepiphyseal microfractures. **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.

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

Congenital Talipes Equinovarus (CTEV). **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.

Q: 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?

Pulled elbow. ### 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).

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

Genu varus. **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 1

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

Accepted Answer

Developmental dysplasia of the hip

Answer

Perthes disease

Answer

Slipped capital femoral epiphysis

Answer

Congenital coxa vara

Question 2

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?

Accepted Answer

As soon as possible after birth

Answer

1 month after birth

Answer

1 year after birth

Answer

None of the above

Question 3

What is the cause of coxa vera?

Accepted Answer

All of the above

Answer

Congenital

Answer

Perthe's disease

Answer

SCFE

Question 4

Which of the following are features of cleidocranial dysplasia?

Accepted Answer

All of the above.

Answer

Clavicle is small or absent.

Answer

Wormian bones are present.

Answer

Air sinuses are absent.

Question 5

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

Accepted Answer

Subepiphyseal microfractures

Answer

Metaphyseal corner fracture

Answer

Metaphyseal bucket handle fracture

Answer

Metaphyseal fragment displacement

Question 6

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

Accepted Answer

Congenital Talipes Equinovarus (CTEV)

Answer

Rickets

Answer

Blount's disease

Answer

Congenital vertical talus

Question 7

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

Accepted Answer

Wadding gait, Shenton's line broken, Spine lordosis present

Answer

Genu valgum, Wadding gait, Shenton's line broken

Answer

Genu valgum, Wadding gait, Spine lordosis present

Answer

Usually unilateral, Wadding gait, Shenton's line broken, Spine lordosis present

Question 8

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?

Accepted Answer

Pulled elbow

Answer

Monteggia fracture

Answer

Cellulitis

Answer

None of the above

Question 9

What is the characteristic deformity in Blount's disease?

Accepted Answer

Genu varus

Answer

Genu valgum

Answer

Coxa vara

Answer

Coxa valgus

Question 10

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

Accepted Answer

Progression to kyphosis deformity is least likely with lumbar lesions.

Answer

The most common sites are the hip (40%), spine (20%), and knee (10%).

Answer

The most common site affected is the upper limb.

Answer

The dorsolumbar spine is the most commonly affected site.

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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