Pediatric Orthopaedics Practice Questions

Q: Green extra-articular arthrodesis is done for which of the following conditions?

Congenital vertical talus. **Explanation:** **Congenital Vertical Talus (CVT)**, also known as "Rocker-bottom foot," is a rare congenital deformity characterized by a fixed dorsal dislocation of the navicular on the talus. The **Green extra-articular arthrodesis** (specifically the Green-Grice procedure) is a surgical technique used to stabilize the subtalar joint without interfering with the growth of the tarsal bones. It involves placing a bone graft into the sinus tarsi to maintain the reduction of the talocalcaneal joint, correcting the hindfoot valgus associated with CVT. **Analysis of Options:** * **Genu valgum (Knock-knees):** This is a coronal plane deformity of the knee. Treatment typically involves guided growth (hemiepiphysiodesis using 8-plates) or corrective osteotomy (e.g., supracondylar femoral osteotomy), not arthrodesis. * **Coxa vara:** This refers to a decreased neck-shaft angle of the femur (<120°). Management usually involves a valgus subtrochanteric osteotomy (e.g., Pauwels' osteotomy) to realign the mechanical axis. * **Cubitus varus (Gunstock deformity):** A common late complication of supracondylar fractures of the humerus. The gold standard treatment is a lateral closing wedge osteotomy (French osteotomy). **Clinical Pearls for NEET-PG:** * **Radiological Hallmark of CVT:** The talus is vertically oriented, and the long axis of the talus fails to line up with the first metatarsal on a forced plantarflexion lateral X-ray. * **Reverse Clubfoot:** CVT is often called "reverse clubfoot" because the foot is in calcaneovalgus rather than equinovarus. * **Grice-Green Procedure:** Primarily indicated in children (usually ages 4–8) with paralytic or flexible flatfoot deformities to provide lateral column stability.

Q: All of the following are done for the management of clubfoot at birth EXCEPT?

Posteromedial soft tissue release. **Explanation:** The management of **Congenital Talipes Equinovarus (CTEV)**, or clubfoot, follows a strict chronological hierarchy, starting from non-operative methods at birth to surgical interventions if conservative management fails. **Why Option D is the Correct Answer:** **Posteromedial Soft Tissue Release (PMSTR)** is a major surgical procedure. In modern orthopaedics (following the **Ponseti method**), surgery is never the first-line treatment at birth. It is reserved for "resistant" cases or neglected clubfoot, typically performed between **6 to 12 months of age**. Performing an invasive surgery at birth is contraindicated due to the small size of the tarsal bones and the high success rate of conservative management. **Analysis of Incorrect Options:** * **A & B (Manipulation and Serial Casting):** These are the gold standard treatments initiated immediately after birth (ideally within the first week). The Ponseti technique involves gentle manual manipulation followed by long-leg serial casts applied weekly to gradually correct the components of the deformity. * **C (Recording the Deformity):** Objective assessment is crucial for monitoring progress. The **Pirani Scoring System** (0 to 6) or **Catterall/Dimeglio Score** is used at birth and during every follow-up to document improvement and decide if a tenotomy is required. **Clinical Pearls for NEET-PG:** * **Order of Correction (Ponseti):** Remember the mnemonic **CAVE** — **C**avus (corrected first), **A**dduction, **V**arus, and **E**quinus (corrected last). * **Percutaneous Achilles Tenotomy:** The most common minor surgical procedure in the Ponseti method, performed to correct residual Equinus after other components are addressed. * **Bracing:** After casting, a **Steenbeek foot abduction brace** (Dennis Browne splint) is used to prevent recurrence (23 hours/day for 3 months, then at night until age 4). * **Most common relapse:** Equinus deformity.

Q: Gallow's traction for fracture shaft femur is used in which of the following age groups?

< 2 years. **Explanation:** **Gallow’s traction** (also known as Bryant’s traction) is a specific type of skin traction used for the management of femoral shaft fractures in children. **Why Option A is correct:** The primary indication for Gallow’s traction is a child **under 2 years of age** (or weighing less than 12–15 kg). In this method, both legs are suspended vertically using skin traction such that the **buttocks are just lifted off the bed**. The child’s body weight acts as the counter-traction. This position is ideal for infants because it simplifies nursing care and prevents soaking of bandages with urine or feces. **Why other options are incorrect:** * **Options B, C, and D:** As a child grows older and heavier (>15 kg), the hydrostatic pressure required to maintain vertical traction can lead to **vascular compromise** (compartment syndrome or ischemia) of the feet. Furthermore, the increased muscle mass in older children makes skin traction insufficient to maintain reduction. For children aged 2–10 years, Thomas splint traction or flexible intramedullary nails are preferred, while older adolescents (>13 years) are treated similarly to adults with rigid nailing. **High-Yield Clinical Pearls for NEET-PG:** * **The "Lift" Rule:** The buttocks must be cleared off the mattress just enough to allow a hand to pass underneath. * **Complication:** The most dreaded complication is **ischemia** of the limb. Frequent neurovascular checks are mandatory. * **Alternative:** For children aged 2–6 years, **Hamilton-Russell traction** or a **90-90 traction** may be used before definitive casting or surgery. * **Immediate Spica:** In many modern protocols, an immediate 1.5-hip spica cast is preferred over traction if the fracture displacement is minimal.

Q: Frieberg osteochondritis is inflammation of which anatomical structure?

2nd metatarsal head. **Explanation:** **Freiberg’s Infraction (Osteochondritis)** is a form of avascular necrosis (AVN) affecting the metatarsal heads. It most commonly involves the **2nd metatarsal head (Option A)** because it is the longest and most rigid metatarsal, making it subject to repetitive microtrauma and excessive loading during the toe-off phase of walking. * **Why Option A is correct:** The 2nd metatarsal head is the classic site. It typically affects adolescent females (ratio 3:1) and presents with pain, swelling, and limited range of motion at the metatarsophalangeal (MTP) joint. * **Why Options B, C, and D are incorrect:** While other metatarsals can be affected (the 3rd metatarsal is the second most common), the **base** of the metatarsals is not the site of this specific osteochondritis. The 5th metatarsal base is a common site for **Iselin’s disease** (traction apophysitis) or Jones fractures, but not Freiberg’s. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in adolescent girls (13–18 years) who are physically active or wear high-heeled shoes. * **Radiological Sign:** Flattening and sclerosis of the metatarsal head (Smillie’s Classification is used for staging). * **Other Osteochondritis to Remember:** * **Kohler’s Disease:** Navicular bone. * **Panner’s Disease:** Capitellum of the humerus. * **Kienbock’s Disease:** Lunate bone. * **Sever’s Disease:** Calcaneal apophysis. * **Management:** Initial treatment is conservative (activity modification, stiff-soled shoes, or orthotics). Surgery is reserved for refractory cases.

Q: A 30-year-old male presents with his 3-year-old daughter who is crying. The father reports the child was swung by her forearm. What is the most probable diagnosis?

Pulled elbow. **Explanation:** **Correct Answer: D. Pulled Elbow (Nursemaid’s Elbow)** The clinical scenario describes a classic mechanism of injury for a **Pulled Elbow**: sudden longitudinal traction on an extended, pronated forearm (e.g., swinging or pulling a child by the hand). * **Pathophysiology:** In children under 5 years, the **annular ligament** is relatively lax. Sudden traction causes the radial head to slip partially out of the ligament, which then becomes trapped between the radial head and the capitellum (subluxation). * **Clinical Presentation:** The child typically holds the arm in a fixed position of **extension and pronation**, refusing to use it. There is usually no significant swelling or deformity. **Why Incorrect Options are Wrong:** * **A. Supracondylar Humerus Fracture:** Usually results from a fall on an outstretched hand (FOOSH). It presents with significant swelling, ecchymosis, and bony tenderness, which are absent here. * **B. Elbow Dislocation:** Rare in this age group; it requires high-energy trauma and presents with gross deformity and severe swelling. * **C. Stress Fracture:** These are chronic overuse injuries (e.g., in young athletes) and do not occur following a single acute traction event. **High-Yield Clinical Pearls for NEET-PG:** 1. **Age Group:** Most common between **1–4 years** (rare after age 5 as the annular ligament strengthens). 2. **Management:** Closed reduction via **Supination-Flexion maneuver** or the **Hyperpronation maneuver** (often preferred due to higher success rates). 3. **Post-reduction:** A characteristic "click" is felt, and the child typically resumes normal limb use within minutes. No immobilization or X-rays are required if the history is classic.

Q: Periosteal new bone formation is seen in which of the following conditions?

All of the above. **Explanation:** Periosteal new bone formation (periostitis) in children is a non-specific reaction to various stimuli, including inflammation, trauma, metabolic disorders, and genetic conditions. In this question, all three conditions listed are classic causes of pathological periosteal reactions. 1. **Caffey’s Disease (Infantile Cortical Hyperostosis):** This is a rare, self-limiting inflammatory disorder characterized by a triad of irritability, soft tissue swelling, and massive subperiosteal new bone formation. It typically involves the **mandible** (most common), ribs, and clavicles in infants under six months of age. 2. **Hypervitaminosis A:** Chronic Vitamin A toxicity leads to painful soft tissue swellings and cortical thickening. Unlike Caffey’s disease, it usually affects older children (over 1 year) and typically involves the **ulna and metatarsals**, sparing the mandible. 3. **Syphilis (Congenital):** Early congenital syphilis causes widespread osteochondritis and periostitis. A characteristic radiographic finding is **Wimberger’s sign** (localized erosion of the medial aspect of the proximal tibial metaphysis). **Clinical Pearls for NEET-PG:** * **Physiological Periostitis:** Common in infants (2–6 months); it is always bilateral, symmetrical, and involves the lateral aspect of the femoral shaft. * **Scurvy:** Periosteal reaction occurs only during the **healing phase** (due to subperiosteal hemorrhage calcification). * **Differential Diagnosis Tip:** If the mandible is involved, think **Caffey’s Disease**; if the mandible is spared in an older child with bone pain, consider **Hypervitaminosis A**.

Q: Kohler's disease is due to osteonecrosis of which bone?

Tarsal bone. **Explanation:** **Kohler’s disease** is a self-limiting condition characterized by **avascular necrosis (osteonecrosis) of the tarsal navicular bone**. It typically affects children between the ages of 3 and 7 years and is more common in boys. The navicular bone is the last bone of the foot to ossify; it is thought that mechanical compression of the bone before it is fully ossified leads to ischemia and subsequent necrosis. **Analysis of Options:** * **Option B (Correct):** The navicular bone is a **tarsal bone**. On X-ray, it appears flattened, sclerotic (increased density), and fragmented (the "wafer-like" appearance). * **Option A (Incorrect):** Osteochondrosis of the calcaneum is known as **Sever’s disease** (calcaneal apophysitis), a common cause of heel pain in adolescents. * **Option C (Incorrect):** While the talus can undergo avascular necrosis (often post-traumatic following a Hawkins fracture), it is not referred to as Kohler’s disease. * **Option D (Incorrect):** Osteonecrosis of the capitulum of the humerus is known as **Panner’s disease**, which typically affects the dominant elbow of young athletes. **High-Yield Clinical Pearls for NEET-PG:** 1. **Clinical Presentation:** Gradual onset of pain over the midfoot, swelling, and a characteristic limp (walking on the lateral edge of the foot). 2. **Radiology:** The navicular appears as a thin, dense, "silver-dollar" or "wafer-like" disc. 3. **Management:** Conservative treatment is the mainstay. Most cases resolve spontaneously with activity modification or a short-leg walking cast for 4–6 weeks. 4. **Prognosis:** Excellent; the bone usually reconstitutes completely without long-term deformity.

Q: All are true about congenital talipes equinovarus (CTEV) EXCEPT:

Talus is the only bone involved. **Explanation:** **1. Why Option A is the correct answer (The Exception):** Congenital Talipes Equinovarus (CTEV) is a complex **three-dimensional deformity** involving multiple bones and joints of the foot, not just the talus. While the talus is the "primary" bone affected (it is smaller, with a medially and plantarly deviated neck), the deformity involves the **calcaneus** (adducted and inverted), the **navicular** (medially displaced), and the **cuboid**. Therefore, stating the talus is the *only* bone involved is anatomically incorrect. **2. Analysis of other options:** * **Option B:** True. There is significant contracture of the **posterior** (Achilles tendon) and **medial** (Tibialis posterior, FDL, FHL) structures, leading to the characteristic equinus and varus. * **Option C:** True. The **Tibialis posterior** is the most severely contracted muscle. It acts like a "guy rope," pulling the navicular medially and maintaining the deformity. * **Option D:** True. The four components of CTEV are remembered by the mnemonic **CAVE**: **C**avus (midfoot), **A**dduction (forefoot), **V**arus (hindfoot/inversion), and **E**quinus (ankle). **Clinical Pearls for NEET-PG:** * **Gold Standard Treatment:** **Ponseti Method** (Serial casting). The order of correction is **CAV-E** (Cavus first, Equinus last). * **Pirani Score:** Used to assess the severity of CTEV (0 to 6 scale). * **Radiology:** The **Kite’s Angle** (talocalcaneal angle) is reduced in both AP and lateral views (Normal: 20–40°). * **Associated Conditions:** Always screen for Developmental Dysplasia of the Hip (DDH) and Spina Bifida in children with CTEV.

Question 1

Green extra-articular arthrodesis is done for which of the following conditions?

Accepted Answer

Congenital vertical talus

Answer

Genu valgum

Answer

Coxa vara

Answer

Cubitus varus

Question 2

All of the following statements are true about developmental dysplasia of the hip (DDH), except?

Accepted Answer

Twin pregnancy is a known risk factor.

Answer

It is more common in females.

Answer

Oligohydramnios is associated with a higher risk of DDH.

Answer

The hourglass appearance of the capsule may prevent a successful closed reduction.

Question 3

All of the following are done for the management of clubfoot at birth EXCEPT?

Accepted Answer

Posteromedial soft tissue release

Answer

Manipulation

Answer

Serial casting

Answer

Recording the deformity to see improvements serially

Question 4

Gallow's traction for fracture shaft femur is used in which of the following age groups?

Accepted Answer

< 2 years

Answer

3-6 years

Answer

7-13 years

Answer

> 13 years

Question 5

Frieberg osteochondritis is inflammation of which anatomical structure?

Accepted Answer

2nd metatarsal head

Answer

2nd metatarsal base

Answer

5th metatarsal head

Answer

5th metatarsal base

Question 6

A 30-year-old male presents with his 3-year-old daughter who is crying. The father reports the child was swung by her forearm. What is the most probable diagnosis?

Accepted Answer

Pulled elbow

Answer

Supracondylar humerus fracture

Answer

Elbow dislocation

Answer

Stress fracture

Question 7

In children, all are true regarding bone properties and injuries EXCEPT:

Accepted Answer

Comminuted fractures are common.

Answer

Dislocations are rare.

Answer

The periosteum is thick.

Answer

Bones are soft.

Question 8

Periosteal new bone formation is seen in which of the following conditions?

Accepted Answer

All of the above

Answer

Caffey’s disease

Answer

Hypervitaminosis A

Answer

Syphilis

Question 9

Kohler's disease is due to osteonecrosis of which bone?

Accepted Answer

Tarsal bone

Answer

Calcaneum

Answer

Talus

Answer

Humerus-Capitulum

Question 10

All are true about congenital talipes equinovarus (CTEV) EXCEPT:

Accepted Answer

Talus is the only bone involved

Answer

Posterior and medial tendons are involved

Answer

Tibialis posterior acts like a guy rope

Answer

Inversion and equinus are seen

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

On this page

Practice by Chapter

Want unlimited practice?