Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics Indian Medical PG Practice Questions and MCQs

Question 51: Green extra-articular arthrodesis is done for which of the following conditions?

A. Genu valgum
B. Coxa vara
C. Congenital vertical talus (Correct Answer)
D. Cubitus varus

Explanation: **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.

Question 52: All of the following statements are true about developmental dysplasia of the hip (DDH), except?

A. It is more common in females.
B. Oligohydramnios is associated with a higher risk of DDH.
C. The hourglass appearance of the capsule may prevent a successful closed reduction.
D. Twin pregnancy is a known risk factor. (Correct Answer)

Explanation: **Explanation** Developmental Dysplasia of the Hip (DDH) is a spectrum of disorders ranging from mild acetabular dysplasia to frank dislocation. **Why Option D is the Correct Answer (The False Statement):** Contrary to common belief, **twin pregnancy is not an independent risk factor for DDH**. While overcrowding in the uterus is a risk factor, statistics show that the incidence of DDH in twins is actually lower than in singletons. This is likely because twins are often smaller in size and are more frequently born prematurely, which may reduce the mechanical stress on the hip joints during the final weeks of gestation. **Analysis of Other Options:** * **Option A (Females):** True. DDH is significantly more common in females (ratio approx. 8:1) due to the increased sensitivity of the female fetus to maternal **relaxin**, which causes ligamentous laxity. * **Option B (Oligohydramnios):** True. Reduced amniotic fluid leads to intrauterine crowding and restricted fetal movement, increasing mechanical pressure on the hips, which predisposes them to dislocation. * **Option C (Hourglass Capsule):** True. In chronic dislocations, the capsule stretches and becomes constricted in the middle by the **iliopsoas tendon**, creating an "hourglass" shape. This constriction acts as an anatomical block, often preventing the femoral head from being returned to the acetabulum via closed reduction. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Breech presentation (strongest risk factor), First-born child, Female sex, and Family history. * **Screening Tests:** **Barlow’s test** (dislocates a reducible hip) and **Ortolani’s test** (reduces a dislocated hip). * **Imaging:** Ultrasound is the investigation of choice before 4–6 months (alpha angle <60° is abnormal). X-rays are used after 6 months once the femoral head ossifies. * **Treatment:** **Pavlik Harness** is the gold standard for infants under 6 months.

Question 53: All of the following are done for the management of clubfoot at birth EXCEPT?

A. Manipulation
B. Serial casting
C. Recording the deformity to see improvements serially
D. Posteromedial soft tissue release (Correct Answer)

Explanation: **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.

Question 54: Gallow's traction for fracture shaft femur is used in which of the following age groups?

A. < 2 years (Correct Answer)
B. 3-6 years
C. 7-13 years
D. > 13 years

Explanation: **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.

Question 55: Frieberg osteochondritis is inflammation of which anatomical structure?

A. 2nd metatarsal head (Correct Answer)
B. 2nd metatarsal base
C. 5th metatarsal head
D. 5th metatarsal base

Explanation: **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.

Question 56: 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?

A. Supracondylar humerus fracture
B. Elbow dislocation
C. Stress fracture
D. Pulled elbow (Correct Answer)

Explanation: **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.

Question 57: In children, all are true regarding bone properties and injuries EXCEPT:

A. Dislocations are rare.
B. Comminuted fractures are common. (Correct Answer)
C. The periosteum is thick.
D. Bones are soft.

Explanation: In pediatric orthopaedics, the biomechanical properties of bone differ significantly from those of adults. Understanding these differences is crucial for NEET-PG. ### **Explanation of the Correct Answer** **Option B (Comminuted fractures are common) is FALSE.** Comminuted fractures (where bone breaks into multiple fragments) are **rare** in children. This is because pediatric bone is highly porous, less mineralized, and has a lower modulus of elasticity (it is "softer"). Instead of shattering under stress, pediatric bone tends to bend or buckle, leading to unique fracture patterns like **Greenstick** or **Torus (Buckle)** fractures. Comminution usually requires high-energy trauma, which the elastic nature of child bone often absorbs. ### **Analysis of Other Options** * **A. Dislocations are rare:** In children, the ligaments and joint capsules are functionally stronger than the adjacent growth plates (physes). Therefore, a traumatic force is more likely to cause a **physeal fracture** (Salter-Harris injury) than a joint dislocation. * **C. The periosteum is thick:** Children possess a very thick, osteogenic, and vascular periosteum. This acts as a "hinge" during fractures, aiding in reduction stability and facilitating rapid callus formation and remodeling. * **D. Bones are soft:** Due to lower mineral content and higher collagen ratios, pediatric bones are more ductile. This allows for significant **plastic deformation** (bowing) before a complete break occurs. ### **High-Yield Clinical Pearls for NEET-PG** * **Remodeling:** Children have a tremendous capacity for bone remodeling, especially if the fracture is near a physis and in the plane of joint motion. * **Heal Time:** Fractures heal much faster in children due to the active periosteum (e.g., a neonatal femur fracture heals in ~2-3 weeks). * **Overgrowth:** Fractures of the femoral shaft in children (age 2-10) can lead to limb length discrepancy due to compensatory hypervascularity stimulating the growth plate.

Question 58: Periosteal new bone formation is seen in which of the following conditions?

A. Caffey’s disease
B. Hypervitaminosis A
C. Syphilis
D. All of the above (Correct Answer)

Explanation: **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**.

Question 59: Kohler's disease is due to osteonecrosis of which bone?

A. Calcaneum
B. Tarsal bone (Correct Answer)
C. Talus
D. Humerus-Capitulum

Explanation: **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.

Question 60: All are true about congenital talipes equinovarus (CTEV) EXCEPT:

A. Talus is the only bone involved (Correct Answer)
B. Posterior and medial tendons are involved
C. Tibialis posterior acts like a guy rope
D. Inversion and equinus are seen

Explanation: **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.

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

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Cerebral Palsy: Orthopaedic Aspects

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Neuromuscular Disorders in Children

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Pediatric Bone and Joint Infections

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Limb Length Discrepancies

Practice Questions

Orthopedic Manifestations of Genetic Disorders

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