Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics Indian Medical PG Practice Questions and MCQs

Question 71: Osteochondritis of the epiphysis of the head of the femur is known as which of the following conditions?

A. Panner's disease
B. Kienbock's disease
C. Legg-Calvé-Perthes disease (Correct Answer)
D. Osgood-Schlatter disease

Explanation: ### Explanation **Correct Answer: C. Legg-Calvé-Perthes disease** **Legg-Calvé-Perthes disease (LCPD)** is an idiopathic avascular necrosis (osteochondritis) of the capital femoral epiphysis. It typically affects children between 4 and 10 years of age and is characterized by a temporary loss of blood supply to the femoral head, leading to bone infarction, collapse, and subsequent remodeling. Clinically, it presents as a painless limp or hip/knee pain with restricted abduction and internal rotation. **Analysis of Incorrect Options:** * **A. Panner’s disease:** This is osteochondritis of the **capitellum** of the humerus, usually seen in young athletes (throwers) aged 5–10 years. * **B. Kienbock’s disease:** This refers to avascular necrosis of the **lunate** bone in the wrist, typically seen in adults rather than the pediatric population. * **C. Osgood-Schlatter disease:** This is a traction apophysitis of the **tibial tuberosity** caused by repetitive strain from the quadriceps tendon, common in adolescent athletes. **High-Yield Clinical Pearls for NEET-PG:** * **Radiological Stages:** Waldenström classification (Initial, Fragmentation, Reossification, and Healed). * **Gage’s Sign:** A V-shaped lucency on the lateral side of the epiphysis (a "Head-at-risk" sign). * **Catterall Classification:** Used to grade the extent of femoral head involvement. * **Management Goal:** "Containment" of the femoral head within the acetabulum to ensure it heals in a spherical shape, preventing early-onset osteoarthritis. * **Prognosis:** The most important prognostic factor is the **age at onset**; younger children (<6 years) have a better prognosis due to higher remodeling potential.

Question 72: Dennis Brown splint is used for which condition?

A. Congenital Talipes Equinovarus (CTEV) (Correct Answer)
B. Rocker bottom foot
C. Manus valgus
D. Manus varus

Explanation: **Explanation:** **Denis Browne Splint (DB Splint)** is a classic orthotic device used in the maintenance phase of **Congenital Talipes Equinovarus (CTEV)** treatment. After the deformity is corrected—typically via the Ponseti method of serial casting—the DB splint is used to maintain the correction and prevent relapse. It consists of two metal shoes attached to a spreader bar, which holds the feet in **70° of external rotation** and **15° of dorsiflexion**. **Analysis of Options:** * **A. CTEV (Correct):** The splint maintains the corrected position of the foot, specifically addressing the adduction and inversion components of the deformity. * **B. Rocker Bottom Foot:** This is a complication of over-correction in CTEV (breaking the midfoot) or seen in Congenital Vertical Talus (CVT). A DB splint would be contraindicated here as it could worsen the deformity. * **C & D. Manus Valgus/Varus:** These refer to wrist/hand deformities (e.g., Radial or Ulnar club hand). The DB splint is strictly a lower-limb orthosis. **Clinical Pearls for NEET-PG:** * **Protocol:** In CTEV, the splint is worn 23 hours a day for the first 3 months, then only at night/nap time until the child is 4 years old. * **The "Kick" Factor:** The bar allows the child to kick their legs, which helps in stretching the gastro-soleus complex and maintaining dorsiflexion. * **CTE Deformity Components (CAVE):** **C**avirus, **A**dduction, **V**arus, and **E**quinus. * **CTE Correction Sequence:** The order of correction is **A-V-E** (Adduction, then Varus, then Equinus). Cavus is corrected first by aligning the forefoot with the hindfoot.

Question 73: Which of the following is the most sensitive clinical sign for the detection of developmental dysplasia of the hip (DDH) in a 6-month-old infant?

A. Galeazzi test
B. Asymmetric skin folds in the thighs
C. Limited hip abduction in flexion (Correct Answer)
D. Ortolani's test

Explanation: **Explanation:** The clinical presentation of Developmental Dysplasia of the Hip (DDH) changes significantly as the infant grows. In a **6-month-old infant**, the hip has often become "fixed" in a dislocated position, leading to soft tissue contractures (specifically of the adductor muscles). Therefore, **Limited hip abduction in flexion** becomes the **most sensitive** and reliable clinical sign. **Analysis of Options:** * **Limited hip abduction (Correct):** By 6 months, the capsule tightens and adductors shorten. A difference of $20^\circ$ or more between sides, or abduction less than $60^\circ$, is highly suggestive of DDH. * **Ortolani’s test:** This is the most important test for a **neonate** (0–3 months) to detect a dislocated hip that is reducible. By 6 months, the hip is often no longer reducible due to soft tissue changes, making this test negative (False negative). * **Galeazzi test:** This detects limb length discrepancy (apparent shortening of the femur). While useful, it is a sign of unilateral dislocation and can be negative in bilateral cases, making it less sensitive than limited abduction. * **Asymmetric skin folds:** This is a common finding but is highly **non-specific**, as it occurs in many normal infants. **High-Yield Clinical Pearls for NEET-PG:** * **Age < 3 months:** Use **Ortolani** (reduction) and **Barlow** (provocative) tests. * **Age > 3–6 months:** Limited abduction is the hallmark. * **Radiology:** Ultrasound is the investigation of choice before 6 months (Graf classification). X-rays are used after 6 months (once the femoral head ossifies), looking for **Hilgenreiner’s line**, **Perkin’s line**, and **Shenton’s line** disruption. * **Treatment:** **Pavlik harness** is the gold standard for infants < 6 months.

Question 74: Which of the following is NOT a radiological sign of Perthes' disease?

A. Widening of joint space
B. Lateral subluxation of femur head
C. Rotting picket fence appearance of femur neck
D. Epiphyseal calcification (Correct Answer)

Explanation: ### Explanation **Legg-Calvé-Perthes Disease (LCPD)** is an idiopathic avascular necrosis of the proximal femoral epiphysis in children. The radiological features follow the progression of ischemia, revascularization, and remodeling. **Why "Epiphyseal calcification" is the correct answer:** In Perthes' disease, the primary pathology is **osteonecrosis**, which leads to a **decrease in the size** and an **increase in the density** (sclerosis) of the femoral head epiphysis. It does not present as "calcification" (which implies new mineral deposition in soft tissue); rather, it shows fragmentation and eventual ossification during the healing phase. **Analysis of other options:** * **Widening of joint space:** This is often the earliest radiological sign (Waldenström's sign), caused by synovitis and thickening of the articular cartilage. * **Lateral subluxation of femur head:** As the disease progresses, the femoral head may move laterally out of the acetabulum (Gage’s sign), which is a poor prognostic indicator. * **Rotting picket fence appearance:** This refers to the irregular, jagged appearance of the femoral neck metaphysis due to cysts and remodeling during the fragmentation stage. **Clinical Pearls for NEET-PG:** * **Demographics:** Most common in boys aged 4–8 years; usually unilateral. * **Early Sign:** Crescent sign (subchondral fracture). * **Head at Risk Signs (Catterall):** Gage’s sign, calcification lateral to the epiphysis, lateral subluxation, and horizontal growth plate. * **Classification:** Waldenström (Radiographic stages), Catterall (Extent of involvement), and Herring (Lateral pillar classification—most prognostic). * **Management:** The goal is "Containment" of the femoral head within the acetabulum using braces (e.g., Atlanta brace) or surgery (e.g., Salter osteotomy).

Question 75: Which one of the following is the investigation of choice for evaluation of suspected Perthes' disease?

A. Plain X-ray
B. Ultrasonography (US)
C. Computed Tomography (CT)
D. Magnetic Resonance Imaging (MRI) (Correct Answer)

Explanation: **Explanation:** **Legg-Calvé-Perthes Disease (LCPD)** is an idiopathic avascular necrosis (AVN) of the capital femoral epiphysis in children. **Why MRI is the Investigation of Choice:** MRI is the most sensitive imaging modality for Perthes' disease. It is the **investigation of choice** because it can detect early ischemic changes in the femoral head (marrow edema and perfusion defects) long before they become visible on plain radiographs. It is also superior for evaluating the extent of necrosis, revascularization, and the "containment" of the femoral head within the acetabulum. **Analysis of Other Options:** * **Plain X-ray:** Usually the **initial** investigation. While it shows classic signs like the "Crescent sign" (subchondral fracture) or fragmentation in later stages, it may appear normal in the early (ischemic) phase. * **Ultrasonography (US):** Useful for detecting joint effusion (synovitis) but cannot evaluate the bony architecture or necrosis of the femoral head effectively. * **Computed Tomography (CT):** Excellent for viewing cortical bone and complex fractures, but it involves high radiation and is less sensitive than MRI for early soft tissue and marrow changes in AVN. **Clinical Pearls for NEET-PG:** * **Age Group:** Typically affects children aged 4–8 years (Male > Female). * **Clinical Presentation:** Painless limp or hip/knee pain with restricted abduction and internal rotation. * **Early X-ray Sign:** Increased joint space (Waldenström’s sign) and smaller epiphysis. * **Gage’s Sign:** A V-shaped lucency on the lateral side of the epiphysis (a "head-at-risk" sign). * **Bone Scan:** Historically used for early diagnosis if MRI was unavailable, showing a "cold spot" in the femoral head.

Question 76: A 4-year-old child presents with a history of a fall on the left forearm, resulting in a fracture on the dorsal surface of the mid-radius. What is the best treatment?

A. Immobilize with plaster of Paris (POP)
B. Open reduction and internal fixation
C. K-wire fixation
D. Break the cortex on the other side and immobilize with POP (Correct Answer)

Explanation: ### Explanation The clinical scenario describes a **Greenstick fracture**, a common pediatric injury where the bone bends and cracks but does not break completely through. In this case, the fracture occurs on the dorsal surface (convex side), while the volar cortex remains intact but bowed. **1. Why Option D is Correct:** The intact cortex in a greenstick fracture acts like a "hinge" or a spring. If the fracture is simply reduced and casted, the elastic recoil of the intact cortex often leads to a **recurrence of the deformity** within the cast. To ensure a stable reduction and prevent malunion, the surgeon must "complete the fracture" by breaking the intact cortex on the opposite side. This converts the unstable greenstick fracture into a stable, complete fracture that can then be effectively immobilized in a neutral position with a **Plaster of Paris (POP) cast**. **2. Why Other Options are Incorrect:** * **Option A:** Simple immobilization without completing the fracture carries a high risk of the bone springing back into its original deformed position due to the tension in the intact cortex. * **Options B & C:** Pediatric fractures have excellent remodeling potential and thick periosteum. Surgical interventions like Open Reduction Internal Fixation (ORIF) or K-wire fixation are generally reserved for displaced intra-articular fractures or unstable physeal injuries, not simple mid-shaft greenstick fractures. **3. Clinical Pearls for NEET-PG:** * **Greenstick vs. Torus (Buckle) Fracture:** Greenstick involves a break in one cortex; Torus is a compression injury where the cortex "buckles" but does not break. Torus fractures are stable and do not require breaking the other cortex. * **Remodeling:** Children have a thick, osteogenic periosteum. The closer the fracture is to the physis (growth plate), the better the remodeling potential. * **Plastic Deformation:** A unique pediatric condition where the bone bows without any visible cortical break on X-ray; it also requires forceful correction.

Question 77: Breech presentation is a risk factor for which of the following conditions?

A. Congenital Talipes Equinovarus (CTEV)
B. Slipped Capital Femoral Epiphysis (SCFE)
C. Developmental Dysplasia of the Hip (DDH) (Correct Answer)
D. Pehhe's disease

Explanation: **Explanation:** **Developmental Dysplasia of the Hip (DDH)** is the correct answer because breech presentation is one of the strongest clinical risk factors for this condition. In a breech position, the fetal hips are often acutely flexed with the knees extended (frank breech), which puts significant mechanical strain on the hip joint. This position stretches the hip capsule and forces the femoral head out of the acetabulum, leading to instability or dislocation. **Analysis of Options:** * **CTEV (Clubfoot):** While the exact etiology is multifactorial (including genetic and intrauterine packing), breech presentation is not a primary specific risk factor compared to DDH. * **SCFE:** This typically occurs in obese adolescents (10–16 years) due to hormonal changes and mechanical shear stress at the growth plate. It is not related to birth presentation. * **Perthes Disease:** This is an idiopathic avascular necrosis of the femoral head seen in children aged 4–8 years. Its etiology is related to vascular compromise, not intrauterine positioning. **High-Yield Clinical Pearls for NEET-PG:** * **The "6 F's" Risk Factors for DDH:** **F**irst-born, **F**emale (8:1 ratio), **F**oot first (Breech), **F**amily history, **F**luid deficiency (Oligohydramnios), and **F**lexibility (Ligamentous laxity). * **Screening:** Any female infant born in the breech position should undergo a mandatory screening ultrasound of the hips at 4–6 weeks, even if the clinical exam is normal. * **Clinical Tests:** Ortolani (reduction) and Barlow (dislocation) maneuvers are gold standards for neonatal diagnosis. * **Left Hip:** The left hip is more commonly involved (60%) due to the common Left Occiput Anterior (LOA) fetal position, where the left hip is pressed against the mother's sacrum.

Question 78: Congenital Dislocation of Hip (CDH) classically occurs due to?

A. Small femoral head epiphysis
B. Abnormal angle of the femoral neck
C. Hypertrophied ligamentum teres
D. Developmental acetabular dysplasia (Correct Answer)

Explanation: **Explanation:** **Developmental Dysplasia of the Hip (DDH)**, formerly known as CDH, is primarily a failure of the normal development of the acetabulum. The fundamental pathology is **acetabular dysplasia**, where the acetabulum is shallow, steep, and fails to provide adequate coverage for the femoral head. This lack of structural containment allows the femoral head to displace superiorly and posteriorly. **Analysis of Options:** * **Option D (Correct):** The primary defect is the malformation of the acetabular roof. In utero or early infancy, if the femoral head does not sit deeply within the acetabulum, the stimulus for the socket to deepen is lost, leading to persistent dysplasia and eventual dislocation. * **Option A:** A small femoral head epiphysis is a *sequela* (result) of the dislocation due to delayed ossification, not the primary cause. * **Option B:** While an increased angle of anteversion is often seen in DDH, it is considered a secondary adaptive change rather than the initiating cause of the dislocation. * **Option C:** A hypertrophied ligamentum teres is an **intracapsular obstacle** that prevents successful reduction of a dislocated hip, but it develops only after the head has already left the socket. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** First-born, Female (8:1 ratio), Frank breech presentation, Family history, and Fluid (Oligohydramnios). * **Clinical Signs:** **Ortolani test** (reduces the hip/“clunk in”) and **Barlow test** (dislocates the hip/“clunk out”). * **Radiological Markers:** Look for **Hilgenreiner’s line**, **Perkin’s line**, and a broken **Shenton’s line**. * **Treatment:** **Pavlik Harness** is the gold standard for infants <6 months. For 6 months to 2 years, closed reduction and Spica casting are preferred.

Question 79: Radial club hand is characterized by which of the following skeletal abnormalities?

A. Absence of the ulna
B. Absence of the radius (Correct Answer)
C. Absence of carpal bones
D. Absence of the humerus

Explanation: **Explanation:** **Radial Club Hand (Radial Longitudinal Deficiency)** is a congenital longitudinal deficiency characterized by the partial or complete **absence of the radius**. This leads to a lack of support on the lateral side of the forearm, causing the hand to deviate radially (towards the thumb side), resulting in a "club-like" appearance. * **Why Option B is Correct:** The hallmark of this condition is the hypoplasia or total absence of the radius. This skeletal deficiency causes the forearm to be short and the wrist to be unstable, leading to a characteristic radial deviation. * **Why Options A, C, and D are Incorrect:** * **Absence of the ulna:** This characterizes **Ulnar Club Hand**, which is much rarer than radial club hand and typically involves ulnar deviation of the hand. * **Absence of carpal bones:** While some carpal bones (like the scaphoid or trapezium) may be delayed in ossification or absent in radial club hand, the primary defining skeletal abnormality is the radius itself. * **Absence of the humerus:** This refers to **Phocomelia** (seal-like limbs), often associated historically with Thalidomide use, rather than a localized club hand deformity. **High-Yield Clinical Pearls for NEET-PG:** * **Associated Anomalies:** Radial club hand is frequently associated with the **VACTERL** association and **TAR syndrome** (Thrombocytopenia Absent Radius). *Note: In TAR syndrome, the thumb is usually present, whereas in isolated radial club hand, the thumb is often absent.* * **Most Common Type:** Type IV (Complete absence of the radius) is the most common presentation. * **Muscle Involvement:** The **Brachioradialis** and **Extensor Carpi Radialis** muscles are often absent or fibrotic. * **Treatment:** Initial management involves stretching and splinting; surgical "centralization" or "radialization" of the carpus over the ulna is performed later to improve function.

Question 80: Which one of the following is the investigation of choice for evaluation of suspected Phes' disease?

A. Plain X-ray
B. Ultrasonography (US)
C. Computed Tomography (CT)
D. Magnetic Resonance Imaging (MRI) (Correct Answer)

Explanation: **Explanation:** **Perthes’ disease** (Legg-Calvé-Perthes disease) is an idiopathic avascular necrosis (AVN) of the capital femoral epiphysis in children. **Why MRI is the Investigation of Choice:** MRI is the most sensitive imaging modality for the early diagnosis of Perthes’ disease. It can detect changes in bone marrow signal and perfusion deficits (ischemia) long before any findings appear on a plain radiograph. It is essential for identifying the "pre-radiographic" stage (Stage I) and is superior in assessing the extent of necrosis and the integrity of the articular cartilage. **Analysis of Incorrect Options:** * **Plain X-ray:** While usually the first investigation performed, it often appears normal in the early stages of the disease. It only shows changes (like increased density or fragmentation) once significant bone remodeling has occurred. * **Ultrasonography (US):** Useful for detecting joint effusion (synovitis) in a "irritable hip," but it cannot visualize the internal bony architecture or confirm necrosis. * **Computed Tomography (CT):** CT is excellent for viewing cortical bone and collapse in late stages but lacks the soft tissue and marrow sensitivity required for early diagnosis compared to MRI. **Clinical Pearls for NEET-PG:** * **Age Group:** Typically affects children aged 4–8 years; more common in boys (4:1 ratio). * **Earliest Sign on X-ray:** "Caffey’s Resorption Sign" (subchondral fracture line). * **Gage’s Sign:** A V-shaped lucency on the lateral side of the epiphysis (a poor prognostic sign). * **Prognosis:** The most important prognostic factor is the **age at onset** (younger children <6 years have a better prognosis). * **Classification:** Catterall (extent of involvement) and Herring Lateral Pillar (height of the lateral part of the epiphysis) are commonly used for staging and prognosis.

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

Practice Questions

Neuromuscular Disorders in Children

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Pediatric Bone and Joint Infections

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Limb Length Discrepancies

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Orthopedic Manifestations of Genetic Disorders

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