Pediatric Orthopaedics Practice Questions

Q: Which fracture in children is commonly associated with vascular injury?

Lower end of humerus. **Explanation:** The correct answer is **Lower end of humerus**, specifically the **Supracondylar fracture of the humerus**. This is the most common fracture in children (peaking at ages 5–8) and is notorious for its association with vascular complications. **Why it is correct:** In the common **extension-type** supracondylar fracture, the proximal fracture fragment is displaced anteriorly. This sharp edge can easily impinge upon or lacerate the **Brachial Artery**, which lies directly anterior to the distal humerus. This can lead to an absent radial pulse, and if left untreated, results in **Volkmann’s Ischemic Contracture (VIC)** due to compartment syndrome. **Why the other options are incorrect:** * **Lower end of radius:** While common (e.g., Colles' in adults or distal physeal injuries in children), it is rarely associated with major vascular injury; median nerve involvement is more common. * **Upper end of femur:** These are rare in children and are more significantly associated with **Avascular Necrosis (AVN)** of the femoral head due to disruption of the circumflex vessels, rather than acute limb-threatening vascular trauma. * **Upper end of radius:** Radial neck fractures in children are common, but they typically involve the radial nerve (posterior interosseous branch) rather than major arteries. **Clinical Pearls for NEET-PG:** * **Most common nerve injured:** Median nerve (specifically the **Anterior Interosseous Nerve**). * **Nerve injured in flexion-type:** Ulnar nerve. * **Gartland Classification** is used to grade these fractures. * **Pink Pulseless Hand:** A clinical scenario where the hand is perfused (capillary refill <2s) but the radial pulse is absent; it requires urgent orthopedic consultation. * **Deformity:** Malunion often leads to **Cubitus Varus** (Gunstock deformity).

Q: Which classification system is NOT used for Perthes' disease?

Salter Harris Classification. **Explanation:** The correct answer is **D. Salter-Harris Classification**. This system is used to categorize **physeal (growth plate) fractures** in children based on the involvement of the epiphysis, physis, and metaphysis. It is not used for Perthes' disease, which is an idiopathic avascular necrosis of the femoral head. **Analysis of other options:** * **Catterall Classification:** Based on the extent of involvement of the femoral head seen on AP and lateral X-rays. It divides the disease into four groups (I-IV) based on the size of the necrotic segment. * **Salter-Thompson Classification:** A simplified version of Catterall’s, focusing on the extent of the **subchondral fracture (crescent sign)**. Group A involves less than half the head, while Group B involves more than half. * **Stulberg Classification:** This is used to assess the **long-term prognosis** and end-stage morphology of the hip after the disease has run its course. It classifies the femoral head shape (spherical, ovoid, or flat) and its congruency with the acetabulum. **High-Yield Clinical Pearls for NEET-PG:** * **Herring (Lateral Pillar) Classification:** Currently the most popular prognostic system. It is based on the height of the lateral pillar of the capital femoral epiphysis during the fragmentation stage. * **Age of Onset:** Typically occurs in children aged 4–8 years; more common in boys. * **Earliest Sign:** The earliest radiographic sign is often a **widening of the joint space** or a small, dense epiphysis. * **Gage’s Sign:** A V-shaped radiolucency on the lateral side of the epiphysis (a "Head-at-risk" sign).

Q: Which of the following conditions is NOT associated with a bird-face appearance?

Scleroderma. **Explanation:** The "bird-face" appearance (micrognathia and retrognathia) is characterized by a receding chin and a prominent nose, typically resulting from the failure of normal mandibular development or restricted growth at the temporomandibular joint (TMJ). **Why Scleroderma is the Correct Answer:** Scleroderma (Systemic Sclerosis) is associated with a **"Mask-like" facies** or "Mousier facies." The skin becomes tight, shiny, and loses its folds. Characteristic features include microstomia (small mouth) and radial furrowing around the lips (Maussage sign), but it does not typically produce the skeletal retrognathia seen in bird-face appearance. **Analysis of Incorrect Options:** * **Bilateral TMJ Ankylosis:** If this occurs during the growth period (childhood), the mandible fails to grow forward and downward. This leads to severe retrognathia and a classic bird-face deformity. * **Treacher Collins Syndrome:** An autosomal dominant disorder of craniofacial development (1st and 2nd branchial arches). It presents with mandibular hypoplasia, malar hypoplasia, and downward-slanting palpebral fissures, creating a bird-like profile. * **Pierre Robin Syndrome:** A triad of micrognathia, glossoptosis (tongue falling back), and cleft palate. The underdeveloped mandible is a hallmark feature, leading to the bird-face look. **High-Yield Clinical Pearls for NEET-PG:** * **Bird-face appearance:** Think of conditions causing **Mandibular Hypoplasia.** * **Stickler Syndrome:** Another high-yield association with bird-face appearance and Pierre Robin sequence. * **Hallermann-Streiff Syndrome:** Also known as "Bird-headed dwarfism." * **Scleroderma:** Look for "Raynaud’s phenomenon" and "CREST syndrome" in the history to differentiate it from primary skeletal deformities.

Q: In a post-polio case, what is the likely result of an iliotibial tract contracture?

Flexion at the hip and the knee. **Explanation:** The **Iliotibial Tract (ITT)** is a thickened lateral portion of the fascia lata. Its anatomical orientation is crucial: it originates from the iliac crest, passes over the greater trochanter, and inserts into **Gerdy’s tubercle** on the lateral condyle of the tibia. Because the ITT lies **anterior to the axis of the hip** and **posterior to the axis of the knee** (when the knee is flexed beyond 30 degrees), a contracture leads to a characteristic deformity pattern. In post-polio residual paralysis (PPRP), the ITT often becomes tight due to muscle imbalances, resulting in: 1. **Flexion, Abduction, and External Rotation at the hip.** 2. **Flexion and Valgus deformity at the knee.** **Analysis of Options:** * **Option C (Correct):** The ITT acts as a tether. When contracted, it pulls the hip into flexion and abduction. At the knee, the insertion point pulls the joint into flexion and lateral rotation (valgus). * **Options A, B, and D (Incorrect):** These suggest extension. The ITT contracture is a classic cause of **flexion deformities**. It cannot cause extension because its shortened state prevents the joints from reaching a neutral or extended position. **Clinical Pearls for NEET-PG:** * **Ober’s Test:** Used to clinically diagnose a tight Iliotibial band/tract. * **Yount’s Fasciotomy:** A surgical procedure involving the excision of a segment of the ITT and lateral intermuscular septum to release these contractures. * **Deformity Triad:** In PPRP, ITT contracture is often associated with pelvic tilt and scoliosis due to the "short leg" effect and hip abduction.

Q: A six-year-old child presented with a gradually progressive valgus deformity at his right elbow for the past 3 years. He has a history of cast application for 6 weeks after a fall on an outstretched hand 3 years ago. What is the probable fracture that occurred?

Malunited lateral condylar fracture of the humerus. ### Explanation The correct answer is **Malunited lateral condylar fracture of the humerus**. **1. Why it is correct:** Lateral condyle fractures are "fractures of necessity" (usually requiring ORIF) because they are intra-articular and prone to non-union due to the pull of the extensor muscles and bathing in synovial fluid. If treated conservatively with a cast (as in this case), they often result in **non-union** or malunion. This leads to a cessation of growth on the lateral side of the distal humerus while the medial side continues to grow. This asymmetrical growth results in a **progressive cubitus valgus** deformity. **2. Why the other options are incorrect:** * **Malunited supracondylar fracture:** This is the most common pediatric elbow fracture. Malunion here typically results in **Cubitus Varus** (Gunstock deformity) due to coronal tilt, not progressive valgus. * **Posterior dislocation of the elbow:** While it can cause stiffness or heterotopic ossification, it does not typically result in a progressive angular deformity over years. * **Fracture of the medial condyle:** This is rare in children. If it leads to growth arrest or malunion, it would result in a **cubitus varus** deformity. **3. Clinical Pearls for NEET-PG:** * **Tardy Ulnar Nerve Palsy:** A classic complication of long-standing cubitus valgus (secondary to lateral condyle non-union). The ulnar nerve gets stretched over the medial epicondyle. * **Milch Classification:** Used for lateral condyle fractures (Type I: through the epiphysis; Type II: through the physis—most common). * **Progressive vs. Static:** Supracondylar malunion is a **static** deformity (occurs at the time of healing), whereas lateral condyle non-union causes a **progressive** deformity (due to growth plate disturbance).

Q: Type VI Salter-Harris (Rang) injury includes -

Perichondrial ring injury. **Explanation:** The **Salter-Harris classification** is the standard system for describing physeal (growth plate) injuries. While the original classification includes types I through V, **Rang’s modification** added **Type VI** to account for injuries involving the **perichondrial ring** (the Zone of Ranvier). **1. Why Option D is Correct:** Type VI (Rang) injury involves an avulsion or direct trauma to the peripheral portion of the physis, specifically the **perichondrial ring**. This structure is vital for the appositional (width-wise) growth of the physis. Damage here often leads to the formation of a **peripheral bony bridge**, resulting in significant angular deformities (e.g., valgus or varus) rather than simple limb shortening. **2. Analysis of Incorrect Options:** * **Option A:** This describes a variant of physeal injury but does not fit the specific definition of Rang’s Type VI. * **Option B:** This describes **Ogden’s Type VII** (isolated injury to the epiphyseal plate) or **Type IX** (injury to the periosteum), or a severe open injury. It is not part of the Rang classification. * **Option C:** **Thurston Holland’s sign** is a classic radiological feature of **Salter-Harris Type II** injuries. It refers to the triangular metaphyseal fragment that remains attached to the epiphysis. **Clinical Pearls for NEET-PG:** * **Salter-Harris Type II** is the **most common** type of physeal injury. * **Salter-Harris Type V** (compression injury) has the **worst prognosis** due to the high risk of premature physeal closure. * **Mnemonic for Salter-Harris (SALTR):** * **S**ame (Type I: Slipped) * **A**bove (Type II: Metaphysis) * **L**ower (Type III: Epiphysis) * **T**hrough (Type IV: Metaphysis + Epiphysis) * **R**ammed (Type V: Ruined/Crushed) * **Rang’s Type VI** is often caused by lawnmower injuries or heavy machinery accidents involving the side of the joint.

Q: Which of the following terms is synonymous with Blount's disease?

Infantile Tibia Vara. **Explanation:** **Blount’s Disease** is a developmental disorder characterized by disordered endochondral ossification of the medial aspect of the proximal tibial physis. This leads to a progressive varus deformity (bowing) of the legs. 1. **Why the correct answer is right:** The term **Infantile Tibia Vara** is synonymous with the early-onset form of Blount's disease (typically appearing between ages 2–5). It is the most common presentation of the condition. The underlying pathology involves excessive compressive forces across the medial growth plate, leading to growth suppression (Heuter-Volkmann Law) and subsequent medial tibial beaking. 2. **Why the incorrect options are wrong:** * **Genu Valgum:** This refers to "knock-knees," where the knees angle in and the ankles are apart. Blount’s disease causes Genu Varum (bow-legs). * **Genu Recurvatum:** This refers to hyperextension of the knee joint, which is not the primary deformity in Blount’s. * **Adolescent Tibia Vara:** While this is a form of Blount's disease (late-onset), it is not considered a *synonym* for the disease as a whole. "Tibia Vara" is the general clinical term, but "Infantile Tibia Vara" is the classic synonym used in textbooks to describe the primary entity. **High-Yield Clinical Pearls for NEET-PG:** * **Radiographic Hallmark:** The **Drennan’s Metaphyseal-Diaphyseal Angle (MDA)**. An angle **>16°** is highly suggestive of Blount’s rather than physiologic bowing. * **Langenskiöld Classification:** Used to stage the severity based on the degree of metaphyseal depression and epiphyseal changes (Stages I-VI). * **Risk Factors:** Early walking, obesity, and African-American ethnicity. * **Treatment:** Bracing (KAFO) is effective for Stage I-II in children <3 years; surgical osteotomy is required for advanced stages or older children.

Q: Absent or hypoplastic radius is a characteristic feature of which of the following conditions?

Holt-Oram syndrome. **Explanation:** **1. Why Holt-Oram Syndrome is Correct:** Holt-Oram syndrome, also known as **Heart-Hand Syndrome**, is an autosomal dominant disorder characterized by upper limb deformities and congenital heart defects. The hallmark orthopedic feature is **radial ray deficiency**, which ranges from a triphalangeal thumb to complete **aplasia (absence) or hypoplasia of the radius**. This typically presents as a "radial club hand." The most common associated cardiac defect is an Atrial Septal Defect (ASD), specifically the ostium secundum type. **2. Analysis of Incorrect Options:** * **Spondyloepiphyseal dysplasia (SED):** This is a primary disorder of bone growth affecting the vertebrae (spine) and the epiphyses of long bones, leading to short-trunk dwarfism. It does not typically involve radial deficiency. * **Chondrodysplasia punctata:** Characterized by "stippled epiphyses" (calcifications) on X-ray. While it involves limb shortening (rhizomelia), it is not specifically associated with an absent radius. * **Cornelia de Lange syndrome:** While this syndrome involves limb abnormalities (like micromelia or oligodactyly), the classic presentation is characterized by "synophrys" (monobrow), hirsutism, and intellectual disability rather than isolated radial ray defects. **3. High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic for Radial Ray Defects (VACTERL):** **V**ertebral, **A**nal atresia, **C**ardiac, **T**racheo-**E**sophageal fistula, **R**enal, and **L**imb (Radial) defects. * **TAR Syndrome:** Thrombocytopenia-Absent Radius. **Crucial distinction:** In TAR syndrome, the **thumb is present**, whereas in Holt-Oram and Fanconi Anemia, the thumb is usually absent or hypoplastic. * **Fanconi Anemia:** Always rule this out in a child with radial hypoplasia by checking for pancytopenia and café-au-lait spots.

Question 1

Which fracture in children is commonly associated with vascular injury?

Accepted Answer

Lower end of humerus

Answer

Lower end of radius

Answer

Upper end of femur

Answer

Upper end of radius

Question 2

Which classification system is NOT used for Perthes' disease?

Accepted Answer

Salter Harris Classification

Answer

Catterall classification

Answer

Salter Thompson classification

Answer

Stulberg classification

Question 3

A one-and-a-half-year-old child fell while holding her father's hand. She subsequently cried and held her forearm in a pronated position, refusing to move the affected extremity. What is the most appropriate management at this stage?

Accepted Answer

Supinate the forearm

Answer

Examine the child under general anesthesia

Answer

Elevate the limb and observe

Answer

Investigate for osteomyelitis

Question 4

Which of the following conditions is NOT associated with a bird-face appearance?

Accepted Answer

Scleroderma

Answer

Bilateral temporomandibular joint ankylosis

Answer

Treacher Collins syndrome

Answer

Pierre Robin syndrome

Question 5

In a post-polio case, what is the likely result of an iliotibial tract contracture?

Accepted Answer

Flexion at the hip and the knee

Answer

Extension at the hip and knee

Answer

Extension at the hip

Answer

Extension at the knee

Question 6

A six-year-old child presented with a gradually progressive valgus deformity at his right elbow for the past 3 years. He has a history of cast application for 6 weeks after a fall on an outstretched hand 3 years ago. What is the probable fracture that occurred?

Accepted Answer

Malunited lateral condylar fracture of the humerus

Answer

Malunited supracondylar fracture of the humerus

Answer

Posterior dislocation of the elbow

Answer

Fracture of the medial condyle of the humerus

Question 7

Type VI Salter-Harris (Rang) injury includes -

Accepted Answer

Perichondrial ring injury

Answer

Transverse fracture of metaphysis with longitudinal extension into physis

Answer

Open injury with loss of physis

Answer

Thurston Holland's sign

Question 8

In a newborn child, abduction and internal rotation producing a click sound is indicative of which sign?

Accepted Answer

Ortolani's sign

Answer

Telescoping sign

Answer

Lachman's sign

Answer

Mc Murray's sign

Question 9

Which of the following terms is synonymous with Blount's disease?

Accepted Answer

Infantile Tibia Vara

Answer

Genu Valgum

Answer

Genu Recurvatum

Answer

Adolescent tibia vara

Question 10

Absent or hypoplastic radius is a characteristic feature of which of the following conditions?

Accepted Answer

Holt-Oram syndrome

Answer

Spondyloepiphyseal dysplasia

Answer

Chondrodysplasia punctata

Answer

Cornelia de Lange syndrome

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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