Pediatric Orthopaedics Practice Questions

Q: Vertebral plana is a finding in a child with which of the following conditions?

Eosinophilic granuloma. **Explanation:** **Vertebra Plana** (also known as Calvé disease) refers to the uniform collapse of a vertebral body, resulting in a thin, wafer-like or "pancake" appearance on a lateral X-ray, while the adjacent intervertebral discs remain preserved. **1. Why Eosinophilic Granuloma (EG) is correct:** Eosinophilic Granuloma is the most common cause of vertebra plana in children. It is the localized form of **Langerhans Cell Histiocytosis (LCH)**. The pathology involves the infiltration of the vertebral body by histiocytes, leading to focal bone destruction and subsequent collapse under physiological load. Despite the severe collapse, the neurological status usually remains intact, and the bone often has a remarkable capacity for partial reconstitution over time. **2. Why the other options are incorrect:** * **Hyperparathyroidism:** Typically presents with generalized osteopenia, subperiosteal bone resorption (classically in the phalanges), and "Brown tumors." It does not cause isolated, uniform vertebral collapse. * **Osteomalacia:** Characterized by defective mineralization of the osteoid. In the spine, it leads to "codfish vertebrae" (biconcave appearance due to pressure from the discs) rather than the flat, wafer-like collapse of vertebra plana. **3. High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad of Hand-Schüller-Christian disease (a form of LCH):** Exophthalmos, Diabetes Insipidus, and lytic bone lesions. * **Differential Diagnosis for Vertebra Plana:** Use the mnemonic **"COMPRESS"**: **C**alvé disease (EG), **O**steomyelitis (TB), **M**etastasis/Malignancy (Neuroblastoma/Leukemia), **P**seudotumor, **R**eticuloendotheliosis, **E**osinophilic Granuloma, **S**cheuermann's disease (rarely), **S**teroids. * **Radiological Sign:** The "Coin-on-edge" appearance is synonymous with vertebra plana in EG.

Q: A 13-year-old girl complains of backache and fatigue. Her mother has noticed that she is becoming increasingly round-shouldered. On examination, she has a smooth thoracic kyphosis. X-ray shows wedge-shaped vertebral bodies in the thoracic spine. What is the most likely diagnosis?

Scheuermann's disease. **Explanation:** The clinical presentation and radiological findings are classic for **Scheuermann’s Disease** (Juvenile Kyphosis). This condition typically affects adolescents (13–16 years) and presents with a "round-back" deformity, backache, and fatigue. **Why Scheuermann’s Disease is correct:** The hallmark of this condition is a structural thoracic kyphosis caused by anterior wedging of the vertebral bodies. The diagnosis is confirmed radiologically by **Sorensen’s Criteria**: 1. Anterior wedging of ≥5° in at least three adjacent vertebrae. 2. Kyphosis angle >40° (Cobb’s angle). 3. Presence of **Schmorl’s nodes** (herniation of the disc into the vertebral endplate) and irregular endplates. **Why other options are incorrect:** * **Ankylosing Spondylitis:** Typically presents in young adults (not 13-year-olds) with morning stiffness, sacroiliitis, and "bamboo spine" on X-ray. It is an inflammatory condition, not a structural wedging disorder. * **Intervertebral Disc Prolapse:** Presents with acute radicular pain (sciatica) and neurological deficits; it does not cause structural kyphosis or vertebral wedging. * **Spinal Stenosis:** A degenerative condition seen in the elderly, characterized by neurogenic claudication. It is extremely rare in a 13-year-old. **High-Yield Pearls for NEET-PG:** * **Clinical Sign:** Unlike postural kyphosis, Scheuermann’s is a **fixed** deformity; the curve does not disappear on hyperextension or Adam’s forward bend test. * **Site:** Most common in the thoracic spine (T7-T9). * **Management:** Bracing (Milwaukee brace) is indicated for curves between 50°–75° in skeletally immature patients. Surgery is considered if the curve exceeds 75°.

Q: Epiphyseal enlargement is seen in which of the following conditions?

All of the above. **Explanation:** Epiphyseal enlargement (widening of the bone ends) is a clinical and radiological sign that can result from metabolic, inflammatory, or infectious processes affecting the growth plate and surrounding joint structures. 1. **Rickets:** This is the most common metabolic cause. Due to a deficiency in Vitamin D, calcium, or phosphorus, there is a failure of osteoid mineralization. This leads to an accumulation of non-mineralized hypertrophic chondrocytes, causing the growth plate to thicken and the metaphysis to widen (cupping, splaying, and fraying). Clinically, this manifests as **widened wrists** and **double malleoli**. 2. **Scurvy:** Although not listed as a primary option, it is a common differential. However, in the context of this question, **Septic Arthritis** is a critical inflammatory cause. 3. **Septic Arthritis:** Acute infection of the joint space leads to inflammatory exudate and increased intra-articular pressure. This causes soft tissue swelling and can lead to apparent epiphyseal enlargement on examination. If chronic or severe, the hyperemia associated with inflammation can cause premature enlargement of the epiphysis (overgrowth) due to increased blood flow to the growth plate. **Clinical Pearls for NEET-PG:** * **Rickets:** Look for "Wrist widening" as the earliest clinical sign. Radiologically, the distance between the epiphysis and metaphysis increases. * **Scurvy:** Characterized by "Ground glass" osteoporosis and Wimberger’s ring sign (dense rim around the epiphysis), but the epiphysis itself does not widen in the same hypertrophic manner as Rickets. * **Differential Diagnosis of Epiphyseal Enlargement:** Includes Rickets, Septic Arthritis, Juvenile Idiopathic Arthritis (JIA), and Hemophilia (due to chronic hemarthrosis causing hyperemia).

Q: Sabre tibia is associated with:

Congenital syphilis. **Explanation:** **Sabre Tibia** is a classic clinical sign characterized by a sharp, anterior bowing of the tibia. It is a hallmark feature of **Late Congenital Syphilis** (manifesting after 2 years of age). **Why Congenital Syphilis is correct:** The deformity results from chronic **periostitis**. In congenital syphilis, the *Treponema pallidum* infection causes persistent inflammation of the periosteum. This leads to the deposition of new subperiosteal bone specifically along the anterior aspect of the tibial shaft, making it appear thickened and convex (resembling a "sabre" or curved sword). **Analysis of Incorrect Options:** * **Gonorrhea:** This is primarily a cause of neonatal conjunctivitis (ophthalmia neonatorum) or acute septic arthritis in adults; it does not cause chronic periosteal bone remodeling. * **Renal Osteodystrophy:** This leads to "Rugger-Jersey spine" and general osteopenia due to secondary hyperparathyroidism, but not specific anterior tibial bowing. * **Rickets:** While Rickets causes bowing of long bones, it typically results in **lateral bowing** (Genu varum) due to softening of the osteoid (osteomalacia), rather than the anterior cortical thickening seen in syphilis. **High-Yield Clinical Pearls for NEET-PG:** * **Hutchinson’s Triad (Late Syphilis):** Interstitial keratitis, Sensorineural hearing loss (8th nerve deafness), and Hutchinson’s teeth (notched incisors). * **Clutton’s Joints:** Painless, symmetrical hydrarthrosis (usually of the knee) seen in late congenital syphilis. * **Wimberger’s Sign:** Radiographic finding in early syphilis showing focal erosion of the medial aspect of the proximal tibial metaphysis. * **Differential Diagnosis:** Sabre tibia can also be seen in **Paget’s disease**, but in the context of pediatric orthopaedics and standard NEET-PG patterns, Congenital Syphilis is the primary association.

Q: Which of the following is NOT true regarding osteogenesis imperfecta?

Metaphyseal fractures are common.. **Explanation:** Osteogenesis Imperfecta (OI), also known as "Brittle Bone Disease," is a genetic disorder primarily caused by mutations in the **COL1A1** and **COL1A2** genes, leading to defective Type 1 collagen synthesis. **Why Option B is correct (The False Statement):** In Osteogenesis Imperfecta, the primary pathology is generalized bone fragility. The most common site for fractures is the **diaphysis** (shaft) of long bones. **Metaphyseal fractures** (specifically "corner fractures" or "bucket-handle fractures") are highly characteristic of **Non-Accidental Injury (Child Abuse)**, not OI. While OI patients can have fractures anywhere, the predilection for the metaphysis is a classic "distractor" used to differentiate OI from child abuse in exams. **Analysis of Incorrect Options:** * **Option A:** Diaphyseal fractures are indeed the hallmark of OI due to the cortical thinning and bowing of long bones. * **Option C:** The **Sillence Classification** is the gold standard for categorizing OI. It originally described four types (Type I: Mild/Blue sclera; Type II: Perinatal lethal; Type III: Severe deforming; Type IV: Moderate/Normal sclera). * **Option D:** Type 1 collagen is found in the sclera and dentin. Deficiencies lead to **blue sclera** (due to uveal tissue showing through thin collagen) and **dentinogenesis imperfecta** (opalescent teeth). **High-Yield Clinical Pearls for NEET-PG:** * **Inheritance:** Most common types are Autosomal Dominant. * **Radiology:** Look for "Zebra stripe sign" (post-bisphosphonate therapy), "Popcorn calcifications" at metaphyses, and "Wormian bones" in the skull. * **Treatment:** Medical management involves **Bisphosphonates** (e.g., Pamidronate) to increase bone density; surgical management involves **Sofield-Millar procedure** (multiple osteotomies and intramedullary nailing).

Q: A 3-year-old child presents with a complaint of limp. What is the most likely diagnosis?

Developmental dysplasia of the hip (DDH). ***Developmental dysplasia of the hip (DDH)*** - Most common cause of **painless limp** in toddlers aged **1-3 years**, presenting with **leg length discrepancy** and **asymmetric hip abduction**. - Radiological findings include **shallow acetabulum**, **lateral displacement of femoral head**, **disrupted Shenton's line**, and **elevated acetabular index**. *Septic arthritis* - Presents as an **acute febrile illness** with **severe hip pain**, **inability to bear weight**, and **systemic toxicity**. - Patient would appear **unwell** with **raised inflammatory markers** (CRP, ESR, WCC), which is not described here. *Slipped capital femoral epiphysis* - Typically occurs in **adolescents** aged **10-16 years**, especially those who are **obese** or have **endocrine disorders**. - Presents with **hip or knee pain** that worsens with activity, not typically seen in **3-year-olds**. *Perthes' disease* - Most commonly affects children aged **4-8 years**, with peak incidence around **5-6 years**. - Involves **avascular necrosis of femoral head** causing **progressive hip pain** and **restricted range of motion**, rare in **3-year-olds**.

Q: What is the ideal age for performing a Posterior Malleolar Stress Test (PMSTR)?

1 - 3 years. **Explanation:** The **Posterior Medial Soft Tissue Release (PMSTR)**, also known as the Turco procedure, is a comprehensive surgical intervention used for the management of **Congenital Talipes Equinovarus (CTEV)** or Clubfoot that has failed conservative management (Ponseti method). **Why 1–3 years is the ideal age:** The primary goal of PMSTR is to achieve a plantigrade foot by releasing tight ligaments, tendons, and joint capsules on the posterior and medial aspects of the foot. * **Before 1 year:** The tarsal bones are largely cartilaginous and small, making surgical stabilization difficult and increasing the risk of avascular necrosis or crush injuries to the cartilage. * **Between 1–3 years:** The bones have sufficient ossification to hold sutures and pins, yet the foot still possesses enough remodeling potential to adapt to the corrected position. This is the "sweet spot" for achieving a balanced, functional foot before significant adaptive bony changes occur. **Analysis of Incorrect Options:** * **A. Less than 1 year:** Conservative management (Ponseti casting) is the gold standard during this period. Surgery is avoided due to the small size of structures and the risk of damaging growth plates. * **C & D. 3–9 years:** Beyond the age of 3–4, the deformity becomes "neglected" or "relapsed" with significant bony changes. Soft tissue release alone is usually insufficient; these cases often require **bony procedures** (like Evans calcaneal osteotomy or Dwyer’s osteotomy) or salvage procedures (Triple Arthrodesis if >10–12 years). **High-Yield Clinical Pearls for NEET-PG:** * **Turco’s Incision:** A hockey-stick shaped incision used for PMSTR. * **Order of Correction in Ponseti:** CAVE (Cavus, Adduction, Varus, Equinus). * **Most common residual deformity:** Equinus (corrected by Percutaneous Achilles Tenotomy). * **Kite’s Angle:** Decreased in CTEV (on AP and Lateral X-rays).

Question 1

Nail-patella syndrome is characterized by which of the following?

Accepted Answer

Absent patella

Answer

Iliac horn

Answer

Sacral horn

Answer

Knee deformity

Question 2

Vertebral plana is a finding in a child with which of the following conditions?

Accepted Answer

Eosinophilic granuloma

Answer

Hyperparathyroidism

Answer

Osteomalacia

Answer

None of the above

Question 3

A 13-year-old girl complains of backache and fatigue. Her mother has noticed that she is becoming increasingly round-shouldered. On examination, she has a smooth thoracic kyphosis. X-ray shows wedge-shaped vertebral bodies in the thoracic spine. What is the most likely diagnosis?

Accepted Answer

Scheuermann's disease

Answer

Ankylosing spondylitis

Answer

Intervertebral disc prolapse

Answer

Spinal stenosis

Question 4

Perthes disease is treated by which of the following methods?

Accepted Answer

Supervised containment of the femoral head in the acetabulum

Answer

High dose of calcium with steroids

Answer

Total hip replacement

Answer

Relieving weight bearing

Question 5

Epiphyseal enlargement is seen in which of the following conditions?

Accepted Answer

All of the above

Answer

Rickets

Answer

Rickets

Answer

Septic arthritis

Question 6

Sabre tibia is associated with:

Accepted Answer

Congenital syphilis

Answer

Gonorrhea

Answer

Renal osteodystrophy

Answer

Rickets

Question 7

Which of the following is NOT true regarding osteogenesis imperfecta?

Accepted Answer

Metaphyseal fractures are common.

Answer

Diaphyseal fractures are common.

Answer

It is classified by the Sillence classification.

Answer

Scleral and dental abnormalities are present.

Question 8

A 3-year-old child presents with a complaint of limp. What is the most likely diagnosis?

Accepted Answer

Developmental dysplasia of the hip (DDH)

Answer

Septic arthritis

Answer

Slipped capital femoral epiphysis

Answer

Perthes' disease

Question 9

What is the ideal age for performing a Posterior Malleolar Stress Test (PMSTR)?

Accepted Answer

1 - 3 years

Answer

Less than 1 year

Answer

3 - 6 years

Answer

6 - 9 years

Question 10

What is the most common associated injury with a fracture of the medial epicondyle?

Accepted Answer

Elbow dislocation

Answer

Monteggia fracture-dislocation

Answer

Supracondylar humerus fracture

Answer

Vascular deficit

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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