Pediatric Orthopaedics Practice Questions

Q: The classical flexion and rotation deformities at hip and knee joints, as a sequela of poliomyelitis, are due to the contracture of which muscle?

Tensor fascia lata. **Explanation:** The **Tensor Fascia Lata (TFL)** and the associated **Iliotibial Band (ITB)** are the primary culprits behind the classic triad of deformities seen in the lower limbs of poliomyelitis patients. **Why Tensor Fascia Lata is correct:** The TFL originates from the iliac crest and inserts into the ITB, which crosses both the hip and knee joints. Due to its anatomical orientation, contracture of the TFL/ITB complex exerts a multi-planar pull leading to: 1. **At the Hip:** Flexion, Abduction, and External Rotation. 2. **At the Knee:** Flexion and Valgus deformity (due to its insertion on Gerdy’s tubercle). 3. **At the Pelvis:** Pelvic obliquity and exaggerated lumbar lordosis. **Why other options are incorrect:** * **Gastrocnemius & Tendo Achilles:** Contracture of these structures primarily results in **Equinus deformity** at the ankle. While they cross the knee, they do not cause the characteristic hip rotation/flexion triad. * **Hamstrings:** While hamstring contracture leads to knee flexion, it does not typically cause the specific external rotation and abduction deformities at the hip associated with polio sequelae. **Clinical Pearls for NEET-PG:** * **Ober’s Test:** Used clinically to identify ITB/TFL contracture. * **Soutter’s Release:** A surgical procedure involving the transverse incision of the fascia lata and muscle release to correct these hip deformities. * **Yount’s Procedure:** Specifically targets the distal ITB to correct knee flexion and valgus deformities. * **Key Triad:** Remember the "Polio Hip" is characterized by **Flexion, Abduction, and External Rotation.**

Q: What is the most likely diagnosis in a 23-year-old, mentally alert dwarf with disproportionate arm and leg to body growth, prominent forehead, and retruded maxilla?

Achondroplasia. **Explanation:** The clinical presentation described is characteristic of **Achondroplasia**, the most common cause of disproportionate short-limb dwarfism. It is an autosomal dominant condition caused by a gain-of-function mutation in the **FGFR3 gene**, which inhibits chondrocyte proliferation at the epiphyseal plate. **Why Achondroplasia is correct:** * **Disproportionate Growth:** Characterized by **rhizomelic shortening** (proximal segments like arms and legs are shorter than the trunk). * **Craniofacial features:** Macrocephaly with a **prominent forehead (frontal bossing)** and **midface hypoplasia (retruded maxilla)** are classic signs. * **Mental Status:** Unlike some other forms of dwarfism, individuals with achondroplasia have **normal intelligence** (mentally alert). **Why other options are incorrect:** * **Cretinism (Congenital Hypothyroidism):** Presents with mental retardation, coarse features, and a protuberant abdomen. It is not associated with the specific skeletal features of achondroplasia. * **Pituitary Dwarfism:** Results from Growth Hormone deficiency. It causes **proportionate dwarfism** (the head, trunk, and limbs are all small but in proportion) and delayed bone age. * **Acromegaly:** This is a condition of growth hormone excess in adults, leading to enlargement of hands, feet, and jaw (prognathism), not dwarfism. **High-Yield Clinical Pearls for NEET-PG:** * **Inheritance:** 80% of cases are due to **de novo mutations**, often associated with **advanced paternal age**. * **Radiology:** Look for "squared-off" iliac wings, narrowing of the interpedicular distance in the lumbar spine, and a **Trident hand** (persistent space between the 3rd and 4th digits). * **Motor Milestones:** Often delayed in infancy due to hypotonia and a large head, but catch up later.

Q: An 8-year-old boy has a history of a fall from 10 feet with pain in the right ankle. The initial X-ray was normal. Two years later, he developed a calcaneovalgus deformity. What is the likely diagnosis?

Tibial epiphyseal injury. **Explanation:** The correct diagnosis is **Tibial epiphyseal injury**. In pediatric orthopaedics, a "normal" initial X-ray following trauma does not rule out a growth plate injury. This scenario describes a **Salter-Harris Type V injury** (crush injury to the physis), which is notoriously difficult to detect on initial radiographs. The development of a **calcaneovalgus deformity** two years later indicates asymmetrical growth arrest. If the lateral or posterior aspect of the distal tibial physis is damaged while the rest continues to grow, it leads to progressive angular deformities (valgus) and gait changes (calcaneus). **Why other options are incorrect:** * **Fibular fracture:** While common, a simple fibular fracture in a child usually heals well without causing a progressive calcaneovalgus deformity unless the distal fibular physis is involved, which would more likely cause a varus deformity. * **Bimalleolar fracture:** These are overt fractures that would be clearly visible on the initial X-ray. They are rare in 8-year-olds as the physis usually fails before the bone (malleoli). * **Subtalar joint injury:** This involves the talocalcaneal articulation. While it can cause stiffness or pain, it does not typically result in a progressive developmental deformity linked to a "normal" initial X-ray in a growing child. **Clinical Pearls for NEET-PG:** * **Salter-Harris Type V:** Highest risk of growth arrest; initial X-rays are often deceptive/normal. * **Law of Heuter-Volkmann:** Increased pressure on a physis inhibits growth, while decreased pressure accelerates it—explaining how partial arrests lead to progressive deformities. * **Commonest Salter-Harris Type:** Type II is the most common overall. * **Rule of Thumb:** Any persistent pain over a physis in a child with normal X-rays should be treated as a Type I or V injury (immobilization and follow-up).

Q: What is the preferred treatment for a shaft femur fracture in a 3-year-old boy?

Russell traction. ### Explanation The management of pediatric femoral shaft fractures is primarily determined by the **age and weight** of the child. For a 3-year-old boy, conservative management is the standard of care. **Why Russell Traction is Correct:** Russell traction (a type of skin traction) is the preferred initial treatment for children aged **2 to 10 years**. It uses a sling under the knee and a single pulley system to provide longitudinal traction while suspending the limb. This stabilizes the fracture, controls pain, and maintains alignment until a **Hip Spica cast** can be applied (usually after 2–3 weeks once a "sticky callus" forms). **Analysis of Incorrect Options:** * **Gallow’s Traction (Overhead Traction):** This is indicated for children **under 2 years of age** (or weighing 5–6 years**). Flexible intramedullary nails (TENS - Titanium Elastic Nailing System) are used to avoid damaging the open growth plates. * **Plating:** This is generally reserved for open fractures, polytrauma, or cases where intramedullary nailing is contraindicated. It is not the first-line treatment for a simple shaft fracture in a toddler. **High-Yield Clinical Pearls for NEET-PG:** * **0–6 months:** Pavlik harness or Spica cast. * **6 months–2 years:** Gallow’s traction followed by Hip Spica. * **2–6 years:** Russell traction followed by Hip Spica (Early Spica is also an option). * **6–12 years:** Flexible Intramedullary Nails (TENS). * **>12 years/Skeletally mature:** Locked Intramedullary Nail (Adult type). * **Note:** In pediatric femur fractures, **2 cm of shortening** is acceptable because the fracture stimulus often leads to compensatory overgrowth of the limb.

Q: Apert syndrome is a disease of:

Bones and joints. **Explanation:** **Apert Syndrome** (Acrocephalosyndactyly Type I) is a rare genetic disorder characterized by multisystem involvement, primarily affecting the **bones and joints**. It is caused by a mutation in the **FGFR2 gene** (Fibroblast Growth Factor Receptor 2), which leads to the premature fusion of skull bones (**craniosynostosis**) and severe limb abnormalities. **Why the correct answer is right:** The hallmark of Apert syndrome is the fusion of skeletal elements. This includes **acrocephaly** (tower-shaped skull) due to coronal suture synostosis and **complex syndactyly** (fusion of fingers and toes), often referred to as "mitten hands" or "sock feet." Because the primary pathology involves skeletal development and joint formation, it is classified as a disease of the bones and joints. **Why other options are wrong:** * **Blood:** Apert syndrome is a genetic structural disorder; it does not involve hematological abnormalities or bone marrow failure. * **Skin:** While skin changes like acne or hyperhidrosis can occur, they are secondary features. The primary pathology is skeletal. * **Autoimmune disorder:** This is a congenital genetic mutation (autosomal dominant), not an immune-mediated attack on body tissues. **High-Yield Clinical Pearls for NEET-PG:** * **Genetics:** Autosomal Dominant; associated with **advanced paternal age**. * **Hand Finding:** Symmetrical "mitten hand" syndactyly involving the 2nd, 3rd, and 4th digits. * **Facial Features:** Midface hypoplasia, proptosis (bulging eyes), and a high arched palate. * **Intellectual Disability:** Often present due to increased intracranial pressure from craniosynostosis.

Q: A child presents with a limp and limb shortening. An X-ray is provided. What is the diagnosis?

Developmental dysplasia of the hip (DDH). ***Developmental dysplasia of the hip (DDH)*** - Presents with **limp and limb shortening** in a child, with X-ray showing **shallow acetabulum**, **disrupted Shenton's line**, and **laterally displaced femoral head**. - Classic features include **delayed walking**, **asymmetric skin folds**, and **limited hip abduction** on the affected side. *Perthes disease* - Affects children aged **4-8 years** with **avascular necrosis** of the femoral head, showing **flattening and sclerosis** on X-ray. - Typically presents with **gradual onset hip pain** and **antalgic gait**, but maintains normal **acetabular development**. *Slipped capital femoral epiphysis (SCFE)* - Occurs in **adolescents** (10-16 years), especially **obese males**, with **posterior and inferior displacement** of the femoral head. - X-ray shows **widened growth plate** and **ice cream falling off the cone** appearance, distinct from DDH findings. *Fracture of the neck of the femur* - Usually follows **significant trauma** in children, presenting with **acute severe pain** and **inability to bear weight**. - X-ray would show **clear fracture line** through the **femoral neck**, not the developmental abnormalities seen in DDH.

Q: A 3-year-old girl has developed a painful elbow after being jerked by the forearm. What is the next step to be done?

Fully supinate the forearm.. ### Explanation **Underlying Medical Concept: Pulled Elbow (Nursemaid’s Elbow)** The clinical scenario describes a classic case of **Pulled Elbow** (Subluxation of the Radial Head). In children under 5 years, the annular ligament is relatively lax. Sudden longitudinal traction on an extended, pronated forearm causes the radial head to slip distally, allowing a portion of the **annular ligament** to become trapped between the radial head and the capitellum. **Why Option D is Correct:** The definitive management is **manual reduction**. The most common and successful technique involves **fully supinating the forearm** while the elbow is flexed to 90 degrees. A palpable "click" often signifies the ligament returning to its normal position, followed by a rapid return of limb function. **Why Other Options are Incorrect:** * **Option A & B:** Immobilization or elbow pads are unnecessary. Once reduced, the joint is stable, and the child usually resumes normal activity within minutes. * **Option C:** X-rays are typically **normal** in pulled elbow and are not required unless there is focal bony tenderness or a history of a direct fall (to rule out fractures). A posterior slab is contraindicated as it delays the simple curative maneuver. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Sudden upward pull (traction) on a pronated forearm. * **Clinical Presentation:** The child holds the arm in slight flexion and **pronation** (pseudoparalysis); they refuse to use the arm. * **Pathology:** Entrapment of the **annular ligament** in the radio-capitellar joint. * **Reduction Techniques:** 1. Supination-Flexion (Traditional) 2. Hyperpronation (Often more successful on the first attempt). * **Post-reduction:** No immobilization is needed; if the child uses the arm to reach for a toy, the reduction is successful.

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

1-3 years. **Explanation:** The question refers to the surgical management of **Posterior Medial Soft Tissue Release (PMSTR)**, a definitive surgical procedure for the correction of resistant or neglected **Congenital Talipes Equinovarus (CTEV)**. **1. Why 1–3 years is the correct answer:** The ideal age for PMSTR is **1–3 years**. At this stage, the child has usually started walking, which helps in remodeling the bones after the soft tissues (ligaments, tendons, and capsules) are surgically released. Before 1 year, the bones are largely cartilaginous and may be crushed by surgical handling; after 3 years, significant bony deformities (secondary adaptive changes) often develop, making soft tissue release alone insufficient. **2. Analysis of Incorrect Options:** * **Less than 1 year:** Most cases of CTEV are now managed by the **Ponseti method** (serial casting), which is highly successful in infants. Surgery is reserved for cases that fail conservative management. Performing extensive PMSTR too early increases the risk of scarring and stiffness. * **3–6 years:** By this age, soft tissue release alone is rarely successful. Children in this age group usually require **"Dwyer’s Osteotomy"** or lateral column shortening to correct the bony architecture. * **6–9 years:** In older children (neglected CTEV), salvage procedures like **Triple Arthrodesis** or the use of an **Ilizarov external fixator** are preferred over simple soft tissue releases. **High-Yield Clinical Pearls for NEET-PG:** * **Order of Correction (Ponseti):** CAVE (Cavus, Adduction, Varus, Equinus). * **Turco’s Incision:** The standard surgical approach used for PMSTR. * **Components of PMSTR:** Release of the Master Knot of Henry, lengthening of the Tendo-Achilles (TAL), and release of the posterior ankle capsule and subtalar joints. * **Radiology:** The **Kite’s Angle** (talocalcaneal angle) is decreased in CTEV (<20°).

Question 1

The classical flexion and rotation deformities at hip and knee joints, as a sequela of poliomyelitis, are due to the contracture of which muscle?

Accepted Answer

Tensor fascia lata

Answer

Gastrocnemius

Answer

Tendo Achilles

Answer

Hamstrings

Question 2

What is the most likely diagnosis in a 23-year-old, mentally alert dwarf with disproportionate arm and leg to body growth, prominent forehead, and retruded maxilla?

Accepted Answer

Achondroplasia

Answer

Cretinism

Answer

Pituitary dwarfism

Answer

Acromegaly

Question 3

An 8-year-old boy has a history of a fall from 10 feet with pain in the right ankle. The initial X-ray was normal. Two years later, he developed a calcaneovalgus deformity. What is the likely diagnosis?

Accepted Answer

Tibial epiphyseal injury

Answer

Fibular fracture

Answer

Bimalleolar fracture

Answer

Subtalar joint injury

Question 4

What is the preferred treatment for a shaft femur fracture in a 3-year-old boy?

Accepted Answer

Russell traction

Answer

Gallow's traction

Answer

Intramedullary nailing

Answer

Plating

Question 5

In congenital dislocation of the hip, which clinical sign shows that the affected thigh is at a lower level when the knees and hips are flexed to 90 degrees?

Accepted Answer

Galeazzi's sign

Answer

Oolani's sign

Answer

Barlow's sign

Answer

Von Rosen's sign

Question 6

Apert syndrome is a disease of:

Accepted Answer

Bones and joints

Answer

Blood

Answer

Skin

Answer

Autoimmune disorder

Question 7

Ortolani's test is done in which condition?

Accepted Answer

Congenital Dysplasia of the Hip (CDH)

Answer

Perthes disease

Answer

Posterior dislocation of the hip

Answer

Septic arthritis

Question 8

A child presents with a limp and limb shortening. An X-ray is provided. What is the diagnosis?

Accepted Answer

Developmental dysplasia of the hip (DDH)

Answer

Perthes disease

Answer

Slipped capital femoral epiphysis (SCFE)

Answer

Fracture of the neck of the femur

Question 9

A 3-year-old girl has developed a painful elbow after being jerked by the forearm. What is the next step to be done?

Accepted Answer

Fully supinate the forearm.

Answer

Cuff and collar sling immobilization.

Answer

Reduction, setting, and application of an elbow pad.

Answer

X-ray and elevation of the limb in a posterior slab.

Question 10

What is the ideal age for performing a Posterior Malleolar Screw Fixation (PMSTR)?

Accepted Answer

1-3 years

Answer

Less than 1 year

Answer

3-6 years

Answer

6-9 years

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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