Pediatric Orthopaedics Practice Questions

Q: Eye examination of a child shows blue sclera. In which condition is it characteristically observed?

Osteogenesis imperfecta. **Explanation:** **Osteogenesis Imperfecta (OI)**, also known as "Brittle Bone Disease," is the correct answer. The underlying medical concept involves a genetic defect in **Type I collagen** synthesis. The sclera of the eye is primarily composed of collagen; in OI, the scleral collagen is abnormally thin. This thinness allows the underlying **uveal pigment** (choroid) to show through, giving the sclera a characteristic **blue or slate-gray appearance**. This is a classic clinical sign, particularly in Type I (the most common and mildest form) and Type II (the lethal form) of the disease. **Analysis of Incorrect Options:** * **Amelogenesis Imperfecta:** This is a hereditary disorder affecting dental enamel formation. While it affects the teeth (making them yellow or brown), it does not involve collagen defects that affect the sclera. * **Tetracycline Hypoplasia:** This occurs due to the ingestion of tetracycline during the period of tooth calcification. It causes permanent yellow-brown discoloration of the **teeth**, not the sclera. * **Fluorosis:** Chronic ingestion of high levels of fluoride leads to "mottled enamel." It affects the appearance of the teeth (chalky white patches or brown staining) but has no association with blue sclera. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of OI (Type I):** Blue sclera, fragile bones (multiple fractures), and early-onset conductive hearing loss (otosclerosis). * **Dentinogenesis Imperfecta:** Often associated with OI; teeth appear translucent or opalescent. * **Differential Diagnosis for Blue Sclera:** Apart from OI, consider **Ehlers-Danlos Syndrome (Type VI)**, Marfan Syndrome, and Pseudoxanthoma Elasticum. * **Wormian Bones:** Multiple small bones within the cranial sutures, often seen on X-rays of patients with OI.

Q: What is the treatment of choice for a fracture of the shaft of the femur in a child less than 2 years of age?

Gallows traction. **Explanation:** The management of pediatric femoral shaft fractures is primarily determined by the **age and weight** of the child. **Why Gallows Traction is Correct:** Gallows traction (also known as Bryant’s traction) is the treatment of choice for children **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 counter-traction. It is preferred because it allows for easy nursing care and diapering while maintaining alignment in a population where rapid remodeling occurs. **Analysis of Incorrect Options:** * **Hip Spica Cast:** While often used for children aged 6 months to 5 years, it is typically the primary treatment for stable fractures or used *after* a brief period of traction. In very young infants ( 5 years) or adults for pre-operative stabilization. It involves a sling under the knee and does not suspend the patient vertically. * **Intramedullary (IM) Nail:** Rigid IM nails are contraindicated in young children due to the risk of damaging the trochanteric epiphysis and blood supply to the femoral head (leading to AVN). Flexible (Elastic) nails are used for children aged 5–12 years. **NEET-PG High-Yield Pearls:** * **Age 12 years:** Lateral entry Rigid Intramedullary Nail. * **Caution:** In Gallows traction, always monitor **peripheral circulation** (dorsalis pedis pulse) to prevent compartment syndrome or ischemia.

Q: Regarding congenital torticollis, all of the following are true EXCEPT:

Always caused by breech presentation.. **Explanation:** Congenital Muscular Torticollis (CMT) is a common postural deformity characterized by the shortening of the sternocleidomastoid (SCM) muscle, leading to an ipsilateral head tilt and contralateral rotation. **1. Why Option A is the Correct Answer (The "Except"):** While breech presentation and difficult instrumental deliveries (forceps) are significant **risk factors** due to potential birth trauma or intrauterine malpositioning, they are not the "always" cause. Many cases occur following normal vertex deliveries. The exact etiology is often multifactorial, involving intrauterine compartment syndrome or primary venous obstruction within the SCM. In NEET-PG, absolute terms like "always" or "never" often indicate the incorrect statement. **2. Analysis of Other Options:** * **Option B:** Most cases (approx. 90%) resolve spontaneously or with conservative management (stretching exercises and positioning) within the first year of life. * **Option C:** If left untreated, the persistent pressure on one side of the skull while sleeping leads to **plagiocephaly** (flattening of the occiput) and facial asymmetry. * **Option D:** A "pseudotumor" or SCM mass is often palpable within the first 2–4 weeks of life. It is a non-tender, firm olive-shaped fibrotic mass that typically disappears by 6 months. **Clinical Pearls for NEET-PG:** * **Diagnosis:** Primarily clinical; Ultrasound is the imaging modality of choice to confirm SCM thickening. * **Associated Conditions:** Always screen for **Developmental Dysplasia of the Hip (DDH)**, as there is a 10–15% co-occurrence. * **Management:** First-line is physical therapy. Surgery (SCM release) is reserved for refractory cases after 1 year of age.

Q: Bilateral congenital dislocation of the hip is associated with all, EXCEPT:

Excess genu valgum. In **Developmental Dysplasia of the Hip (DDH)**, specifically bilateral congenital dislocation, the femoral head is displaced superiorly and posteriorly out of the acetabulum. This structural change alters the biomechanics of the pelvis and lower limbs. **Explanation of the Correct Answer:** * **Option B (Excess genu valgum):** This is the correct answer because it is **not** typically associated with DDH. In fact, patients with DDH often exhibit a "pseudo-genu varum" appearance or neutral alignment. Genu valgum (knock-knees) is more commonly associated with conditions like rickets or certain skeletal dysplasias, rather than isolated hip dislocation. **Analysis of Incorrect Options:** * **Option A (Lordotic spine):** In bilateral dislocation, the center of gravity shifts forward because the femoral heads are posterior to the acetabulum. To maintain balance, the patient compensates by increasing the lumbar curvature, leading to **exaggerated lumbar lordosis**. * **Option C (Waddling gait):** Due to the lack of a stable fulcrum (dislocated hip) and the resulting functional shortening/weakness of the gluteus medius muscles, the patient exhibits a bilateral Trendelenburg gait, commonly known as a **waddling gait**. * **Option D (Shenton’s line deformity):** Shenton’s line is an imaginary curved line formed by the inferior border of the pubic ramus and the medial margin of the femoral neck. In DDH, the superior displacement of the femur **breaks this continuity**, making it a hallmark radiological sign. **Clinical Pearls for NEET-PG:** * **Trendelenburg Test:** Positive in DDH due to abductor insufficiency. * **Galeazzi Sign:** Used for unilateral DDH (apparent shortening of the femur). * **Ortolani & Barlow Maneuvers:** Most reliable clinical tests for neonatal screening (up to 2-3 months). * **Radiology:** Von Rosen’s view is used for diagnosis; Perkins' line and Hilgenreiner's line help define the quadrants of dislocation.

Q: A metaphyseal fracture that touches the physis but does not cross it is classified under which type of Salter-Harris physeal injury?

Type II. The **Salter-Harris classification** is the most widely used system to describe physeal (growth plate) injuries in children. The classification is based on the involvement of the physis, epiphysis, and metaphysis. ### **Explanation of the Correct Answer** **Option B (Type II)** is correct because it involves a fracture through the **physis** that extends upwards into the **metaphysis**. In this injury, the fracture line "touches" the physis and travels along it before exiting through the metaphyseal bone. This results in a triangular fragment of the metaphysis remaining attached to the epiphysis, known as the **Thurston-Holland sign**. Type II is the most common type of Salter-Harris fracture. ### **Why Other Options are Incorrect** * **Type I:** The fracture occurs exclusively through the **physis** (hypertrophic zone). It does not involve the metaphysis or epiphysis. It is often a clinical diagnosis as X-rays may appear normal. * **Type III:** The fracture line runs through the physis and extends downwards into the **epiphysis** (intra-articular). It does not touch the metaphysis. * **Type IV:** This is a vertical fracture that crosses **all three layers**: the metaphysis, the physis, and the epiphysis. It is intra-articular and carries a high risk of growth arrest. ### **NEET-PG High-Yield Pearls** * **Mnemonic (SALTER):** * **S** (Type I): **S**lip (Separated physis) * **A** (Type II): **A**bove (Metaphysis) — *Most common* * **L** (Type III): **L**ower (Epiphysis) * **T** (Type IV): **T**hrough (Metaphysis, Physis, and Epiphysis) * **ER** (Type V): **ER**asure/Crush (Compression of physis) — *Worst prognosis* * **Prognosis:** Types I and II usually have a good prognosis and can be managed conservatively. Types III and IV are intra-articular and often require Open Reduction and Internal Fixation (ORIF) to prevent joint incongruity and growth plate closure.

Q: A 10-year-old boy presents with increasing left hip pain and a limp after playing baseball. He is afebrile. An X-ray of the femoral head shows a fracture and irregular densities of the cancellous bone. The suspected diagnosis is Legg-Calve-Perthes disease. Which of the following best describes the underlying pathological findings?

Avascular osteonecrosis. **Explanation:** **Legg-Calvé-Perthes Disease (LCPD)** is an idiopathic clinical syndrome characterized by **avascular osteonecrosis (AVN)** of the femoral head. It typically affects children aged 4–10 years and presents with an insidious onset of hip pain and a characteristic limp. 1. **Why Option A is correct:** The underlying pathology is a temporary interruption of the blood supply to the capital femoral epiphysis. This leads to bone cell death (necrosis), followed by a process of revascularization and remodeling. On X-ray, this manifests as increased density (sclerosis) of the femoral head, fragmentation, and potential collapse (fracture), as seen in this patient. 2. **Why the other options are incorrect:** * **B. Chondroma:** A benign cartilaginous tumor. While it can cause pathological fractures, it typically presents as a well-defined lucent lesion, not the diffuse irregular densities seen in AVN. * **C. Fibrous Dysplasia:** A condition where normal bone is replaced by fibrous tissue and immature "Chinese-figure" trabeculae. It presents with a "ground-glass" appearance on X-ray. * **D. Osteitis Fibrosa Cystica:** This is the result of hyperparathyroidism (excess PTH), leading to subperiosteal bone resorption and "brown tumors." It is systemic rather than localized to the femoral head. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in boys (4:1 ratio) between 4 and 10 years. * **Radiology:** Look for the **"Crescent sign"** (subchondral fracture line) and increased radiodensity of the femoral head. * **Pathology Stages:** Avascular phase → Fragmentation/Resorption → Re-ossification → Remodeling. * **Differential:** Always rule out Slipped Capital Femoral Epiphysis (SCFE), which typically occurs in obese adolescents.

Q: Which is the most common bone fractured during birth?

Humerus. **Explanation:** The correct answer is **Humerus**. While historically the clavicle was cited as the most common birth-related fracture, recent epidemiological data and clinical studies (often cited in standard orthopaedic textbooks like Campbell’s) indicate that the **humerus** is the most frequently fractured bone during the delivery process, particularly in cases of shoulder dystocia or breech presentations. **Breakdown of Options:** * **Humerus (Correct):** It is the most common long bone fracture. It typically occurs during the delivery of the extended arms in a breech presentation or during maneuvers to resolve shoulder dystocia in a cephalic presentation. Most are "greenstick" or displaced midshaft fractures. * **Clavicle (Incorrect):** Although very common and often cited in older literature as the most frequent, it is frequently asymptomatic and may go undiagnosed until a callus forms. In many modern competitive exams, the humerus is prioritized as the most common "documented" bone fracture. * **Femur (Incorrect):** This is much less common than humeral or clavicular fractures. It usually occurs during a difficult breech extraction when traction is applied to the lower extremities. **Clinical Pearls for NEET-PG:** 1. **Presentation:** Most neonatal fractures present with **pseudoparalysis** (the infant avoids moving the limb due to pain), which must be differentiated from Erb’s palsy. 2. **Management:** Neonatal fractures have an immense remodeling potential. Humerus fractures are typically treated with simple immobilization (pinning the sleeve to the shirt) for 2–3 weeks. 3. **Healing:** A visible callus usually forms within 7–10 days, which is often how undiagnosed clavicle fractures are eventually discovered. 4. **Prognosis:** Excellent; permanent deformity or limb length discrepancy is extremely rare due to rapid remodeling at this age.

Q: Sever's disease involves which of the following bones?

Calcaneum. **Explanation:** **Sever’s disease**, also known as **calcaneal apophysitis**, is a common cause of heel pain in physically active children (typically aged 8–14 years). It is a traction-overuse injury caused by repetitive microtrauma from the Achilles tendon pulling on the unossified calcaneal apophysis. * **Why Calcaneum is correct:** The disease specifically involves the posterior growth plate (apophysis) of the **calcaneum**. During growth spurts, the heel bone grows faster than the surrounding tendons, leading to increased tension. Clinical signs include tenderness over the posterior aspect of the calcaneum and a positive "squeeze test" (pain on mediolateral compression of the heel). **Analysis of Incorrect Options:** * **Lunate:** Involvement of the lunate bone is seen in **Kienböck’s disease** (avascular necrosis), which typically presents in adults with wrist pain. * **Tibial Tubercle:** Inflammation of the tibial tubercle apophysis is known as **Osgood-Schlatter disease**, the most common cause of knee pain in adolescents. * **Navicular:** Osteochondritis of the tarsal navicular bone is called **Köhler’s disease**, usually seen in younger children (3–7 years). **High-Yield Clinical Pearls for NEET-PG:** * **Radiological sign:** Increased density and fragmentation of the calcaneal apophysis (though diagnosis is primarily clinical). * **Management:** Conservative treatment including rest, ice, heel cups/inserts, and stretching of the gastrocnemius-soleus complex. * **Mnemonic for Osteochondroses:** * **S**ever’s = **S**hoe (Heel/Calcaneum) * **F**reiberg’s = **F**oot (2nd Metatarsal head) * **P**erthes = **P**elvis (Femoral head) * **P**anner’s = **P**unch (Capitellum of humerus)

Question 1

What is true about slipped capital femoral epiphysis?

Accepted Answer

Treethowan sign is seen

Answer

Seen in obese children

Answer

It is a major traumatic condition

Answer

Seen in adults

Question 2

Eye examination of a child shows blue sclera. In which condition is it characteristically observed?

Accepted Answer

Osteogenesis imperfecta

Answer

Amelogenesis Imperfecta

Answer

Tetracycline hypoplasia

Answer

Fluorosis

Question 3

What is the treatment of choice for a fracture of the shaft of the femur in a child less than 2 years of age?

Accepted Answer

Gallows traction

Answer

Hip spica cast

Answer

Russell traction

Answer

Intramedullary nail

Question 4

Regarding congenital torticollis, all of the following are true EXCEPT:

Accepted Answer

Always caused by breech presentation.

Answer

Spontaneous resolution occurs in most cases.

Answer

Untreated congenital torticollis can lead to plagiocephaly.

Answer

A palpable sternocleidomastoid tumor may be present.

Question 5

Bilateral congenital dislocation of the hip is associated with all, EXCEPT:

Accepted Answer

Excess genu valgum

Answer

Lordotic spine

Answer

Waddling gait

Answer

Shelton's line deformity

Question 6

A metaphyseal fracture that touches the physis but does not cross it is classified under which type of Salter-Harris physeal injury?

Accepted Answer

Type II

Answer

Type I

Answer

Type III

Answer

Type IV

Question 7

How should failure of the Ponsetti technique in children be managed?

Accepted Answer

Posteromedial soft tissue release

Answer

Anterolateral soft tissue release

Answer

Triple arthrodesis

Answer

Lateral closing wedge osteotomy of calcaneum

Question 8

A 10-year-old boy presents with increasing left hip pain and a limp after playing baseball. He is afebrile. An X-ray of the femoral head shows a fracture and irregular densities of the cancellous bone. The suspected diagnosis is Legg-Calve-Perthes disease. Which of the following best describes the underlying pathological findings?

Accepted Answer

Avascular osteonecrosis

Answer

Chondroma

Answer

Fibrous dysplasia

Answer

Osteitis fibrosa cystica

Question 9

Which is the most common bone fractured during birth?

Accepted Answer

Humerus

Answer

Clavicle

Answer

Femur

Answer

None of the above

Question 10

Sever's disease involves which of the following bones?

Accepted Answer

Calcaneum

Answer

Lunate

Answer

Tibial tubercle

Answer

Navicular

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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