Pediatric Orthopaedics Practice Questions

Q: What is the least common complication of a closed supracondylar fracture in an 8-year-old child?

Nonunion. **Explanation:** Supracondylar fractures of the humerus are the most common pediatric elbow fractures. Understanding the complication profile is critical for NEET-PG. **Why Nonunion is the Correct Answer:** Nonunion is extremely rare in pediatric supracondylar fractures. This is due to the **thick, osteogenic periosteum** in children and the fact that the fracture occurs through cancellous bone, which has an excellent blood supply and high remodeling potential. These fractures typically heal rapidly, often within 3–4 weeks. **Analysis of Incorrect Options:** * **Cubitus Varus (Gunstock Deformity):** This is the **most common late complication**. It usually results from malreduction (medial tilt or rotation) rather than growth arrest. While functionally acceptable, it is cosmetically distressing. * **Cubitus Valgus:** This is much less common than varus but can occur. It is clinically significant because it may lead to **tardy ulnar nerve palsy** years later. * **Vessel Injury:** The brachial artery is at significant risk, especially in Gartland Type III (displaced) posterolateral fractures, where the proximal fragment pierces the brachialis muscle and injures the artery. **High-Yield Clinical Pearls for NEET-PG:** * **Most common nerve injured:** Anterior Interosseous Nerve (AIN) — test by asking the child to make an "OK" sign. * **Most common nerve injured in flexion type:** Ulnar nerve. * **Volkmann’s Ischemic Contracture:** The most dreaded acute complication resulting from unrecognized compartment syndrome. * **Management Gold Standard:** Closed reduction and percutaneous pinning (CRPP) for displaced fractures.

Q: Bavarian cast is used in which of the following conditions?

Developmental dysplasia of the hip (DDH). ### Explanation The **Bavarian cast** (also known as a Lorenz cast or a "frog-leg" cast) is a specialized type of hip spica cast used in the management of **Developmental Dysplasia of the Hip (DDH)**. **Why it is correct:** In the treatment of DDH, once a closed or open reduction of the femoral head into the acetabulum is achieved, the hip must be immobilized to maintain stability and allow the joint capsule to tighten. The Bavarian cast holds the hips in the **"Frog-leg position"**—characterized by 90° of flexion and 60–70° of abduction. This position ensures maximum congruency between the femoral head and the acetabulum, promoting normal joint development. **Analysis of Incorrect Options:** * **A. Fracture of the radius:** These are typically managed with Colles' casts, sugar-tong splints, or above-elbow/below-elbow casts depending on the site. * **B. Club foot (CTEV):** The gold standard is the **Ponseti technique**, which utilizes serial long-leg corrective casts, followed by a Denis Browne splint. * **C. Fracture of the calcaneus:** These are managed with non-weight-bearing below-knee casts or specific orthotics like the Essex-Lopresti reduction. **High-Yield Clinical Pearls for NEET-PG:** * **Safe Zone of Ramsey:** When applying a cast for DDH, abduction should not exceed 60–70° to avoid **Avascular Necrosis (AVN)** of the femoral head due to compression of the medial circumflex femoral artery. * **Pavlik Harness:** The most common initial treatment for DDH in infants <6 months (dynamic splint). * **Von Rosen Splint:** Another rigid splint used for neonatal DDH. * **Batchelor Cast:** A variation of the hip spica used in older children where the hips are abducted but internally rotated.

Q: Complications of supracondylar fracture of humerus include all of the following except:

Nonunion. **Explanation:** Supracondylar fracture of the humerus is the most common pediatric elbow fracture. The correct answer is **Nonunion** because this fracture occurs through the metaphyseal region of the distal humerus. Metaphyseal bone is highly vascular and has a robust healing potential; consequently, nonunion is extremely rare in supracondylar fractures. **Analysis of Options:** * **Nonunion (Correct):** As mentioned, the excellent blood supply to the metaphysis ensures rapid healing. If a distal humerus fracture fails to unite, it is more likely a fracture of the **lateral condyle** (which is intra-articular and bathed in synovial fluid). * **Elbow Stiffness:** This is the **most common** complication. It results from prolonged immobilization or soft tissue fibrosis following the trauma. * **Malunion:** Very common, typically resulting in a **Cubitus Varus** (Gunstock deformity) due to inadequate reduction of the medial tilt or rotation. It is primarily a cosmetic deformity rather than a functional one. * **Myositis Ossificans:** This occurs due to heterotopic ossification in the brachialis muscle, often triggered by forceful passive stretching or vigorous massage post-injury. **Clinical Pearls for NEET-PG:** 1. **Most common complication:** Elbow stiffness. 2. **Most common deformity:** Cubitus Varus (Malunion). 3. **Most serious immediate complication:** Volkmann’s Ischemic Contracture (VIC) due to brachial artery injury or Compartment Syndrome. 4. **Most common nerve injured:** Anterior Interosseous Nerve (AIN) in extension type; Ulnar nerve in flexion type.

Q: Malunited supracondylar humerus fracture causes which deformity?

Cubitus varus. **Explanation:** Supracondylar fractures of the humerus are the most common pediatric elbow fractures. The most frequent late complication of a malunited supracondylar fracture (specifically the extension type) is **Cubitus Varus**, also known as **"Gunstock Deformity."** **Why Cubitus Varus is correct:** The deformity occurs due to the malalignment of the distal fragment, primarily caused by **coronal plane tilt (medial tilt)**, often combined with internal rotation and posterior displacement. While it is primarily a cosmetic issue and rarely affects the range of motion or joint function, it is a classic hallmark of poor reduction in these fractures. **Analysis of Incorrect Options:** * **Dinner Fork Deformity:** This is characteristic of a **Colles’ fracture** (distal radius fracture with dorsal displacement), not elbow trauma. * **Cubitus Valgus:** While less common in supracondylar fractures, cubitus valgus is the classic complication of a **Non-union of the Lateral Condyle** of the humerus. Chronic cubitus valgus can lead to tardy ulnar nerve palsy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common complication:** Stiffness (overall); Cubitus varus (most common deformity). * **Most serious complication:** Volkmann’s Ischemic Contracture (VIC) due to injury to the brachial artery or compartment syndrome. * **Nerve Injuries:** The **Anterior Interosseous Nerve (AIN)** is the most commonly injured nerve in extension-type fractures, while the **Ulnar nerve** is most commonly injured in flexion-type fractures or during percutaneous pinning (iatrogenic). * **Treatment of Cubitus Varus:** If cosmetically unacceptable, it is corrected using a **French Osteotomy** (Lateral closed-wedge osteotomy).

Q: A 10-year-old obese child presents with a painful limp and hip pain. Which of the following investigations is not required?

CT scan of the hip. **Explanation:** The clinical presentation of an **obese 10-year-old child** with a painful limp and hip pain is a classic "spotter" for **Slipped Capital Femoral Epiphysis (SCFE)**. In SCFE, the femoral head slips posteriorly and inferiorly relative to the femoral neck through the growth plate. **Why CT scan is the correct answer (Not Required):** A CT scan provides excellent bony detail but is **not** part of the standard diagnostic protocol for SCFE. It involves significant radiation exposure and rarely changes the management plan, which is primarily based on clinical findings and plain radiographs. **Analysis of other options:** * **X-ray of the hip (A):** This is the **initial and gold-standard investigation**. AP and Frog-leg lateral views are essential. Key signs include **Klein’s line** (which fails to intersect the femoral head) and the **Steel sign** (metaphyseal blanch). * **MRI of the hip (B):** MRI is the most sensitive tool for detecting **"Pre-slip" SCFE** (where clinical symptoms exist but X-rays are normal) by showing marrow edema and physeal widening. * **USG of the hip (C):** Ultrasound is useful for detecting a **joint effusion**, which is common in acute or acute-on-chronic slips, and can sometimes visualize the step-off at the physeal-metaphyseal junction. **NEET-PG High-Yield Pearls:** * **Demographics:** Most common in obese adolescent males (10–16 years). * **Referred Pain:** Hip pathology in children often presents as **isolated knee pain** (obturator nerve distribution). Always examine the hip in a child with a knee limp. * **Clinical Sign:** **Drehmann Sign** (obligate external rotation of the hip during passive flexion). * **Management:** Emergency stabilization with **In-situ Percutaneous Pinning/Screwing** to prevent further slip and Avascular Necrosis (AVN).

Q: Fracture neck of femur in children is treated by:

Spica cast in abduction and internal rotation. **Explanation:** Fracture neck of femur in children is a high-energy injury and a surgical emergency due to the precarious blood supply to the developing femoral head [1]. The primary goal of treatment is stable reduction to prevent **Avascular Necrosis (AVN)** and **Coxa Vara**. **Why Option B is Correct:** For undisplaced fractures (Delbet Type II, III, and IV) or as a post-operative stabilizer after internal fixation, a **Spica cast in abduction and internal rotation** is the standard of care [1]. * **Abduction** places the femoral head securely into the acetabulum (congruency) and neutralizes the varus-producing forces of the abductor muscles. * **Internal rotation** helps in achieving anatomical alignment by compensating for the natural anteversion of the femoral neck, effectively "locking" the fracture fragments into a stable position. **Why Other Options are Wrong:** * **Option A & D (Adduction):** Adduction is contraindicated as it increases the risk of **Coxa Vara** (a common complication) by allowing the distal fragment to ride upward. * **Option C (External Rotation):** External rotation is the typical deformity position of a hip fracture; maintaining this would result in malunion and significant gait abnormalities. **NEET-PG High-Yield Pearls:** 1. **Delbet Classification:** The most important prognostic factor. Type I (Transepiphyseal) has the highest risk of AVN (~80-100%) [1]. 2. **Most Common Type:** Type II (Transcervical) [1]. 3. **Most Common Complication:** AVN (Avascular Necrosis), followed by Coxa Vara [1]. 4. **Management Rule:** Unlike adults, even minimally displaced fractures in children often require **urgent internal fixation** (using cannulated screws or wires) because the thick periosteum and high intra-articular pressure can easily compromise blood flow [1]. Cast alone is reserved only for strictly undisplaced fractures in very young children [1].

Q: All are true statements about talipes equinovarus, EXCEPT:

Treatment should start after 3 months. **Explanation:** **Talipes Equinovarus (TEV)**, commonly known as Clubfoot, is a congenital deformity characterized by four specific components represented by the mnemonic **CAVE**: **C**avus, **A**dduction (forefoot), **V**arus (hindfoot), and **E**quinus. **Why Option D is the correct answer (The Exception):** The gold standard for TEV management is the **Ponseti method**. Treatment should ideally begin **as soon as possible after birth**, typically within the first week of life. Delaying treatment until 3 months makes the soft tissues less pliable, increases the difficulty of manual correction, and often necessitates more invasive surgical intervention rather than serial casting. **Analysis of Incorrect Options:** * **Option A & B:** Inversion and forefoot adduction are core clinical components of the deformity. The hindfoot is in varus (inversion) and the forefoot is adducted at the midtarsal joints. * **Option C:** While most cases are idiopathic, TEV can be **secondary** to neuromuscular conditions. **Arthrogryposis Multiplex Congenita** is a well-known cause of rigid, syndromic clubfoot that is often resistant to standard casting. **High-Yield Clinical Pearls for NEET-PG:** * **Order of Correction (Ponseti):** Remember **CAVE** in reverse—**C**avus first, then **A**dduction and **V**arus simultaneously, and **E**quinus last (often requiring a percutaneous Achilles tenotomy). * **Radiology:** Kite’s angle (talocalcaneal angle) is **decreased** (<20°) on both AP and lateral views. * **Maintenance:** After casting, a **Steenbeek or Denis Browne splint** is used (23 hours/day for 3 months, then at night for 3–4 years) to prevent recurrence.

Q: What is the most common mode of inheritance for Achondroplasia?

Autosomal dominant. **Explanation:** **Achondroplasia** is the most common cause of disproportionate short-limb dwarfism. The correct answer is **Autosomal Dominant (B)** because the condition is caused by a gain-of-function mutation in the **FGFR3 gene** (Fibroblast Growth Factor Receptor 3) located on chromosome 4p. This mutation leads to constant inhibition of chondrocyte proliferation at the epiphyseal growth plate, resulting in impaired endochondral ossification. **Why other options are incorrect:** * **Sporadic (A):** While approximately **80% of cases** arise from *de novo* (new) mutations—often associated with advanced paternal age—the **mode of inheritance** itself is classified as Autosomal Dominant. If an affected individual has children, the trait follows a dominant pattern. * **Autosomal Recessive (C) & X-linked Recessive (D):** These do not apply to Achondroplasia. However, it is important to note that homozygous inheritance (two dominant alleles) is lethal in the neonatal period. **High-Yield Clinical Pearls for NEET-PG:** * **Genetics:** Specifically, a point mutation (G380R) in the FGFR3 gene. * **Clinical Features:** Rhizomelic shortening (proximal limb segments), "Trident hand" (persistent space between 3rd and 4th fingers), frontal bossing, and lumbar lordosis. * **Radiology:** Narrowing of the interpedicular distance (caudally), "Champagne glass" pelvis, and "Square" iliac wings. * **Intelligence:** Patients typically have normal intelligence and a normal lifespan. * **Complication:** Foramen magnum stenosis is a critical risk in infancy, potentially leading to sudden death or hydrocephalus.

Question 1

What is the least common complication of a closed supracondylar fracture in an 8-year-old child?

Accepted Answer

Nonunion

Answer

Cubitus valgus

Answer

Cubitus varus

Answer

Vessel injury

Question 2

A 4-year-old boy presents with recurrent fractures, hyperextensible joints, and hearing problems. What is your diagnosis?

Accepted Answer

Osteogenesis imperfecta

Answer

Achondroplasia

Answer

Osteopetrosis

Answer

Ehlers-Danlos syndrome

Question 3

Bavarian cast is used in which of the following conditions?

Accepted Answer

Developmental dysplasia of the hip (DDH)

Answer

Fracture of the radius

Answer

Club foot

Answer

Fracture of the calcaneus

Question 4

Complications of supracondylar fracture of humerus include all of the following except:

Accepted Answer

Nonunion

Answer

Elbow stiffness

Answer

Malunion

Answer

Myositis ossificans

Question 5

Malunited supracondylar humerus fracture causes which deformity?

Accepted Answer

Cubitus varus

Answer

Dinner fork deformity

Answer

Cubitus valgus

Answer

None

Question 6

A 10-year-old obese child presents with a painful limp and hip pain. Which of the following investigations is not required?

Accepted Answer

CT scan of the hip

Answer

X-ray of the hip

Answer

MRI of the hip

Answer

USG of the hip

Question 7

Fracture neck of femur in children is treated by:

Accepted Answer

Spica cast in abduction and internal rotation

Answer

Spica cast in internal rotation and adduction

Answer

Spica cast in abduction and external rotation

Answer

Spica cast in flexion and adduction

Question 8

All are true statements about talipes equinovarus, EXCEPT:

Accepted Answer

Treatment should start after 3 months

Answer

Inversion of the foot

Answer

Adduction of the forefoot

Answer

Anrogryposis multiplex congenita causes it

Question 9

Which of the following statements is NOT true about Perthes disease?

Accepted Answer

Femoral valgus derotation osteotomy

Answer

Chiari osteotomy

Answer

Coxa plana

Answer

More common in females

Question 10

What is the most common mode of inheritance for Achondroplasia?

Accepted Answer

Autosomal dominant

Answer

Sporadic

Answer

Autosomal recessive

Answer

X-linked recessive

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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