Pediatric Orthopaedics Practice Questions

Q: What is a green-stick fracture?

Periosteum of cortex is intact and periosteum is crumpled. ### Explanation **Concept Overview:** A **Greenstick fracture** is an incomplete fracture typically seen in children. Because pediatric bones are more flexible and have a thick, active periosteum, they tend to bend and partially break rather than snap completely. The term is an analogy to a "green" (young) branch of a tree that bends and splinters on one side when stressed, rather than breaking into two distinct pieces. **Why Option D is Correct:** In a greenstick fracture, the bone undergoes **plastic deformation**. The cortex on the convex side (tension side) breaks, while the cortex and **periosteum on the concave side (compression side) remain intact** but often appear "crumpled" or buckled. This intact periosteal hinge provides stability to the fracture, though it can also make anatomical reduction difficult unless the bone is "completed" (broken fully) during manipulation. **Analysis of Incorrect Options:** * **Option A:** These are seen in **children**, not the elderly. Elderly bones are brittle and prone to comminuted or osteoporotic fractures. * **Option B:** A **Fatigue (Stress) fracture** results from repetitive submaximal loading on normal bone (e.g., March fracture in recruits), not a single traumatic bending force. * **Option C:** A **Spiral fracture** is a complete fracture caused by a rotational/twisting force, common in long bones but distinct from the incomplete nature of a greenstick injury. **High-Yield Clinical Pearls for NEET-PG:** * **Common Site:** Forearm (Radius and Ulna). * **Management:** Often requires closed reduction. If the deformity is significant, the surgeon may need to "complete" the fracture to prevent the intact periosteum from pulling the bone back into a malaligned position (recoil). * **Related Pediatric Fracture:** **Torus (Buckle) fracture**, where the cortex bulges due to axial loading without any visible break in the cortex.

Q: A six-year-old boy presents to the emergency department with a painful limp. Clinical examination reveals tenderness in the femoral triangle and some limitation of hip movements. An X-ray was normal. What is the next appropriate investigation?

MRI Scan. ### Explanation The clinical presentation of a 6-year-old with a painful limp, femoral triangle tenderness, and restricted hip motion—coupled with a **normal X-ray**—is highly suspicious for early-stage **Perthes disease (Legg-Calvé-Perthes)** or **Septic Arthritis**. **Why MRI Scan is the correct answer:** In pediatric hip pathologies, X-rays often remain normal during the early stages (Stage I of Perthes or early infection). **MRI is the most sensitive imaging modality** for detecting early marrow edema, ischemia (avascular necrosis), or joint effusions that are not visible on plain radiographs. It allows for early diagnosis before irreversible bony changes occur. **Analysis of Incorrect Options:** * **Observation (A):** This is inappropriate in a symptomatic child with limited range of motion. Delaying diagnosis in conditions like Septic Arthritis or Perthes can lead to permanent joint destruction. * **Ultrasonography (B):** While excellent for detecting a joint effusion (Transient Synovitis), it cannot evaluate the bone marrow or confirm ischemia, making MRI superior for a definitive diagnosis when X-rays are negative. * **Aspiration (C):** This is an invasive procedure. It is indicated only if there is a high suspicion of Septic Arthritis (based on Kocher’s criteria: fever, non-weight bearing, elevated ESR/CRP). MRI is a better non-invasive next step to differentiate between various pathologies. **NEET-PG High-Yield Pearls:** * **Perthes Disease:** Most common in boys aged 4–8 years. Earliest X-ray sign is the "Caffey’s Silver Lining" or "Gage’s sign," but MRI is the earliest diagnostic tool overall. * **Transient Synovitis:** The most common cause of hip pain in children; usually follows a viral URI. Diagnosis of exclusion. * **Kocher’s Criteria:** Used to differentiate Septic Arthritis from Transient Synovitis (WBC >12k, ESR >40, Fever >38.5°C, Inability to bear weight).

Q: An 11-year-old, 70 kg child presents with limitation of abduction and internal rotation of the hip. There is tenderness in Scarpa's triangle. On flexing the hip, the limb is abducted. What is the diagnosis?

Slipped capital femoral epiphyses. ### Explanation **Diagnosis: Slipped Capital Femoral Epiphysis (SCFE)** The clinical presentation is classic for **Slipped Capital Femoral Epiphysis (SCFE)**. The key diagnostic features in this scenario are: 1. **Demographics:** An 11-year-old child weighing 70 kg (obesity is a major risk factor). 2. **Clinical Sign:** The pathognomonic finding is **obligate external rotation during hip flexion** (Drehmann sign). This occurs because the femoral neck slips anteriorly and superiorly relative to the epiphysis, causing the limb to abduct and rotate externally when flexed. 3. **Range of Motion:** Limitation of internal rotation and abduction is a hallmark of the deformity. --- ### Differential Diagnosis * **Perthes Disease:** Typically affects younger children (4–8 years) who are usually of small stature. While it limits internal rotation and abduction, it does not present with the obligate external rotation/abduction on flexion seen in SCFE. * **Observation Hip (Transient Synovitis):** This is an acute, self-limiting condition usually following a viral infection in younger children (3–6 years). It presents with an acute limp but lacks the chronic weight-related associations and specific mechanical signs of SCFE. * **Tuberculosis of the Hip:** This would typically present with systemic symptoms (fever, weight loss), night cries, and a "pancytopenia" of hip movements (limitation in all planes), often with a more chronic, wasting clinical picture. --- ### High-Yield Pearls for NEET-PG * **Most Common Age:** 10–16 years (Adolescent growth spurt). * **Associations:** Obesity, Hypothyroidism, and Growth hormone abnormalities. * **Radiology:** Look for **Trethowan’s Sign** (Klein’s line does not intersect the femoral head) and the **Steel Metaphyseal Blanch Sign**. * **Management:** Emergency stabilization with **In-situ pinning** (Single cannulated screw) to prevent further slip and Avascular Necrosis (AVN).

Q: Sprengel's shoulder is associated with which of the following congenital anomalies?

All of the above. **Explanation:** **Sprengel’s deformity** is the most common congenital anomaly of the shoulder, characterized by a **high-lying, undescended scapula**. During the 9th to 12th week of gestation, the scapula normally migrates from the cervical level to its permanent thoracic position (T2–T7). Failure of this descent results in Sprengel’s shoulder. **Why "All of the above" is correct:** Because the insult occurs during early embryogenesis, it is frequently associated with other regional musculoskeletal and midline defects: * **Klippel-Feil Anomaly:** This is the most common association (seen in up to 30% of cases), characterized by the triad of a short neck, low posterior hairline, and restricted neck motion due to fused cervical vertebrae. * **Hemivertebra & Scoliosis:** Failure of proper vertebral formation often accompanies the failure of scapular descent. * **Cervical Spina Bifida:** Midline fusion defects of the neural arch are common associated findings. * **Omovertebral Bone:** A high-yield finding where a fibrous, cartilaginous, or bony connection exists between the superior angle of the scapula and the cervical spine (C4–C7). **Clinical Pearls for NEET-PG:** 1. **Clinical Presentation:** The affected shoulder is higher, the scapula is hypoplastic and rotated, and there is a significant **restriction of shoulder abduction**. 2. **Gender Predominance:** More common in **females** and usually unilateral (left side more common). 3. **Surgery:** Indicated for cosmetic improvement or functional limitation. The **Green’s procedure** or **Woodward’s procedure** are the classic surgical techniques used to relocate the scapula inferiorly. 4. **Associated Muscles:** The trapezius, levator scapulae, and rhomboids are often hypoplastic or fibrotic.

Q: A six-year-old boy presents to the emergency department with a painful limp. Clinical examination reveals tenderness in the femoral triangle and some limitation of hip movements. An X-ray was done which was normal. Which of the following should be the next course of action?

Wait and Watch/Observation. ### Explanation The clinical presentation of a 6-year-old with a painful limp, tenderness in the femoral triangle, and limited hip motion—coupled with a **normal X-ray**—is classic for **Transient Synovitis (Toxic Synovitis)**. This is the most common cause of acute hip pain in children aged 3–10 years. **1. Why "Wait and Watch" is correct:** Transient synovitis is a self-limiting, non-specific inflammatory condition, often following a viral upper respiratory tract infection. Since the child is hemodynamically stable and the X-ray is normal (ruling out Perthes disease or fractures), the standard management is **conservative**, involving bed rest and NSAIDs. Most cases resolve spontaneously within 7–10 days. **2. Why other options are incorrect:** * **Ultrasonography:** While USG is sensitive for detecting joint effusion, it cannot reliably differentiate between sterile transient synovitis and septic arthritis. It is indicated only if the child is febrile or the diagnosis is in doubt. * **Aspiration:** This is an invasive procedure reserved for suspected **Septic Arthritis**. In this scenario, the absence of systemic symptoms (fever, high inflammatory markers) makes aspiration unnecessary. * **MRI Scan:** This is highly sensitive but expensive and usually unnecessary for the initial management of a suspected transient synovitis. It is reserved for chronic cases or suspected early osteomyelitis. **Clinical Pearls for NEET-PG:** * **Kocher’s Criteria:** Used to differentiate Septic Arthritis from Transient Synovitis. It includes: (1) Non-weight bearing, (2) ESR >40 mm/hr, (3) Fever >38.5°C, (4) WBC >12,000/mm³. * **Age Group:** Transient Synovitis (3–10 yrs) vs. Perthes Disease (4–8 yrs) vs. SCFE (Obese adolescents, 10–15 yrs). * **First-line Investigation:** X-ray is always the first step to rule out bony pathology. If X-ray is normal and the child is afebrile, **observation** is the next step.

Q: A patient sustained an upper limb injury 3 years ago and now presents with a valgus deformity of the elbow and paresthesias over the medial border of the hand. What is the likely nature of the original injury?

Lateral condyle humerus fracture. ### Explanation The clinical presentation describes a classic case of **Tardy Ulnar Nerve Palsy** following a malunited fracture. **1. Why Lateral Condyle Fracture is correct:** Lateral condyle fractures in children are "fractures of necessity" (requiring ORIF) because they are intra-articular and prone to **non-union**. Non-union leads to a progressive **cubitus valgus** (increased carrying angle) deformity. As the valgus deformity increases over years, the ulnar nerve is chronically stretched as it passes behind the medial epicondyle. This results in delayed ulnar neuropathy, manifesting as paresthesias over the medial border of the hand and wasting of intrinsic hand muscles. **2. Why other options are incorrect:** * **Supracondylar Humerus Fracture:** This is the most common pediatric elbow fracture. Malunion typically results in **Cubitus Varus** (Gunstock deformity). While it can cause acute nerve injuries (Median/AIB), it rarely causes tardy ulnar nerve palsy. * **Medial Condyle Humerus Fracture:** These are rare. While they could theoretically involve the ulnar nerve acutely, they do not typically result in the progressive valgus deformity required for "tardy" palsy. * **Posterior Dislocation of the Humerus:** This is an acute injury. While it may cause immediate nerve traction, it does not lead to a progressive 3-year valgus deformity. **3. High-Yield Clinical Pearls for NEET-PG:** * **Tardy Ulnar Nerve Palsy:** Most commonly follows non-union of the **Lateral Condyle**. * **Cubitus Varus:** Most common complication of Supracondylar fracture (due to malunion). * **Milch Classification:** Used for Lateral Condyle fractures. * **Treatment for Tardy Ulnar Nerve Palsy:** Anterior transposition of the ulnar nerve. * **Remember:** Valgus = Lateral condyle; Varus = Supracondylar.

Q: What is the ideal treatment of bilateral idiopathic clubfoot in a newborn?

Manipulation and casts. **Explanation:** The gold standard for the management of idiopathic congenital talipes equinovarus (CTEV/Clubfoot) in a newborn is the **Ponseti Method**, which consists of serial **manipulation and casting**. **Why Option C is Correct:** In a newborn, the bones and soft tissues are highly malleable. The Ponseti technique involves specific weekly manipulations to stretch the contracted tissues, followed by the application of long-leg plaster casts to maintain the correction. The sequence of correction follows the mnemonic **CAVE**: **C**avus is corrected first, followed by **A**dduction, **V**arus, and finally **E**quinus (often requiring a percutaneous Achilles tenotomy). **Why Other Options are Incorrect:** * **Option A:** Manipulation by the mother is insufficient to achieve the precise anatomical realignment required and cannot maintain the correction without immobilization. * **Option B:** The Denis Browne splint is a **maintenance tool**, not a primary treatment. It is used *after* the deformity has been fully corrected by casts to prevent recurrence. * **Option C:** Surgical release (e.g., Turco’s procedure) was common in the past but is now reserved for resistant cases or late presentations (usually after 6–12 months of age) due to the risk of long-term stiffness and scarring. **NEET-PG High-Yield Pearls:** * **Ideal time to start:** Within the first week of life. * **Order of correction:** Cavus → Adduction → Varus → Equinus. * **Achilles Tenotomy:** Required in ~80-90% of cases to correct the residual equinus. * **Maintenance:** After the final cast, the child wears a Foot Abduction Orthosis (FAO/Denis Browne Splint) for 23 hours a day for 3 months, then at night until age 4. * **Pirani Score:** Used to assess the severity and progress of clubfoot.

Q: Which splint is used in the management of a fracture of the shaft of the femur in the age group of 2 to 10 years?

Split Russell's traction. **Explanation:** The management of femoral shaft fractures in children is primarily determined by the patient's age and weight. For the **2 to 10-year age group**, **Split Russell’s traction** is the preferred conservative management. **1. Why Split Russell’s Traction is Correct:** Split Russell’s traction is a form of skin traction that utilizes a sling under the knee and a longitudinal pull on the leg. It employs a system of pulleys to create a resultant force that aligns with the long axis of the femur. This "double-pull" mechanism allows for hip flexion and knee stabilization, which helps neutralize the muscle forces (iliopsoas and hamstrings) that typically cause displacement in this age group. **2. Analysis of Incorrect Options:** * **Gallows Traction (Bryant’s Traction):** Used for children **under 2 years** of age (or weighing less than 12-15 kg). Both legs are suspended vertically so that the buttocks are just cleared off the bed. * **Buck’s Traction:** A simple longitudinal skin traction without a knee sling. It is generally used for temporary immobilization of hip fractures or femoral shaft fractures in **adults** before surgery, but it does not provide the necessary angular control for pediatric femoral shafts. * **Brandon Traction:** This is not a standard orthopedic term used in the management of femoral fractures; it is likely a distractor. **Clinical Pearls for NEET-PG:** * **Age 10 years:** Flexible Intramedullary Nails (TENS - Titanium Elastic Nailing System) is the treatment of choice. * **Complication:** The most common complication of pediatric femoral shaft fractures treated conservatively is **malunion** (specifically, limb length discrepancy due to overgrowth/hyperemia).

Q: A 24-year-old male presents for a routine checkup. Radiographs reveal supernumerary teeth. General examination shows hypermobility of the shoulders, and the Gorlin sign is absent. What is the most probable diagnosis?

Marie-Sainton Disease. **Explanation:** The clinical presentation of **supernumerary teeth** and **hypermobility of the shoulders** (the ability to bring shoulders together anteriorly) is the classic hallmark of **Cleidocranial Dysplasia**, also known as **Marie-Sainton Disease**. **1. Why Marie-Sainton Disease is correct:** This is an autosomal dominant skeletal dysplasia caused by a mutation in the **RUNX2 gene**. Key features include: * **Clavicular Hypoplasia/Aplasia:** Leads to the characteristic hypermobility of shoulders. * **Dental Anomalies:** Delayed eruption of permanent teeth and multiple **supernumerary teeth**. * **Cranial Features:** Delayed closure of fontanelles and Wormian bones. * **Gorlin Sign:** While the "Gorlin sign" (touching the tip of the nose with the tongue) is often associated with Ehlers-Danlos, its absence here helps rule out EDS, pointing specifically to the skeletal pathology of Marie-Sainton. **2. Why other options are incorrect:** * **Sturge-Weber Syndrome:** A neurocutaneous disorder characterized by a Port-wine stain (Nevus Flammeus), leptomeningeal angiomas, and glaucoma. It does not involve clavicular or supernumerary tooth anomalies. * **Hallermann-Streiff Syndrome:** Characterized by "bird-like" facies, microphthalmia, congenital cataracts, and hypotrichosis. While dental anomalies occur, shoulder hypermobility is not a feature. * **Ehlers-Danlos Syndrome (EDS):** While EDS presents with joint hypermobility and a positive Gorlin sign (due to a long/flexible lingual frenulum), it does not typically feature supernumerary teeth or clavicular aplasia. **NEET-PG High-Yield Pearls:** * **RUNX2 Gene:** The specific molecular marker for Cleidocranial Dysplasia. * **Wormian Bones:** Frequently tested association with this condition. * **Shoulder Sign:** If a patient can touch their shoulders in the midline, think Marie-Sainton.

Question 1

What is a green-stick fracture?

Accepted Answer

Periosteum of cortex is intact and periosteum is crumpled

Answer

Seen mostly in the elderly

Answer

Fatigue fracture

Answer

Spiral fracture of long bone

Question 2

A six-year-old boy presents to the emergency department with a painful limp. Clinical examination reveals tenderness in the femoral triangle and some limitation of hip movements. An X-ray was normal. What is the next appropriate investigation?

Accepted Answer

MRI Scan

Answer

Observation

Answer

Ultrasonography

Answer

Aspiration

Question 3

What is the most common cause of genu valgum in children?

Accepted Answer

Rickets

Answer

Osteoarthritis

Answer

Paget disease

Answer

Rheumatoid arthritis

Question 4

An 11-year-old, 70 kg child presents with limitation of abduction and internal rotation of the hip. There is tenderness in Scarpa's triangle. On flexing the hip, the limb is abducted. What is the diagnosis?

Accepted Answer

Slipped capital femoral epiphyses

Answer

Perthes disease

Answer

Observation hip

Answer

Tuberculosis of the hip

Question 5

Sprengel's shoulder is associated with which of the following congenital anomalies?

Accepted Answer

All of the above

Answer

Hemivertebra

Answer

Klippel-Feil anomaly

Answer

Cervical spina bifida

Question 6

A six-year-old boy presents to the emergency department with a painful limp. Clinical examination reveals tenderness in the femoral triangle and some limitation of hip movements. An X-ray was done which was normal. Which of the following should be the next course of action?

Accepted Answer

Wait and Watch/Observation

Answer

Ultrasonography

Answer

Aspiration

Answer

MRI Scan

Question 7

A patient sustained an upper limb injury 3 years ago and now presents with a valgus deformity of the elbow and paresthesias over the medial border of the hand. What is the likely nature of the original injury?

Accepted Answer

Lateral condyle humerus fracture

Answer

Supracondylar humerus fracture

Answer

Medial condyle humerus fracture

Answer

Posterior dislocation of the humerus

Question 8

What is the ideal treatment of bilateral idiopathic clubfoot in a newborn?

Accepted Answer

Manipulation and casts

Answer

Manipulation by mother

Answer

Manipulation and Dennis Brown splint

Answer

Surgical release

Question 9

Which splint is used in the management of a fracture of the shaft of the femur in the age group of 2 to 10 years?

Accepted Answer

Split Russell's traction

Answer

Gallows traction

Answer

Buck's traction

Answer

Brandon traction

Question 10

A 24-year-old male presents for a routine checkup. Radiographs reveal supernumerary teeth. General examination shows hypermobility of the shoulders, and the Gorlin sign is absent. What is the most probable diagnosis?

Accepted Answer

Marie-Sainton Disease

Answer

Sturge Weber Syndrome

Answer

Hallerman-Streiff syndrome

Answer

Ehlers Danlos Syndrome

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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