Pediatric Orthopaedics Practice Questions

Q: Fairbank's triangle is seen in which of the following conditions?

Congenital coxa vara. **Explanation:** **Congenital Coxa Vara** is a developmental deformity characterized by a decreased neck-shaft angle (less than 120°). The hallmark radiographic feature of this condition is **Fairbank’s Triangle**. This is a triangular fragment of bone located at the inferior aspect of the femoral neck, demarcated by two lucent bands forming an inverted "V." These bands represent a vertical, disordered epiphyseal plate. The presence of this triangle is pathognomonic for developmental/congenital coxa vara and helps differentiate it from other causes of a short femoral neck. **Analysis of Incorrect Options:** * **A. Congenital Dislocation of the Hip (CDH/DDH):** Characterized by Shenton’s line break, Perkins’ line lateralization, and Hilgenreiner’s line measurements. It does not involve a metaphyseal triangular fragment. * **B. Slipped Capital Femoral Epiphysis (SCFE):** Features the "Trethowan’s sign" (Klein’s line not intersecting the epiphysis) and the "Steel’s blanch sign." * **D. Perthes Disease:** Characterized by avascular necrosis findings such as the "Crescent sign" (subchondral fracture), fragmentation, and eventual re-ossification of the femoral head. **High-Yield Clinical Pearls for NEET-PG:** * **Hilgenreiner-Epiphyseal (H-E) Angle:** Used to assess the severity and progression of Coxa Vara. An angle **>60°** is likely to progress and requires surgical intervention (e.g., Valgus Osteotomy). * **Clinical Presentation:** Patients typically present with a painless "painless waddling gait" (if bilateral) or a Trendelenburg gait (if unilateral) due to abductor insufficiency. * **Neck-Shaft Angle:** Normal is ~135°; in Coxa Vara, it is significantly reduced, often reaching <90°.

Q: What is the most common elbow injury in adolescents?

Supracondylar fracture. **Explanation:** **Supracondylar fracture of the humerus** is the most common elbow injury in the pediatric and adolescent age group, accounting for approximately 60% of all pediatric elbow fractures. The peak incidence occurs between **5 to 8 years** of age. The injury typically occurs due to a fall on an outstretched hand (FOOSH) with the elbow in extension, leading to a fracture through the thin bone of the olecranon fossa. **Analysis of Options:** * **A. Dislocation:** While common in adults, elbow dislocations are relatively rare in children because the ligaments and joint capsules are often stronger than the adjacent growth plates (physes). * **B. Physeal injury:** Although common in the pediatric skeleton, specific physeal injuries (like Lateral Condyle fractures) are second in frequency to supracondylar fractures. * **D. Olecranon fracture:** These are much less common in children compared to adults and are often associated with other injuries like radial head dislocations (Monteggia fracture-dislocation). **High-Yield Clinical Pearls for NEET-PG:** * **Classification:** The **Gartland Classification** is used to grade these fractures (Type I: Undisplaced; Type II: Displaced with intact posterior cortex; Type III: Completely displaced). * **Neurological Complication:** The **Anterior Interosseous Nerve (AIN)**—a branch of the Median nerve—is the most commonly injured nerve in extension-type fractures (test: "OK" sign). * **Vascular Complication:** Injury to the **Brachial Artery** can lead to **Volkmann’s Ischemic Contracture**, the most dreaded complication. * **Deformity:** Malunion typically results in **Cubitus Varus** (Gunstock deformity), which is primarily a cosmetic rather than functional issue.

Q: When should treatment for Congenital Talipes Equinovarus (CTEV) start?

Immediately after birth. **Explanation:** The primary goal in managing **Congenital Talipes Equinovarus (CTEV)**, also known as Clubfoot, is to achieve a functional, pain-free, plantigrade foot. The correct answer is **Immediately after birth** because the neonatal period offers a unique physiological window where the connective tissues (ligaments, tendons, and joint capsules) are extremely pliable due to the presence of maternal hormones (like relaxin) still circulating in the infant’s blood. **Why Option A is correct:** Early intervention—ideally within the first week of life—utilizes this maximum elasticity. Starting treatment immediately allows for easier manual correction of the four components of the deformity (**CAVE**: Cavus, Adduction, Varus, and Equinus) using the **Ponseti Method**. Delaying treatment leads to the stiffening of these structures, making non-operative correction significantly more difficult. **Why other options are incorrect:** * **Option B & C (3 and 6 months):** Waiting this long allows the soft tissues to contract and the bones to begin ossifying in a deformed position. This often necessitates more invasive surgical releases rather than simple serial casting. * **Option D (After 24 hours):** While treatment can technically start after 24 hours, the clinical teaching emphasizes "immediately" (as soon as the baby is stable) to reinforce the urgency of early manipulation. **High-Yield Clinical Pearls for NEET-PG:** * **Ponseti Method:** The gold standard treatment involving serial casting. * **Order of Correction:** Remember the mnemonic **CAVE**. Cavus is corrected first; Equinus is always corrected last. * **Tenotomy:** Approximately 85-90% of cases require a Percutaneous Achilles Tenotomy to correct the residual Equinus. * **Pirani Score:** Used to assess the severity of the deformity and monitor progress during casting.

Q: What is the recommended conservative treatment for neurogenic dislocation?

Botulinum toxin A injection. **Explanation:** **Neurogenic dislocation** (most commonly seen at the hip) is a frequent complication in patients with Upper Motor Neuron (UMN) lesions, such as Cerebral Palsy or Spinal Cord Injury. The underlying pathophysiology involves **spasticity** and muscle imbalance, where overactive adductors and flexors (e.g., adductor longus, iliopsoas) overpower the weaker abductors, gradually levering the femoral head out of the acetabulum. **Why Botulinum Toxin A (BTX-A) is the Correct Answer:** The primary goal of conservative management is to reduce the spasticity that drives the subluxation. **Botulinum toxin A** acts by inhibiting the release of acetylcholine at the neuromuscular junction, causing temporary chemo-denervation and muscle relaxation. When injected into the spastic adductors, it restores muscle balance, reduces pain, and prevents further lateral migration of the femoral head, especially in the early stages of displacement (Reimers’ migration index < 30-40%). **Analysis of Incorrect Options:** * **Prolotherapy:** This involves injecting irritant solutions (like hypertonic dextrose) into ligaments or tendons to promote healing through inflammation. It has no role in managing neurogenic spasticity or dislocations. * **Sclerotherapy:** This is used to treat vascular malformations or varicose veins by inducing fibrosis. It is not indicated for musculoskeletal dislocations. **NEET-PG High-Yield Pearls:** * **Reimers' Migration Index:** The gold standard for quantifying hip displacement in neurogenic cases. * **Surgical Management:** If conservative measures fail or the migration index exceeds 40-50%, surgical interventions like **Adductor Tenotomy** or **Varus Derotation Osteotomy (VDRO)** are indicated. * **BTX-A Duration:** The effect typically lasts 3–6 months; it is often used as a "bridge" to delay surgery in young children.

Q: Open reduction and internal fixation is definitely required in a child with which of the following fractures?

Lateral condylar fracture of the humerus. **Explanation:** The correct answer is **Lateral condylar fracture of the humerus**. This is a classic "must-know" topic in pediatric orthopedics for NEET-PG. **Why it is the correct answer:** Unlike many pediatric fractures that can be managed conservatively due to the high remodeling potential of young bone, a lateral condyle fracture is an **intra-articular fracture** and a **Salter-Harris Type IV injury**. It is considered a "fracture of necessity" for surgery because: 1. **Instability:** The pull of the common extensor muscles tends to rotate and displace the fragment. 2. **Non-union Risk:** The fragment is bathed in synovial fluid, which inhibits callus formation, leading to a high risk of non-union if not perfectly stabilized. 3. **Growth Disturbance:** Precise anatomical reduction is mandatory to prevent future cubitus valgus deformity and tardy ulnar nerve palsy. **Why other options are incorrect:** * **A & B (Femur and Tibia):** Most long bone fractures in children (especially shaft fractures) can be managed with closed reduction and casting (e.g., Gallow’s traction or Spica casting) because the thick periosteum and rapid remodeling usually correct minor angulations. * **D (Forearm bones):** These are typically managed by closed reduction and casting. Surgery is only reserved for unstable or irreducible cases, unlike the lateral condyle which almost always requires ORIF if displaced >2mm. **High-Yield Clinical Pearls:** * **Milch Classification** is used to categorize these fractures. * **Complications of untreated lateral condyle fracture:** Non-union → Cubitus Valgus → **Tardy Ulnar Nerve Palsy** (occurs years later). * **Supracondylar fractures**, by contrast, are extra-articular and often managed with closed reduction and K-wire fixation (CRIF).

Q: A 10-year-old child presents with pain and restricted movement in the right upper limb after falling from a wall with an outstretched hand. Radiographic findings are shown below. What is the management?

Above-elbow cast with forearm in supination. ***Above-elbow cast with forearm in supination*** - This is a **Monteggia fracture (Bado Type I)** - proximal ulna fracture with **anterior radial head dislocation** from fall on outstretched hand (FOOSH). - **Closed reduction** followed by **above-elbow cast in supination** is the standard treatment for pediatric Monteggia fractures to maintain alignment. *Open reduction and fixation* - **ORIF** is reserved for **failed closed reduction** attempts or in **older children/adolescents** where closed methods are inadequate. - Most pediatric Monteggia fractures can be successfully managed with **closed reduction** and casting. *Plaster cast with forearm in pronation* - **Pronation is contraindicated** in Monteggia fractures as it promotes **re-dislocation** of the radial head. - Proper positioning requires **supination** to maintain reduction of both the ulnar fracture and radial head alignment. *Closed reduction with below-elbow cast* - **Below-elbow cast is insufficient** for Monteggia fractures as it cannot adequately control **proximal radioulnar joint** stability. - **Above-elbow immobilization** is essential to prevent loss of reduction and maintain proper alignment of the radiocapitellar joint.

Q: What imaging is required for a suspected medial epicondylar fracture of the humerus in a 4-year-old child?

X-ray of both arms with elbows for comparison. **Explanation:** The correct answer is **A. X-ray of both arms with elbows for comparison.** In pediatric orthopaedics, the elbow is one of the most challenging areas to interpret due to the sequential appearance of six different ossification centers. At age 4, several centers (like the medial epicondyle, which typically appears at age 5) may be in the process of appearing or may be cartilaginous and invisible on X-ray. Comparison views of the contralateral, uninjured elbow are the **gold standard** for identifying subtle fractures, displacements, or abnormal ossification patterns in children. **Analysis of Incorrect Options:** * **B. X-ray of the same limb only:** This is often insufficient in children because normal growth plates can be easily mistaken for fracture lines (and vice versa) without a baseline for comparison. * **C. Examination under anesthesia (EUA):** While EUA is useful for assessing joint stability or performing a closed reduction, it is not the primary *imaging* modality required for initial diagnosis. * **D. Plaster of Paris cast:** This is a treatment modality, not a diagnostic imaging step. Furthermore, immobilizing a suspected fracture in full flexion without confirming the diagnosis can lead to compartment syndrome or neurovascular compromise. **High-Yield Clinical Pearls for NEET-PG:** * **CRITOE Mnemonic:** Remember the order of ossification centers: **C**apitellum (1y), **R**adial head (3y), **I**nternal/Medial epicondyle (5y), **T**rochlea (7y), **O**lecranon (9y), **E**xternal/Lateral epicondyle (11y). * **The "Trap":** The medial epicondyle is the most common "missed" fracture because it can be displaced into the joint space and mistaken for the trochlea. * **Clinical Sign:** Medial epicondyle fractures are often associated with elbow dislocations and ulnar nerve injuries.

Q: Which of the following is NOT a feature of Achondroplasia?

Mental retardation. **Achondroplasia** is the most common cause of disproportionate short-limbed dwarfism. It is caused by a gain-of-function mutation in the **FGFR3 gene** (Fibroblast Growth Factor Receptor 3) on chromosome 4p. ### **Explanation of Options:** * **A. Mental Retardation (Correct Answer):** Patients with achondroplasia typically have **normal intelligence** and a normal lifespan. While they may experience motor delays due to hypotonia and a large head (macrocephaly), their cognitive development is unaffected. * **B. Autosomal Recessive Inheritance (Incorrect/Note):** While the question lists this as a feature to be excluded, it is important to note that Achondroplasia is actually **Autosomal Dominant**. However, 80% of cases are due to *de novo* mutations associated with advanced paternal age. (Note: In some versions of this MCQ, this option is also factually incorrect, but "Mental Retardation" is the most classic "distractor" used in exams). * **C. Defective Endochondral Ossification:** This is the core pathophysiology. The FGFR3 mutation over-inhibits the proliferation of chondrocytes in the growth plate, specifically affecting **long bones** (endochondral) while sparing flat bones (intramembranous). * **D. Familial Occurrence:** Since it is an Autosomal Dominant condition, it can be passed down from an affected parent to offspring (50% chance). ### **High-Yield Clinical Pearls for NEET-PG:** * **Rhizomelic Shortening:** Shortening is most prominent in the proximal segments (humerus/femur). * **Trident Hand:** A characteristic wide space between the 3rd and 4th digits. * **Champagne Glass Pelvis:** Radiographic finding showing a flat, broad pelvis with narrow sacrosciatic notches. * **Foramen Magnum Stenosis:** A critical complication in infancy that can lead to sudden death or hydrocephalus. * **Spinal Stenosis:** Common in adults due to short pedicles and a narrowed spinal canal.

Q: Coxa vara is caused by:

All of the above. **Explanation:** **Coxa vara** is a clinical deformity of the hip where the **neck-shaft angle** of the femur is reduced to **less than 120°** (normal is 120°–135°). This reduction in angle leads to a shortened limb and a characteristic abductor lurch (Trendelenburg gait). **Why "All of the Above" is correct:** Coxa vara is not a single disease but a structural manifestation of various underlying pathologies that weaken the femoral neck or affect the proximal femoral growth plate: 1. **SCFE (Slipped Capital Femoral Epiphysis):** In this condition, the femoral head slips posteriorly and inferiorly relative to the neck. This displacement results in a "relative" coxa vara and retroversion of the femoral neck. 2. **Rickets:** Metabolic bone diseases like Rickets (in children) or Osteomalacia (in adults) lead to softened osteoid. Under the physiological stress of weight-bearing, the softened femoral neck bends, leading to an acquired coxa vara. 3. **Paget’s Disease:** This is a disorder of bone remodeling resulting in structurally weak, hypervascular bone. When it involves the proximal femur, the "shepherd’s crook deformity" occurs, which is a severe form of coxa vara. **Clinical Pearls for NEET-PG:** * **Congenital Coxa Vara:** Characterized by a **vertical epiphyseal plate** and a **Fairbank’s triangle** (a triangular bone fragment in the inferior neck) on X-ray. * **Hilgenreiner’s Epiphyseal Angle (HEA):** Used to assess severity; an angle **>60°** usually requires surgical correction (Valgus Osteotomy). * **Differential Diagnosis:** Must be distinguished from Developmental Dysplasia of the Hip (DDH); in coxa vara, the femoral head is *inside* the acetabulum, whereas in DDH, it is displaced. * **Common presentation:** Painless limping, positive Trendelenburg sign, and restricted abduction and internal rotation.

Question 1

Fairbank's triangle is seen in which of the following conditions?

Accepted Answer

Congenital coxa vara

Answer

Congenital dislocation of the hip (CDH)

Answer

Slipped capital femoral epiphysis (SCFE)

Answer

Perthes disease

Question 2

What is the most common elbow injury in adolescents?

Accepted Answer

Supracondylar fracture

Answer

Dislocation

Answer

Physeal injury

Answer

Olecranon fracture

Question 3

When should treatment for Congenital Talipes Equinovarus (CTEV) start?

Accepted Answer

Immediately after birth

Answer

After 3 months

Answer

After 6 months

Answer

After 24 hours

Question 4

What is the recommended conservative treatment for neurogenic dislocation?

Accepted Answer

Botulinum toxin A injection

Answer

Prolotherapy

Answer

Sclerotherapy

Answer

None of the above

Question 5

Open reduction and internal fixation is definitely required in a child with which of the following fractures?

Accepted Answer

Lateral condylar fracture of the humerus

Answer

Fracture of the femur shaft

Answer

Fracture of the tibia with displacement

Answer

Fracture of both bones of the forearm

Question 6

A 10-year-old child presents with pain and restricted movement in the right upper limb after falling from a wall with an outstretched hand. Radiographic findings are shown below. What is the management?

Accepted Answer

Above-elbow cast with forearm in supination

Answer

Open reduction and fixation

Answer

Plaster cast with forearm in pronation

Answer

Closed reduction with below-elbow cast

Question 7

What imaging is required for a suspected medial epicondylar fracture of the humerus in a 4-year-old child?

Accepted Answer

X-ray of both arms with elbows for comparison

Answer

X-ray of the same limb only

Answer

Examination under general anesthesia

Answer

Plaster of Paris cast in fully flexed position

Question 8

Which of the following is NOT a feature of Achondroplasia?

Accepted Answer

Mental retardation

Answer

Autosomal recessive inheritance

Answer

Defective endochondral ossification

Answer

Familial occurrence

Question 9

A six-year-old child presented with a valgus deformity at his right elbow, which has been gradually progressive for the past 3 years. He has a history of a cast applied for 6 weeks after falling on an outstretched hand 3 years prior. What is the probable diagnosis?

Accepted Answer

Malunited lateral condylar fracture of the humerus

Answer

Malunited supracondylar fracture of the humerus

Answer

Posterior dislocation of the elbow

Answer

Fracture of the medial condyle of the humerus

Question 10

Coxa vara is caused by:

Accepted Answer

All of the above

Answer

SCFE

Answer

Rickets

Answer

Paget's disease

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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