Pediatric Orthopaedics Practice Questions

Q: What is the most common cause of acute compartment syndrome in children?

Supracondylar humerus fracture. **Explanation:** **Supracondylar humerus fractures (Option A)** are the most common cause of acute compartment syndrome (ACS) in the pediatric population. This is primarily due to the unique anatomy of the elbow in children. A displaced fracture (especially Gartland Type III) can cause significant swelling, hematoma formation, and direct kinking or injury to the brachial artery. The rigid deep fascia of the forearm (volar compartment) cannot accommodate this rapid increase in pressure, leading to ischemia. If untreated, this progresses to **Volkmann’s Ischemic Contracture**. **Analysis of Incorrect Options:** * **Transphyseal humerus fracture (Option B):** These are rare injuries, usually seen in infants (often due to birth trauma or non-accidental injury). While serious, they do not carry the same high incidence of vascular compromise as supracondylar fractures. * **Fracture of radius/ulna (Option C):** While forearm fractures are the most common pediatric fractures overall, they are the *second* most common cause of ACS. Supracondylar fractures remain the leading cause due to the proximal vascular "choke point" at the antecubital fossa. * **Fracture of the shaft of the humerus (Option D):** These are typically associated with radial nerve palsy (Holstein-Lewis fracture in adults) rather than compartment syndrome, as the mid-shaft area has more room for soft tissue expansion. **Clinical Pearls for NEET-PG:** * **The "6 Ps":** Pain (out of proportion), Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia. **Pain on passive extension** of fingers is the earliest and most sensitive clinical sign. * **Management:** Immediate removal of tight casts/bandages, keeping the limb at heart level (not elevated), and urgent **fasciotomy** if compartment pressure is within 30 mmHg of diastolic blood pressure (Delta P). * **Most common nerve injured:** Anterior Interosseous Nerve (AIN) – check for the "OK sign."

Q: Pyle's disease is characterized by which of the following?

Metaphyseal dysplasia. **Explanation:** **Pyle’s Disease**, also known as **Familial Metaphyseal Dysplasia**, is a rare autosomal recessive skeletal disorder. The hallmark of this condition is a failure of normal modeling of the metaphyses of long bones, leading to a characteristic **"Erlenmeyer flask" deformity**. 1. **Why Option B is Correct:** The primary defect in Pyle’s disease is a failure of periosteal remodeling during growth. This results in significant expansion (widening) of the **metaphyses** of long bones (especially the distal femur and proximal tibia), while the epiphyses and diaphyses remain relatively unaffected. Unlike Craniometaphyseal dysplasia, Pyle’s disease has minimal involvement of the skull. 2. **Why Other Options are Incorrect:** * **Option A (Epiphyseal dysplasia):** Conditions like Multiple Epiphyseal Dysplasia (MED) involve the ends of the bones, leading to early-onset osteoarthritis, which is not a feature of Pyle’s. * **Option C (Diaphyseal dysplasia):** Camurati-Engelmann disease is the classic example of diaphyseal dysplasia, characterized by cortical thickening of the mid-shafts. * **Option D (Sclerosis of cortex):** While some metaphyseal conditions involve increased density (like Osteopetrosis), Pyle’s disease is characterized by cortical thinning and expansion rather than generalized sclerosis. **High-Yield Clinical Pearls for NEET-PG:** * **Erlenmeyer Flask Deformity:** A classic radiological sign seen in Pyle’s disease, Gaucher’s disease, Osteopetrosis, and Thalassemia. * **Clinical Presentation:** Patients are often asymptomatic but may present with genu valgum (knock-knees), dental malocclusion, or mild joint pain. * **Key Distinction:** Pyle’s disease is primarily a **metaphyseal** problem with **minimal skull involvement**, distinguishing it from Craniometaphyseal dysplasia (which features significant facial bone sclerosis).

Q: A 7-year-old boy presents with abrupt onset of hip pain and the hip is held in abduction. Hemogram is normal, but ESR is raised. What is the next line of management?

Ultrasound-guided aspiration of the hip. ### Explanation The clinical presentation of a 7-year-old with acute hip pain, abduction deformity, and an elevated ESR creates a diagnostic dilemma between **Transient Synovitis (TS)** and **Septic Arthritis (SA)**. **Why Option D is correct:** In pediatric orthopaedics, the "Golden Rule" is to **rule out Septic Arthritis**, as it is a surgical emergency that can lead to rapid joint destruction and avascular necrosis. While the normal hemogram might suggest Transient Synovitis, the raised ESR is a sensitive (though non-specific) marker for infection. According to the **Kocher Criteria**, when there is clinical suspicion of an infected joint, **Ultrasound-guided aspiration** is the definitive next step. It allows for immediate Gram stain and culture to differentiate between a sterile effusion (TS) and pyogenic infection (SA). **Why other options are incorrect:** * **A & B (Observation):** Observation is only appropriate *after* Septic Arthritis has been excluded. Delaying diagnosis in a potential case of SA can lead to permanent hip damage. * **C (IV Antibiotics):** Antibiotics should never be started before obtaining a joint aspirate for culture, as this can "decapitate" the infection and lead to false-negative results, making long-term management difficult. **High-Yield Clinical Pearls for NEET-PG:** * **Kocher Criteria for Septic Arthritis:** (1) Non-weight bearing, (2) Fever >38.5°C, (3) ESR >40 mm/hr, (4) WBC >12,000/mm³. * **Transient Synovitis:** Most common cause of hip pain in children (3–8 years); often follows a viral URTI; managed conservatively with NSAIDs and rest. * **Position of Ease:** In Septic Arthritis/TS, the hip is held in **flexion, abduction, and external rotation** (position of maximum joint capacity).

Q: A 4-year-old child complains of a painful limb. What is the most likely cause?

Perthe's disease. ***Perthe's disease*** - **Avascular necrosis** of the femoral head typically presents in children aged **4-8 years** with painful limping, matching this case perfectly. - The hallmark presentation is a **painful limp** with hip pain that may radiate to the knee, often worse with activity. *Poliomyelitis* - This is a **viral infection** affecting the anterior horn cells of the spinal cord, causing **flaccid paralysis** rather than limb pain. - The condition is now extremely rare due to **vaccination programs** and would present with weakness, not isolated pain. *Infantile coxa vara* - This is a **developmental deformity** of the hip that typically presents in **infancy to early childhood** (under 3 years). - The condition is usually **painless** and presents with limping due to limb length discrepancy, not pain. *Congenital talipes equinovarus (CTEV)* - This is a **congenital foot deformity** present at birth, characterized by inward and downward turning of the foot. - The condition affects the **foot and ankle**, not causing limb pain, and would be evident from birth rather than presenting at age 4.

Q: What is the most common complication of a supracondylar fracture?

Malunion with gunstock deformity. **Explanation:** Supracondylar fractures of the humerus are the most common pediatric elbow fractures. **1. Why Malunion (Gunstock Deformity) is correct:** The most common complication of this fracture is **malunion**, specifically resulting in **Cubitus Varus** (also known as **Gunstock Deformity**). This occurs due to inadequate reduction or loss of fixation, leading to a collapse of the medial column or internal rotation of the distal fragment. While it is primarily a cosmetic deformity with minimal functional impairment, it remains the most frequent late complication. **2. Analysis of Incorrect Options:** * **A. Osteosarcoma:** This is a primary malignant bone tumor and is not a complication of trauma or fractures. * **B. Genu valgum:** This refers to "knock-knees," a deformity of the lower limb (knee joint), unrelated to the humerus or elbow. * **C. Blood vessel injury:** While **Brachial artery injury** is the most common *vascular* complication (occurring in about 5-10% of cases), it is less frequent than malunion. It is a serious acute complication but not the "most common" overall. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common nerve injured:** Median nerve (specifically the **Anterior Interosseous Nerve/AIN**) in extension-type fractures; Ulnar nerve in flexion-type or iatrogenic (K-wire) cases. * **Most serious complication:** Volkmann’s Ischemic Contracture (VIC) due to compartment syndrome. * **Radiographic Sign:** Look for the **Fat Pad Sign** (Sail sign) indicating intra-articular effusion and the **Anterior Humeral Line** (which should normally bisect the middle third of the capitellum). * **Management:** Displaced fractures (Gartland Type II & III) typically require Closed Reduction and Internal Fixation (CRIF) with K-wires.

Q: Posterior iliac horns are seen in which of the following conditions?

Nail patella syndrome. **Explanation:** **Nail-Patella Syndrome (NPS)**, also known as **Fong’s Disease** or Hereditary Osteo-onychodysplasia (HOOD), is an autosomal dominant disorder caused by a mutation in the **LMX1B gene**. The presence of **posterior iliac horns** is considered a **pathognomonic** radiological feature of this condition, occurring in approximately 80% of cases. These are bilateral, symmetrical bony outgrowths arising from the posterior aspect of the iliac bones. **Why the other options are incorrect:** * **Fisher’s Syndrome:** A variant of Guillain-Barré syndrome characterized by the triad of ataxia, areflexia, and ophthalmoplegia. It is a neurological condition with no specific orthopedic bony outgrowths. * **Crouzon Syndrome:** A branchial arch syndrome involving craniosynostosis (premature fusion of skull bones), resulting in midface hypoplasia and proptosis, but not iliac abnormalities. * **Pierre Robin Sequence:** Characterized by the triad of micrognathia, glossoptosis, and cleft palate. It affects the craniofacial structures rather than the pelvic girdle. **High-Yield Clinical Pearls for NEET-PG:** * **Tetrad of NPS:** 1. **Nails:** Hypoplastic or absent (especially the thumb). 2. **Patella:** Hypoplastic or absent (leads to recurrent dislocations). 3. **Elbows:** Limited extension/supination due to radial head hypoplasia. 4. **Iliac Horns:** Pathognomonic radiological sign. * **Systemic Involvement:** Up to 40% of patients develop **nephropathy** (resembling glomerulonephritis), which is the most serious complication and can lead to renal failure. * **Lester’s Sign:** Hyperpigmentation of the pupillary margin of the iris (seen in some NPS patients).

Q: Which of the following are associated with supracondylar fracture of humerus?

All of the above.. **Explanation:** Supracondylar fractures of the humerus are the most common elbow fractures in the pediatric population, typically occurring between the ages of 5 and 10 years. * **Option A:** These fractures are **uncommon after 15 years of age** because the physis (growth plate) closes and the supracondylar area becomes thicker and stronger. In adults, trauma to this region more commonly results in intercondylar fractures or dislocations. * **Option B:** **Extension type** is significantly more common, accounting for approximately **95-98%** of cases. It occurs due to a fall on an outstretched hand with the elbow in hyperextension. Flexion type (2-5%) occurs from a direct blow to the posterior aspect of the flexed elbow. * **Option C:** **Cubitus varus** (Gunstock deformity) is the most common late complication. It results from **malunion** (specifically due to inadequate reduction of medial tilt, internal rotation, or posterior displacement), rather than a growth disturbance. While cosmetically displeasing, it rarely affects functional range of motion. **Clinical Pearls for NEET-PG:** * **Gartland Classification:** Used to grade extension-type fractures (Type I: Undisplaced; Type II: Displaced with intact posterior cortex; Type III: Completely displaced). * **Neurological Injury:** The **Anterior Interosseous Nerve (AIN)** is the most commonly injured nerve in extension-type fractures (specifically posterolateral displacement). The **Ulnar nerve** is most commonly injured in flexion-type fractures or during iatrogenic medial pinning. * **Vascular Emergency:** Absence of radial pulse indicates brachial artery involvement. **Volkmann’s Ischemic Contracture (VIC)** is the most dreaded vascular complication. * **Radiology:** Look for the **"Fat Pad Sign"** (suggests occult fracture) and the **Anterior Humeral Line**, which should normally bisect the middle third of the capitellum.

Q: All are true about supracondylar fracture of humerus except?

Common in the elderly. ### Explanation Supracondylar fracture of the humerus is a classic pediatric injury, most commonly occurring in children aged **5–10 years**. It is rarely seen in the elderly, where distal humerus fractures are more likely to be intercondylar or comminuted due to osteoporosis. **Analysis of Options:** * **D. Common in the elderly (Correct Answer):** This is false. The supracondylar area is the weakest part of the adolescent humerus (due to remodeling), making it highly susceptible to injury from a fall on an outstretched hand (FOOSH). In adults, the bone is stronger here, and injuries typically involve the joint surface. * **A. Posterior shift of distal fragment:** In the **extension type** (95% of cases), the distal fragment is displaced posteriorly and proximally. This is the most common displacement pattern. * **B. Median nerve is the most common nerve damaged:** Overall, the **Median nerve** (specifically the Anterior Interosseous Nerve branch) is the most frequently injured nerve in extension-type fractures. However, in posterolateral displacement, the median nerve is at risk, while posteromedial displacement often affects the radial nerve. * **C. Injury of brachial artery may occur:** The sharp proximal fragment can easily pierce or entrap the brachial artery, leading to pulselessness or the limb-threatening **Volkmann’s Ischemic Contracture**. ### Clinical Pearls for NEET-PG: * **Gartland Classification:** Used to grade displacement (Type I: Undisplaced; Type II: Angulated but intact posterior cortex; Type III: Completely displaced). * **Baumann’s Angle:** Used radiologically to assess the adequacy of reduction. * **Fat Pad Sign:** A "Sail sign" (anterior fat pad elevation) or the presence of a posterior fat pad on X-ray indicates an occult fracture. * **Complication:** The most common late complication is **Cubitus Varus** (Gunstock deformity) due to malunion.

Q: The Kebab treatment is used for the treatment of which of the following conditions?

Osteogenesis imperfecta. **Explanation:** The **Kebab treatment** (also known as the **Sillence technique** or **Sofield-Millar procedure**) is a classic surgical intervention for **Osteogenesis Imperfecta (OI)**. In patients with OI, bones are extremely fragile and prone to multiple fractures, leading to severe bowing and deformities. The "Kebab" technique involves performing multiple osteotomies (cutting the bone) along the shaft of a long bone (usually the femur or tibia). These segments are then realigned and threaded onto a single, long intramedullary rod—much like pieces of meat on a skewer (kebab). This provides internal stabilization, corrects the deformity, and prevents future fractures. Modern variations use **telescoping rods** (e.g., Bailey-Dubow or Fassier-Duval rods) that elongate as the child grows. **Why other options are incorrect:** * **Paget’s Disease:** Treated primarily with bisphosphonates (medical) or joint replacement if secondary arthritis occurs. * **Osteoarthritis:** Managed with lifestyle changes, analgesics, and ultimately Total Joint Replacement (Arthroplasty). * **Myositis Ossificans:** Managed with rest, NSAIDs, and surgical excision only after the ectopic bone has matured (usually after 6–12 months). **High-Yield Clinical Pearls for NEET-PG:** * **Osteogenesis Imperfecta:** Caused by a defect in **Type I Collagen** synthesis. * **Clinical Triad:** Blue sclera, fragile bones (multiple fractures), and early-onset deafness (otosclerosis). * **Drug of Choice:** Bisphosphonates (e.g., Pamidronate/Zoledronate) to increase bone mineral density. * **Radiology:** Look for "Popcorn calcifications" near the growth plates and "Codfish vertebrae."

Question 1

What is the most common cause of acute compartment syndrome in children?

Accepted Answer

Supracondylar humerus fracture

Answer

Transphyseal humerus fracture

Answer

Fracture of radius/ulna

Answer

Fracture of the shaft of the humerus

Question 2

Pyle's disease is characterized by which of the following?

Accepted Answer

Metaphyseal dysplasia

Answer

Epiphyseal dysplasia

Answer

Diaphyseal dysplasia

Answer

Sclerosis of cortex

Question 3

A 7-year-old boy presents with abrupt onset of hip pain and the hip is held in abduction. Hemogram is normal, but ESR is raised. What is the next line of management?

Accepted Answer

Ultrasound-guided aspiration of the hip

Answer

Hospitalize and observe

Answer

Ambulatory observation

Answer

Intravenous antibiotics

Question 4

A 4-year-old child complains of a painful limb. What is the most likely cause?

Accepted Answer

Perthe's disease

Answer

Poliomyelitis

Answer

Infantile coxa vara

Answer

Congenital talipes equinovarus (CTEV)

Question 5

What is the most common complication of a supracondylar fracture?

Accepted Answer

Malunion with gunstock deformity

Answer

Osteosarcoma

Answer

Genu valgum

Answer

Blood vessel injury

Question 6

Posterior iliac horns are seen in which of the following conditions?

Accepted Answer

Nail patella syndrome

Answer

Fisher's syndrome

Answer

Crouzan syndrome

Answer

Pierre Robbins syndrome

Question 7

Which of the following are associated with supracondylar fracture of humerus?

Accepted Answer

All of the above.

Answer

It is uncommon after 15 years of age.

Answer

Extension type fracture is more common than the flexion type.

Answer

Cubitus varus deformity commonly results following malunion.

Question 8

All are true about supracondylar fracture of humerus except?

Accepted Answer

Common in the elderly

Answer

Posterior shift of distal fragment

Answer

Median nerve is the most common nerve damaged

Answer

Injury of brachial artery may occur

Question 9

All of the following are true about a pulled elbow except?

Accepted Answer

The elbow is fully flexed

Answer

The forearm lies in pronation

Answer

It is treated by fully supinating the forearm

Answer

It is a dislocation of the radial head

Question 10

The Kebab treatment is used for the treatment of which of the following conditions?

Accepted Answer

Osteogenesis imperfecta

Answer

Paget's disease

Answer

Osteoarthritis

Answer

Myositis ossificans

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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