Pediatric Orthopaedics Practice Questions

Q: French osteotomy is used in the treatment of which condition?

Cubitus varus. **Explanation:** **French osteotomy** is a specific surgical procedure used to correct **Cubitus varus** deformity, commonly known as "Gunstock deformity." This deformity most frequently occurs as a late complication of a malunited supracondylar fracture of the humerus in children. 1. **Why Cubitus Varus is Correct:** The French osteotomy is a **lateral closing wedge osteotomy** of the distal humerus. It involves removing a wedge of bone from the lateral side and fixing it with two screws and a tension-band wire (or a small plate). This procedure corrects the triplanar deformity (primarily the varus angulation and internal rotation) to restore the normal carrying angle of the elbow. 2. **Why Other Options are Incorrect:** * **Cubitus valgus:** While osteotomies can treat this (often caused by lateral condyle non-union), the French technique is specifically described for varus correction. * **Coxa vara:** This is a hip deformity (decreased neck-shaft angle). It is treated with proximal femoral osteotomies, such as the **Pauwel’s osteotomy** or **Borden’s osteotomy**, not the French osteotomy. * **Coxa valga:** This is an increased neck-shaft angle of the femur, usually managed with a **Varus Derotation Osteotomy (VDRO)**. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of Cubitus varus:** Malunited supracondylar fracture (due to inadequate reduction of the medial tilt/rotation). * **Deformity components:** It is a triplanar deformity (Varus + Internal rotation + Hyperextension). * **Indication for surgery:** Primarily cosmetic; it rarely affects elbow function or range of motion. * **Other osteotomies for Cubitus varus:** King’s osteotomy, Amspacher and Fowler osteotomy.

Q: Which statement is not true about Perthes disease?

The bone age is the same as the chronological age. **Explanation:** **Legg-Calvé-Perthes Disease (LCPD)** is an idiopathic avascular necrosis of the proximal femoral epiphysis in children. **Why Option C is the correct answer (False statement):** In Perthes disease, there is a characteristic **delay in skeletal maturation**. Therefore, the **bone age is typically less than the chronological age** (often delayed by 1–2 years). This is a high-yield diagnostic feature used to differentiate it from other hip pathologies. **Analysis of other options:** * **Option A (True):** The fundamental pathology is **avascular necrosis (AVN)** of the femoral head due to a temporary interruption of blood supply, followed by revascularization and remodeling. * **Option B (True):** LCPD shows a strong gender predilection, being **4 to 5 times more common in males** than females. It typically affects children between 4 and 8 years of age. **NEET-PG High-Yield Pearls:** * **Clinical Presentation:** Painless limping (antalgic gait) or hip/knee pain with limited abduction and internal rotation. * **Radiological Signs:** * **Crescent Sign:** Subchondral fracture (best seen on lateral view). * **Gage’s Sign:** V-shaped lucency at the lateral aspect of the epiphysis. * **Snowcap Appearance:** Increased density of the femoral head. * **Classification:** **Catterall** (based on extent of necrosis) and **Herring Lateral Pillar** (prognostic classification based on the height of the lateral pillar). * **Prognosis:** "The younger the age at onset, the better the prognosis." Females generally have a worse prognosis than males.

Q: What is the treatment for congenital coxa vara?

Osteotomy. **Explanation:** **Congenital Coxa Vara** is a developmental deformity characterized by a decreased neck-shaft angle (less than 120°) and a more vertical orientation of the physis. The primary pathology is a defect in the ossification of the femoral neck, leading to progressive varus deformity, limb shortening, and a Trendelenburg gait. **Why Osteotomy is the Correct Answer:** The definitive treatment for symptomatic congenital coxa vara is a **Valgus Subtrochanteric Osteotomy** (e.g., Pauwels' osteotomy). The goal is to convert the shear forces across the vertical physis into compressive forces by increasing the neck-shaft angle. This promotes healing of the defective femoral neck and improves the biomechanical efficiency of the hip abductors. Surgery is typically indicated when the **Hilgenreiner-epiphyseal (H-E) angle** is greater than 60°. **Why Other Options are Incorrect:** * **A. Fixation by SP Nail:** Smith-Petersen (SP) nails are historically used for femoral neck fractures in adults. They do not correct the angular deformity or the vertical physis in a growing child. * **C. Bone Grafting:** While bone grafting may be used as an adjunct in some non-unions, it does not address the primary mechanical issue (the varus angle). * **D. Traction:** Traction is ineffective as it cannot correct a structural bony deformity or the underlying ossification defect. **Clinical Pearls for NEET-PG:** * **Radiographic Hallmark:** A characteristic **inverted Y-shaped** (triangular) bone fragment in the inferior aspect of the femoral neck (Fairbank’s triangle). * **H-E Angle:** 60° requires surgical intervention (Osteotomy). * **Clinical Sign:** Patients often present with a painless "waddling" or Trendelenburg gait and a prominent greater trochanter.

Q: A 16-year-old boy presents with progressive knee pain that began soon after starting basketball season. Physical examination reveals a swollen and prominent tibial tubercle with associated tenderness. Radiographs of the area are unremarkable. What is the most likely diagnosis?

Osgood-Schlatter disease. **Explanation:** **Osgood-Schlatter Disease (OSD)** is the correct diagnosis. It is a classic **traction apophysitis** of the tibial tubercle caused by repetitive microtrauma from the patellar tendon. It typically occurs in adolescent athletes (boys aged 12–15, girls aged 10–13) during periods of rapid growth. The clinical hallmark is a **swollen, prominent, and tender tibial tubercle**, often exacerbated by activities involving quadriceps contraction like basketball or jumping. Radiographs are often normal or may show soft tissue swelling/fragmentation of the tubercle. **Why the other options are incorrect:** * **Popliteal Cyst (Baker’s Cyst):** Presents as a fluid-filled swelling in the **posterior** aspect (popliteal fossa) of the knee, not the anterior tibial tubercle. * **Slipped Capital Femoral Epiphysis (SCFE):** An adolescent hip pathology. While it can present with referred knee pain, it would not cause localized swelling or tenderness at the tibial tubercle. * **Legg-Calvé-Perthes Disease:** An idiopathic avascular necrosis of the femoral head seen in younger children (typically 4–8 years). It presents with a limp and hip pain, not localized tibial swelling. **Clinical Pearls for NEET-PG:** * **Management:** Primarily conservative (Rest, Ice, NSAIDs, and activity modification). It is self-limiting and resolves with skeletal maturity. * **Radiographic Sign:** Fragmentation of the tibial tubercle (though clinical diagnosis is sufficient). * **Differential:** Sinding-Larsen-Johansson syndrome (similar traction apophysitis but at the **inferior pole of the patella**).

Q: A 3-year-old child presents with a limp. What is the most likely diagnosis?

Septic arthritis. ***Septic arthritis*** - In a 3-year-old with acute limp, **septic arthritis** is most common, presenting with **fever**, **toxic appearance**, and hip held in **flexion, abduction, and external rotation**. - X-ray shows **widened joint space** due to effusion and inflammation, requiring urgent **surgical drainage** and antibiotics. *Slipped capital femoral epiphysis* - Typically occurs in **adolescents** (10-16 years), particularly **obese males** during growth spurts. - This 3-year-old is **too young** for SCFE, which involves slippage of the femoral head epiphysis. *Perthes disease* - Usually affects children **4-8 years old** with **insidious onset** of limp and hip pain. - This child is **too young** and the acute presentation doesn't match the **gradual onset** typical of Perthes disease. *Developmental dysplasia of the hip (DDH)* - Typically diagnosed in **infancy** or when child starts walking, not at 3 years with acute limp. - Presents with **hip instability** and **asymmetric skin folds**, not acute painful limp with systemic symptoms.

Q: Which of the following statements regarding supracondylar fracture of the humerus in children is true?

Admission to the hospital is essential following reduction.. **Explanation:** Supracondylar fracture of the humerus is the most common elbow fracture in children (peak age 5–8 years). It is considered an **orthopaedic emergency** due to its proximity to vital neurovascular structures. **1. Why Option A is correct:** Admission following reduction is mandatory for **monitoring neurovascular status**. The primary concern is the development of **Volkmann’s Ischemia**, which can lead to Volkmann’s Ischemic Contracture (VIC). Post-reduction swelling or tight casting can compromise the brachial artery or cause Compartment Syndrome. Hourly observation for the "5 Ps" (Pain, Pallor, Pulselessness, Paresthesia, Paralysis) is essential for at least 24 hours. **2. Why the other options are incorrect:** * **Option B:** It is typically caused by a **fall on an outstretched hand (FOOSH)** with the elbow in extension (Extension type, >95%). A fall on the point of the elbow usually results in the rarer flexion-type fracture. * **Option C:** Most cases are managed by **Closed Reduction and Internal Fixation (CRIF)** using percutaneous K-wires. Open reduction is reserved only for failed closed attempts, vascular compromise, or compound injuries. * **Option D:** These are usually **closed fractures**. While the sharp proximal fragment can pierce the brachialis muscle and skin (puckering sign), frank compound injuries are not the norm. **High-Yield Clinical Pearls for NEET-PG:** * **Most common nerve injured:** Anterior Interosseous Nerve (AIN) – branch of the Median nerve (test by asking the child to make an "OK" sign). * **Most common deformity:** Cubitus Varus (Gun-stock deformity) due to malunion (remodeling does not correct rotation). * **Gartland Classification:** Used to grade severity (Type I: Undisplaced; Type II: Displaced with intact posterior cortex; Type III: Completely displaced).

Q: All of the following are associated with supracondylar fracture of humerus, except?

Ulnar nerve is most commonly involved. **Explanation:** Supracondylar fracture of the humerus is the most common pediatric elbow fracture. Understanding its complications and anatomy is crucial for NEET-PG. **Why Option D is the correct answer (The Exception):** In supracondylar fractures, the **Median nerve** (specifically the **Anterior Interosseous Nerve branch**) is the most commonly injured nerve in the extension type, followed by the Radial nerve. The **Ulnar nerve** is rarely injured in the primary trauma; it is more commonly associated with the rare **flexion-type** fracture or occurs iatrogenically during medial percutaneous pinning. **Analysis of other options:** * **Option A:** This fracture is primarily seen in children (peak age 5–8 years) because the supracondylar area is thin and weak during skeletal development. After age 15, the physis closes and the bone strengthens, making dislocations more common than fractures. * **Option B:** **Extension type** accounts for approximately **95-98%** of cases, usually resulting from a fall on an outstretched hand. Flexion type is rare (2-5%). * **Option C:** **Cubitus varus** (Gunstock deformity) is the most common late complication due to malunion (specifically due to uncorrected coronal tilt or internal rotation). While it is a cosmetic deformity, it rarely affects function. **Clinical Pearls for NEET-PG:** * **Most common complication:** Cubitus varus (Malunion). * **Most serious complication:** Volkmann’s Ischemic Contracture (VIC) due to brachial artery injury or compartment syndrome. * **Gartland Classification:** Used to grade displacement (Type I: Undisplaced; Type II: Displaced with intact posterior cortex; Type III: Completely displaced). * **Radiological Sign:** Look for the **"Fat pad sign"** (occult fracture) and the **Anterior Humeral Line** (which should normally bisect the middle third of the capitellum).

Q: In children, acute osteomyelitis most commonly affects which part of the long bone?

Metaphysis. **Explanation:** Acute Hematogenous Osteomyelitis (AHO) is most common in children, and the **metaphysis** is the site of predilection due to its unique vascular anatomy. **Why Metaphysis is the correct answer:** 1. **Hairpin Loops:** The nutrient arteries end in sharp "hairpin" loops at the growth plate before entering large venous sinusoids. This sudden change in direction causes turbulent blood flow and stasis. 2. **Sluggish Circulation:** The slow blood flow in these sinusoids allows bacteria (most commonly *Staphylococcus aureus*) to settle and proliferate. 3. **Deficient Phagocytosis:** The capillary loops in this region lack a robust population of functioning phagocytic cells (macrophages), making it an ideal environment for infection to take root. **Why other options are incorrect:** * **Diaphysis:** While it can be involved in conditions like Ewing’s Sarcoma or Sickle Cell-related *Salmonella* osteomyelitis, it is not the primary site for AHO due to faster blood flow. * **Epiphysis:** This area is generally protected by the physis (growth plate), which acts as a mechanical barrier to the spread of infection. It is only commonly involved in infants (where trans-physeal vessels exist) or in septic arthritis. * **Physis:** The growth plate consists of dense cartilage and is relatively avascular; it acts as a barrier rather than a site of primary infection. **High-Yield Clinical Pearls for NEET-PG:** * **Most common organism:** *Staphylococcus aureus* (overall); *Salmonella* (in Sickle Cell Disease). * **Most common site:** Distal femur and proximal tibia (areas of rapid growth). * **Infant Exception:** In children <1 year, trans-physeal vessels allow infection to spread from the metaphysis to the epiphysis, frequently leading to **septic arthritis**. * **Diagnosis:** MRI is the most sensitive early imaging modality; X-rays may remain normal for the first 10–14 days.

Question 1

French osteotomy is used in the treatment of which condition?

Accepted Answer

Cubitus varus

Answer

Cubitus valgus

Answer

Coxa vara

Answer

Coxa valga

Question 2

Which statement is not true about Perthes disease?

Accepted Answer

The bone age is the same as the chronological age

Answer

It is characterized by avascular necrosis

Answer

It is more common in males

Answer

All are true

Question 3

What is the treatment for congenital coxa vara?

Accepted Answer

Osteotomy

Answer

Fixation by SP Nail

Answer

Bone grafting

Answer

Traction

Question 4

A 16-year-old boy presents with progressive knee pain that began soon after starting basketball season. Physical examination reveals a swollen and prominent tibial tubercle with associated tenderness. Radiographs of the area are unremarkable. What is the most likely diagnosis?

Accepted Answer

Osgood-Schlatter disease

Answer

Popliteal cyst

Answer

Slipped capital femoral epiphysis

Answer

Legg-Calve-Perthes disease

Question 5

A 3-year-old child presents with a limp. What is the most likely diagnosis?

Accepted Answer

Septic arthritis

Answer

Slipped capital femoral epiphysis

Answer

Perthes disease

Answer

Developmental dysplasia of the hip (DDH)

Question 6

Which of the following statements regarding supracondylar fracture of the humerus in children is true?

Accepted Answer

Admission to the hospital is essential following reduction.

Answer

It is typically caused by a fall on the point of the elbow.

Answer

It usually requires open reduction.

Answer

It is commonly a compound fracture.

Question 7

All of the following are associated with supracondylar fracture of humerus, except?

Accepted Answer

Ulnar nerve is most commonly involved

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

A 40-year-old patient presents with an inability to keep the arm in contact with the chest. When the arm is forcibly brought into contact with the chest, there is winging of the scapula. There is a history of repeated intramuscular injections into the deltoid muscle. What is the diagnosis?

Accepted Answer

Deltoid contracture

Answer

Serratus anterior muscle palsy

Answer

Poliomyelitis

Answer

Neglected anterior dislocation of the shoulder

Question 9

In children, acute osteomyelitis most commonly affects which part of the long bone?

Accepted Answer

Metaphysis

Answer

Diaphysis

Answer

Epiphysis

Answer

Physis

Question 10

An eight-year-old child is suffering from transient synovitis of the hip joint. Which of the following statements is false?

Accepted Answer

The hip is typically held in adduction and internal rotation.

Answer

May follow upper respiratory tract infection.

Answer

WBC count and ESR are usually normal.

Answer

Widening of the joint space will be seen on ultrasound.

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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