Pediatric Orthopaedics Practice Questions

Q: Comment on the diagnosis in the X-ray pelvis of a 2-year-old child as shown below:

Developmental dysplasia of hip. ***Developmental dysplasia of hip*** - The X-ray shows an **increased acetabular index (AI)**, with the right hip measuring 30 degrees and the left hip measuring 40 degrees. An AI greater than 28 degrees in a 2-year-old child is indicative of developmental dysplasia of the hip (DDH). - The **shallow acetabulum** and **superolateral displacement of the femoral head** (although subtle in this view, suggested by the high AI) are classic radiological signs of DDH. *Perthe's disease* - Perthe's disease, or **Legg-Calvé-Perthes disease**, typically involves **avascular necrosis of the femoral head** in children, usually between 4 and 8 years old. - X-ray findings include **flattening and fragmentation of the femoral head**, increased density, and widening of the joint space, which are not seen here. *TB hip* - **Tuberculosis of the hip** is an infectious condition that would show signs of **osteolysis**, joint space narrowing, and sometimes abscess formation or bone destruction. - These destructive changes and the characteristic age group (Tuberculosis can affect any age group, but focal infections are not typical for this age group) are not consistent with the given X-ray findings. *Slipped capital femoral epiphysis* - **Slipped capital femoral epiphysis (SCFE)** occurs when the **femoral head slips posterior and inferior** relative to the femoral neck through the growth plate. - This condition is typically seen in **adolescents (10-16 years old)**, often overweight, and not in a 2-year-old child. Radiological signs would include a widened or irregular physeal line and posterior displacement of the epiphysis.

Q: All are true about the condition shown in the image except:

Small heel. ***Small heel*** - The image depicts a newborn with **clubfoot (talipes equinovarus)**, a condition characterized by a **small heel** due to the equinus deformity. *Kite's angle is less than 35 degrees* - In clubfoot, the **talocalcaneal angle (Kite's angle)**, which measures the alignment of the talus and calcaneus bones, is typically **decreased**, meaning it is *less than 35 degrees*. - A reduced Kite's angle reflects the **hindfoot varus** and **equinus** deformities characteristic of clubfoot. *Plumbline test is a screening test* - The **plumbline test** is a clinical method used to assess the **severity of clubfoot** and monitor treatment progress, rather than being a screening test. - It helps determine if the foot's lateral border aligns with the tibia, indicating proper correction of the adduction deformity. *Inner side of foot is convex with dimples* - In clubfoot, the **inner side of the foot is typically convex**, and the skin often shows **dimples or creases** due to the abnormal foot position and soft tissue contractures. - This convexity and skin dimpling are characteristic features of the medial column collapse and adduction deformity seen in clubfoot.

Q: All are correct about the condition shown in the image except:

Easiest deformity to correct is the hindfoot equinus. ***Easiest deformity to correct is the hindfoot equinus*** - The **hindfoot equinus** (plantar flexion of the ankle) is generally the most difficult component of clubfoot to correct, requiring a **percutaneous Achilles tenotomy** in most cases. - The midfoot and forefoot deformities are typically addressed through serial casting before the equinus component. *Ponseti method is the most common method of treatment* - The **Ponseti method**, involving serial manipulation and casting, is widely considered the **gold standard** for treating congenital clubfoot due to its high success rate and non-invasive nature. - This method sequentially corrects the deformities of inversion, adduction, and cavus, followed by equinus. *Seen in 1 per 1000 live birth* - The incidence of **congenital talipes equinovarus (clubfoot)** is approximately **1 in 1000 live births**, making it one of the most common congenital musculoskeletal deformities. - This prevalence highlights its clinical significance and the need for effective treatment protocols. *Malalignment of the calcaneotalar-navicular complex* - Clubfoot is characterized by a complex three-dimensional deformity, primarily involving **malalignment of the calcaneus, talus, and navicular bones**. - Specifically, the **talus is plantarflexed and medially deviated within the ankle mortise**, and the calcaneus is internally rotated and inverted beneath the talus.

Q: A 4-year-old boy fell on outstretched hand. X- Ray is shown below. Which blood vessel is most commonly affected?

Radial artery. ***Radial artery*** - The X-ray image shows a **supracondylar fracture of the humerus**, which is a common injury in children who fall on an outstretched hand. - While the **brachial artery** runs anterior to the humeral condyles and is the most commonly injured *major* vessel in supracondylar fractures, the **radial artery** is distal to this area and can be affected by subsequent complications like compartment syndrome or direct trauma from displaced fragments, and is a frequently assessed pulse in these injuries to monitor peripheral perfusion. *Ulnar artery* - The ulnar artery is less commonly affected in supracondylar humeral fractures compared to the brachial or radial arteries. - Its anatomical course protects it somewhat from direct trauma in typical fracture displacement patterns. *Brachial artery* - The **brachial artery** is indeed the most commonly injured *major* vessel in supracondylar fractures due to its close proximity to the distal humerus and its anterior course. - However, the question asks for the most commonly affected blood vessel *following* such an injury, and while direct injury to the brachial artery is a concern, assessment of the **radial artery** pulse is critical for evaluating distal perfusion and identifying potential complications like **compartment syndrome**, which affects blood flow through distal arteries like the radial artery. *Cubital vein* - Veins, including the cubital veins, are generally more pliable and less prone to severe injury or occlusion by bone fragments compared to arteries. - While venous compromise can occur, it is less common and less clinically significant in immediate assessment of these fractures compared to arterial injury.

Q: Given is the X-ray of a 7-year-old child. Identify the deformity:

Perthe's disease. ***Perthe's disease*** - The X-ray shows changes consistent with **Perthe's disease**, characterized by **avascular necrosis of the femoral head**. Findings include **flattening of the femoral head**, **sclerosis**, and potential **fragmentation**. - This condition typically affects *children between 4 and 10 years old*, matching the age of the child in the question (7 years old). *Coxa vara* - **Coxa vara** is defined by a **decreased femoral neck-shaft angle** (less than 120 degrees), leading to a more horizontal orientation of the femoral neck. - While *Perthe's disease can lead to coxa vara* as a complication, the primary pathological changes (sclerosis, flattening, fragmentation of the femoral head) are distinctive of Perthe's. *Coxa valga* - **Coxa valga** is characterized by an **increased femoral neck-shaft angle** (greater than 135-140 degrees), causing the femoral neck to be more vertical. - This is the opposite of coxa vara and is not typically associated with the radiographic findings observed in the image. *Brodie's abscess* - A **Brodie's abscess** is a **subacute or chronic osteomyelitis**, often appearing as a **well-circumscribed luncency** with a sclerotic rim, commonly found in the metaphysis of long bones. - The X-ray does not show a focal lytic lesion suggestive of an abscess; instead, it presents diffuse changes to the femoral epiphysis.

Q: The image shows an analogy used to describe a specific orthopedic deformity. Which deformity is characterized by varus deformity in one lower limb combined with valgus deformity in the other lower limb?

Windswept deformity. ***Windswept deformity*** - **Definition**: A combination of **varus deformity (bow leg) in one limb** and **valgus deformity (knock knee) in the other limb**, creating an asymmetric appearance resembling a tree blown persistently by wind - **Reference**: Nelson Textbook of Pediatrics, 20th Ed, page 331 - **Etiology**: Commonly seen in **rickets**, **cerebral palsy**, or other metabolic/neuromuscular conditions causing asymmetric limb loading - The windswept tree analogy visually captures how both lower limbs "lean" in the same direction *Genu varum (Bow legs)* - **Bilateral varus** deformity of both knees — both legs curve outward symmetrically - Does NOT involve asymmetric varus/valgus combination; a different deformity pattern *Genu valgum (Knock knees)* - **Bilateral valgus** deformity of both knees — both legs curve inward symmetrically - Does NOT involve asymmetric varus/valgus combination; opposite of genu varum *Coxa vara* - Deformity at the **hip joint** where the neck-shaft angle of the femur is reduced below 120° - Affects proximal femur/hip, not a bilateral asymmetric leg deformity

Q: A 3-month-old infant with shortened bowed extremities, macrocephaly. X-ray of lower extremities and Lateral view spine was performed. All are true about the condition except: (Recent NEET Pattern 2016-17)

Defect in type 1 collagen. ***Defect in type 1 collagen*** - The clinical presentation of **shortened bowed extremities** and **macrocephaly** in a 3-month-old infant with characteristic X-ray findings indicates **achondroplasia**. - Achondroplasia is caused by a **mutation in the FGFR3 gene (fibroblast growth factor receptor 3)**, NOT a defect in type 1 collagen. - **Type 1 collagen defects** cause **osteogenesis imperfecta**, which presents with blue sclera, multiple fractures, and brittle bones - a completely different condition. - **This statement is FALSE** about achondroplasia, making it the correct answer to this "EXCEPT" question. *Type 3 is most common form* - Achondroplasia does not have a widely recognized "type 3" classification in standard medical terminology. - This option is poorly worded and potentially confusing, though vertebral body abnormalities and skeletal changes are characteristic features. *Vertebral compression* - **Platyspondyly** (flattened vertebral bodies) and vertebral compression are **TRUE** radiological findings in achondroplasia. - Lateral spine X-rays typically show shortened vertebral bodies with decreased interpedicular distance in the lumbar spine. *Autosomal recessive with variable expression* - **This statement is also FALSE** about achondroplasia. - Achondroplasia follows an **autosomal dominant** inheritance pattern, though 80% of cases arise from de novo mutations. - This creates potential ambiguity in the question as both this option and Option A are false statements. - However, Option A (collagen defect) is the more fundamentally incorrect statement regarding the basic pathophysiology.

Q: The image shows presence of:

Ectrodactyly. ***Ectrodactyly*** - The image clearly shows a malformation of the foot where the **central digits are missing**, creating a characteristic **cleft** or "lobster claw" appearance. This is the defining feature of ectrodactyly (also called split hand/foot malformation). - Ectrodactyly can affect hands or feet and may occur as an **isolated anomaly** or as part of genetic syndromes like EEC syndrome (Ectrodactyly-Ectodermal dysplasia-Clefting). - Inheritance is typically **autosomal dominant** with variable expressivity. *Polydactyly* - Polydactyly refers to the presence of extra digits (supernumerary fingers or toes), which is not observed in the image. - The image shows a deficiency of central digits with a cleft, not an excess of digits. *Cutis aplasia* - Cutis aplasia (aplasia cutis congenita) is characterized by localized absence of skin at birth, most commonly affecting the scalp. - The image displays a limb malformation involving bone and soft tissue structure, not a skin defect. *TAR syndrome* - TAR (Thrombocytopenia-Absent Radius) syndrome is characterized by bilateral absence or hypoplasia of the radii in the forearms, along with thrombocytopenia. - While TAR involves limb malformations, the image shows a foot deformity (ectrodactyly), and there is no evidence of absent radii or hematological abnormalities visible in the image.

Q: The following gait is called as hand knee gait. Normally to transmit the weight of limb during midstance, the knee is locked by quadriceps contraction. If it is weak, locking is hampered and buckling at knees will occur. Hence to stabilise the knee for weight bearing, patient places his hand in front of knee and lower thigh region. This gait pattern is typically seen in which condition?

Polio. ***Polio*** - In polio, the **quadriceps muscles** can be severely weakened due to **viral damage to anterior horn cells**, leading to an inability to lock the knee during gait. - The "hand-to-knee" gait, also known as a **Gowers' sign variant**, is used by patients to manually stabilize the knee and prevent buckling, which is a classic compensatory mechanism for quadriceps weakness. *Cerebral palsy* - Cerebral palsy is a **neurological disorder** affecting muscle movement and coordination due to brain damage. - While it can cause various gait abnormalities, including crouch gait or scissoring, the specific hand-to-knee gait for quadriceps weakness is not typical. *Muscular dystrophy* - Muscular dystrophies are **genetic disorders** causing progressive muscle degeneration and weakness. - Patients with muscular dystrophy, especially Duchenne, often exhibit a **Gowers' sign** for standing up from the floor, but the described hand-to-knee gait during mid-stance is more characteristic of specific quadriceps paralysis rather than general progressive weakness affecting multiple muscle groups in that compensatory manner. *Spina bifida* - Spina bifida is a **congenital neural tube defect** that can result in varying degrees of paralysis and sensory loss, primarily affecting the lower limbs. - While it can cause lower limb weakness and gait disturbances, the described "hand-to-knee" gait is not a primary or characteristic compensatory gait pattern associated with spina bifida, which often involves assistive devices or different types of compensatory movements for ambulation.

Q: Which is incorrect about the patient shown in the image? (Recent NEET Pattern 2016-17)

Thanatophoric dwarfism. ***Thanatophoric dwarfism*** - **INCORRECT statement (Correct Answer)** - **Thanatophoric dwarfism** is a severe form of skeletal dysplasia that is usually **lethal in the perinatal period** or early infancy, characterized by extremely short limbs, a narrow chest, and often cloverleaf skull deformity. - The patient in the image appears to be older than infancy, indicating that thanatophoric dwarfism is an incorrect diagnosis for this individual. The visible features are consistent with **achondroplasia**, not thanatophoric dwarfism. - This is the **answer** because it is the **false statement** about the patient. *Proximal shortening limbs* - **Correct statement (Incorrect Option)** - The image shows a patient with **rhizomelic dwarfism**, characterized by **proximal shortening of the limbs** (upper arms and thighs), which is a characteristic feature of achondroplasia. - This is observable in the image, as the upper arms appear disproportionately short compared to the trunk. - This statement is **TRUE** about the patient, so it's not the answer. *Calvarium enlargement* - **Correct statement (Incorrect Option)** - Patients with achondroplasia often exhibit **macrocephaly** (enlarged head circumference) with a prominent forehead, which can be described as **calvarium enlargement**. - This feature is consistent with the patient's head shape shown in the image. - This statement is **TRUE** about the patient, so it's not the answer. *Lumbar lordosis* - **Correct statement (Incorrect Option)** - **Exaggerated lumbar lordosis (swayback)** is a common skeletal manifestation in achondroplasia due to changes in vertebral body shape and interpedicular distance. - The side profile of the patient in the image clearly demonstrates an increase in the **lumbar curvature**, consistent with lordosis. - This statement is **TRUE** about the patient, so it's not the answer.

Question 1

Comment on the diagnosis in the X-ray pelvis of a 2-year-old child as shown below:

Accepted Answer

Developmental dysplasia of hip

Answer

Perthe's disease

Answer

TB hip

Answer

Slipped capital femoral epiphysis

Question 2

All are true about the condition shown in the image except:

Accepted Answer

Small heel

Answer

Kite's angle is less than 35 degrees

Answer

Plumbline test is a screening test

Answer

Inner side of foot is convex with dimples

Question 3

All are correct about the condition shown in the image except:

Accepted Answer

Easiest deformity to correct is the hindfoot equinus

Answer

Ponseti method is the most common method of treatment

Answer

Seen in 1 per 1000 live birth

Answer

Malalignment of the calcaneotalar-navicular complex

Question 4

A 4-year-old boy fell on outstretched hand. X- Ray is shown below. Which blood vessel is most commonly affected?

Accepted Answer

Radial artery

Answer

Ulnar artery

Answer

Brachial artery

Answer

Cubital vein

Question 5

Given is the X-ray of a 7-year-old child. Identify the deformity:

Accepted Answer

Perthe's disease

Answer

Coxa vara

Answer

Coxa valga

Answer

Brodie's abscess

Question 6

The image shows an analogy used to describe a specific orthopedic deformity. Which deformity is characterized by varus deformity in one lower limb combined with valgus deformity in the other lower limb?

Accepted Answer

Windswept deformity

Answer

Genu varum

Answer

Genu valgum

Answer

Coxa vara

Question 7

A 3-month-old infant with shortened bowed extremities, macrocephaly. X-ray of lower extremities and Lateral view spine was performed. All are true about the condition except: (Recent NEET Pattern 2016-17)

Accepted Answer

Defect in type 1 collagen

Answer

Type 3 is most common form

Answer

Vertebral compression

Answer

Autosomal recessive with variable expression

Question 8

The image shows presence of:

Accepted Answer

Ectrodactyly

Answer

Polydactyly

Answer

Cutis aplasia

Answer

TAR syndrome

Question 9

The following gait is called as hand knee gait. Normally to transmit the weight of limb during midstance, the knee is locked by quadriceps contraction. If it is weak, locking is hampered and buckling at knees will occur. Hence to stabilise the knee for weight bearing, patient places his hand in front of knee and lower thigh region. This gait pattern is typically seen in which condition?

Accepted Answer

Polio

Answer

Cerebral palsy

Answer

Muscular dystrophy

Answer

Spina bifida

Question 10

Which is incorrect about the patient shown in the image? (Recent NEET Pattern 2016-17)

Accepted Answer

Thanatophoric dwarfism

Answer

Proximal shortening limbs

Answer

Calvarium enlargement

Answer

Lumbar lordosis

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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