Pediatric Orthopaedics Practice Questions

Q: Combination of appearance in CTEV

Equinus, inversion, forefoot adduction, cavus. ***Equinus, inversion, forefoot adduction, cavus*** - The classic presentation of **clubfoot** (CTEV) involves a characteristic combination of deformities: **equinus** (fixed plantarflexion of the ankle), **inversion** (tilting of the heel inward), **forefoot adduction** (inward turning of the front of the foot), and **cavus** (an abnormally high arch). - These four components are essential for the diagnosis and classification of CTEV. *Equinus, eversion, forefoot adduction, cavus* - This option incorrectly lists **eversion** instead of inversion. Eversion involves the outward tilting of the heel and is not a feature of CTEV. - While equinus, forefoot adduction, and cavus are typical, the presence of eversion rules out classic CTEV. *Equinus, inversion, forefoot adduction, planus* - This option incorrectly lists **planus** (pes planus or flatfoot) instead of cavus. Cavus (high arch) is a defining characteristic of CTEV, not a flatfoot. - While equinus, inversion, and forefoot adduction are correct, the presence of planus makes this option incorrect. *Equinus, eversion, forefoot abduction, cavus* - This option incorrectly lists both **eversion** and **forefoot abduction**. Eversion is the outward tilting of the heel, and forefoot abduction is the outward turning of the front of the foot. - Both eversion and forefoot abduction are opposite to the deformities seen in classical CTEV.

Q: A 13-year-old Hispanic boy is brought to the physician by his mother because of left groin pain for 1 month. The pain radiates to his left knee and is aggravated on walking. He fell during soccer practice 5 weeks ago but did not see a doctor about it and does not recall any immediate and persistent pain after the event. He has hypothyroidism. His only medication is levothyroxine. His immunizations are up-to-date. He appears uncomfortable. He is at the 50th percentile for height and at the 95th percentile for weight. His temperature is 37.1°C (98.9°F), pulse is 77/min, respirations are 14/min, and blood pressure is 100/70 mm Hg. The patient has a left-sided, antalgic gait. The left lower extremity is externally rotated. The left hip is tender to palpation and internal rotation is limited by pain. Laboratory studies show: Hemoglobin 13.1 g/dL Leukocyte count 9,100/mm3 Platelet count 250,000/mm3 Serum TSH 3.6 μU/mL Which of the following is the most likely diagnosis?

Slipped capital femoral epiphysis. ***Slipped capital femoral epiphysis*** - This condition is characterized by a **slippage of the femoral head** off the femoral neck, occurring through the growth plate. - Classic presentation includes **obesity**, male sex, **mild trauma**, pain radiating to the knee, and **external rotation** of the affected leg, all of which are present in this patient. **Hypothyroidism** is also a risk factor. *Osteomyelitis of the left hip* - **Osteomyelitis** is an infection of the bone, typically presenting with fever, localized tenderness, and elevated inflammatory markers (e.g., ESR, CRP). This patient is **afebrile** and has normal leukocyte count. - While pain and an antalgic gait can occur, the absence of systemic signs of infection and the characteristic external rotation point away from osteomyelitis. *Developmental dysplasia of the left hip* - **DDH** usually presents in infancy or early childhood with hip instability, limited abduction, or limb length discrepancy. - It is unlikely to present for the first time with pain and external rotation in a 13-year-old boy following a minor trauma. *Transient synovitis* - **Transient synovitis** is a self-limiting inflammatory condition of the hip, typically seen in younger children (3-8 years old) and often follows a viral illness. - It usually presents with sudden onset of hip pain and limp, but the chronic nature (1 month) and the characteristic physical exam findings (external rotation, obesity) make SCFE more likely. *Septic arthritis of the left hip* - Similar to osteomyelitis, **septic arthritis** is a serious infection of the joint space, presenting with acute onset of severe pain, fever, inability to bear weight, and elevated inflammatory markers. - This patient lacks systemic signs of infection (no fever, normal WBC count) and the chronic presentation further argues against septic arthritis.

Q: Blount Disease is involvement of

Proximal tibia. ***Proximal tibia*** - Blount disease, also known as **tibia vara**, is a growth disorder affecting the **tibia** (shin bone) in children. - It specifically involves the **medial physis of the proximal tibia**, leading to abnormal growth in this area and resulting in a **bow-legged** deformity. *Distal femur* - Malformations or growth disturbances of the **distal femur** are typically associated with conditions like genu valgum (**knock-knees**) or other angular deformities originating higher up in the leg. - Blount disease's primary pathology does not originate from the distal femur. *Distal tibia* - Conditions affecting the **distal tibia** can lead to ankle deformities or foot problems. - Blount disease is distinctly a problem of the knee region, not the ankle. *Proximal femur* - Problems in the **proximal femur** are commonly associated with conditions like Legg-Calvé-Perthes disease or developmental dysplasia of the hip. - While these can also cause gait abnormalities, Blount disease's characteristic bowing deformity originates from the tibia.

Q: A 6-year-old child is suspected with supracondylar fracture of right hand, complaining of pain and swelling. X-ray of right elbow was not significant. What is the next best step in this case?

Compare with X-ray of left hand. ***Compare with X-ray of left hand*** - In pediatric elbow injuries, a seemingly **normal X-ray** in the presence of strong clinical suspicion (pain, swelling, suspected supracondylar fracture) often warrants a comparison view of the contralateral unaffected limb. - This helps identify subtle findings like **epiphyseal separations** or **minimally displaced fractures** that might otherwise be missed due to the developing osseous structures in children. *Cast* - Applying a cast without definitive diagnosis or clear radiographic evidence of a fracture can lead to **unnecessary immobilization** and potential complications if no fracture is present, or inadequate treatment if a specific type of fracture requires reduction. - While immobilization is appropriate for confirmed fractures, it's not the **initial diagnostic step** when X-rays are inconclusive. *Closed reduction with K wire fixation* - This is an **invasive procedure** reserved for **displaced or unstable fractures** after a clear diagnosis has been established. - Performing this without a confirmed and characterized fracture is inappropriate and carries risks of **iatrogenic injury** and complications. *Closed reduction and slab* - Similar to casting, this is a treatment for **confirmed fractures**, typically for acute, stable, or minimally displaced fractures that can be managed non-surgically after a reduction. - It is not a diagnostic step and should not be performed when initial imaging is **inconclusive** and the exact nature of the injury is unknown.

Q: A child presents with a limp and limb shortening. The X-ray is shown below. What is the diagnosis?

DDH. ***DDH*** - **DDH (Developmental Dysplasia of the Hip)** often presents with a **limp**, **limb shortening**, and characteristic X-ray findings showing a **dislocated or dysplastic hip joint**. - The image would likely show the **femoral head displaced** from the acetabulum, confirming the diagnosis. *SCFE* - **SCFE (Slipped Capital Femoral Epiphysis)** presents with pain and a limp, but typically involves the **femoral head slipping posteriorly and inferiorly** relative to the femoral neck. - It usually occurs in **adolescents** who are overweight or rapidly growing, and the X-ray would show the **epiphysis displaced** rather than a fully dislocated hip. *Fracture neck of femur* - A **fracture of the neck of the femur** in a child is a rare traumatic injury that would present with **acute pain** and inability to bear weight. - The X-ray would clearly show a **break in the continuity** of the femoral neck, which is distinct from the developmental abnormality seen in DDH. *Perthes* - **Perthes disease** involves **avascular necrosis of the femoral head** and typically presents with a limp and pain, often in younger children (4-10 years old). - X-rays would show signs of **collapse, fragmentation, and later reossification** of the femoral head, rather than a dislocated hip.

Q: Most common site of osteomyelitis in children

Metaphysis. ***Metaphysis*** - The **metaphysis** is the most common site for osteomyelitis in children due to its rich, **slow-flowing sinusoidal blood supply**, which facilitates bacterial seeding. - The **nutrient arteries** in the metaphysis make sharp loops, creating a turbulent flow that slows circulation and allows bacteria to lodge more easily. *Epiphysis* - The **epiphysis** is less commonly affected in children because its separate blood supply is not as prone to bacterial seeding as the metaphysis. - In infants, however, infection can spread from the metaphysis to the epiphysis and joint space due to **transphyseal vessels**. *Growth plate* - The **growth plate** itself is generally resistant to infection due to its avascular nature. - However, infection in the adjacent metaphysis or epiphysis can potentially disrupt its function. *Diaphysis* - While the **diaphysis** has a blood supply, it is less common for osteomyelitis to originate here compared to the metaphysis. - It usually occurs as a secondary spread from a metaphyseal infection or in specific scenarios like in **sickle cell disease**.

Q: Charlie Chaplin gait is seen in?

Tibial torsion. ***Tibial torsion*** - **Tibial torsion** typically causes an out-toeing gait, where the feet are externally rotated, mimicking the classic Charlie Chaplin gait. - This condition involves a rotational deformity of the **tibial bone**, leading to an altered foot progression angle during walking. *DDH* - **Developmental dysplasia of the hip (DDH)** usually presents with a **Trendelenburg gait** if unilateral, or a waddling gait if bilateral, due to hip instability. - It involves abnormal development of the **hip joint**, leading to dislocation or subluxation, rather than an out-toeing pattern. *Genu valgus* - **Genu valgus** (knock-knees) causes the knees to touch or come very close together while the ankles remain apart. - This condition generally leads to an ungainly gait with the feet often wide apart to maintain balance, not an out-toeing characteristic. *Congenital coxa vara* - **Congenital coxa vara** is characterized by a decreased angle between the femoral neck and shaft, leading to a shortened leg and often a **Trendelenburg gait**. - It can result in a functionally shorter limb and a characteristic limp, but not typically the exaggerated out-toeing seen in Charlie Chaplin gait.

Q: Omovertebral bone is associated with?

Sprengel's deformity. ***Sprengel's deformity*** - An **omovertebral bone** is the most common associated skeletal anomaly with **Sprengel's deformity**, a congenital elevation of the scapula. - This fibrous, cartilaginous, or osseous bar connects the **superior medial border of the scapula** to the **cervical spine**. *Hemivertebra* - A **hemivertebra** is a congenital malformation where only half of a vertebral body develops, leading to a **wedge-shaped vertebra**. - While it can cause spinal deformities, it is **not directly associated** with an omovertebral bone. *Scoliosis* - **Scoliosis** is a lateral curvature of the spine, which can be congenital, neuromuscular, or idiopathic. - Although it can be secondary to or co-exist with other spinal anomalies, **scoliosis itself is not directly linked** to the presence of an omovertebral bone. *Cervical rib* - A **cervical rib** is a supernumerary rib arising from the seventh cervical vertebra, which can cause symptoms of **thoracic outlet syndrome**. - It is a distinct congenital anomaly and has **no direct association** with an omovertebral bone connecting the scapula to the spine.

Q: All of the following are described surgical procedures for CTE V except -

Salter's osteotomy. ***Salter's osteotomy*** - **Salter's osteotomy** is a procedure primarily used for treating **developmental dysplasia of the hip (DDH)**, aiming to redirect the acetabulum. - It is not a described surgical procedure for the correction of **congenital talipes equinovarus (CTEV)**. *Dwyer's osteotomy* - **Dwyer's osteotomy** is a surgical procedure performed on the **calcaneus** to correct **hindfoot varus**, typically seen in CTEV. - It involves removing a wedge of bone from the lateral aspect of the calcaneus. *Posteromedial soft tissue release* - This is a common and traditional surgical procedure for correcting severe **CTEV** by addressing the contracted soft tissues on the medial and posterior aspects of the foot. - It involves releasing structures such as the **tibial tendon**, **flexor digitorum longus**, **flexor hallucis longus**, and the **posterior ankle joint capsule**. *Triple Arthrodesis* - **Triple arthrodesis** is a salvage procedure that involves fusing three joints in the foot: the **talonavicular**, **calcaneocuboid**, and **subtalar** joints. - It is used in older children or adolescents with severe, rigid, or recurrent CTEV, often after failed conservative or primary surgical treatments.

Question 1

Combination of appearance in CTEV

Accepted Answer

Equinus, inversion, forefoot adduction, cavus

Answer

Equinus, eversion, forefoot adduction, cavus

Answer

Equinus, inversion, forefoot adduction, planus

Answer

Equinus, eversion, forefoot abduction, cavus

Question 2

A 13-year-old Hispanic boy is brought to the physician by his mother because of left groin pain for 1 month. The pain radiates to his left knee and is aggravated on walking. He fell during soccer practice 5 weeks ago but did not see a doctor about it and does not recall any immediate and persistent pain after the event. He has hypothyroidism. His only medication is levothyroxine. His immunizations are up-to-date. He appears uncomfortable. He is at the 50th percentile for height and at the 95th percentile for weight. His temperature is 37.1°C (98.9°F), pulse is 77/min, respirations are 14/min, and blood pressure is 100/70 mm Hg. The patient has a left-sided, antalgic gait. The left lower extremity is externally rotated. The left hip is tender to palpation and internal rotation is limited by pain. Laboratory studies show:
Hemoglobin 13.1 g/dL
Leukocyte count 9,100/mm3
Platelet count 250,000/mm3
Serum
TSH 3.6 μU/mL
Which of the following is the most likely diagnosis?

Accepted Answer

Slipped capital femoral epiphysis

Answer

Osteomyelitis of the left hip

Answer

Developmental dysplasia of the left hip

Answer

Transient synovitis

Answer

Septic arthritis of the left hip

Question 3

Blount Disease is involvement of

Accepted Answer

Proximal tibia

Answer

Distal femur

Answer

Distal tibia

Answer

Proximal femur

Question 4

A 6-year-old child is suspected with supracondylar fracture of right hand, complaining of pain and swelling. X-ray of right elbow was not significant. What is the next best step in this case?

Accepted Answer

Compare with X-ray of left hand

Answer

Cast

Answer

Closed reduction with K wire fixation

Answer

Closed reduction and slab

Question 5

A child presents with a limp and limb shortening. The X-ray is shown below. What is the diagnosis?

Accepted Answer

DDH

Answer

SCFE

Answer

Fracture neck of femur

Answer

Perthes

Question 6

Most common site of osteomyelitis in children

Accepted Answer

Metaphysis

Answer

Epiphysis

Answer

Growth plate

Answer

Diaphysis

Question 7

Charlie Chaplin gait is seen in?

Accepted Answer

Tibial torsion

Answer

DDH

Answer

Genu valgus

Answer

Congenital coxa vara

Question 8

Omovertebral bone is associated with?

Accepted Answer

Sprengel's deformity

Answer

Hemivertebra

Answer

Scoliosis

Answer

Cervical rib

Question 9

All of the following statements regarding bone remodeling are TRUE EXCEPT

Accepted Answer

Injuries involving the epiphyseal plate are more likely to remodel successfully

Answer

young children have a greater capacity for remodeling than adults

Answer

Remodeling is related to the degree of angulation

Answer

angulation in the natural plane of the joint motion will remodel more successfully than angulation outside the plane of joint motion

Question 10

All of the following are described surgical procedures for CTE V except -

Accepted Answer

Salter's osteotomy

Answer

Dwyer's osteotomy

Answer

Posteromedial soft tissue release

Answer

Triple Arthrodesis

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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