Pediatric Orthopaedics Practice Questions

Q: Fish tail deformity on X-ray in children is most commonly associated with fractures of?

Distal humerus. **Distal humerus** - **Fish-tail deformity** (also known as a **condylar growth disturbance**) is a classic delayed complication of **distal humeral fractures** in children, particularly **supracondylar fractures** and **lateral condyle fractures**. - This deformity results from **avascular necrosis** or growth arrest of the **trochlear ossification center**, leading to a characteristic inverted V-shape or fish-tail appearance of the **distal humerus** on X-ray. *Distal Radius* - Fractures of the **distal radius** in children, such as **Salter-Harris fractures**, can lead to growth arrest but typically result in characteristic angulation or shortening, not specifically a "fish-tail" deformity. - While growth disturbances can occur, the **physis** of the distal radius has a different anatomy and growth pattern than the **distal humerus**. *Distal Tibia* - Fractures involving the **distal tibia** growth plate (e.g., **Tillaux fractures**, **triplane fractures**) can cause angular deformities or leg length discrepancies. - "Fish-tail deformity" specifically refers to changes in the **distal humeral epiphysis/trochlea**, not to the **distal tibia**. *Distal Femur* - **Distal femoral physeal fractures** in children carry a high risk of growth arrest due to the vigorous growth at this physis. - However, the resulting deformities are typically **leg length discrepancies** or **angular deformities** such as genu recurvatum, not the distinct "fish-tail" appearance seen in the humerus.

Q: Which Salter-Harris fracture type involves a metaphyseal fragment?

Type II. **Type II** - **Type II Salter-Harris fractures** involve a fracture line that extends through the growth plate (physis) and then exits through the metaphysis, carrying a portion of the metaphysis with it. - This is the most common type of Salter-Harris fracture, characterized by the presence of a **metaphyseal fragment** attached to the epiphysis. *Type I* - **Type I Salter-Harris fractures** involve a complete separation of the epiphysis from the metaphysis through the physis, without any bone fracture. - There is no involvement of the metaphysis or epiphysis in the fracture line itself, making it difficult to detect on X-ray unless displacement is significant. *Type III* - **Type III Salter-Harris fractures** involve a fracture line that extends through the growth plate and then exits through the epiphysis, extending into the joint. - This type does not involve a metaphyseal fragment; instead, a portion of the **epiphysis is fractured**. *Type IV* - **Type IV Salter-Harris fractures** involve a fracture line that passes through the epiphysis, across the growth plate, and then through the metaphysis. - This type extends through all three components (epiphysis, physis, and metaphysis) as a single fracture line, but it does not specifically involve a detached metaphyseal fragment in the way Type II does.

Q: A teenage boy presents with a painful lump below his knee. Which condition involving inflammation of the tibial tuberosity is most likely?

Osgood-Schlatter disease. ***Osgood-Schlatter disease*** - This condition is characterized by **inflammation of the patellar tendon insertion** into the **tibial tuberosity**, causing **painful lumps** below the knee, especially in active adolescent boys. - It results from **repetitive stress** on the growth plate during periods of rapid growth and increased physical activity. *Septic arthritis* - This is a **bacterial infection** of a joint, presenting with severe pain, swelling, redness, and fever, and is typically in a joint capsule, not a bony prominence. - It would involve the knee joint itself, not specifically the tibial tuberosity, and is generally associated with systemic signs of infection. *Slipped capital femoral epiphysis* - This condition involves the **femoral head slipping off the femoral neck** during growth, typically presenting with hip or knee pain and a characteristic limp. - The pain is usually referred to the knee, but the pathology is in the hip, and it does not result in a lump below the knee. *Osteochondritis dissecans* - This involves a **segment of bone and cartilage detaching** from a joint surface, most commonly the knee, causing pain, clicking, and catching. - While it affects the knee, it doesn't typically present as a painful lump specifically at the tibial tuberosity.

Q: A 12-year-old boy presents with a limp and knee pain. X-rays reveal a slipped capital femoral epiphysis. What is the most appropriate initial management?

Immediate orthopedic referral. ***Immediate orthopedic referral*** - **Slipped capital femoral epiphysis (SCFE)** is an orthopedic emergency requiring urgent surgical stabilization to prevent further slippage and complications like **avascular necrosis**. - Delay in intervention can lead to increased severity of the slip, poorer outcomes, and long-term disability. *Physical therapy* - **Physical therapy** is not an initial management for SCFE as it can worsen the slip during the acute phase. - It may be considered later during rehabilitation after surgical stabilization, but only under orthopedic guidance. *Bed rest* - While activity restriction is important, **bed rest alone** is insufficient to prevent progression of SCFE. - It does not address the underlying mechanical instability of the femoral head. *NSAIDs* - **NSAIDs** can help manage pain associated with SCFE but do not treat the underlying mechanical problem. - Relying solely on pain relief without addressing the slip significantly increases the risk of serious complications.

Q: A 9-year-old with recent onset of limping, no history of trauma, and intermittent knee pain. Physical examination shows decreased hip range of motion and a normal knee exam. X-ray reveals a flattened femoral head. What is the next step in evaluation and management?

Physical therapy + non-weight bearing. ***Physical therapy + non-weight bearing*** - The presentation is highly suggestive of **Legg-Calvé-Perthes disease (LCPD)**, characterized by **avascular necrosis** of the femoral head in children. **Non-weight-bearing** and **containment** (often through bracing or casts directed by physical therapy) are crucial to prevent further collapse and promote healing. - The goal of conservative treatment is to maintain a spherical femoral head and a good range of motion, allowing for **revascularization** and remodeling of the femoral head. *Rest and NSAIDs* - While **NSAIDs** can help with pain, mere rest and pain relief are insufficient for managing LCPD, as the underlying process of avascular necrosis and potential collapse requires specific mechanical protection. - This approach does not address the need for **femoral head containment** or prevent further deformity, which is critical in LCPD. *MRI to assess soft tissue* - While an **MRI** can provide more detailed information on the extent of avascular necrosis, the plain X-ray showing a **flattened femoral head** is sufficient for initial diagnosis and guiding the immediate management strategy for LCPD. - The primary concern here is the **structural integrity of the femoral head** and not primarily soft tissue injury, so an MRI is not the immediate "next step" before instituting protective measures. *Orthopedic referral for surgery* - **Surgery** (osteotomy) is considered for LCPD when conservative measures fail or in cases with significant femoral head deformity and poor containment, but it is not the immediate first step for every patient. - The initial management for most children with LCPD involves aiming for **conservative containment** and non-weight bearing to optimize femoral head remodeling.

Q: In a pediatric patient with a displaced supracondylar fracture of the humerus, what is the most appropriate treatment?

Closed reduction and casting. **Closed reduction and casting** - For **displaced supracondylar fractures** in children, **closed reduction** is usually the preferred method to realign the bone fragments, followed by casting to stabilize the fracture. - This approach minimizes disruption to the tissues, preserves the blood supply, and reduces the risk of complications associated with more invasive procedures. *Open reduction and internal fixation* - **Open reduction and internal fixation (ORIF)** is generally reserved for **unstable, highly comminuted, or open fractures**, or when closed reduction attempts have failed. - It is more invasive and carries a higher risk of complications such as infection, neurovascular injury, and disruption of the physis (growth plate). *Observation* - **Observation** is only appropriate for **nondisplaced or minimally displaced** supracondylar fractures where the risk of neurovascular compromise or further displacement is low. - For a **displaced fracture**, observation would lead to malunion, functional impairment, and potential long-term complications. *Skeletal traction* - **Skeletal traction** was historically used for complex or highly unstable supracondylar fractures, but its use has largely been replaced by percutaneous pinning or ORIF due to the long duration of hospitalization required and the risk of complications such as pin site infection and joint stiffness. - It is not considered the most appropriate initial treatment for a typical displaced supracondylar fracture.

Q: A 6-year-old child presents with a limp and limited hip abduction. An X-ray reveals flattening of the femoral head. What is the most likely diagnosis?

Legg-Calvé-Perthes disease. ***Legg-Calvé-Perthes disease*** - Characterized by **avascular necrosis** of the femoral head, leading to **flattening** seen on X-ray and symptoms such as a limp and limited hip abduction. - Typically presents in children ages **4-8**, aligning with this child's age and symptoms. *Slipped capital femoral epiphysis* - Generally occurs in **older children** and adolescents, usually presenting with **hip pain** and not primarily limp or abduction issues. - X-ray findings typically show **displacement of the femoral head**, rather than **flattening**. *Developmental dysplasia of the hip* - This condition usually presents at **birth or early infancy**, characterized by a palpable **clunk** on physical examination rather than isolated limp in a 6-year-old. - X-ray would likely show **joint dislocation** or **shallow acetabulum**, not a **flattened femoral head**. *Osteomyelitis* - More commonly presenting with **fever** and localized pain, accompanied by **systemic signs of infection**, which are absent here. - X-ray typically shows **bone infection** signs, not exclusively **joint deformity** like flattening of the femoral head.

Q: What is the most common cause of scoliosis in pediatric patients?

Idiopathic scoliosis. ***Idiopathic scoliosis*** - This is the most common form of scoliosis, making up about 80% of all cases, particularly in pediatric and adolescent populations, with no identifiable cause. - It often progresses during periods of rapid growth, especially during adolescence. *Congenital spinal deformities* - These are present at birth due to **vertebral malformations** but account for a smaller percentage of scoliosis cases compared to idiopathic forms. - The severity and progression of congenital scoliosis are often linked to the specific type of vertebral anomaly. *Neuromuscular conditions* - Conditions such as **cerebral palsy**, **muscular dystrophy**, or **spinal muscular atrophy** can cause scoliosis due to muscle weakness or imbalance. - While significant in affected individuals, the overall prevalence of neuromuscular scoliosis is lower than that of idiopathic scoliosis in the general pediatric population. *Trauma* - **Spinal trauma** can lead to scoliosis, but this is a relatively rare cause, typically resulting from fractures or injuries to the vertebral growth plates. - The onset is usually acute and directly attributable to a specific injury, unlike the gradual progression often seen in idiopathic cases.

Q: A 4-year-old child presents with fever and a mass in the thigh. An X-ray shows periosteal reaction and bone destruction. What is the next best step in diagnosis?

Bone biopsy. ***Bone biopsy*** - The combination of **fever**, a **mass**, and **X-ray findings of periosteal reaction and bone destruction** in a child is highly suspicious for **osteosarcoma** or an infectious process like **osteomyelitis**. - A **bone biopsy** is the definitive diagnostic step to differentiate between these conditions, allowing for histological examination and culture if indicated. *Bone scan* - A bone scan would show increased metabolic activity in the affected area, indicating bone pathology, but it is **not specific enough** to determine the exact nature (benign, malignant, or infectious) of the lesion. - It could help identify other areas of involvement but wouldn't provide a definitive diagnosis for the primary lesion. *Blood culture* - While **fever** could suggest an infectious process like osteomyelitis, a **blood culture** alone is often negative in bone infections, and it **cannot address the possibility of a malignant tumor**. - It would be part of the workup for infection but not the next best step for definitive diagnosis given the presence of a mass and destructive bone changes. *CT Scan* - A **CT scan** would provide more detailed anatomical information about the bone lesion, including its extent and involvement of surrounding tissues. - However, it is an **imaging modality** and cannot provide a definitive histological diagnosis, which is crucial for distinguishing between tumor and infection.

Q: What is the most common type of fracture in children?

Greenstick fracture. ***Greenstick fracture*** - **Greenstick fractures** are common in children because their bones are more flexible and softer than adult bones. - The bone **bends and cracks** but does not break completely through, similar to how a young tree branch would break. *Transverse fracture* - A **transverse fracture** involves a clean break straight across the bone, which is less common in the flexible bones of children. - This type of fracture often results from a **direct blow** perpendicular to the bone's long axis. *Comminuted fracture* - A **comminuted fracture** involves the bone breaking into three or more pieces, indicating a high-energy trauma. - These are **rare in children** due to the elasticity of their bones. *Oblique fracture* - An **oblique fracture** has an angled break across the bone, typically caused by a twisting force. - While possible, it is **less common** than a greenstick fracture in children.

Question 1

Fish tail deformity on X-ray in children is most commonly associated with fractures of?

Accepted Answer

Distal humerus

Answer

Distal Radius

Answer

Distal Tibia

Answer

Distal Femur

Question 2

Which Salter-Harris fracture type involves a metaphyseal fragment?

Accepted Answer

Type II

Answer

Type I

Answer

Type III

Answer

Type IV

Question 3

A teenage boy presents with a painful lump below his knee. Which condition involving inflammation of the tibial tuberosity is most likely?

Accepted Answer

Osgood-Schlatter disease

Answer

Septic arthritis

Answer

Slipped capital femoral epiphysis

Answer

Osteochondritis dissecans

Question 4

A 12-year-old boy presents with a limp and knee pain. X-rays reveal a slipped capital femoral epiphysis. What is the most appropriate initial management?

Accepted Answer

Immediate orthopedic referral

Answer

Physical therapy

Answer

Bed rest

Answer

NSAIDs

Question 5

A 9-year-old with recent onset of limping, no history of trauma, and intermittent knee pain. Physical examination shows decreased hip range of motion and a normal knee exam. X-ray reveals a flattened femoral head. What is the next step in evaluation and management?

Accepted Answer

Physical therapy + non-weight bearing

Answer

Rest and NSAIDs

Answer

MRI to assess soft tissue

Answer

Orthopedic referral for surgery

Question 6

In a pediatric patient with a displaced supracondylar fracture of the humerus, what is the most appropriate treatment?

Accepted Answer

Closed reduction and casting

Answer

Observation

Answer

Skeletal traction

Answer

Open reduction and internal fixation

Question 7

A 6-year-old child presents with a limp and limited hip abduction. An X-ray reveals flattening of the femoral head. What is the most likely diagnosis?

Accepted Answer

Legg-Calvé-Perthes disease

Answer

Slipped capital femoral epiphysis

Answer

Developmental dysplasia of the hip

Answer

Osteomyelitis

Question 8

What is the most common cause of scoliosis in pediatric patients?

Accepted Answer

Idiopathic scoliosis

Answer

Congenital spinal deformities

Answer

Neuromuscular conditions

Answer

Trauma

Question 9

A 4-year-old child presents with fever and a mass in the thigh. An X-ray shows periosteal reaction and bone destruction. What is the next best step in diagnosis?

Accepted Answer

Bone biopsy

Answer

Bone scan

Answer

Blood culture

Answer

CT Scan

Question 10

What is the most common type of fracture in children?

Accepted Answer

Greenstick fracture

Answer

Transverse fracture

Answer

Comminuted fracture

Answer

Oblique fracture

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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