Pediatric Orthopaedics Practice Questions

Q: Which of the following statements about manipulation methods for correcting clubfoot (CTEV) is true?

Ponseti's technique has success rate of 90 - 98%. ***Ponseti's technique has success rate of 90 - 98%*** - The **Ponseti method** is highly successful for treating congenital talipes equinovarus (CTEV), with reported success rates in correcting the deformity ranging from 90% to 98%. - This high success minimizes the need for extensive surgery and improves long-term functional outcomes. *Involves serial casting and above knee plaster casting for 6-8 weeks* - While **serial casting** is part of the Ponseti method, the typical duration for the initial casting phase is usually around 5-7 weeks, not strictly 6-8 weeks, and consists of weekly cast changes. - The casting is indeed typically **above-knee** to effectively control rotation and maintain correction, but this option alone doesn't differentiate it sufficiently. *In Kite's method deformities are corrected sequentially equinus → adduction → inversion* - In **Kite's method**, correction is usually attempted in the sequence of **adduction → varus → equinus**, which is the reverse of the sequence stated in the option. - Kite's method is generally considered less effective than the Ponseti method and carries a higher risk of producing a "rocker-bottom" foot due to forceful, incorrect manipulation. *Ponseti's method of correction involves equinus → cavus → adduction → heel varus* - The specific order of correction in **Ponseti's method** is *cavus* (first part of equinus) → *adduction* → *varus* → and finally the *equinus*, with a **percutaneous Achilles tenotomy** often performed to correct the residual equinus. - The goal is to correct the foot by abducting and dorsiflexing it, with the heel varus correcting as the forefoot adduction and varus are addressed.

Q: All of the following are true regarding fracture of lateral condyle of humerus except:

Results in gun stock deformity. ***Results in gun stock deformity*** - A **gunstock deformity** is also known as **cubitus varus**, where the forearm is angled inward when the elbow is extended. - This deformity is classically associated with a **malunited supracondylar fracture of the humerus**, not typically a lateral condyle fracture. *Usually seen at 6-10 years of age* - **Lateral condyle fractures** are common in **children**, particularly between the ages of 6 and 10 years, as this is when the secondary ossification center for the lateral condyle is still largely cartilaginous and vulnerable to trauma. - The **ossification center** for the lateral condyle appears around age 1 and fuses around age 16, making the bone susceptible during this growing period. *Cubitus valgus occurs* - **Lateral condyle fractures** can lead to **cubitus valgus** (increased carrying angle) if the fracture heals with lateral displacement or nonunion, causing the elbow to angle away from the body. - The **physis (growth plate)** of the lateral condyle contributes to the normal growth of the elbow joint, and damage can disrupt this alignment. *Tardy ulnar nerve palsy is seen* - **Cubitus valgus** (a common complication of lateral condyle fractures) stretches the **ulnar nerve** behind the medial epicondyle over time, leading to **tardy ulnar nerve palsy**. - This chronic stretching can cause **neuropathic symptoms** such as numbness, tingling, and weakness in the distribution of the ulnar nerve years after the initial injury.

Q: What is the usual first deformity to be seen in Charcot-Marie-Tooth (CMT) disease?

Pes cavus (high arch). ***Pes cavus (high arch)*** - **Pes cavus**, or a high arch, is the **most characteristic and often the first foot deformity** to develop in individuals with Charcot-Marie-Tooth disease due to muscular imbalances. - This deformity results from weakness in the **peroneal and intrinisic foot muscles**, leading to an overpull of strong opposing muscles and a characteristic foot shape. *Hammer toes* - **Hammer toes** are a common secondary deformity that can develop in CMT, but they typically occur **after the development of pes cavus**. - They are characterized by a bend in the middle joint of the toe (proximal interphalangeal joint) and are not usually the initial sign. *Flatfoot* - **Flatfoot (pes planus)** is characterized by a collapsed arch and is generally **not associated with CMT disease**. - CMT typically causes muscle weakness that leads to an overly high arch, making flatfoot a rare and atypical presentation. *Claw toes* - **Claw toes** are another toe deformity seen in CMT, involving hyper-extension of the metatarsophalangeal joint and flexion of the interphalangeal joints. - While common in CMT, they usually develop **concurrently with or after pes cavus**, rather than being the very first deformity.

Q: The primary diagnostic evaluation for developmental dysplasia of hip is -

USG. ***USG*** - **Ultrasound** is the gold standard for diagnosing **developmental dysplasia of the hip (DDH)** in infants younger than 4-6 months. - It allows for dynamic assessment of hip stability and provides detailed imaging of the unossified cartilaginous femoral head and acetabulum. *Clinical examination* - While initial screening involves clinical examination (e.g., **Ortolani** and **Barlow maneuvers**), it can have false negatives and is less reliable than imaging for definitive diagnosis. - It's a crucial first step but not the primary diagnostic evaluation for confirmation. *X-ray* - **X-rays** are primarily used for DDH diagnosis in infants older than 4-6 months, once the femoral head and acetabulum have begun to ossify significantly. - In younger infants, the cartilaginous structures are not well-visualized on X-ray, limiting its diagnostic utility. *CT Scan* - **CT scans** are generally reserved for complex cases of DDH, typically before or after surgical intervention, or when assessing femoral head reduction in a cast. - It involves radiation exposure and is not the preferred initial or primary diagnostic tool for routine DDH evaluation.

Q: What sound does the examiner hear when the Ortolani test is positive?

Clunk of entry on abduction and flexion of the hip. ***Clunk of entry on abduction and flexion of the hip*** - A positive **Ortolani test** involves hearing a distinct "clunk" as the **femoral head** reduces back into the acetabulum. - This maneuver is performed by **abducting and flexing** the hip from an adducted position in an infant with a dislocated hip. *Clunk of entry on extension and adduction of the hip* - This description is incorrect; the Ortolani test is performed with hip **flexion and abduction**, not extension and adduction. - **Reduction** of the femoral head typically occurs with abduction, not adduction. *Click of exit on abduction and flexion of the hip* - The Ortolani test indicates **reduction** of a dislocated hip, which is characterized by a "clunk" of entry, not a "click of exit." - A "click of exit" when abducting and flexing the hip is more characteristic of the **Barlow maneuver's** results, which tests for reducibility and dislocation. *Click of exit on extension and adduction of the hip* - This describes neither the correct maneuver nor the characteristic sound of a positive Ortolani test. - The Ortolani test focuses on **reducing a dislocated hip** with a distinct "clunk" during a flexion and abduction maneuver.

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

Posteromedial extension. ***Posteromedial extension*** - The vast majority of supracondylar humerus fractures in children are **extension-type fractures** (about 95-98%), and among these, **posteromedial displacement** is the most common pattern. - This type typically results from a **fall on an outstretched hand** with the elbow extended, causing the distal fragment to displace posteriorly and medially relative to the proximal fragment. *Anteromedial flexion* - **Flexion-type supracondylar fractures** are much less common (2-5%) and involve the distal fragment displacing anteriorly. - While medial displacement can occur with flexion, it's not the predominant type of supracondylar fracture. *Anterolateral flexion* - This describes a **flexion-type fracture** with anterior and lateral displacement of the distal fragment, which is rare. - Flexion fractures themselves are uncommon, and specific lateral displacement patterns are even less frequent. *Posterolateral extension* - While part of the common **extension-type fractures**, **posterolateral displacement** is less common than posteromedial displacement. - In extension fractures, the distal fragment typically displaces either posteromedially or posterolaterally, with posteromedial being seen more frequently.

Q: A 4-year-old child while playing suddenly had his elbow pulled by his servant maid's hand and is now continuously crying, not allowing anyone to touch his elbow. He is keeping his elbow extended. What is the most likely diagnosis?

Pulled elbow. ***Pulled elbow*** - This classic presentation involves a sudden pull on the extended arm, causing the **annular ligament** to slip over the **radial head**, characteristic of a pulled elbow (Nursemaid's elbow). - The child holds the arm in a pronated-extended position, refusing to use it due to pain, and cries when the elbow is touched, which aligns with the clinical picture. *Radial head fracture* - While a fracture can occur with trauma, a history of a distinct pulling mechanism and the absence of swelling or deformity make a **pulled elbow** more likely. - A radial head fracture would typically present with more localized pain and potentially **crepitus** or obvious swelling upon examination. *Supracondylar fracture* - This fracture usually results from a fall onto an outstretched hand, a different mechanism than described. - A supracondylar fracture would typically involve significant swelling, **ecchymosis**, and potential neurovascular compromise, which are not mentioned here. *Elbow dislocation* - Elbow dislocations usually result from high-energy trauma and present with obvious deformity and severe pain. - The history of a "pull" and the child holding the arm in an **extended, pronated position** are more consistent with a pulled elbow than a full dislocation.

Q: The anterior humeral line and radiocapitellar alignment are most commonly disturbed in -

Supracondylar Fracture of the humerus. ***Supracondylar Fracture of the humerus*** - **Anterior humeral line** passes through the **anterior cortex of the humerus** and should intersect the middle third of the capitellum in a normal elbow. - In supracondylar fractures, particularly those with **posterior displacement**, this line is often displaced **anteriorly or posteriorly**, failing to intersect the capitellum correctly. Additionally, the **radiocapitellar alignment** refers to the relationship between the **radius head** and the **capitellum**. Fractures and displacements around the elbow joint, such as supracondylar fractures, can disrupt this alignment. *Fracture lateral condyle of the humerus* - While a fracture of the lateral condyle can affect the elbow joint, it primarily involves a part of the **articular surface** and not necessarily the overall alignment of the entire distal humerus relative to the capitellum in the same way a supracondylar fracture does. - The **lateral condyle** is a smaller segment, and its fracture may not significantly alter the anterior humeral line **unless there is significant displacement** that indirectly affects the alignment of the capitellum. *Monteggia Fracture dislocation* - A **Monteggia fracture** involves a fracture of the **ulna** with dislocation of the **radial head** at the elbow. - While radiocapitellar alignment is severely disrupted, the **anterior humeral line** itself, which assesses the distal humerus, is typically **unaffected** as the primary injury is in the forearm bones and the radial head. *Fracture of Proximal Radius* - A fracture of the proximal radius (e.g., **radial head or neck fracture**) primarily affects the **radial articular surface** and its alignment with the capitellum. - While **radiocapitellar alignment** would clearly be disturbed, the position of the **distal humerus** relative to the capitellum, which the anterior humeral line evaluates, usually remains intact.

Q: What condition is characterized by a waddling gait?

Bilateral congenital dysplasia of hip. ***Bilateral congenital dysplasia of hip*** - A **waddling gait**, also known as a **Trendelenburg gait**, occurs due to weakness of the hip abductor muscles (gluteus medius and minimus) on both sides. - In bilateral congenital dysplasia of the hip, the **femoral heads are poorly seated** or dislocated, leading to ineffective abductor function and the characteristic gait. *Coxa valga* - This condition involves an **increased angle** between the femoral neck and shaft, which can alter biomechanics but does not typically cause a waddling gait in isolation. - While it can be associated with other hip pathologies, **coxa valga itself is not the primary cause** of a waddling gait. *CTEV* - **CTEV (Congenital Talipes Equinovarus)**, or **clubfoot**, is a deformity of the foot and ankle, not the hip. - It affects the patient's ability to walk normally, but results in a different type of gait abnormality, typically involving limping or walking on the outer edge of the foot, **not a waddling gait**. *Muscular dystrophy* - While many forms of muscular dystrophy can lead to a waddling gait due to **proximal muscle weakness**, it is a broad category of genetic disorders. - Without further context or specific type of muscular dystrophy, **bilateral congenital hip dysplasia is a more direct and specific cause** for the symptom described.

Question 1

Which of the following statements about manipulation methods for correcting clubfoot (CTEV) is true?

Accepted Answer

Ponseti's technique has success rate of 90 - 98%

Answer

Involves serial casting and above knee plaster casting for 6-8 weeks

Answer

In Kite's method deformities are corrected sequentially equinus → adduction → inversion

Answer

Ponseti's method of correction involves equinus → cavus → adduction → heel varus

Question 2

All of the following are true regarding fracture of lateral condyle of humerus except:

Accepted Answer

Results in gun stock deformity

Answer

Tardy ulnar nerve palsy is seen

Answer

Usually seen at 6-10 years of age

Answer

Cubitus valgus occurs

Question 3

What is the usual first deformity to be seen in Charcot-Marie-Tooth (CMT) disease?

Accepted Answer

Pes cavus (high arch)

Answer

Hammer toes

Answer

Flatfoot

Answer

Claw toes

Question 4

The primary diagnostic evaluation for developmental dysplasia of hip is -

Accepted Answer

USG

Answer

Clinical examination

Answer

X-ray

Answer

CT Scan

Question 5

What sound does the examiner hear when the Ortolani test is positive?

Accepted Answer

Clunk of entry on abduction and flexion of the hip

Answer

Clunk of entry on extension and adduction of the hip

Answer

Click of exit on abduction and flexion of the hip

Answer

Click of exit on extension and adduction of the hip

Question 6

What is the most common type of supracondylar fracture in children?

Accepted Answer

Posteromedial extension

Answer

Anteromedial flexion

Answer

Anterolateral flexion

Answer

Posterolateral extension

Question 7

A 4-year-old child while playing suddenly had his elbow pulled by his servant maid's hand and is now continuously crying, not allowing anyone to touch his elbow. He is keeping his elbow extended. What is the most likely diagnosis?

Accepted Answer

Pulled elbow

Answer

Radial head fracture

Answer

Elbow dislocation

Answer

Supracondylar fracture

Question 8

The anterior humeral line and radiocapitellar alignment are most commonly disturbed in -

Accepted Answer

Supracondylar Fracture of the humerus

Answer

Monteggia Fracture dislocation

Answer

Fracture of Proximal Radius

Answer

Fracture lateral condyle of the humerus

Question 9

Greenstick/ Nightstick fractures are seen in -

Accepted Answer

Children

Answer

Elderly

Answer

Common in all age groups

Answer

Young adults

Question 10

What condition is characterized by a waddling gait?

Accepted Answer

Bilateral congenital dysplasia of hip

Answer

Coxa valga

Answer

CTEV

Answer

Muscular dystrophy

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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