Pediatric Orthopaedics Practice Questions

Q: A 6-year-old boy presents with a painful limp, tenderness in the femoral triangle, and some limitation of hip movements. The X-ray is normal. What is the next investigation?

MRI. ***MRI*** - An **MRI** is the most sensitive imaging modality for detecting early changes in bone marrow and soft tissues, such as **avascular necrosis of the femoral head** (Legg-Calvé-Perthes disease), which can present with a painful limp and normal initial X-rays. - It can visualize bone edema, cartilage irregularities, and effusions that are not apparent on plain radiographs. *CT scan* - While useful for detailed bone anatomy, a **CT scan** exposes the child to significant **radiation** and is less effective than MRI for detecting early soft tissue and bone marrow changes in conditions like Perthes disease. - It is often reserved for complex fracture assessments or when MRI is contraindicated. *Arthroscopy* - **Arthroscopy** is an **invasive surgical procedure** used for direct visualization, diagnosis, and treatment of joint problems. - It is not a primary diagnostic investigation for a painful limp with a normal X-ray, as less invasive imaging like MRI should be performed first. *Bone scan* - A **bone scan** (scintigraphy) is sensitive for detecting increased **metabolic activity** in bone, such as in infections or tumors, but it is less specific than MRI for detailed anatomical changes in early Perthes disease. - It involves radiation exposure and may not provide the detailed soft tissue information needed to differentiate various causes of a painful hip.

Q: The malunion of a supracondylar fracture of the humerus most commonly leads to:

Cubitus varus. ***Cubitus varus*** - A **supracondylar fracture** malunion often results in posterior and medial displacement of the distal fragment, leading to a **loss of the carrying angle** or even its reversal, known as **cubitus varus** or **gunstock deformity**. - This characteristic deformity is the most common and recognizable long-term complication of improperly healed supracondylar humerus fractures. *Flexion deformity* - While some limitation of extension can occur, a pure **flexion deformity** is not the most common or defining malunion pattern for supracondylar fractures. - The primary angular deformity is typically in the coronal plane (varus) rather than the sagittal plane (flexion/extension). *Cubitus valgus* - **Cubitus valgus** is an increased carrying angle, where the forearm deviates laterally, and is relatively rare after supracondylar fracture malunion. - It is more commonly associated with **lateral condyle fractures** or physeal injuries. *Extension deformity* - An **extension deformity** would imply an increase in the normal extension of the elbow, which is not a common consequence of supracondylar fracture malunion. - The typical angular malunion involves either varus or, less commonly, some degree of flexion contracture.

Q: What is true about pulled elbow?

Treatment is quick supination and flexion of elbow. ***Treatment is quick supination and flexion of elbow*** - The classic **reduction maneuver** for a pulled elbow involves applying gentle pressure to the radial head while **supinating the forearm** and then **flexing the elbow**. - A palpable or audible click may be felt as the **annular ligament** slips back into place over the radial head. - This maneuver is successful in over 90% of cases and provides immediate relief. *Occurs due to sudden axial pull on extended elbow* - A pulled elbow, or **nursemaid's elbow**, typically occurs due to a sudden **longitudinal traction on a pronated and extended forearm**. - Common scenario: An adult pulls a child by the hand/wrist while the arm is extended and pronated. - This action causes the **annular ligament** to slip over and trap the radial head. *Forearm is held in pronation and extension* - In a pulled elbow, the forearm is typically held in **pronation** and **slight flexion**, not extension. - The child usually refuses to use the arm (pseudoparalysis) and holds it close to the body. - Pain occurs when attempting to supinate or move the elbow. *Most commonly occurs between 2 - 5 years of age* - Pulled elbow most commonly occurs in children between **6 months and 5 years** of age, with peak incidence at **1-3 years**. - While the option states 2-5 years, this misses the critical earlier period when the condition is also very common. - The **annular ligament** is relatively lax and the radial head is not fully developed during these years, making it more susceptible to subluxation.

Q: All the following are causes of a painful limp, except which of the following?

Infantile Coxa Vara (Coxa Vara). ***Infantile Coxa Vara (Coxa Vara)*** - **Infantile coxa vara** is a developmental condition characterized by a **reduced femoral neck-shaft angle**, often leading to a painless waddling gait or limp. - While it causes a limp, the limp itself is typically **painless**, distinguishing it from the other conditions listed. *Slipped femoral epiphysis (SCFE)* - **SCFE** involves displacement of the **femoral head** from the neck through the growth plate and is a classic cause of a **painful limp** in adolescents, often associated with obesity. - Patients typically experience **hip, groin, thigh, or knee pain** and may present with a shortened leg with external rotation. *Tuberculosis (TB) of the hip* - **TB of the hip** is a chronic infectious arthritis that causes significant **pain**, swelling, and reduced range of motion, leading to a **painful limp**. - It often presents insidiously with **constitutional symptoms** like fever and weight loss, in addition to localized pain. *Perthes disease (Legg-Calvé-Perthes disease)* - **Perthes disease** is characterized by avascular necrosis of the **femoral head** in children, causing a **painful limp** and restricted hip movement. - The pain typically worsens with activity and improves with rest, and may be referred to the knee or thigh.

Q: Avascular necrosis of which bone results in Kohler's disease?

Navicular Bone. ***Navicular Bone*** - **Kohler's disease** is an **avascular necrosis** condition specifically affecting the **navicular bone** in the foot, primarily observed in children. - It leads to focal pain, swelling, and tenderness over the **medial arch of the foot**. *Lunate bone* - Avascular necrosis of the **lunate bone** is known as **Kienbock's disease**, which affects the wrist. - This condition presents with chronic wrist pain and stiffness, distinct from **Kohler's disease** and its location. *Femoral neck* - Avascular necrosis of the **femoral neck** is a cause of **hip pain** and typically occurs in adults, often associated with trauma, steroid use, or alcohol abuse. - It is distinct from pediatric foot conditions like **Kohler's disease**. *Medial cuneiform bone* - While located in the foot, the **medial cuneiform bone** is not the primary site for **Kohler's disease**. - Avascular necrosis of the **medial cuneiform bone** is rare and does not have a specific eponymous designation like **Kohler's disease**.

Q: Which of the following statements about Sprengel's deformity is false?

Associated with Dextrocardia. ***Associated with Dextrocardia*** - Sprengel's deformity, characterized by an **elevated and undescended scapula**, is not typically associated with **dextrocardia**. Dextrocardia is a congenital heart condition where the heart is pointed towards the right side of the chest. - The congenital abnormalities commonly linked with Sprengel's deformity are primarily musculoskeletal or neurological, not cardiac. *Associated with Diastematomyelia* - Sprengel's deformity can be associated with **diastematomyelia**, a congenital anomaly of the spinal cord where the cord is split longitudinally. - This association highlights the potential for multiple congenital malformations in patients with Sprengel's deformity. *High incidence with Klippel Feil syndrome* - Sprengel's deformity has a **high incidence** of co-occurrence with **Klippel-Feil syndrome**, a condition characterized by congenital fusion of cervical vertebrae. - Both conditions involve developmental abnormalities of the cervical spine and scapula, indicating a common developmental pathway disruption. *Associated with Congenital scoliosis* - **Congenital scoliosis**, a sideways curvature of the spine present at birth, is a known association with Sprengel's deformity. - This connection further emphasizes that Sprengel's deformity often presents as part of a broader spectrum of musculoskeletal and vertebral anomalies.

Q: Which of the following statements regarding fractures of the lateral condyle of the humerus is false?

Cubitus varus occur more commonly than valgus. ***Cubitus varus occur more commonly than valgus*** - This statement is **false**. Fractures of the lateral condyle of the humerus typically lead to **cubitus valgus** deformity, not cubitus varus, due to growth disturbances at the lateral physis. - The fragment displaces laterally and distally, leading to a loss of the normal valgus angle of the elbow. *Salter Harris type IV injury* - Fractures of the lateral condyle of the humerus are indeed classified as **Salter-Harris Type IV injuries** because the fracture line extends through the epiphysis, crosses the physis, and exits through the metaphysis. - This classification indicates involvement of the **growth plate**, which carries a higher risk of growth disturbances and deformity. *Tardy ulnar nerve palsy occurs* - **Tardy ulnar nerve palsy** is a known long-term complication of lateral condyle fractures, particularly when a cubitus valgus deformity develops. - The valgus deformity can stretch the ulnar nerve behind the medial epicondyle, leading to delayed onset nerve symptoms and dysfunction. *Most common complication of surgically treated cases is cubitus valgus deformity* - Even with surgical treatment, **cubitus valgus deformity** remains a significant and common complication due to potential growth arrest at the lateral physis or incomplete reduction and fixation. - Inadequate reduction or fixation can lead to continued growth disturbance and subsequent angular deformity.

Q: Osgood-Schlatter disease primarily affects which joint?

The knee joint. ***The knee joint*** - **Osgood-Schlatter disease** is characterized by inflammation of the **patellar tendon** at its insertion on the **tibial tuberosity**, which is located just below the knee joint. - It results from repetitive stress and microtrauma to the growth plate in growing adolescents, leading to pain and swelling around the **knee**. *Pelvis* - Conditions affecting the pelvis typically involve the **hip joint** or **sacroiliac joints**, such as **apophysitis of the iliac crest** or **ischial tuberosity**. - These conditions present with pain in the respective pelvic regions, distinct from the anterior knee pain seen in Osgood-Schlatter disease. *Wrist joint* - The wrist joint is composed of the distal radius and ulna articulating with the carpal bones; conditions here include **ganglion cysts**, **carpal tunnel syndrome**, or **distal radial fractures**. - Symptoms would be localized to the hand and wrist, completely separate from the knee. *Cervical spine* - The cervical spine involves the neck vertebrae and is associated with conditions like **cervical spondylosis**, **whiplash injuries**, or **herniated discs**. - These conditions manifest as neck pain, stiffness, or radiating symptoms down the arms, which are unrelated to the lower limb.

Q: All of the following are true regarding congenital dislocation of the hip except which of the following?

It is always bilateral. ***It is always bilateral*** - **Congenital dislocation of the hip (CDH)** is more commonly **unilateral**, with a predilection for the left hip. - While it can be bilateral, stating it is *always* bilateral is incorrect. - **Bilateral CDH** occurs in only about 20% of cases. *Asymmetric thigh folds may be seen* - **Asymmetric thigh folds** are a common soft sign of **developmental dysplasia of the hip (DDH)**, though they can also be seen in normal infants. - This asymmetry is due to the femoral head's abnormal position, leading to unequal skin fold distribution on the affected side. *Galeazzi sign and Ortolani's test may be positive* - The **Galeazzi sign** (also known as the Allis sign) indicates limb length discrepancy, often seen in unilateral hip dislocation when the knees are flexed. - **Ortolani's test** is a specific maneuver used to reduce a dislocated hip, producing a characteristic *clunk* as the femoral head re-enters the acetabulum. *Oligohydramnios is a known risk factor for congenital dislocation of the hip* - **Oligohydramnios** (decreased amniotic fluid) is a well-established risk factor for CDH due to restricted fetal movement and abnormal intrauterine positioning. - Other risk factors include **breech presentation**, **female sex**, **firstborn child**, and **family history**. - **Polyhydramnios** (excess amniotic fluid) is NOT associated with increased risk of CDH.

Question 1

A 6-year-old boy presents with a painful limp, tenderness in the femoral triangle, and some limitation of hip movements. The X-ray is normal. What is the next investigation?

Accepted Answer

MRI

Answer

CT scan

Answer

Arthroscopy

Answer

Bone scan

Question 2

The malunion of a supracondylar fracture of the humerus most commonly leads to:

Accepted Answer

Cubitus varus

Answer

Cubitus valgus

Answer

Extension deformity

Answer

Flexion deformity

Question 3

What is true about pulled elbow?

Accepted Answer

Treatment is quick supination and flexion of elbow

Answer

Forearm is held in pronation and extension

Answer

Occurs due to sudden axial pull on extended elbow

Answer

Most commonly occurs between 2 - 5 years of age

Question 4

All the following are causes of a painful limp, except which of the following?

Accepted Answer

Infantile Coxa Vara (Coxa Vara)

Answer

Slipped femoral epiphysis (SCFE)

Answer

Tuberculosis (TB) of the hip

Answer

Perthes disease (Legg-Calvé-Perthes disease)

Question 5

Avascular necrosis of which bone results in Kohler's disease?

Accepted Answer

Navicular Bone

Answer

Lunate bone

Answer

Femoral neck

Answer

Medial cuneiform bone

Question 6

Which of the following statements is true regarding femoral shaft fractures in infants?

Accepted Answer

Child abuse is a common cause of femoral shaft fractures in infants.

Answer

Femoral shaft fractures in infants heal rapidly.

Answer

Traction is usually sufficient for treatment.

Answer

Femoral shaft fractures in non-ambulatory infants are most commonly caused by accidental mechanisms such as falls.

Question 7

Which of the following statements about Sprengel's deformity is false?

Accepted Answer

Associated with Dextrocardia

Answer

Associated with Diastematomyelia

Answer

High incidence with Klippel Feil syndrome

Answer

Associated with Congenital scoliosis

Question 8

Which of the following statements regarding fractures of the lateral condyle of the humerus is false?

Accepted Answer

Cubitus varus occur more commonly than valgus

Answer

Salter Harris type IV injury

Answer

Tardy ulnar nerve palsy occurs

Answer

Most common complication of surgically treated cases is cubitus valgus deformity

Question 9

Osgood-Schlatter disease primarily affects which joint?

Accepted Answer

The knee joint

Answer

Pelvis

Answer

Wrist joint

Answer

Cervical spine

Question 10

All of the following are true regarding congenital dislocation of the hip except which of the following?

Accepted Answer

It is always bilateral

Answer

Asymmetric thigh folds may be seen

Answer

Galeazzi sign and Ortolani's test may be positive

Answer

Oligohydramnios is a known risk factor for congenital dislocation of the hip

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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