Pediatric Orthopaedics Practice Questions

Q: Cubitus varus is most commonly seen in:

Fracture of the lateral condyle of the humerus. ***Fracture of the lateral condyle of the humerus*** - A fracture of the **lateral condyle of the humerus** that goes untreated or is improperly treated is a common cause of **cubitus varus** due to growth disturbance of the lateral physis. - This type of fracture often leads to **growth arrest** or **asymmetrical growth** of the distal humerus, resulting in an angular deformity. *Rickets* - **Rickets** is a metabolic bone disease characterized by defective bone mineralization, primarily affecting rapidly growing bones. - While rickets can cause various bone deformities, including bowing of the legs (genu varum), it does not directly lead to **cubitus varus** in the elbow through a specific mechanism. *Malunited supracondylar fracture* - A **malunited supracondylar fracture** of the humerus is the most common cause of **cubitus varus** deformity. - This occurs due to rotational or angular malalignment causing the distal fragment to unite in an altered position. *Post-inflammatory epiphyseal damage* - **Post-inflammatory epiphyseal damage** can lead to altered growth and angular deformities, but it is a less common and less specific cause of **cubitus varus** compared to a malunited supracondylar fracture or lateral condyle fracture. - This type of damage can result from conditions like **septic arthritis**, but its association with cubitus varus is secondary to growth plate disruption.

Q: A 10-year-old obese boy was referred to the emergency department with a history of hip pain. He was observed to be limping and complained of severe pain. Which of the following investigations is least appropriate for this condition?

USG of hip. ***USG of hip*** - An **ultrasound (USG)** of the hip is generally not the primary imaging modality for diagnosing conditions like **slipped capital femoral epiphysis (SCFE)**, which is suggested by the patient's presentation. - While USG can detect effusions or synovitis, it provides poor visualization of bony structures and the physeal plate, which are crucial for diagnosing SCFE. *X-ray of the hip* - **X-rays** (AP and frog-leg lateral views) are the **initial and most important imaging study** for diagnosing SCFE. - They effectively visualize the **epiphyseal displacement** relative to the metaphysis and are sufficient for diagnosis in most cases. *MRI of the hip* - **MRI** is highly sensitive for detecting early or subtle SCFE, especially when X-rays are inconclusive. - It can evaluate the **physeal edema**, chondral changes, and avascular necrosis, providing more detailed information than X-rays. *CT scan of hip* - A **CT scan** provides excellent bony detail and can precisely assess the **degree of physeal slip** and femoral head deformity. - It may be used for surgical planning, especially in complex cases or when the slip is difficult to assess with X-rays.

Q: Which one of the following is the most ideal treatment for a displaced fracture of the lateral condyle of the humerus in a 7-year-old child?

Open reduction and internal fixation. ***Open reduction and internal fixation*** - **Displaced lateral condyle fractures** in children require **anatomical reduction** and stable fixation to prevent complications like **non-union** and **cubitus valgus deformity**. - **Internal fixation** provides the necessary stability for healing and allows for earlier mobilization, which is crucial for elbow joint function. *Open reduction with plaster immobilization* - While it achieves open reduction, relying solely on **plaster immobilization** after reducing a displaced fracture of the lateral humeral condyle in a child often leads to **loss of reduction**. - This method does not provide adequate stability for this type of fracture, increasing the risk of **displacement** and **malunion**. *Closed reduction with plaster immobilization* - **Closed reduction** is typically attempted only for **minimally displaced** or **undisplaced fractures** of the lateral condyle. - Given that the fracture is described as **displaced**, closed reduction is unlikely to achieve and maintain an adequate anatomical alignment.

Q: The most common presenting feature of bilateral congenital hip dislocation in children is:

Waddling. ***Waddling*** - **Bilateral congenital hip dislocation** leads to an unstable gait where the body sways from side to side to maintain balance over the affected hip. - This characteristic gait is known as a **waddling gait** or **Trendelenburg gait**, making it the most common presenting feature when the child begins to walk. - Occurs due to bilateral hip instability causing the pelvis to tilt to the unsupported side during walking. *Stumbling* - **Stumbling** is generally associated with difficulties in coordination, muscle weakness, or neurological issues, rather than a primary presentation of hip dislocation. - It does not specifically describe the compensatory gait seen in bilateral congenital hip dislocation. *Knock knee* - **Knock knee** (genu valgum) is an angular deformity of the knees where they touch while the ankles are apart, which is unrelated to hip dislocation. - It is a lower limb alignment issue, distinct from hip joint instability. *Antalgic* - An **antalgic gait** is adopted to reduce pain in a limb or joint, often involving a shortened stance phase on the affected side. - While hip dislocation can cause pain, the specific and most common gait pattern in bilateral congenital hip dislocation is **waddling**, not merely an antalgic response. - Antalgic gait is more typical of unilateral painful conditions.

Q: A 3-year-old patient reports painless progressive bilateral facial swellings. The tentative diagnosis is

Cherubism. ***Cherubism*** - This genetic condition characteristically presents in **early childhood** (age 2-5 years) with **painless, bilateral swelling of the jaws**. - The distinctive clinical feature is the **"cherubic" facial appearance** due to bilateral expansion of the mandible and maxilla. *Monostotic fibrous dysplasia* - This condition is typically **unilateral** and affects a **single bone**, presenting as a localized swelling rather than bilateral facial involvement. - While it can manifest in childhood, its presentation of a solitary bone lesion doesn't match the described bilateral facial swellings. *Polyostotic fibrous dysplasia* - This form of fibrous dysplasia involves **multiple bones** and may present with facial asymmetry or swelling, often accompanied by **pathological fractures** and **skin pigmentation (café-au-lait spots)**. - While it can affect facial bones, the classic **bilateral, symmetrical, progressive facial swelling** described is more indicative of Cherubism. *Central giant cell granuloma* - This is a **benign intraosseous lesion** that can occur in the jaws but is typically **unilateral** and presents as a localized swelling, often causing **pain** or paresthesia. - It does not usually present with the **bilateral, progressive facial swelling** characteristic of Cherubism.

Q: A 10-year-old boy presenting with cubitus varus deformity and a history of trauma 3 months prior, on clinical examination, has preserved the normal relationship of the three bony points of the elbow. What is the most probable diagnosis?

Malunited supracondylar fracture of the humerus. ***Malunited supracondylar fracture of the humerus*** - A malunited **supracondylar fracture** is the most common cause of **cubitus varus** deformity, also known as gunstock deformity, in children, which results from the medial displacement and internal rotation of the distal fragment. - The **normal relationship of the three bony points** (medial epicondyle, lateral epicondyle, and olecranon) is preserved because the fracture is usually extra-articular and the trochlea and capitellum maintain their normal relationship with the ulna and radius. *Old unreduced elbow dislocation* - An **elbow dislocation** would disrupt the normal anatomical relationship between the radius, ulna, and humerus, leading to an **abnormal relationship of the three bony points** of the elbow. - While it can cause deformity, it typically presents with obvious joint incongruity and significant functional limitations that would be evident on examination. *Malunited intercondylar fracture of the humerus* - An **intercondylar fracture** involves the articular surface of the humerus, suggesting an intra-articular injury. - Such a fracture, even if malunited, would likely disrupt the **normal alignment of the trochlea and capitellum** with the olecranon and radial head, thus altering the relationship of the three bony points. *Non-union of lateral condylar fracture of the humerus* - A **non-union of a lateral condylar fracture** can lead to progressive valgus deformity (cubitus valgus) or instability, not typically cubitus varus. - While it affects the elbow joint, the primary issue is joint instability and changes in the carrying angle, not the varus deformity described with preserved bony point relationships.

Q: Clavicle is absent in which of the following conditions?

Cleidocranial dysostosis. ***Cleidocranial dysostosis*** [1] - Characterized by the **absence of clavicles**, leading to wide-set shoulders, which is a hallmark feature of this condition. - It is a genetic disorder due to mutations in the **RUNX2** gene [1], impacting bone development. *Osteogenesis imperfecta* - Known as "brittle bone disease," primarily affecting **collagen production**, leading to fragile bones. - Does not typically involve **clavicular absence**; clavicles are usually present, though they may be brittle. *Osteopetrosis* - A condition marked by **abnormal bone density** due to osteoclast dysfunction, leading to dense yet fragile bones. - The clavicles remain intact, although may show **thickening** rather than absence. *Fibrous dysplasia* - Characterized by **replacement of normal bone with fibrous tissue**, leading to bone deformities or fractures. - The clavicle is usually preserved, although it can be affected by **expansile lesions** in some cases. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Bones, Joints, and Soft Tissue Tumors, p. 1186.

Q: All are true regarding congenital talipes equinovarus (CTEV) except:

Increased dorsiflexion. ***Increased dorsiflexion*** - Congenital talipes equinovarus (CTEV), or **clubfoot**, is characterized by an **equinus deformity**, meaning the foot is pointing downwards, thus having significantly **reduced dorsiflexion**. - **Increased dorsiflexion** would imply the foot can be brought closer to the shin, which is directly opposite to the characteristic presentation of CTEV. *Hindfoot varus* - **Hindfoot varus** is a characteristic component of CTEV, where the heel is turned inward. - This inward turning of the heel contributes to the overall deformity and is one of the four main components of a clubfoot. *Cavus* - **Cavus** refers to a high arch in the foot, which is another defining feature of CTEV. - This exaggerated arch contributes to the rigidity and complex nature of the deformity. *Forefoot adduction* - **Forefoot adduction** means the front part of the foot is turned inward towards the body's midline, which is a key component of CTEV. - This inward deviation contributes to the 'club' shape of the foot and is often described as metatarsus adductus within the overall deformity.

Q: Von Rosen splint is used for?

congenital displacement of hip. ***congenital displacement of hip*** - The **Von Rosen splint** is a specific orthopedic device used for the early management of **congenital displacement of the hip**, also known as **developmental dysplasia of the hip (DDH)**. - It maintains the hip in a position of **flexion and abduction**, which helps to reduce and stabilize the dislocated or subluxated femoral head within the acetabulum. *ctev* - **CTEV (Congenital Talipes Equinovarus)**, or clubfoot, is a deformity of the foot and ankle, not the hip. - It is typically treated with the **Ponseti method** involving serial casting, followed by a foot abduction brace. *fracture of shaft of femur* - A fracture of the **shaft of the femur** in a child or infant usually requires immobilization with a **traction splint** (e.g., Bryant's traction) or a **spica cast**, depending on age and fracture type. - The Von Rosen splint is not designed to stabilize long bone fractures. *paralytic poliomyelitis* - **Paralytic poliomyelitis** causes muscle weakness and paralysis, which can lead to various musculoskeletal deformities as a late sequela, but it is not a congenital hip displacement. - Management focuses on supportive care, physiotherapy, and potentially surgical correction of established deformities, not a primary splint for acute hip dislocation.

Question 1

Cubitus varus is most commonly seen in:

Accepted Answer

Fracture of the lateral condyle of the humerus

Answer

Rickets

Answer

Malunited supracondylar fracture

Answer

Post-inflammatory epiphyseal damage

Question 2

A 10-year-old obese boy was referred to the emergency department with a history of hip pain. He was observed to be limping and complained of severe pain. Which of the following investigations is least appropriate for this condition?

Accepted Answer

USG of hip

Answer

MRI of the hip

Answer

CT scan of hip

Answer

X-ray of the hip

Question 3

Which one of the following is the most ideal treatment for a displaced fracture of the lateral condyle of the humerus in a 7-year-old child?

Accepted Answer

Open reduction and internal fixation

Answer

Open reduction with plaster immobilization

Answer

Closed reduction with plaster immobilization

Answer

All of the above

Question 4

The most common presenting feature of bilateral congenital hip dislocation in children is:

Accepted Answer

Waddling

Answer

Knock knee

Answer

Antalgic

Answer

Stumbling

Question 5

A 3-year-old patient reports painless progressive bilateral facial swellings. The tentative diagnosis is

Accepted Answer

Cherubism

Answer

Monostotic fibrous dysplasia

Answer

Polyostotic fibrous dysplasia

Answer

Central giant cell granuloma

Question 6

A 10-year-old boy presenting with cubitus varus deformity and a history of trauma 3 months prior, on clinical examination, has preserved the normal relationship of the three bony points of the elbow. What is the most probable diagnosis?

Accepted Answer

Malunited supracondylar fracture of the humerus

Answer

Old unreduced elbow dislocation

Answer

Malunited intercondylar fracture of the humerus

Answer

Non-union of lateral condylar fracture of the humerus

Question 7

Clavicle is absent in which of the following conditions?

Accepted Answer

Cleidocranial dysostosis

Answer

Osteogenesis imperfecta

Answer

Fibrous dysplasia

Answer

Osteopetrosis

Question 8

All are true regarding congenital talipes equinovarus (CTEV) except:

Accepted Answer

Increased dorsiflexion

Answer

Hindfoot varus

Answer

Cavus

Answer

Forefoot adduction

Question 9

Von Rosen splint is used for?

Accepted Answer

congenital displacement of hip

Answer

ctev

Answer

fracture of shaft of femur

Answer

paralytic poliomyelitis

Question 10

A 15-year-old boy with Marfan syndrome is experiencing back pain, and on examination, he has a curvature of his thoracic spine to the left. Which of the following is the most appropriate next step in management?

Accepted Answer

a vigorous exercise program

Answer

a prophylactic surgical procedure

Answer

imaging studies (X-rays) to assess curvature

Answer

mechanical back bracing

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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