Pediatric Orthopaedics Practice Questions

Q: Which of the following is NOT an X-ray feature of child abuse?

Subepiphyseal microfractures. **Explanation:** The correct answer is **D. Subepiphyseal microfractures.** In pediatric orthopaedics, the hallmark of Non-Accidental Injury (NAI) or child abuse is the **Classic Metaphyseal Lesion (CML)**. This occurs due to violent shaking or pulling of the limbs, which creates shearing forces across the fragile primary spongiosa of the metaphysis. * **Why D is correct:** The term "subepiphyseal microfractures" is not a standard radiological description of child abuse. The actual pathology involves **transverse microfractures through the primary spongiosa of the metaphysis**, not the subepiphyseal region. * **Why A and B are incorrect:** **Metaphyseal corner fractures** and **Bucket handle fractures** are two different radiographic views of the same injury (CML). When the avulsed metaphyseal fragment is viewed at an angle, it appears as a "corner" chip; when viewed head-on, it appears as a "bucket handle" arc. These are considered **highly specific (pathognomonic)** for child abuse. * **Why C is incorrect:** **Metaphyseal fragment displacement** is a direct consequence of the shearing forces in CML, where a thin planar fragment of the metaphysis is separated from the shaft. **Clinical Pearls for NEET-PG:** 1. **High Specificity Lesions:** CML (Corner/Bucket handle), posterior rib fractures (due to squeezing), scapular fractures, and sternal fractures. 2. **Dating Fractures:** Presence of fractures in different stages of healing is a major red flag. 3. **Commonest Bone Involved:** Long bones (Femur/Humerus), but the *pattern* (e.g., spiral fracture in a non-ambulatory infant) is more suspicious than the location. 4. **Initial Investigation:** A **Skeletal Survey** (not a bone scan) is the gold standard for suspected child abuse in children under 2 years.

Q: The Ponseti method is primarily used for the treatment of which condition?

Congenital Talipes Equinovarus (CTEV). **Explanation:** The **Ponseti method** is the gold-standard conservative treatment for **Congenital Talipes Equinovarus (CTEV)**, also known as clubfoot. The underlying medical concept involves the manipulation of the foot to correct the three-dimensional deformity by rotating the foot around the head of the talus (the "pivot"). This is followed by serial long-leg casting to maintain the correction. **Why the correct answer is right:** CTEV is characterized by the mnemonic **CAVE**: **C**avirus, **A**dductus, **V**arus, and **E**quinus. The Ponseti method corrects these in a specific sequence (CAV first, then E). A key component is the **Percutaneous Achilles Tenotomy**, required in about 80-90% of cases to correct the residual equinus after the other components are addressed. **Why the incorrect options are wrong:** * **Rickets:** This is a metabolic bone disease treated primarily with Vitamin D and Calcium supplementation, not serial casting. * **Blount's disease:** This involves disordered ossification of the medial proximal tibial phalanx (tibia vara). Treatment ranges from bracing to corrective osteotomy. * **Congenital Vertical Talus (CVT):** While CVT is also a foot deformity ("Rocker-bottom foot"), it is treated using the **Reverse Ponseti method**, where the foot is manipulated into equinus and varus (the opposite of CTEV). **High-Yield Clinical Pearls for NEET-PG:** * **Order of correction:** C $\rightarrow$ A $\rightarrow$ V $\rightarrow$ E. * **The Pivot Point:** The head of the talus (never touch the calcaneus during manipulation). * **Maintenance:** After casting, a **Steenbeek or Denis Browne splint** is used (70° external rotation) to prevent recurrence. * **Pirani Score:** Used to assess the severity and progress of CTEV during Ponseti treatment.

Q: A short-statured patient presents with an X-ray showing vertebral flattening and beaking. What is the likely diagnosis?

Achondroplasia. ### Explanation **Correct Option: A. Achondroplasia** Achondroplasia is the most common cause of disproportionate short-limb dwarfism. It is an autosomal dominant condition caused by a mutation in the **FGFR3 gene**. The characteristic spinal finding in achondroplasia is **vertebral flattening (platyspondyly)** and **anterior beaking** (specifically at the L1-L2 level). This occurs due to defective endochondral ossification. Other classic radiological features include: * **Spine:** Progressive narrowing of the interpedicular distance (caudally), posterior scalloping of vertebrae, and "bullet-shaped" vertebrae. * **Pelvis:** "Champagne glass" pelvis (short, broad iliac bones) and "square" iliac wings. * **Hands:** "Trident hand" (increased space between the 3rd and 4th digits). **Why other options are incorrect:** * **B. Protein Energy Malnutrition:** Primarily affects soft tissues and growth plates (growth arrest lines), but does not cause specific vertebral beaking or flattening. * **C. Rickets:** Characterized by **cupping, fraying, and splaying** of the metaphyses and widening of the growth plate. While it can cause "rachitic rosary" and bowing of legs, it does not present with the specific vertebral morphology of achondroplasia. * **D. Down’s Syndrome:** Associated with skeletal findings like **atlanto-axial instability** and "hyper-extensible" joints, but the classic spinal feature is increased height of the lumbar vertebrae (tall vertebrae), not flattening. **NEET-PG High-Yield Pearls:** * **Anterior Beaking:** If central, think **Morquio Syndrome** (Mucopolysaccharidosis IV); if inferior/anteroinferior, think **Hurler Syndrome**. * **Interpedicular Distance:** In a normal spine, this distance *increases* downwards; in Achondroplasia, it *decreases* (pathognomonic). * **Rhizomelic shortening:** Shortening of the proximal segments (humerus/femur), typical of Achondroplasia.

Q: A 4-year-old boy complains of pain around the elbow with the hand held in pronation and extension. Radiographs of the elbow joint are normal. What is the most probable diagnosis?

Pulled elbow. ### Explanation **Correct Option: A. Pulled elbow** Pulled elbow, also known as **Nursemaid’s elbow** or **Subluxation of the Radial Head**, is a common pediatric injury occurring typically between ages 1–4 years. It is caused by sudden longitudinal traction on an extended, pronated arm (e.g., pulling a child up a curb). * **Pathophysiology:** The annular ligament, which is relatively lax in toddlers, slips over the head of the radius and becomes trapped in the radio-capitellar joint. * **Clinical Presentation:** The child holds the arm in a characteristic position of **pronation and slight flexion/extension**, refusing to use it. Crucially, **radiographs are typically normal** because it is a subluxation, not a fracture. **Why other options are incorrect:** * **B. Monteggia fracture:** This involves a fracture of the proximal third of the ulna associated with a dislocation of the radial head. It would show obvious bony deformity and significant findings on an X-ray. * **C. Cellulitis:** This is an inflammatory/infectious condition presenting with localized redness, warmth, swelling, and fever, rather than a sudden mechanical injury. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Sudden traction on a pronated forearm. * **Pathology:** Interposition of the **annular ligament**. * **Management:** Reduction is performed via **supination** of the forearm followed by **flexion** at the elbow (a "click" is often felt). No immobilization is required once the child starts using the arm. * **Radiology:** Always normal; X-rays are only indicated if a fracture is suspected (e.g., history of a fall or focal bony tenderness).

Q: What is the preferred treatment for cubitus varus?

Lateral closing wedge osteotomy. **Explanation:** **Cubitus varus**, commonly known as "Gunstock deformity," is the most frequent late complication of malunited supracondylar fractures of the humerus. It is a three-dimensional deformity involving varus angulation, internal rotation, and hyperextension. **Why Lateral Closing Wedge Osteotomy (French Osteotomy) is the Correct Choice:** The **Lateral Closing Wedge Osteotomy** is the gold standard treatment for correcting cubitus varus. In this procedure, a wedge of bone is removed from the lateral aspect of the distal humerus. This allows the surgeon to tilt the distal fragment laterally, effectively correcting the varus angle. It is preferred because: 1. **Stability:** Closing a wedge provides better bone-on-bone contact, leading to faster healing and inherent stability. 2. **Simplicity:** It avoids the need for bone grafting and minimizes tension on the ulnar nerve. **Analysis of Incorrect Options:** * **Medial Closing Wedge Osteotomy:** This would worsen the varus deformity by further tilting the forearm toward the midline. * **Medial/Lateral Opening Wedge Osteotomies:** These require bone grafting to fill the gap, carry a higher risk of non-union, and can lead to increased tension on neurovascular structures (especially the ulnar nerve in medial opening procedures). **Clinical Pearls for NEET-PG:** * **Most common cause:** Malunited supracondylar fracture (specifically, failure to correct the medial tilt). * **Indication for surgery:** Primarily cosmetic; functional impairment is rare. * **French Osteotomy:** A specific type of lateral closing wedge osteotomy using two screws and a tension band wire. * **Ulnar Nerve:** While cubitus varus is usually asymptomatic, it can occasionally lead to **tardy ulnar nerve palsy** or posterolateral rotatory instability in adulthood.

Q: What is the characteristic deformity in Blount's disease?

Genu varus. **Explanation:** **Blount’s Disease (Tibia Vara)** is a developmental disorder characterized by disordered endochondral ossification of the **medial aspect of the proximal tibial physis**. This leads to a progressive growth suppression of the medial tibial plateau, resulting in **Genu Varus** (bow-legs). 1. **Why Genu Varus is Correct:** In Blount’s disease, the posteromedial part of the proximal tibia fails to grow normally. As the lateral side continues to grow at a standard rate while the medial side lags, the tibia angles inward toward the midline, creating a varus deformity. It is distinguished from physiological bowing by its progressive nature and specific radiographic findings (e.g., Langenskiöld classification). 2. **Why Incorrect Options are Wrong:** * **Genu Valgum:** Also known as "knock-knees," this is the opposite of the deformity seen in Blount’s. It is commonly seen in conditions like renal rickets or as a physiological stage in children aged 3–5 years. * **Coxa Vara/Valgus:** These refer to the neck-shaft angle of the **femur** at the hip joint (normal is ~120°–135°). While they are common orthopedic distractors, Blount’s disease specifically affects the proximal **tibia**, not the hip. **Clinical Pearls for NEET-PG:** * **Radiographic Hallmark:** Increased **Metaphyseal-Diaphyseal Angle (Drennan’s Angle)** >16° is highly suggestive of Blount’s. * **Classification:** The **Langenskiöld Classification** (Stages I-VI) is used to assess severity based on the depression of the medial tibial beak. * **Types:** Infantile (early onset, 0–3 years, often bilateral) and Adolescent (late onset, >10 years, often unilateral and associated with obesity). * **Treatment:** Bracing (KAFO) is effective in early stages (Stage I-II); surgical osteotomy is required for advanced stages or persistent deformity.

Q: A newborn child presents with an inverted foot, and the dorsum of the foot cannot touch the anterior tibia. What is the most probable diagnosis?

Congenital talipes equinovarus. **Explanation:** The clinical presentation described—an inverted foot where the dorsum cannot touch the anterior tibia—is the classic description of **Congenital Talipes Equinovarus (CTEV)**, also known as Clubfoot. **1. Why CTEV is correct:** CTEV is characterized by four primary deformities (Mnemonic: **CAVE**): * **C**avus (high arch) * **A**dduction of the forefoot * **V**arus (inversion of the heel) * **E**quinus (plantarflexion at the ankle) The **Equinus** component is the reason the dorsum of the foot cannot touch the anterior tibia (loss of dorsiflexion). The **Varus** component causes the inversion. **2. Why other options are incorrect:** * **Congenital Vertical Talus (CVT):** Also known as "Rocker-bottom foot." Unlike CTEV, the foot is **everted** and the midfoot is dorsiflexed, making the sole convex. * **Arthrogryposis Multiplex:** While CTEV can be a feature of this syndrome, it involves multiple joint contractures present at birth throughout the body, not just an isolated foot deformity. * **Flat Foot (Pes Planus):** This involves the loss of the medial longitudinal arch. It does not present with inversion or fixed equinus deformity in a newborn. **3. High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Treatment:** The **Ponseti Method** (serial casting). The order of correction is **CAVE** (Cavus first, Equinus last). * **Pirani Score:** Used to assess the severity of CTEV (0 to 6 scale). * **Radiology:** Kite’s Angle (Talo-calcaneal angle) is **decreased** (<20°) in CTEV on both AP and lateral views. * **Last deformity to be corrected:** Equinus (often requires a percutaneous Achilles tenotomy).

Q: Which of the following statements regarding genu varum (bowleg) is true?

Occurs due to epiphyseal dysplasia.. **Explanation:** Genu varum (bowleg) is a common clinical presentation in pediatric orthopaedics characterized by an outward bowing of the legs. **Why Option B is Correct:** Pathological genu varum is frequently associated with skeletal dysplasias, specifically **epiphyseal or metaphyseal dysplasias** (e.g., Achondroplasia, Multiple Epiphyseal Dysplasia). In these conditions, abnormal development or premature ossification of the growth plates leads to asymmetric growth, resulting in progressive angular deformities. Other pathological causes include Rickets and Blount’s disease (Tibia Vara). **Analysis of Incorrect Options:** * **Option A:** While "Physiological Genu Varum" is normal in infants up to 18–24 months, the question asks for a definitive statement regarding the pathology. In the context of standard orthopaedic examinations, pathological bowing is distinguished from the self-limiting physiological version. * **Option C:** Genu varum is **frequently** associated with tibial angulation. In fact, in Blount’s disease, the primary pathology is localized to the posteromedial aspect of the proximal tibial physis. * **Option D:** The deformity can involve both the **distal femur** and the **proximal tibia**. For example, in Rickets, softening of the bones leads to bowing across multiple segments of the lower limb. **NEET-PG High-Yield Pearls:** * **Developmental Timeline:** Remember the sequence: Genu Varum (Birth to 2 yrs) → Straight (2 yrs) → Genu Valgum (3 to 4 yrs) → Straight (6 to 7 yrs). * **Blount’s Disease:** Characterized by an abnormal **Metaphyseal-Diaphyseal Angle (>16°)** on X-ray. * **Rickets:** Look for "cupping, splaying, and fraying" of the metaphysis. * **Clinical Measurement:** Genu varum is assessed by measuring the **intercondylar distance** (distance between the medial femoral condyles).

Q: In treating a fractured clavicle in a 14-month-old child, what is the preferred management?

Figure-of-eight bandage. **Explanation:** Fractures of the clavicle are common in the pediatric population due to birth trauma or falls. In a 14-month-old child, the management is almost exclusively **conservative** because of the immense remodeling potential of the bone and the thick periosteal sleeve that stabilizes the fracture. **Why Figure-of-eight bandage is correct:** The **Figure-of-eight bandage** (or a simple broad arm sling) is the treatment of choice. It functions by pulling the shoulders back, which helps in aligning the fragments and providing symptomatic relief by limiting movement. In infants and toddlers, even significant displacement or malalignment (overlap) will remodel completely over time without functional deficit. **Why other options are incorrect:** * **Open reduction:** Surgical intervention is contraindicated in young children due to the risk of infection, scarring, and non-union. It is only considered in rare cases of open fractures or neurovascular compromise. * **Shoulder cast:** A full shoulder cast (like a shoulder spica) is unnecessarily restrictive, heavy, and uncomfortable for a toddler. It provides no additional benefit over a simple bandage. * **Kirschner pin:** Internal fixation with K-wires is avoided in children because of the risk of migration and damage to the growth plates or underlying vital structures. **NEET-PG High-Yield Pearls:** * **Most common site:** The middle third (junction of medial 2/3 and lateral 1/3) is the most common site of clavicle fractures. * **Remodeling:** The younger the child, the greater the remodeling potential. Clinical "lumps" (callus) usually disappear within 6–9 months. * **Birth Injury:** Clavicle fracture is the most common bone fractured during labor (often associated with shoulder dystocia). * **Adult Management:** While children are treated with slings/bandages, adults with significant shortening (>2cm) or comminution may require ORIF with plates and screws.

Question 1

Which of the following is NOT an X-ray feature of child abuse?

Accepted Answer

Subepiphyseal microfractures

Answer

Metaphyseal corner fracture

Answer

Metaphyseal bucket handle fracture

Answer

Metaphyseal fragment displacement

Question 2

The Ponseti method is primarily used for the treatment of which condition?

Accepted Answer

Congenital Talipes Equinovarus (CTEV)

Answer

Rickets

Answer

Blount's disease

Answer

Congenital vertical talus

Question 3

A short-statured patient presents with an X-ray showing vertebral flattening and beaking. What is the likely diagnosis?

Accepted Answer

Achondroplasia

Answer

Protein Energy Malnutrition

Answer

Rickets

Answer

Down's Syndrome

Question 4

A 4-year-old boy complains of pain around the elbow with the hand held in pronation and extension. Radiographs of the elbow joint are normal. What is the most probable diagnosis?

Accepted Answer

Pulled elbow

Answer

Monteggia fracture

Answer

Cellulitis

Answer

None of the above

Question 5

What is the preferred treatment for cubitus varus?

Accepted Answer

Lateral closing wedge osteotomy

Answer

Medial closing wedge osteotomy

Answer

Medial opening wedge osteotomy

Answer

Lateral opening wedge osteotomy

Question 6

What is the characteristic deformity in Blount's disease?

Accepted Answer

Genu varus

Answer

Genu valgum

Answer

Coxa vara

Answer

Coxa valgus

Question 7

A newborn child presents with an inverted foot, and the dorsum of the foot cannot touch the anterior tibia. What is the most probable diagnosis?

Accepted Answer

Congenital talipes equinovarus

Answer

Congenital vertical talus

Answer

Arthrogryposis multiplex

Answer

Flat foot

Question 8

Which of the following statements regarding genu varum (bowleg) is true?

Accepted Answer

Occurs due to epiphyseal dysplasia.

Answer

In infants, it may be considered normal.

Answer

Is seldom associated with tibial angulation.

Answer

Affects only the tibia but not the femur.

Question 9

In treating a fractured clavicle in a 14-month-old child, what is the preferred management?

Accepted Answer

Figure-of-eight bandage

Answer

Open reduction

Answer

Shoulder cast

Answer

Kirschner pin

Question 10

What is true regarding Jumper's Knee?

Accepted Answer

Apophysitis of the patellar tendon as it inserts into the patella.

Answer

Apophysitis of the patellar tendon as it inserts into the tibia.

Answer

Apophysitis of the quadriceps tendon as it inserts into the patella.

Answer

Apophysitis of the hamstring tendon as it inserts into the tibia.

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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