Pediatric Orthopaedics Practice Questions

Q: A 10-year-old girl presents with a fall from a tree. Radiographic and physical examinations reveal Osgood-Schlatter disease. Which bony structure is chiefly affected in this condition?

Tibial tuberosity. **Explanation:** **Osgood-Schlatter disease** is a common cause of knee pain in active adolescents (typically aged 10–15 years). It is characterized as a **traction apophysitis** of the **tibial tuberosity**. 1. **Why the Correct Answer is Right:** The condition results from repetitive strain and microtrauma caused by the powerful pull of the **quadriceps femoris** muscle through the patellar tendon onto the immature tibial tuberosity. During the adolescent growth spurt, this area is a weak link (apophysis). Repeated stress leads to inflammation, micro-avulsion fractures, and subsequent bony prominence at the **tibial tuberosity (Option D)**. 2. **Why the Incorrect Options are Wrong:** * **Medial condyle of tibia (Option A):** This is the site involved in *Blount’s disease* (tibia vara), not traction apophysitis. * **Posterior intercondylar area (Option B):** This is the attachment site for the Posterior Cruciate Ligament (PCL); it is not involved in Osgood-Schlatter disease. * **Intercondylar eminence (Option C):** This is the attachment site for the Anterior Cruciate Ligament (ACL). Fractures here are common in children (ACL avulsion), but it is not the site of Osgood-Schlatter disease. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Pain, swelling, and tenderness localized over the tibial tuberosity, exacerbated by jumping, running, or kneeling. * **Radiology:** May show fragmentation or heterotopic ossification of the tibial tuberosity. * **Management:** Primarily conservative (Rest, Ice, NSAIDs, and activity modification). It is self-limiting and resolves once the physis closes. * **Differential Diagnosis:** Sinding-Larsen-Johansson syndrome (traction apophysitis at the *inferior pole of the patella*).

Q: Irregular thigh folds are seen in?

Developmental dysplasia of the hip. **Explanation:** **Developmental Dysplasia of the Hip (DDH)** is the correct answer because **asymmetric skin folds** (thigh, gluteal, or inguinal) are one of the earliest clinical signs of a dislocated or subluxated hip in an infant. This occurs due to the proximal migration of the femur on the affected side, which causes the soft tissues to bunch up, resulting in an increased number or uneven positioning of the skin folds compared to the normal side. **Analysis of Incorrect Options:** * **Perthes Disease:** This is an avascular necrosis of the femoral head typically seen in children aged 4–8 years. Clinical features include a painless limp and restricted abduction/internal rotation, but not thigh fold asymmetry, as the hip is not dislocated. * **Slipped Capital Femoral Epiphysis (SCFE):** This occurs in obese adolescents (10–15 years). It presents with an external rotation deformity and "obligate external rotation" during hip flexion. Thigh folds are not a diagnostic feature here. * **Congenital Coxa Vara:** This involves a decreased neck-shaft angle (less than 120°). While it causes limb shortening and a painless limp, it does not typically present with the classic irregular thigh folds seen in the neonatal/infant screening for DDH. **Clinical Pearls for NEET-PG:** * **Galeazzi Sign:** Apparent shortening of the femur (uneven knee heights when hips/knees are flexed) is a classic sign of unilateral DDH. * **Screening Tests:** **Barlow’s maneuver** (dislocatable hip - "provocative") and **Ortolani’s maneuver** (reducible hip - "reductive"). * **Imaging:** Ultrasound is the investigation of choice for infants 6 months. * **Treatment:** **Pavlik harness** is the gold standard for infants under 6 months of age.

Q: Which of the following is/are X-ray features of Legg-Calve-Perthes disease?

All the above. **Explanation:** Legg-Calvé-Perthes Disease (LCPD) is an idiopathic avascular necrosis of the femoral head in children (typically aged 4–8 years). The radiological features evolve through stages (Waldenström classification), reflecting the process of necrosis, fragmentation, and eventual remodeling. **Why "All the Above" is correct:** * **Increased medial joint space (Waldenström’s Sign):** This is one of the earliest radiological signs. It occurs due to hypertrophy of the acetabular cartilage and the presence of joint effusion/synovitis. * **Metaphyseal cysts and rarefaction:** During the fragmentation stage, the metaphysis often shows radiolucent "cysts" and generalized rarefaction. This is thought to be due to increased vascularity and osteoclastic activity at the growth plate. * **Lateral extrusion of the femoral head:** As the femoral head softens and flattens (coxa plana), it may be displaced laterally out of the acetabulum. This is a critical "Head at Risk" sign, indicating a poorer prognosis. **High-Yield Clinical Pearls for NEET-PG:** * **Gage’s Sign:** A V-shaped radiolucency on the lateral side of the epiphysis (a "Head at Risk" sign). * **Crescent Sign:** A subchondral fracture line seen on the lateral X-ray, indicating the early fragmentation stage. * **Sagging Rope Sign:** A radiopaque line across the metaphysis seen in late stages, representing a deformed femoral neck. * **Prognosis:** The most important prognostic factor is the **age at onset** (children <6 years have a better prognosis). * **Management:** The primary goal is "containment" of the femoral head within the acetabulum to ensure it remains spherical during remodeling.

Q: Which statement is NOT true regarding CTEV shoes?

Straight outer border. In the management of **Congenital Talipes Equinovarus (CTEV)**, specialized shoes are prescribed once the child begins weight-bearing to maintain the correction achieved by the Ponseti technique (casting and tenotomy). ### Why "Straight outer border" is the correct answer: The statement is **NOT true** because CTEV shoes must have a **lateral (outer) convexity** or an **out-flare**. In CTEV, the forefoot is adducted (curved inward). To counteract this deformity and prevent recurrence, the shoe is designed with an **abducted (outward-curved) forefoot** rather than a straight one. A straight border would not provide the necessary corrective force to keep the forefoot in abduction. ### Explanation of other options: * **Used only from the age the child starts walking (True):** Before walking, correction is maintained using the **Steenbeek or Denis Browne splint** (foot abduction braces). CTEV shoes are functional only during ambulation. * **No heel (True):** CTEV shoes are "flat-soled" with no heel elevation. This prevents the development of **equinus** (plantarflexion) by ensuring the Achilles tendon remains stretched during walking. * **Raised outer portion (True):** These shoes feature a **lateral wedge (outer border elevation)**. This helps to counteract the **varus** (inward tilting) of the heel and the **supination** of the foot by forcing the foot into eversion. ### High-Yield Clinical Pearls for NEET-PG: * **Order of Correction (PONSETI):** **C**aveus $\rightarrow$ **A**dduction $\rightarrow$ **V**arus $\rightarrow$ **E**quinus. * **The "Gold Standard":** The Ponseti method is the treatment of choice. * **Bracing Protocol:** After casting, a foot abduction brace is worn 23 hours/day for 3 months, then at nap/night-time until age 4. * **Relapse:** The most common cause of deformity recurrence is poor compliance with the bracing protocol.

Q: A child presents with short stature and abnormalities of the hand and pelvis. What is your diagnosis?

Achondroplasia. ***Achondroplasia*** - Characterized by **rhizomelic shortening** (proximal limb shortening) and classic **trident hand** deformity with hand and pelvic abnormalities. - X-ray features include **champagne-glass pelvis**, **small squared iliac wings**, **horizontal acetabular roof**, and **narrow sacroiliac notch**. *Rickets* - Primarily causes **metaphyseal** changes with **widening**, **cupping**, and **fraying** of bone ends, not specific hand deformities. - Characterized by **bowing deformities** of weight-bearing bones and **delayed epiphyseal ossification**, but lacks trident hand pattern. *Osteogenesis imperfecta* - Presents with **multiple fractures** with minimal trauma and **blue sclerae** as hallmark features. - Bone deformities result from **recurrent fractures** rather than specific developmental abnormalities of hands and pelvis. *Cushing syndrome* - Causes **centripetal obesity**, **moon facies**, and **purple striae** rather than skeletal deformities. - Growth retardation occurs due to **cortisol excess** affecting growth hormone, not structural bone abnormalities.

Q: Which orthopedic test is being performed?

Galeazzi’s test. ***Galeazzi's test*** - Also known as **Allis sign**, performed with the patient **supine**, **knees and hips flexed to 90°**, looking for **asymmetric knee heights** indicating **DDH** or **femoral shortening**. - A **positive test** shows one knee appearing **lower than the other**, suggesting **developmental dysplasia** or **coxa vara** on the affected side. *Ortolani's test* - Performed by **abducting the hip** while applying **anterior pressure** on the **greater trochanter** to relocate a **dislocated hip**. - A **positive test** produces a **palpable clunk** as the **femoral head** relocates into the **acetabulum**. *Barlow's test* - Involves **adducting the hip** while applying **posterior pressure** to attempt **dislocation** of a **reducible hip**. - A **positive test** demonstrates **hip instability** with the **femoral head** slipping **posteriorly** out of the **acetabulum**. *Trendelenburg's Test* - A **standing test** that evaluates **hip abductor strength** (particularly **gluteus medius**) by having the patient **stand on one leg**. - A **positive test** shows **pelvic drop** on the **contralateral side**, indicating **weakness** or **dysfunction** of the **hip abductors**.

Q: What is the most common fracture in childhood?

Clavicle. **Explanation:** The **clavicle** is the most common bone fractured in childhood. This is primarily due to its anatomical position and the mechanism of injury. It is the first bone to ossify in the fetus (via intramembranous ossification) but among the last to fuse, making it vulnerable during falls onto an outstretched hand or direct trauma to the shoulder. Most pediatric clavicle fractures occur in the **middle third** (80%) because this is the thinnest part of the bone and lacks ligamentous support. **Analysis of Options:** * **A. Femur:** While common in high-energy trauma (like motor vehicle accidents), it is not the most frequent overall. In infants, a femur fracture should raise suspicion for non-accidental injury (child abuse). * **B. Distal Humerus:** This is a very common site for fractures in children (specifically **Supracondylar fractures**), but it ranks second to the clavicle. Supracondylar fractures are the most common fractures *around the elbow* in children. * **C. Clavicle (Correct):** Statistically the most frequent fracture in both neonates (during birth) and older children. * **D. Radius:** Distal radius fractures (like Greenstick or Torus fractures) are extremely common in older children and adolescents, but across the entire pediatric age spectrum, the clavicle remains the most frequent. **High-Yield Clinical Pearls for NEET-PG:** * **Birth Trauma:** The clavicle is the most common bone fractured during labor (often associated with shoulder dystocia). * **Management:** Most pediatric clavicle fractures are managed conservatively with a **Figure-of-eight bandage** or a simple triangular sling. * **Ossification:** Remember, the clavicle is the only long bone that ossifies in membrane and has two primary ossification centers. * **Remodeling:** Children have a thick periosteum and high osteogenic potential, leading to excellent remodeling; hence, significant malunion is rare.

Q: Green extra-articular arthrodesis is done for which of the following conditions?

Congenital vertical talus. **Explanation:** **Green’s extra-articular arthrodesis** (specifically the Green-Grice procedure) is a surgical technique used to stabilize the subtalar joint without interfering with the growth of the tarsal bones. It is primarily indicated for the correction of severe paralytic flatfoot or **Congenital Vertical Talus (CVT)**. 1. **Why it is correct:** In Congenital Vertical Talus (Rocker-bottom foot), there is a rigid dislocation of the talonavicular joint. After initial reduction, maintaining the alignment of the talus and calcaneus is crucial. Green’s procedure involves placing a bone graft into the sinus tarsi (extra-articular) to fuse the subtalar joint in a neutral position. This provides stability and prevents the recurrence of the deformity while allowing the bones to continue growing in children. 2. **Why the other options are incorrect:** * **Genu Valgum (Knock-knees):** Managed by guided growth (hemiepiphyseodesis) using 8-plates or corrective osteotomies (e.g., Supracondylar femoral osteotomy). * **Coxa Vara:** Characterized by a decreased neck-shaft angle of the femur. It is treated with a **Pauwels’ Y-shaped osteotomy** or Valgus subtrochanteric osteotomy. * **Cubitus Varus (Gunstock deformity):** A common complication of malunited supracondylar fractures of the humerus. The gold standard treatment is a **French (Lateral closing wedge) osteotomy**. **High-Yield Pearls for NEET-PG:** * **Congenital Vertical Talus:** Also known as "Rocker-bottom foot." Radiologically, the talus is vertical, and the **first metatarsal-axis-talus-line (Meary’s angle)** is broken. * **Grice-Green Procedure:** It is an **extra-articular** subtalar arthrodesis, distinguishing it from intra-articular fusions like the Triple Arthrodesis (used in adults). * **Reverse Ponseti Technique:** The initial conservative management for CVT involves serial casting in a direction opposite to that used for Clubfoot (CTEV).

Q: A fracture of the anterolateral lower end of the tibia is known as which type of fracture?

Tillaux fracture. ### Explanation **Correct Answer: A. Tillaux fracture** **Mechanism and Anatomy:** A **Tillaux fracture** is an avulsion fracture of the **anterolateral** tubercle of the distal tibia. It occurs due to the pull of the **Anterior Inferior Tibiofibular Ligament (AITFL)** during a forced external rotation of the foot. In adolescents (specifically ages 12–14), this occurs because the medial part of the distal tibial epiphysis closes first, leaving the lateral part vulnerable to avulsion before it completely ossifies. In adults, this is often referred to as a **Chaput fracture**. **Analysis of Incorrect Options:** * **B. Bosworth fracture:** This is a rare fracture-dislocation of the ankle where the proximal fibular fragment becomes trapped behind the posterior tubercle of the tibia, making closed reduction difficult. * **C. Gosselin fracture:** A V-shaped fracture of the distal tibia that extends into the tibial plafond, dividing it into anterior and posterior fragments. * **D. Segond fracture:** An avulsion fracture of the **lateral tibial condyle** (at the knee), associated with the insertion of the anterolateral ligament and highly indicative of an **Anterior Cruciate Ligament (ACL) tear**. **High-Yield Pearls for NEET-PG:** * **Juvenile Tillaux Fracture:** Classic "Salter-Harris Type III" injury occurring in the transitional age group. * **Wagstaffe-Le Fort Fracture:** The counterpart to Tillaux; it is an avulsion of the AITFL from its attachment on the **anterior fibula**. * **Imaging:** While X-rays (AP and Mortise views) are initial, a **CT scan** is the gold standard to assess the degree of displacement (surgical threshold is usually >2mm).

Question 1

Which of the following associations between clinical angles and their corresponding conditions is incorrect?

Accepted Answer

Baumann's angle - fracture of the lateral condyle of the femur

Answer

Kite's angle - club foot

Answer

Gissan's angle - calcaneus fracture

Answer

Cobb's angle - scoliosis

Question 2

A 10-year-old girl presents with a fall from a tree. Radiographic and physical examinations reveal Osgood-Schlatter disease. Which bony structure is chiefly affected in this condition?

Accepted Answer

Tibial tuberosity

Answer

Medial condyle of tibia

Answer

Posterior intercondylar area

Answer

Intercondylar eminence

Question 3

Irregular thigh folds are seen in?

Accepted Answer

Developmental dysplasia of the hip

Answer

Perthe's disease

Answer

Slipped capital femoral epiphysis

Answer

Congenital coxa vara

Question 4

Which of the following is/are X-ray features of Legg-Calve-Perthes disease?

Accepted Answer

All the above

Answer

Increased medial joint space

Answer

Metaphyseal cysts and rarefaction

Answer

Lateral extrusion of femur head

Question 5

Which statement is NOT true regarding CTEV shoes?

Accepted Answer

Straight outer border

Answer

Used only from the age the child starts walking

Answer

No heel

Answer

Raised outer portion

Question 6

A child presents with short stature and abnormalities of the hand and pelvis. What is your diagnosis?

Accepted Answer

Achondroplasia

Answer

Rickets

Answer

Osteogenesis imperfecta

Answer

Cushing syndrome

Question 7

Which orthopedic test is being performed?

Accepted Answer

Galeazzi’s test

Answer

Ortolani’s test

Answer

Barlow’s test

Answer

Trendelenburg’s Test

Question 8

What is the most common fracture in childhood?

Accepted Answer

Clavicle

Answer

Femur

Answer

Distal humerus

Answer

Radius

Question 9

Green extra-articular arthrodesis is done for which of the following conditions?

Accepted Answer

Congenital vertical talus

Answer

Genu Valgum

Answer

Coxa vara

Answer

Cubitus varus

Question 10

A fracture of the anterolateral lower end of the tibia is known as which type of fracture?

Accepted Answer

Tillaux fracture

Answer

Bosworth fracture

Answer

Gosselin fracture

Answer

Segond fracture

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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