Pediatric Orthopaedics Practice Questions

Q: Phocomelia is a condition characterized by limb malformation. What part of the skeletal system is primarily affected?

Long bones. **Explanation:** **Phocomelia** (from the Greek *phoke* meaning "seal" and *melos* meaning "limb") is a rare congenital skeletal malformation characterized by the **absence or severe shortening of the proximal segments of the limbs** (long bones). In this condition, the hands or feet are attached directly to the trunk or are connected by a single, irregularly shaped bone, giving the appearance of a seal's flipper. 1. **Why Long Bones are Correct:** Phocomelia is a type of **meromelia** (partial absence of a limb). It specifically involves the failure of the long bones—such as the humerus, radius, and ulna in the upper limb, or the femur, tibia, and fibula in the lower limb—to develop properly. The defect occurs during the embryonic period (weeks 4 to 8) when the limb buds are differentiating. 2. **Why Other Options are Incorrect:** * **Skull bones:** These are involved in conditions like Craniosynostosis or Cleidocranial Dysplasia, but are unaffected in isolated Phocomelia. * **Carpals and Metacarpals:** While these distal structures may sometimes be malformed or missing digits (ectrodactyly), they are typically present and attached directly to the torso. The defining feature of Phocomelia is the "missing middle" (the long bones), not the absence of the hand/foot itself. **Clinical Pearls for NEET-PG:** * **Thalidomide Tragedy:** Historically, Phocomelia is most famously associated with the use of **Thalidomide** by pregnant women in the late 1950s to treat morning sickness. * **Genetic Association:** It can also occur as part of **Roberts Syndrome**, an autosomal recessive disorder involving a defect in the *ESCO2* gene. * **Classification:** It is classified under "Defects in Longitudinal Development" in the Swanson Classification of congenital limb deficiencies.

Q: All the following are radiological signs that correlate positively with the outcome of Perthes' disease except?

Shallow acetabulum. In Perthes' disease (Legg-Calvé-Perthes), the prognosis depends heavily on the degree of femoral head involvement and its containment within the acetabulum. To predict outcomes, Catterall described specific radiological features known as **"Head-at-Risk" signs**. ### Why "Shallow Acetabulum" is the Correct Answer A **shallow acetabulum** is not a "Head-at-Risk" sign. In fact, Perthes' disease often leads to a secondary *deepening* or remodeling of the acetabulum to accommodate a flattened femoral head (coxa plana). While acetabular dysplasia is a primary feature of Developmental Dysplasia of the Hip (DDH), it is not a prognostic marker for Perthes'. ### Explanation of "Head-at-Risk" Signs (Incorrect Options) The following signs correlate **positively with a poor outcome** (increased risk of femoral head collapse and permanent deformity): * **Lateral subluxation of the femoral head (Option A):** Indicates the head is moving out of the protective cover of the acetabulum, leading to eccentric loading. * **Speckled calcification lateral to the epiphysis (Option B):** Represents calcification in the cartilaginous part of the head outside the acetabulum, signifying severe extrusion. * **Gage sign (Option D):** A V-shaped radiolucency on the lateral side of the epiphysis/metaphysis. It indicates osteolysis and impending collapse of the lateral pillar. * *Other signs include:* Horizontal growth plate and diffuse metaphyseal reactions. ### NEET-PG High-Yield Pearls * **Age of Onset:** Most common in boys aged 4–8 years. * **Pathology:** Avascular necrosis of the proximal femoral epiphysis. * **Classification Systems:** * **Catterall:** Based on the extent of necrosis. * **Herring (Lateral Pillar):** Most widely used for prognosis (Group A, B, and C based on the height of the lateral 1/3rd of the epiphysis). * **Management Goal:** "Containment" of the femoral head within the acetabulum using braces or osteotomy.

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

Congenital vertical talus. **Explanation:** **Congenital Vertical Talus (CVT)**, also known as "Rocker-bottom foot," is a rare congenital deformity characterized by a fixed dorsal dislocation of the navicular on the talus. The **Green 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 involves placing a bone graft into the sinus tarsi to maintain the reduction of the talocalcaneal joint, correcting the hindfoot valgus associated with CVT. **Analysis of Options:** * **Genu valgum (Knock-knees):** This is a coronal plane deformity of the knee. Treatment typically involves guided growth (hemiepiphysiodesis using 8-plates) or corrective osteotomy (e.g., supracondylar femoral osteotomy), not arthrodesis. * **Coxa vara:** This refers to a decreased neck-shaft angle of the femur (<120°). Management usually involves a valgus subtrochanteric osteotomy (e.g., Pauwels' osteotomy) to realign the mechanical axis. * **Cubitus varus (Gunstock deformity):** A common late complication of supracondylar fractures of the humerus. The gold standard treatment is a lateral closing wedge osteotomy (French osteotomy). **Clinical Pearls for NEET-PG:** * **Radiological Hallmark of CVT:** The talus is vertically oriented, and the long axis of the talus fails to line up with the first metatarsal on a forced plantarflexion lateral X-ray. * **Reverse Clubfoot:** CVT is often called "reverse clubfoot" because the foot is in calcaneovalgus rather than equinovarus. * **Grice-Green Procedure:** Primarily indicated in children (usually ages 4–8) with paralytic or flexible flatfoot deformities to provide lateral column stability.

Q: All of the following are done for the management of clubfoot at birth EXCEPT?

Posteromedial soft tissue release. **Explanation:** The management of **Congenital Talipes Equinovarus (CTEV)**, or clubfoot, follows a strict chronological hierarchy, starting from non-operative methods at birth to surgical interventions if conservative management fails. **Why Option D is the Correct Answer:** **Posteromedial Soft Tissue Release (PMSTR)** is a major surgical procedure. In modern orthopaedics (following the **Ponseti method**), surgery is never the first-line treatment at birth. It is reserved for "resistant" cases or neglected clubfoot, typically performed between **6 to 12 months of age**. Performing an invasive surgery at birth is contraindicated due to the small size of the tarsal bones and the high success rate of conservative management. **Analysis of Incorrect Options:** * **A & B (Manipulation and Serial Casting):** These are the gold standard treatments initiated immediately after birth (ideally within the first week). The Ponseti technique involves gentle manual manipulation followed by long-leg serial casts applied weekly to gradually correct the components of the deformity. * **C (Recording the Deformity):** Objective assessment is crucial for monitoring progress. The **Pirani Scoring System** (0 to 6) or **Catterall/Dimeglio Score** is used at birth and during every follow-up to document improvement and decide if a tenotomy is required. **Clinical Pearls for NEET-PG:** * **Order of Correction (Ponseti):** Remember the mnemonic **CAVE** — **C**avus (corrected first), **A**dduction, **V**arus, and **E**quinus (corrected last). * **Percutaneous Achilles Tenotomy:** The most common minor surgical procedure in the Ponseti method, performed to correct residual Equinus after other components are addressed. * **Bracing:** After casting, a **Steenbeek foot abduction brace** (Dennis Browne splint) is used to prevent recurrence (23 hours/day for 3 months, then at night until age 4). * **Most common relapse:** Equinus deformity.

Q: What is the commonest fracture in childhood?

Radius. **Explanation:** **1. Why Radius is Correct:** The **distal radius** is the most common site of fracture in the pediatric population, accounting for approximately 20–25% of all childhood fractures. This is primarily due to the mechanism of injury: a **Fall On an Outstretched Hand (FOOSH)**. In children, the distal radial metaphysis is a biomechanically weak area because of rapid bone turnover and remodeling during growth, making it susceptible to "buckle" (torus) or "greenstick" fractures. **2. Analysis of Incorrect Options:** * **Clavicle (B):** While the clavicle is the most common fracture during **birth/delivery** and a very frequent injury in early childhood, it ranks second to the distal radius in overall pediatric incidence. * **Distal Humerus (C):** Supracondylar fractures of the humerus are the most common fractures **around the elbow** in children and carry a high risk of neurovascular complications, but they are less frequent than distal radius fractures. * **Femur (A):** Femoral fractures are significant injuries but are much less common than upper limb fractures due to the high energy required to break the strongest bone in the body. **3. Clinical Pearls for NEET-PG:** * **Most common site of fracture in children:** Distal Radius. * **Most common fracture during birth:** Clavicle. * **Most common elbow fracture in children:** Supracondylar fracture of the humerus. * **Unique Pediatric Fracture Types:** * *Torus (Buckle) Fracture:* Compression injury causing a bulge in the cortex. * *Greenstick Fracture:* Incomplete fracture where one cortex is broken and the other is bent. * **Physeal Injuries:** Classified using the **Salter-Harris Classification**; Type II is the most common.

Q: Periosteal new bone formation is seen in which of the following conditions?

All of the above. **Explanation:** Periosteal new bone formation (periostitis) in children is a non-specific reaction to various stimuli, including inflammation, trauma, metabolic disorders, and genetic conditions. In this question, all three conditions listed are classic causes of pathological periosteal reactions. 1. **Caffey’s Disease (Infantile Cortical Hyperostosis):** This is a rare, self-limiting inflammatory disorder characterized by a triad of irritability, soft tissue swelling, and massive subperiosteal new bone formation. It typically involves the **mandible** (most common), ribs, and clavicles in infants under six months of age. 2. **Hypervitaminosis A:** Chronic Vitamin A toxicity leads to painful soft tissue swellings and cortical thickening. Unlike Caffey’s disease, it usually affects older children (over 1 year) and typically involves the **ulna and metatarsals**, sparing the mandible. 3. **Syphilis (Congenital):** Early congenital syphilis causes widespread osteochondritis and periostitis. A characteristic radiographic finding is **Wimberger’s sign** (localized erosion of the medial aspect of the proximal tibial metaphysis). **Clinical Pearls for NEET-PG:** * **Physiological Periostitis:** Common in infants (2–6 months); it is always bilateral, symmetrical, and involves the lateral aspect of the femoral shaft. * **Scurvy:** Periosteal reaction occurs only during the **healing phase** (due to subperiosteal hemorrhage calcification). * **Differential Diagnosis Tip:** If the mandible is involved, think **Caffey’s Disease**; if the mandible is spared in an older child with bone pain, consider **Hypervitaminosis A**.

Q: What are the musculoskeletal abnormalities seen in neurofibromatosis?

All of the above. Neurofibromatosis Type 1 (NF1), also known as von Recklinghausen disease, is an autosomal dominant multisystem disorder caused by a mutation in the **neurofibromin gene** on chromosome 17. It has significant musculoskeletal manifestations due to abnormal bone metabolism and mesenchymal dysplasia. **Explanation of Options:** * **Hypertrophy of limb:** This occurs due to **local gigantism** resulting from plexiform neurofibromas and associated hemangiomatous or lymphangiomatous changes. Chronic hyperemia in the affected limb leads to overgrowth of both soft tissue and bone. * **Scoliosis:** This is the **most common** skeletal abnormality in NF1 (seen in ~10–30% of patients). It can present as a "dystrophic" curve, characterized by a short-segment, sharp angular deformity (usually involving 4–6 vertebrae) often associated with vertebral scalloping and rib penciling. * **Pseudoarthrosis:** NF1 is the most common cause of **congenital pseudoarthrosis of the tibia**. It typically presents as anterolateral bowing of the tibia in infancy, which progresses to a non-union (pseudoarthrosis) following a fracture. Since all three conditions are classic orthopedic hallmarks of the disease, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Sphenoid wing dysplasia:** A characteristic "empty orbit" sign on X-ray/CT. * **Tibial Bowing:** In NF1, the bowing is **anterolateral**, whereas in Fibular Hemimelia, it is typically anteromedial. * **Dystrophic Scoliosis:** Requires aggressive surgical management compared to idiopathic scoliosis due to its high risk of rapid progression. * **Diagnostic Criteria:** Remember the mnemonic **CAFE SPOT** (Cafe-au-lait spots, Axillary freckling, Fibromas, Eye Lisch nodules, Skeletal bowing, Pedigree/Family history, Optic Glioma).

Q: What is the most common cause of neurological deficit in the upper limb?

Erb's palsy. **Explanation:** **Erb’s Palsy (Option B)** is the most common cause of neurological deficit in the upper limb, particularly in the pediatric population. It results from an injury to the **upper trunk of the brachial plexus (C5-C6)**, most frequently due to birth trauma (shoulder dystocia) or a forceful downward traction on the shoulder. This leads to the classic "Policeman’s tip" or "Waiter’s tip" deformity, characterized by an adducted, internally rotated arm with an extended elbow and pronated forearm. **Why other options are incorrect:** * **Polio (Option A):** While a significant cause of lower limb paralysis historically, it rarely presents as an isolated upper limb neurological deficit in modern clinical practice due to successful vaccination programs. * **C1-C2 Dislocation (Option C):** This is a life-threatening injury. Because it occurs above the phrenic nerve origin (C3-C5), it typically results in respiratory failure or sudden death rather than a localized upper limb deficit. * **Fracture dislocation of the cervical spine (Option D):** While these injuries cause neurological deficits, they usually result in **quadriplegia** (involving all four limbs) or specific spinal cord syndromes rather than an isolated upper limb palsy. **High-Yield Clinical Pearls for NEET-PG:** * **Site of Injury:** Erb’s point (junction of six nerves). * **Muscles Involved:** Deltoid, Biceps, Brachialis, and Brachioradialis. * **Reflexes:** Biceps and Supinator reflexes are lost; Moro reflex is asymmetrical. * **Klumpke’s Palsy:** Contrast this with C8-T1 injury, which causes a "claw hand" and potential Horner’s syndrome.

Q: All are true about congenital talipes equinovarus (CTEV) EXCEPT:

Talus is the only bone involved. **Explanation:** **1. Why Option A is the correct answer (The Exception):** Congenital Talipes Equinovarus (CTEV) is a complex **three-dimensional deformity** involving multiple bones and joints of the foot, not just the talus. While the talus is the "primary" bone affected (it is smaller, with a medially and plantarly deviated neck), the deformity involves the **calcaneus** (adducted and inverted), the **navicular** (medially displaced), and the **cuboid**. Therefore, stating the talus is the *only* bone involved is anatomically incorrect. **2. Analysis of other options:** * **Option B:** True. There is significant contracture of the **posterior** (Achilles tendon) and **medial** (Tibialis posterior, FDL, FHL) structures, leading to the characteristic equinus and varus. * **Option C:** True. The **Tibialis posterior** is the most severely contracted muscle. It acts like a "guy rope," pulling the navicular medially and maintaining the deformity. * **Option D:** True. The four components of CTEV are remembered by the mnemonic **CAVE**: **C**avus (midfoot), **A**dduction (forefoot), **V**arus (hindfoot/inversion), and **E**quinus (ankle). **Clinical Pearls for NEET-PG:** * **Gold Standard Treatment:** **Ponseti Method** (Serial casting). The order of correction is **CAV-E** (Cavus first, Equinus last). * **Pirani Score:** Used to assess the severity of CTEV (0 to 6 scale). * **Radiology:** The **Kite’s Angle** (talocalcaneal angle) is reduced in both AP and lateral views (Normal: 20–40°). * **Associated Conditions:** Always screen for Developmental Dysplasia of the Hip (DDH) and Spina Bifida in children with CTEV.

Question 1

Phocomelia is a condition characterized by limb malformation. What part of the skeletal system is primarily affected?

Accepted Answer

Long bones

Answer

Skull bones

Answer

Carpals

Answer

Metacarpals

Question 2

All the following are radiological signs that correlate positively with the outcome of Perthes' disease except?

Accepted Answer

Shallow acetabulum

Answer

Lateral subluxation of the femoral head

Answer

Speckled calcification lateral to the capital epiphysis

Answer

Gage sign – a radiolucent V-shaped defect in the lateral epiphysis and adjacent metaphysis

Question 3

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 4

All of the following are done for the management of clubfoot at birth EXCEPT?

Accepted Answer

Posteromedial soft tissue release

Answer

Manipulation

Answer

Serial casting

Answer

Recording the deformity to see improvements serially

Question 5

What is the commonest fracture in childhood?

Accepted Answer

Radius

Answer

Femur

Answer

Clavicle

Answer

Distal humerus

Question 6

In children, all are true regarding bone properties and injuries EXCEPT:

Accepted Answer

Comminuted fractures are common.

Answer

Dislocations are rare.

Answer

The periosteum is thick.

Answer

Bones are soft.

Question 7

Periosteal new bone formation is seen in which of the following conditions?

Accepted Answer

All of the above

Answer

Caffey’s disease

Answer

Hypervitaminosis A

Answer

Syphilis

Question 8

What are the musculoskeletal abnormalities seen in neurofibromatosis?

Accepted Answer

All of the above

Answer

Hypertrophy of limb

Answer

Scoliosis

Answer

Pseudoarthrosis

Question 9

What is the most common cause of neurological deficit in the upper limb?

Accepted Answer

Erb's palsy

Answer

Polio

Answer

C1-C2 dislocation

Answer

Fracture dislocation of the cervical spine

Question 10

All are true about congenital talipes equinovarus (CTEV) EXCEPT:

Accepted Answer

Talus is the only bone involved

Answer

Posterior and medial tendons are involved

Answer

Tibialis posterior acts like a guy rope

Answer

Inversion and equinus are seen

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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