Pediatric Orthopaedics Practice Questions

Q: Sprengel's shoulder is a deformity of which bone?

Scapula. **Explanation:** **Sprengel’s deformity** is the most common congenital anomaly of the shoulder girdle. It is characterized by a **high-sitting, undescended scapula**. 1. **Why Scapula is correct:** During the 5th week of gestation, the scapula normally develops at the level of the C4–C5 vertebrae and descends to its permanent thoracic position (T2–T7) by the 8th week. Sprengel’s deformity occurs due to an **interruption in this caudal migration**, resulting in a hypoplastic, abnormally high, and medially rotated scapula. 2. **Why other options are incorrect:** * **Humerus:** While shoulder abduction is limited in this condition, the primary pathology is scapular, not humeral. * **Clavicle:** The clavicle may be shorter or straighter in these patients, but it is a secondary finding, not the primary site of deformity. * **Vertebra:** Although associated with vertebral anomalies (like Klippel-Feil syndrome), the "Sprengel's shoulder" specifically refers to the scapular malposition. **High-Yield Clinical Pearls for NEET-PG:** * **Omovertebral Bone:** A pathognomonic finding (seen in ~30% of cases) where a fibrous, cartilaginous, or osseous bridge connects the superior angle of the scapula to the cervical spine. * **Associated Conditions:** Frequently associated with **Klippel-Feil Syndrome** (triad of low hairline, short neck, and restricted neck ROM), scoliosis, and rib anomalies. * **Clinical Presentation:** Restricted shoulder abduction and cosmetic deformity (webbing of the neck). * **Treatment:** Surgical correction (e.g., **Woodward procedure** or Green’s procedure) is ideally performed between ages 3 and 8 to improve function and appearance.

Q: All are true about Achondroplasia except?

Acral osteolysis. **Explanation:** Achondroplasia is the most common form of disproportionate short-limbed dwarfism. It is caused by a gain-of-function mutation in the **FGFR3 gene** (Fibroblast Growth Factor Receptor 3) on chromosome 4p, which leads to abnormal endochondral ossification. **Why Option B is the correct answer:** **Acral osteolysis** refers to the resorption of the distal phalanges of the fingers and toes. This is **not** a feature of Achondroplasia. It is classically associated with conditions like **Hadju-Cheney syndrome**, Pycnodysostosis, Hyperparathyroidism, and Scleroderma. **Analysis of other options:** * **Option A (Autosomal dominant):** Achondroplasia follows an autosomal dominant inheritance pattern. However, approximately 80% of cases are due to *de novo* mutations, often associated with advanced paternal age. * **Option C (Trident hand):** This is a classic clinical sign where there is an increased space between the third and fourth fingers, giving the hand a "three-pronged" appearance. * **Option D (Champagne glass pelvis):** Radiographically, the pelvis in achondroplasia is characterized by a short, broad ilium and a flat acetabular roof, resulting in a pelvic inlet that resembles a champagne glass. **High-Yield Clinical Pearls for NEET-PG:** * **Rhizomelic shortening:** The proximal segments (humerus/femur) are more affected than distal segments. * **Radiological signs:** "Bullet-shaped" vertebrae, narrowing of the interpedicular distance (caudally), and a "squared-off" iliac wing. * **Neurological complication:** Foramen magnum stenosis is a critical risk, potentially leading to hydrocephalus or sudden infant death. * **Intelligence:** Patients typically have normal intelligence and a normal lifespan.

Q: What type of cast is typically used after closed reduction for a 4-month-old child diagnosed with developmental dysplasia of the hip (DDH)?

Pavlik harness. **Explanation:** The management of Developmental Dysplasia of the Hip (DDH) is age-dependent. For an infant aged **0 to 6 months**, the **Pavlik harness** is the gold standard and the first line of treatment. **Why Pavlik Harness is Correct:** The Pavlik harness is a dynamic functional brace. It maintains the hip in the "human position" (flexion >90° and moderate abduction). This position centers the femoral head into the acetabulum, promoting normal joint development while allowing active movement. It is highly effective for both reducible and stable hips in this age group. **Analysis of Incorrect Options:** * **Hip Spica:** This is typically used for children aged **6 months to 2 years** or after a surgical (open) reduction. While it provides rigid immobilization, it is not the primary choice for a 4-month-old unless the Pavlik harness fails. * **Minerva Cast:** This is used for cervical and upper thoracic spine immobilization (e.g., cervical fractures), not for hip pathology. * **Riser’s Cast:** This is a specialized body cast used in the treatment of **Scoliosis** to apply corrective forces before surgery or as part of serial casting. **Clinical Pearls for NEET-PG:** * **Age Gold Standard:** 0–6 months = Pavlik Harness; 6 months–2 years = Closed/Open Reduction + Hip Spica. * **Complication:** The most serious complication of the Pavlik harness is **Avascular Necrosis (AVN)** of the femoral head, usually due to excessive abduction (forced vascular compromise). * **Pavlik Paralysis:** Excessive flexion in the harness can lead to femoral nerve palsy. * **Barlow & Ortolani Tests:** These clinical maneuvers are most reliable only up to 2–3 months of age.

Q: A child is spinned around by holding his hand by his father. While doing this, the child started crying and does not allow his father to touch his elbow. What is the most likely diagnosis?

Pulled elbow. **Explanation:** **1. Why the correct answer is right:** The clinical scenario describes a classic case of **Pulled Elbow** (also known as **Nursemaid’s Elbow** or Subluxation of the Radial Head). It typically occurs in children aged 1–4 years when sudden longitudinal traction is applied to an extended, pronated arm (e.g., swinging a child or pulling them up a curb). * **Pathophysiology:** In young children, the radial head is relatively small and the **annular ligament** is lax. Sudden traction causes the annular ligament to slip over the radial head and become trapped in the radio-capitellar joint. * **Clinical Presentation:** The child holds the arm in a fixed position of **flexion and pronation**, refusing to move it. There is no significant swelling or deformity. **2. Why the incorrect options are wrong:** * **B. Radial head dislocation:** This is usually associated with high-energy trauma or a Monteggia fracture-dislocation (ulnar fracture). Pulled elbow is a *subluxation*, not a complete dislocation. * **C. Annular ligament tear:** While the ligament is displaced and trapped, it is rarely actually torn in this mechanism. The pathology is displacement, not a rupture. * **D. Fracture of the olecranon process:** This would present with significant localized swelling, ecchymosis, and a palpable gap or deformity, which are absent in a pulled elbow. **3. NEET-PG High-Yield Pearls:** * **Management:** Reduction is performed by **Supination followed by Flexion** (or the Hyperpronation technique). A "click" is often felt, and the child usually resumes normal arm use within minutes. * **X-ray Findings:** Usually normal; X-rays are only indicated if a fracture is suspected (e.g., history of a fall or focal bony tenderness). * **Age Group:** Most common between **1–4 years**; rare after age 5 as the annular ligament becomes thicker and the radial head grows.

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

It is Haglund's deformity.. **Explanation:** The question appears to be based on a clinical scenario or image describing **Madelung’s Deformity**, but the options mistakenly label it as **Haglund’s Deformity**. In the context of pediatric orthopaedics and competitive exams like NEET-PG, this is a common point of differentiation. 1. **Why Option A is the Correct Answer (False Statement):** The condition described by the clinical features (bilateral involvement, association with Turner’s syndrome, and wrist deformity) is **Madelung’s Deformity**, not Haglund’s deformity. Haglund’s deformity is a bony enlargement on the back of the heel (retrocalcaneal exostosis). Therefore, stating "It is Haglund's deformity" is factually incorrect. 2. **Analysis of Other Options (True for Madelung’s Deformity):** * **Option B:** Madelung’s deformity is indeed **bilateral in approximately 50%** of cases. * **Option C:** It is strongly associated with **Turner’s Syndrome (45, XO)** and Leri-Weill dyschondrosteosis (SHOX gene mutation). * **Option D:** Despite the visible deformity (prominent ulnar head, volar bowing of the radius), patients typically maintain **excellent function** and are often asymptomatic until late adolescence when pain or decreased range of motion (especially supination) may occur. **Clinical Pearls for NEET-PG:** * **Madelung’s Deformity:** Caused by premature closure of the **volar-ulnar** part of the distal radial physis. * **Radiological Sign:** Increased volar tilt and ulnar tilt of the distal radius; the carpus "sinks" between the radius and ulna (V-shaped proximal carpal row). * **Haglund’s Deformity:** Known as "Pump Bump," it involves the posterosuperior aspect of the calcaneus and is associated with retrocalcaneal bursitis.

Q: Which of the following represents an appropriate management of Legg-Calve-Perthes disease in a young patient?

Making sure that the femoral head remains in the acetabulum. **Explanation:** **Legg-Calvé-Perthes Disease (LCPD)** is an idiopathic avascular necrosis of the femoral head occurring in children (typically aged 4–8 years). The primary goal of management is to maintain the spherical shape of the femoral head as it re-ossifies to prevent early-onset osteoarthritis. **Why Option D is Correct:** The fundamental principle of LCPD management is **"Containment."** By ensuring the femoral head remains deep within the acetabulum, the acetabulum acts as a biological mold. This ensures that as the necrotic bone is resorbed and replaced (creeping substitution), the new femoral head develops a spherical shape rather than becoming flattened (coxa plana). Containment can be achieved via non-operative methods (Abduction braces like the Atlanta/Newington brace) or surgical methods (Varus derotation osteotomy). **Why Other Options are Incorrect:** * **A. Total Hip Replacement:** This is contraindicated in children. It is a salvage procedure reserved for end-stage arthritis in adults. * **B. Exercise:** While range-of-motion exercises are helpful to prevent stiffness, "exercise" alone is not a definitive management strategy and does not address the structural deformity. * **C. High dose calcium:** LCPD is a vascular/ischemic issue, not a nutritional deficiency. Calcium supplementation has no role in the revascularization of the femoral head. **Clinical Pearls for NEET-PG:** * **Classic Presentation:** A painless limp or hip/knee pain in a young boy (Male:Female = 4:1). * **Early Sign:** Limitation of **Abduction** and **Internal Rotation**. * **Radiology:** Look for the "Crescent sign" (subchondral fracture) and "Gage’s sign" (V-shaped lucency at the lateral epiphysis). * **Prognosis:** The most important prognostic factor is the **age at onset** (younger children <6 years have a better prognosis due to higher remodeling potential).

Q: Osteochondritis of the epiphysis of the head of the femur is known as which of the following conditions?

Legg-Calvé-Perthes disease. ### Explanation **Correct Answer: C. Legg-Calvé-Perthes disease** **Legg-Calvé-Perthes disease (LCPD)** is an idiopathic avascular necrosis (osteochondritis) of the capital femoral epiphysis. It typically affects children between 4 and 10 years of age and is characterized by a temporary loss of blood supply to the femoral head, leading to bone infarction, collapse, and subsequent remodeling. Clinically, it presents as a painless limp or hip/knee pain with restricted abduction and internal rotation. **Analysis of Incorrect Options:** * **A. Panner’s disease:** This is osteochondritis of the **capitellum** of the humerus, usually seen in young athletes (throwers) aged 5–10 years. * **B. Kienbock’s disease:** This refers to avascular necrosis of the **lunate** bone in the wrist, typically seen in adults rather than the pediatric population. * **C. Osgood-Schlatter disease:** This is a traction apophysitis of the **tibial tuberosity** caused by repetitive strain from the quadriceps tendon, common in adolescent athletes. **High-Yield Clinical Pearls for NEET-PG:** * **Radiological Stages:** Waldenström classification (Initial, Fragmentation, Reossification, and Healed). * **Gage’s Sign:** A V-shaped lucency on the lateral side of the epiphysis (a "Head-at-risk" sign). * **Catterall Classification:** Used to grade the extent of femoral head involvement. * **Management Goal:** "Containment" of the femoral head within the acetabulum to ensure it heals in a spherical shape, preventing early-onset osteoarthritis. * **Prognosis:** The most important prognostic factor is the **age at onset**; younger children (<6 years) have a better prognosis due to higher remodeling potential.

Q: Dennis Brown splint is used for which condition?

Congenital Talipes Equinovarus (CTEV). **Explanation:** **Denis Browne Splint (DB Splint)** is a classic orthotic device used in the maintenance phase of **Congenital Talipes Equinovarus (CTEV)** treatment. After the deformity is corrected—typically via the Ponseti method of serial casting—the DB splint is used to maintain the correction and prevent relapse. It consists of two metal shoes attached to a spreader bar, which holds the feet in **70° of external rotation** and **15° of dorsiflexion**. **Analysis of Options:** * **A. CTEV (Correct):** The splint maintains the corrected position of the foot, specifically addressing the adduction and inversion components of the deformity. * **B. Rocker Bottom Foot:** This is a complication of over-correction in CTEV (breaking the midfoot) or seen in Congenital Vertical Talus (CVT). A DB splint would be contraindicated here as it could worsen the deformity. * **C & D. Manus Valgus/Varus:** These refer to wrist/hand deformities (e.g., Radial or Ulnar club hand). The DB splint is strictly a lower-limb orthosis. **Clinical Pearls for NEET-PG:** * **Protocol:** In CTEV, the splint is worn 23 hours a day for the first 3 months, then only at night/nap time until the child is 4 years old. * **The "Kick" Factor:** The bar allows the child to kick their legs, which helps in stretching the gastro-soleus complex and maintaining dorsiflexion. * **CTE Deformity Components (CAVE):** **C**avirus, **A**dduction, **V**arus, and **E**quinus. * **CTE Correction Sequence:** The order of correction is **A-V-E** (Adduction, then Varus, then Equinus). Cavus is corrected first by aligning the forefoot with the hindfoot.

Q: Which of the following is NOT a radiological sign of Perthes' disease?

Epiphyseal calcification. ### Explanation **Legg-Calvé-Perthes Disease (LCPD)** is an idiopathic avascular necrosis of the proximal femoral epiphysis in children. The radiological features follow the progression of ischemia, revascularization, and remodeling. **Why "Epiphyseal calcification" is the correct answer:** In Perthes' disease, the primary pathology is **osteonecrosis**, which leads to a **decrease in the size** and an **increase in the density** (sclerosis) of the femoral head epiphysis. It does not present as "calcification" (which implies new mineral deposition in soft tissue); rather, it shows fragmentation and eventual ossification during the healing phase. **Analysis of other options:** * **Widening of joint space:** This is often the earliest radiological sign (Waldenström's sign), caused by synovitis and thickening of the articular cartilage. * **Lateral subluxation of femur head:** As the disease progresses, the femoral head may move laterally out of the acetabulum (Gage’s sign), which is a poor prognostic indicator. * **Rotting picket fence appearance:** This refers to the irregular, jagged appearance of the femoral neck metaphysis due to cysts and remodeling during the fragmentation stage. **Clinical Pearls for NEET-PG:** * **Demographics:** Most common in boys aged 4–8 years; usually unilateral. * **Early Sign:** Crescent sign (subchondral fracture). * **Head at Risk Signs (Catterall):** Gage’s sign, calcification lateral to the epiphysis, lateral subluxation, and horizontal growth plate. * **Classification:** Waldenström (Radiographic stages), Catterall (Extent of involvement), and Herring (Lateral pillar classification—most prognostic). * **Management:** The goal is "Containment" of the femoral head within the acetabulum using braces (e.g., Atlanta brace) or surgery (e.g., Salter osteotomy).

Question 1

An 8-year-old boy with a history of a fall from a 10-foot height complains of right ankle pain. Initial X-rays were normal and showed no fracture line. However, after 2 years, he developed a calcaneovalgus deformity. What is the most likely diagnosis?

Accepted Answer

Tibial epiphyseal injury

Answer

Undiagnosed malunited fracture

Answer

Avascular necrosis of the talus

Answer

Ligamentous injury of the ankle joint

Question 2

Sprengel's shoulder is a deformity of which bone?

Accepted Answer

Scapula

Answer

Humerus

Answer

Clavicle

Answer

Vertebra

Question 3

All are true about Achondroplasia except?

Accepted Answer

Acral osteolysis

Answer

Autosomal dominant inheritance

Answer

Trident hand

Answer

Champagne glass pelvis

Question 4

What type of cast is typically used after closed reduction for a 4-month-old child diagnosed with developmental dysplasia of the hip (DDH)?

Accepted Answer

Pavlik harness

Answer

Hip spica

Answer

Minerva cast

Answer

Riser's cast

Question 5

A child is spinned around by holding his hand by his father. While doing this, the child started crying and does not allow his father to touch his elbow. What is the most likely diagnosis?

Accepted Answer

Pulled elbow

Answer

Radial head dislocation

Answer

Annular ligament tear

Answer

Fracture of the olecranon process

Question 6

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

Accepted Answer

It is Haglund's deformity.

Answer

Approximately 50% of cases are bilateral.

Answer

It is associated with Turner's syndrome.

Answer

The condition is typically associated with excellent function.

Question 7

Which of the following represents an appropriate management of Legg-Calve-Perthes disease in a young patient?

Accepted Answer

Making sure that the femoral head remains in the acetabulum

Answer

Total hip replacement

Answer

Exercise

Answer

High dose calcium

Question 8

Osteochondritis of the epiphysis of the head of the femur is known as which of the following conditions?

Accepted Answer

Legg-Calvé-Perthes disease

Answer

Panner's disease

Answer

Kienbock's disease

Answer

Osgood-Schlatter disease

Question 9

Dennis Brown splint is used for which condition?

Accepted Answer

Congenital Talipes Equinovarus (CTEV)

Answer

Rocker bottom foot

Answer

Manus valgus

Answer

Manus varus

Question 10

Which of the following is NOT a radiological sign of Perthes' disease?

Accepted Answer

Epiphyseal calcification

Answer

Widening of joint space

Answer

Lateral subluxation of femur head

Answer

Rotting picket fence appearance of femur neck

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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