Pediatric Orthopaedics Practice Questions

Q: In children, which type of fracture displacement demonstrates the best remodelling potential?

Angulation in the metaphysis. ### Explanation The ability of a pediatric fracture to remodel depends on the child's remaining growth potential and the proximity of the fracture to the physis (growth plate). **Why Option B is Correct:** Remodelling is most effective when the fracture is located in the **metaphysis** and the displacement is **angulation** in the plane of motion of the adjacent joint. The metaphysis is highly vascular and located close to the physis; according to **Heuter-Volkmann’s Law**, the physis responds to asymmetrical pressure by altering growth to "straighten" the bone. The closer a fracture is to the growth plate, the greater the potential for spontaneous correction. **Why Other Options are Incorrect:** * **Options A & C (Diaphysis):** The mid-shaft (diaphysis) is further from the physis. Remodelling potential decreases significantly as you move away from the growth plate toward the center of the bone. * **Options C & D (Rotation):** Rotational deformities (torsion) **do not remodel** regardless of age or location. Unlike angulation, the physis cannot compensate for a twist in the long axis of the bone. These must be corrected anatomically during reduction. **High-Yield Clinical Pearls for NEET-PG:** * **Factors favoring remodelling:** Young age (more growth remaining), proximity to the physis, and angulation in the plane of joint motion. * **Exceptions to the rule:** Displaced **intra-articular fractures** and **rotational deformities** never remodel and require precise reduction. * **Overgrowth Phenomenon:** In femoral shaft fractures of children (2–10 years), the hyperemia of healing can cause 1–2 cm of longitudinal overgrowth. Therefore, a small amount of "bayonet apposition" (shortening) is often acceptable.

Q: What is the most common complication of a supracondylar fracture of the humerus?

Malunion. **Explanation:** Supracondylar fractures of the humerus are the most common pediatric elbow fractures. **1. Why Malunion is the Correct Answer:** Malunion, specifically resulting in **Cubitus Varus (Gunstock Deformity)**, is the **most common complication** overall. It occurs due to inadequate reduction or loss of reduction, leading to a coronal plane deformity. While it is often a cosmetic issue rather than a functional one, its high incidence rate makes it the most frequent complication seen in clinical practice. **2. Analysis of Incorrect Options:** * **Median Nerve Injury:** This is the **most common neurological complication** (specifically the Anterior Interosseous Nerve/AIN), but it occurs less frequently than malunion. * **Myositis Ossificans:** This is a rare complication in supracondylar fractures. It is more commonly associated with posterior elbow dislocations or forceful passive stretching/massage following an injury. * **Volkmann’s Ischemic Contracture (VIC):** This is the **most serious/dreaded complication**, resulting from untreated Compartment Syndrome (brachial artery injury or swelling). While high-yield for exams, its actual incidence is low (<1%) due to modern surgical urgency. **Clinical Pearls for NEET-PG:** * **Most common nerve injured:** Median nerve (specifically **AIN**—test by asking the patient to make an "OK" sign). * **Nerve injured in Extension type:** Median/Radial nerve. * **Nerve injured in Flexion type:** Ulnar nerve. * **Gartland Classification** is used to grade these fractures (Type I: Undisplaced; Type II: Displaced with intact posterior cortex; Type III: Completely displaced). * **Baumann’s Angle:** Used radiologically to assess the adequacy of reduction and predict future varus deformity.

Q: Congenital Dislocation of Hip (CDH) classically occurs due to?

Developmental acetabular dysplasia. **Explanation:** **Developmental Dysplasia of the Hip (DDH)**, formerly known as CDH, is primarily a failure of the normal development of the acetabulum. The fundamental pathology is **acetabular dysplasia**, where the acetabulum is shallow, steep, and fails to provide adequate coverage for the femoral head. This lack of structural containment allows the femoral head to displace superiorly and posteriorly. **Analysis of Options:** * **Option D (Correct):** The primary defect is the malformation of the acetabular roof. In utero or early infancy, if the femoral head does not sit deeply within the acetabulum, the stimulus for the socket to deepen is lost, leading to persistent dysplasia and eventual dislocation. * **Option A:** A small femoral head epiphysis is a *sequela* (result) of the dislocation due to delayed ossification, not the primary cause. * **Option B:** While an increased angle of anteversion is often seen in DDH, it is considered a secondary adaptive change rather than the initiating cause of the dislocation. * **Option C:** A hypertrophied ligamentum teres is an **intracapsular obstacle** that prevents successful reduction of a dislocated hip, but it develops only after the head has already left the socket. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** First-born, Female (8:1 ratio), Frank breech presentation, Family history, and Fluid (Oligohydramnios). * **Clinical Signs:** **Ortolani test** (reduces the hip/“clunk in”) and **Barlow test** (dislocates the hip/“clunk out”). * **Radiological Markers:** Look for **Hilgenreiner’s line**, **Perkin’s line**, and a broken **Shenton’s line**. * **Treatment:** **Pavlik Harness** is the gold standard for infants <6 months. For 6 months to 2 years, closed reduction and Spica casting are preferred.

Q: Radial club hand is characterized by which of the following skeletal abnormalities?

Absence of the radius. **Explanation:** **Radial Club Hand (Radial Longitudinal Deficiency)** is a congenital longitudinal deficiency characterized by the partial or complete **absence of the radius**. This leads to a lack of support on the lateral side of the forearm, causing the hand to deviate radially (towards the thumb side), resulting in a "club-like" appearance. * **Why Option B is Correct:** The hallmark of this condition is the hypoplasia or total absence of the radius. This skeletal deficiency causes the forearm to be short and the wrist to be unstable, leading to a characteristic radial deviation. * **Why Options A, C, and D are Incorrect:** * **Absence of the ulna:** This characterizes **Ulnar Club Hand**, which is much rarer than radial club hand and typically involves ulnar deviation of the hand. * **Absence of carpal bones:** While some carpal bones (like the scaphoid or trapezium) may be delayed in ossification or absent in radial club hand, the primary defining skeletal abnormality is the radius itself. * **Absence of the humerus:** This refers to **Phocomelia** (seal-like limbs), often associated historically with Thalidomide use, rather than a localized club hand deformity. **High-Yield Clinical Pearls for NEET-PG:** * **Associated Anomalies:** Radial club hand is frequently associated with the **VACTERL** association and **TAR syndrome** (Thrombocytopenia Absent Radius). *Note: In TAR syndrome, the thumb is usually present, whereas in isolated radial club hand, the thumb is often absent.* * **Most Common Type:** Type IV (Complete absence of the radius) is the most common presentation. * **Muscle Involvement:** The **Brachioradialis** and **Extensor Carpi Radialis** muscles are often absent or fibrotic. * **Treatment:** Initial management involves stretching and splinting; surgical "centralization" or "radialization" of the carpus over the ulna is performed later to improve function.

Q: What is the commonest congenital deformity?

Congenital club foot. **Explanation:** **Congenital Clubfoot (CTEV - Congenital Talipes Equinovarus)** is the most common congenital musculoskeletal deformity, occurring in approximately 1 to 2 per 1,000 live births. It is characterized by a complex three-dimensional deformity involving four components: **C**avus, **A**dduction (forefoot), **V**arus (heel), and **E**quinus (ankle). The high incidence and its classic presentation make it a frequent topic in postgraduate entrance exams. **Analysis of Options:** * **Congenital Clubfoot (Correct):** Its high prevalence (1:1000) and well-documented genetic/environmental etiology make it the most frequent among the listed options. * **Congenital Club Hand:** This is a longitudinal radial deficiency. While significant, it is much rarer than CTEV, occurring in approximately 1 in 30,000 to 100,000 births. * **Absence of Femur (PFFD):** Proximal Femoral Focal Deficiency is a rare developmental defect (1 in 50,000 births) involving the hip and femur. * **Absence of Fibula:** Fibular hemimelia is the most common long-bone deficiency, but its overall incidence (1 in 40,000) is still significantly lower than that of clubfoot. **High-Yield Clinical Pearls for NEET-PG:** 1. **Standard Treatment:** The **Ponseti Method** (serial casting) is the gold standard. The order of correction follows the acronym **CAVE** (Cavus first, then Adduction and Varus, finally Equinus). 2. **Pirani Score:** Used to assess the severity of CTEV and monitor progress during casting. 3. **Kite’s Angle:** On X-ray (AP view), the angle between the talus and calcaneus is **decreased** in CTEV (parallelism). 4. **Relapse Prevention:** After casting, a **Steenbeek or Denis Browne splint** is used (held in 70° external rotation) until age 3–4 years.

Q: Vertical talus is associated with:

Congenital flat foot. **Explanation:** **Congenital Vertical Talus (CVT)**, also known as **"Rocker-Bottom Foot,"** is a rare form of rigid congenital flat foot. The core pathology involves a fixed dorsal dislocation of the navicular on the head of the talus. Because the talus is locked in a vertical position (plantarflexed), the midfoot is displaced dorsally, resulting in the loss of the medial longitudinal arch and a characteristic convex appearance of the sole. **Analysis of Options:** * **A. Congenital flat foot (Correct):** CVT is the most severe form of rigid flat foot present at birth. Unlike flexible flat foot, it does not resolve with age and requires surgical intervention. * **B. Ankle dislocation:** While the talonavicular joint is dislocated, the ankle joint (talocrural joint) itself remains intact. * **C. Talus fracture:** Vertical talus is a congenital structural deformity, not a traumatic injury. Fractures of the talus in children are rare and usually result from high-energy trauma (e.g., Aviator’s fracture). * **D. Pes cavus:** This is a high-arched foot, the clinical opposite of the flat foot seen in CVT. Pes cavus is often associated with neuromuscular conditions like Friedreich’s ataxia or Charcot-Marie-Tooth disease. **NEET-PG High-Yield Pearls:** 1. **Radiological Hallmark:** On a lateral X-ray in forced plantarflexion, the talus remains vertical and does not align with the first metatarsal (the **Meary’s angle** remains increased). 2. **Associations:** Up to 50% of cases are associated with neuromuscular disorders like **Myelomeningocele** or chromosomal abnormalities (Trisomy 13, 15, 18). 3. **Differential Diagnosis:** Must be distinguished from **Calcaneovalgus foot**, which is a flexible postural deformity that corrects with passive stretching. 4. **Treatment:** The "Reverse Ponseti" technique (serial casting) followed by surgical pinning is the modern management approach.

Q: What is the known etiology of Perthes disease?

Unknown. **Explanation:** **Legg-Calvé-Perthes Disease (LCPD)** is an idiopathic avascular necrosis of the femoral head occurring in children, typically between ages 4 and 8. **1. Why the correct answer is "Unknown":** Despite extensive research, the exact primary cause of Perthes disease remains **unknown (idiopathic)**. The underlying pathophysiology involves a temporary interruption of the blood supply to the capital femoral epiphysis, leading to bone infarction and subsequent remodeling. While various theories suggest associations with hypercoagulability (Protein C or S deficiency), venous obstruction, or delayed skeletal maturity, none have been definitively proven as the universal etiology. **2. Why the other options are incorrect:** * **Options A & B (Pyogenic/Tubercular Infection):** Perthes is a non-infectious, aseptic process. While Septic Arthritis (Pyogenic) or TB Hip can mimic the clinical presentation (limp and pain), they involve inflammatory markers (raised ESR/CRP) and joint destruction driven by pathogens, which are absent in Perthes. * **Option C (Trauma):** While a history of minor trauma is often reported by parents, it is generally considered an incidental finding that brings the pre-existing condition to medical attention rather than being the causative factor. **Clinical Pearls for NEET-PG:** * **Classic Presentation:** A painless (or mildly painful) limp in a young boy (Male:Female ratio = 4:1). * **Radiological Sign:** The **"Crescent Sign"** (subchondral fracture) is a pathognomonic early sign. * **Staging:** Commonly classified using the **Waldenström stages** (Initial, Fragmentation, Reossification, and Healed). * **Prognosis:** The most important prognostic factor is the **age at onset**; children younger than 6 years generally have better outcomes due to higher remodeling potential.

Q: Which fracture in children is commonly associated with vascular injury?

Lower end of humerus. **Explanation:** The correct answer is **Lower end of humerus**, specifically the **Supracondylar fracture of the humerus**. This is the most common fracture in children (peaking at ages 5–8) and is notorious for its association with vascular complications. **Why it is correct:** In the common **extension-type** supracondylar fracture, the proximal fracture fragment is displaced anteriorly. This sharp edge can easily impinge upon or lacerate the **Brachial Artery**, which lies directly anterior to the distal humerus. This can lead to an absent radial pulse, and if left untreated, results in **Volkmann’s Ischemic Contracture (VIC)** due to compartment syndrome. **Why the other options are incorrect:** * **Lower end of radius:** While common (e.g., Colles' in adults or distal physeal injuries in children), it is rarely associated with major vascular injury; median nerve involvement is more common. * **Upper end of femur:** These are rare in children and are more significantly associated with **Avascular Necrosis (AVN)** of the femoral head due to disruption of the circumflex vessels, rather than acute limb-threatening vascular trauma. * **Upper end of radius:** Radial neck fractures in children are common, but they typically involve the radial nerve (posterior interosseous branch) rather than major arteries. **Clinical Pearls for NEET-PG:** * **Most common nerve injured:** Median nerve (specifically the **Anterior Interosseous Nerve**). * **Nerve injured in flexion-type:** Ulnar nerve. * **Gartland Classification** is used to grade these fractures. * **Pink Pulseless Hand:** A clinical scenario where the hand is perfused (capillary refill <2s) but the radial pulse is absent; it requires urgent orthopedic consultation. * **Deformity:** Malunion often leads to **Cubitus Varus** (Gunstock deformity).

Q: Which classification system is NOT used for Perthes' disease?

Salter Harris Classification. **Explanation:** The correct answer is **D. Salter-Harris Classification**. This system is used to categorize **physeal (growth plate) fractures** in children based on the involvement of the epiphysis, physis, and metaphysis. It is not used for Perthes' disease, which is an idiopathic avascular necrosis of the femoral head. **Analysis of other options:** * **Catterall Classification:** Based on the extent of involvement of the femoral head seen on AP and lateral X-rays. It divides the disease into four groups (I-IV) based on the size of the necrotic segment. * **Salter-Thompson Classification:** A simplified version of Catterall’s, focusing on the extent of the **subchondral fracture (crescent sign)**. Group A involves less than half the head, while Group B involves more than half. * **Stulberg Classification:** This is used to assess the **long-term prognosis** and end-stage morphology of the hip after the disease has run its course. It classifies the femoral head shape (spherical, ovoid, or flat) and its congruency with the acetabulum. **High-Yield Clinical Pearls for NEET-PG:** * **Herring (Lateral Pillar) Classification:** Currently the most popular prognostic system. It is based on the height of the lateral pillar of the capital femoral epiphysis during the fragmentation stage. * **Age of Onset:** Typically occurs in children aged 4–8 years; more common in boys. * **Earliest Sign:** The earliest radiographic sign is often a **widening of the joint space** or a small, dense epiphysis. * **Gage’s Sign:** A V-shaped radiolucency on the lateral side of the epiphysis (a "Head-at-risk" sign).

Question 1

In children, which type of fracture displacement demonstrates the best remodelling potential?

Accepted Answer

Angulation in the metaphysis

Answer

Angulation in the diaphysis

Answer

Rotation in the diaphysis

Answer

Rotation in the metaphysis

Question 2

A 4-year-old child presents with a history of a fall on the left forearm, resulting in a fracture on the dorsal surface of the mid-radius. What is the best treatment?

Accepted Answer

Break the cortex on the other side and immobilize with POP

Answer

Immobilize with plaster of Paris (POP)

Answer

Open reduction and internal fixation

Answer

K-wire fixation

Question 3

What is the most common complication of a supracondylar fracture of the humerus?

Accepted Answer

Malunion

Answer

Median nerve injury

Answer

Myositis ossificans

Answer

Volkmann's ischemic contracture

Question 4

Congenital Dislocation of Hip (CDH) classically occurs due to?

Accepted Answer

Developmental acetabular dysplasia

Answer

Small femoral head epiphysis

Answer

Abnormal angle of the femoral neck

Answer

Hypertrophied ligamentum teres

Question 5

Radial club hand is characterized by which of the following skeletal abnormalities?

Accepted Answer

Absence of the radius

Answer

Absence of the ulna

Answer

Absence of carpal bones

Answer

Absence of the humerus

Question 6

What is the commonest congenital deformity?

Accepted Answer

Congenital club foot

Answer

Congenital club hand

Answer

Absence of femur

Answer

Absence of fibula

Question 7

Vertical talus is associated with:

Accepted Answer

Congenital flat foot

Answer

Ankle dislocation

Answer

Talus fracture

Answer

Pes cavus

Question 8

What is the known etiology of Perthes disease?

Accepted Answer

Unknown

Answer

Pyogenic infection

Answer

Tubercular infection

Answer

Trauma

Question 9

Which fracture in children is commonly associated with vascular injury?

Accepted Answer

Lower end of humerus

Answer

Lower end of radius

Answer

Upper end of femur

Answer

Upper end of radius

Question 10

Which classification system is NOT used for Perthes' disease?

Accepted Answer

Salter Harris Classification

Answer

Catterall classification

Answer

Salter Thompson classification

Answer

Stulberg classification

Pediatric Orthopaedics — MCQs

Pediatric Orthopaedics — MCQs

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