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Pediatric Hip MCQs

Practice Set 1 of 104

This practice set contains high-yield board review questions covering key concepts in Pediatric Hip. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 1

Topic: Pediatric Hip
Which condition is characterized by avascular necrosis of the femoral head in children aged 4-8 years?
. Slipped Capital Femoral Epiphysis (SCFE)
. Legg-Calvé-Perthes disease
. Developmental Dysplasia of the Hip (DDH)
. Transient synovitis of the hip
. Septic arthritis of the hip

Correct Answer & Explanation

. Legg-Calvé-Perthes disease

Explanation

Legg-Calvé-Perthes disease is an idiopathic avascular necrosis of the femoral head in children, typically affecting boys between 4 and 8 years of age.

Question 2

Topic: Pediatric Hip
A 45-year-old female presents with anterior hip pain. Radiographs demonstrate a crossover sign and a lateral center-edge angle of 45 degrees, consistent with global acetabular overcoverage. Which condition is most strongly associated with this morphology?
. Cam impingement
. Pincer impingement
. Slipped capital femoral epiphysis
. Legg-Calvé-Perthes disease
. Femoral retroversion

Correct Answer & Explanation

. Pincer impingement

Explanation

A crossover sign and an increased lateral center-edge angle (>40 degrees) indicate acetabular retroversion or overcoverage. These are the classic radiographic hallmarks of Pincer-type femoroacetabular impingement.

Question 3

Topic: Pediatric Hip

A 19-year-old female dancer complains of a deep groin pain and a "clicking" sensation in her hip. Radiographs show a lateral center-edge angle of 15 degrees. What is the most likely underlying structural pathology?

. Femoroacetabular impingement (Cam type)
. Femoroacetabular impingement (Pincer type)
. Developmental dysplasia of the hip
. Slipped capital femoral epiphysis
. Legg-Calve-Perthes disease

Correct Answer & Explanation

. Developmental dysplasia of the hip

Explanation

A lateral center-edge angle of less than 20 degrees is diagnostic for developmental dysplasia of the hip (DDH). The clicking and pain are likely due to secondary labral pathology and capsular overload.

Question 4

Topic: Pediatric Hip

An 8-year-old boy presents with an atraumatic limp and left groin pain. Radiographs reveal a slipped capital femoral epiphysis (SCFE). His weight is in the 45th percentile for his age. Which of the following tests is most appropriate as part of his initial evaluation?

. Thyroid-stimulating hormone (TSH) and free T4
. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
. Rheumatoid factor and Antinuclear antibodies (ANA)
. Bone marrow aspiration
. Genetic testing for COL1A1

Correct Answer & Explanation

. Thyroid-stimulating hormone (TSH) and free T4

Explanation

A patient presenting with SCFE before the age of 10 or with atypical physical features (weight less than 50th percentile) requires a thorough endocrine workup. Hypothyroidism and renal osteodystrophy are among the most common associated endocrine disorders.

Question 5

Topic: Pediatric Hip

A 12-year-old obese male presents with left knee pain and an obligate external rotation of the hip during passive hip flexion. Radiographs confirm a slipped capital femoral epiphysis (SCFE). Which of the following is a recognized specific indication for prophylactic pinning of the contralateral, asymptomatic hip?

. Body Mass Index greater than 30
. Age of 12 years at initial presentation
. Presence of an endocrine or metabolic disorder
. Symptom duration less than 4 weeks prior to diagnosis
. Slip angle greater than 50 degrees on the primarily affected side

Correct Answer & Explanation

. Presence of an endocrine or metabolic disorder

Explanation

Prophylactic pinning of the contralateral hip in SCFE is strongly recommended in patients with endocrine or metabolic disorders (e.g., hypothyroidism, renal osteodystrophy). These patients have a significantly higher risk of developing bilateral slip compared to the idiopathic population.

Question 6

Topic: Pediatric Hip

A 13-year-old obese boy is diagnosed with a mild stable slipped capital femoral epiphysis (SCFE). Which of the following is an accepted absolute indication for prophylactic pinning of the contralateral asymptomatic hip?

. Age greater than 14 years
. Female gender
. Presence of an underlying endocrine disorder
. Body mass index in the 85th percentile
. Closed triradiate cartilage

Correct Answer & Explanation

. Presence of an underlying endocrine disorder

Explanation

Prophylactic pinning of the contralateral hip in SCFE is strongly indicated in patients with underlying endocrinopathies (e.g., hypothyroidism) or metabolic disorders due to a nearly 100% risk of bilateral involvement. Young age is also considered a relative indication.

Question 7

Topic: Pediatric Hip

A 6-week-old female is being treated for developmental dysplasia of the hip with a Pavlik harness. She develops an absent knee jerk and lack of active knee extension on the treated side. What is the most appropriate next step in management?

. Immediate transition to a rigid spica cast
. Loosen the posterior straps to reduce hip abduction
. Loosen the anterior straps to reduce hip flexion
. Order a stat MRI of the lumbar spine
. Continue current treatment as this is a transient normal finding

Correct Answer & Explanation

. Loosen the anterior straps to reduce hip flexion

Explanation

The patient has developed a femoral nerve palsy, a known complication of extreme hip flexion in a Pavlik harness. Immediate management requires loosening the anterior flexion straps or temporarily discontinuing the harness until nerve function recovers.

Question 8

Topic: Pediatric Hip

A 12-year-old obese male presents with a slipped capital femoral epiphysis (SCFE) of the left hip. Prophylactic pinning of the asymptomatic right hip is most strongly indicated if the patient has a history of:

. Asthma treated with occasional bronchodilators
. Type 1 diabetes mellitus
. Hypothyroidism
. Attention deficit hyperactivity disorder
. Previous ipsilateral tibial shaft fracture

Correct Answer & Explanation

. Hypothyroidism

Explanation

Prophylactic pinning of the contralateral hip in SCFE is indicated in patients with underlying endocrine or metabolic disorders, such as hypothyroidism or renal osteodystrophy, due to the high risk of bilateral involvement.

Question 9

Topic: Pediatric Hip

A 6-year-old boy is diagnosed with Legg-Calve-Perthes disease. Which of the following is considered the most significant prognostic factor for the long-term development of osteoarthritis?

. Gender of the patient
. Body mass index
. Age at the onset of symptoms
. Presence of a limp at presentation
. Symmetric bilateral involvement

Correct Answer & Explanation

. Age at the onset of symptoms

Explanation

Age at the onset of symptoms is the most important prognostic factor in Legg-Calve-Perthes disease. Children who develop the disease before age 6 generally have a better prognosis due to greater remodeling potential of the femoral head.

Question 10

Topic: Pediatric Hip

A 4-month-old infant is being treated with a Pavlik harness for developmental dysplasia of the hip (DDH). At a follow-up visit, the infant exhibits decreased spontaneous active extension of the knee. Which of the following adjustments or actions is most appropriate?

. Increase flexion of the anterior straps
. Increase abduction of the posterior straps
. Loosen the anterior straps to reduce hip flexion
. Perform an immediate closed reduction in the operating room
. Apply a spica cast

Correct Answer & Explanation

. Loosen the anterior straps to reduce hip flexion

Explanation

Decreased active knee extension in a Pavlik harness indicates a femoral nerve palsy, typically caused by excessive hip flexion. The appropriate management is to loosen the anterior straps to decrease the degree of hip flexion.

Question 11

Topic: Pediatric Hip

A patient with slipped capital femoral epiphysis (SC FE) should have an endocrine workup if presenting with which of the following features:

. Bilateral involvement
. Body mass index greater than the 95th percentile for age
. Age <10 or >15 years
. Negative family history
. Female gender

Correct Answer & Explanation

. Age <10 or >15 years

Explanation

Endocrine workup is only indicated for age ,10 or .15 years, or stature less than the 10th percentile. Bilaterality, obesity, and negative family history are common findings in idiopathic SC FE. Although SC FE is more common in males, it is not uncommon in females.

Question 12

Topic: Pediatric Hip

An 8-year-old boy presents for evaluation. He has unusually broad shoulders and is able to bring his shoulders together anteriorly at the midline. Radiographs confirm hypoplastic clavicles and delayed skull suture closure. Which of the following pelvic abnormalities is most highly associated with this patient's syndrome?

. Acetabular dysplasia
. Coxa vara
. Slipped capital femoral epiphysis
. Protrusio acetabuli
. Femoroacetabular impingement

Correct Answer & Explanation

. Coxa vara

Explanation

Cleidocranial dysplasia is a skeletal dysplasia caused by a RUNX2 gene mutation. In the lower extremities, it is classically associated with delayed pubic symphysis ossification and developmental coxa vara.

Question 13

Topic: Pediatric Hip

A 12-year-old obese boy presents with right hip and knee pain for 3 months. A radiograph is shown

. He is diagnosed with a stable slipped capital femoral epiphysis (SCFE). Which of the following is the most appropriate initial management?

. In situ pinning with a single cannulated screw
. Closed reduction and spica casting
. Open reduction and internal fixation
. Proximal femoral osteotomy
. Observation and crutch use

Correct Answer & Explanation

. In situ pinning with a single cannulated screw

Explanation

The gold standard treatment for a stable SCFE is in situ pinning with a single central cannulated screw. Attempting closed reduction increases the risk of avascular necrosis.

Question 14

Topic: Pediatric Hip

A 4-week-old female infant is diagnosed with a dislocated but reducible left hip. Treatment with a Pavlik harness is initiated. Which of the following is an absolute contraindication to the continued use of a Pavlik harness?

. Alpha angle of 55 degrees on ultrasound
. Failure to obtain reduction after 3 to 4 weeks of use
. Bilateral hip dysplasia
. Presence of a positive Ortolani sign at initial presentation
. Age greater than 2 weeks at the start of treatment

Correct Answer & Explanation

. Failure to obtain reduction after 3 to 4 weeks of use

Explanation

Failure to achieve reduction within 3-4 weeks is an absolute contraindication to continued Pavlik harness use. Prolonged use of a harness on a dislocated hip causes "Pavlik harness disease" (posterior lip damage) and risks femoral nerve palsy.

Question 15

Topic: Pediatric Hip

An 18-month-old child presents with a painless limp and is found to have an untreated developmental dysplasia of the hip (DDH) on the right side. Which of the following is the most appropriate treatment?

. Pavlik harness
. Closed reduction and spica casting
. Open reduction, capsulorrhaphy, and likely pelvic/femoral osteotomy
. Observation until age 4
. Skeletal traction

Correct Answer & Explanation

. Open reduction, capsulorrhaphy, and likely pelvic/femoral osteotomy

Explanation

In children >18 months of age with DDH, open reduction is generally required due to adaptive soft tissue and bony changes. Concomitant pelvic and/or femoral osteotomies are frequently necessary to maintain reduction.

Question 16

Topic: Pediatric Hip

Which of the following conditions is the strongest indication for prophylactic pinning of the contralateral asymptomatic hip in a patient presenting with a unilateral slipped capital femoral epiphysis (SCFE)?

. Obesity
. Renal osteodystrophy
. Male gender
. Age greater than 14 years
. Family history of SCFE

Correct Answer & Explanation

. Renal osteodystrophy

Explanation

Endocrine and metabolic disorders (such as renal osteodystrophy and hypothyroidism) significantly increase the risk of bilateral SCFE. Prophylactic pinning of the contralateral hip is highly recommended in these high-risk populations.

Question 17

Topic: Pediatric Hip

An infant with developmental dysplasia of the hip (DDH) is being treated with a Pavlik harness. During a follow-up visit, the infant is unable to actively extend the knee on the treated side. Which of the following harness adjustments was most likely flawed?

. Excessive abduction
. Insufficient abduction
. Excessive flexion
. Insufficient flexion
. Excessive external rotation

Correct Answer & Explanation

. Excessive flexion

Explanation

Excessive flexion in a Pavlik harness can compress the femoral nerve against the inguinal ligament, leading to a temporary femoral nerve palsy (manifesting as loss of active knee extension). Excessive abduction, conversely, increases the risk of avascular necrosis.

Question 18

Topic: Pediatric Hip

In Legg-Calve-Perthes disease, the Herring Lateral Pillar classification is most useful for predicting outcome. In a Group C classification, what percentage of the lateral pillar height is maintained?

. 100%
. Greater than 50%
. Less than 50%
. Exactly 75%
. 0%

Correct Answer & Explanation

. Less than 50%

Explanation

In the Herring Lateral Pillar classification, Group C is defined by the lateral pillar retaining less than 50% of its original height. This group carries the poorest prognosis for hip remodeling.

Question 19

Topic: Pediatric Hip

A 13-year-old obese boy presents with 3 weeks of vague left knee pain and a limp. Examination reveals an obligate external rotation of the hip during active flexion.

What is the most devastating potential complication of the underlying condition?

. Chondrolysis
. Avascular necrosis
. Early-onset osteoarthritis
. Femoral neck nonunion
. Septic arthritis

Correct Answer & Explanation

. Avascular necrosis

Explanation

Avascular necrosis (AVN) is the most devastating complication of Slipped Capital Femoral Epiphysis (SCFE), often secondary to unstable slips or overly aggressive reduction attempts. Chondrolysis is another severe complication but generally has a more predictable, albeit stiff, long-term outcome compared to segmental collapse from AVN.

Question 20

Topic: Pediatric Hip

In a 7-year-old boy diagnosed with Legg-Calve-Perthes disease, which of the following radiographic findings is considered a 'head at risk' sign according to Catterall?

. Gage sign
. Waldenstrom sign
. Crescent sign
. Metaphyseal blanch sign
. Klein's line disruption

Correct Answer & Explanation

. Gage sign

Explanation

Catterall's 'head at risk' signs include the Gage sign (a V-shaped radiolucency in the lateral portion of the epiphysis/metaphysis), lateral calcification, lateral subluxation, horizontal growth plate, and metaphyseal cysts. These indicate a poorer prognosis.

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