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Pediatric Hip MCQs

Practice Set 101 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 2001

Topic: Pediatric Hip

A 13-year-old boy presents to the emergency department unable to bear weight on his left leg after minor trauma. Radiographs show a severe left slipped capital femoral epiphysis (SCFE). He is diagnosed with an unstable SCFE. Which of the following factors is most strongly associated with the development of osteonecrosis (AVN) in this patient?

. Degree of epiphyseal displacement on the lateral radiograph
. Presence of an unstable slip (inability to bear weight)
. Prompt prophylactic pinning of the contralateral hip
. The patient's body mass index (BMI) > 95th percentile
. Concomitant endocrine abnormalities

Correct Answer & Explanation

. Presence of an unstable slip (inability to bear weight)

Explanation

The primary risk factor for osteonecrosis (AVN) in SCFE is the clinical stability of the slip. Unstable slips (defined by the inability to bear weight even with crutches) have an AVN rate of up to 47%, compared to nearly 0% in stable slips.

Question 2002

Topic: Pediatric Hip

An 18-month-old girl presents with a painless limp and leg length discrepancy. Pelvic radiographs reveal a completely dislocated left hip with an acetabular index of 40 degrees and a broken Shenton's line. Which of the following represents the most appropriate surgical approach for this patient?

. Closed reduction and spica casting
. Open reduction alone
. Open reduction, capsulorrhaphy, and pelvic osteotomy
. Femoral varus derotational osteotomy (VDRO) alone
. Pavlik harness application

Correct Answer & Explanation

. Open reduction, capsulorrhaphy, and pelvic osteotomy

Explanation

In a child over 18 months of age with developmental dysplasia of the hip, closed reduction is rarely successful. The standard of care is an open reduction and capsulorrhaphy, frequently combined with a pelvic osteotomy (e.g., Salter) to address residual acetabular dysplasia.

Question 2003

Topic: Pediatric Hip

A 2-week-old neonate is brought to the emergency department for irritability and decreased spontaneous movement of the right lower extremity. Ultrasound reveals a significant hip effusion.

What is the most appropriate next step in management?

. Intravenous antibiotics and observation
. Closed reduction and spica casting
. MRI of the pelvis with and without contrast
. Urgent joint aspiration and surgical drainage
. Pavlik harness application

Correct Answer & Explanation

. Urgent joint aspiration and surgical drainage

Explanation

The neonate presents with pseudoparalysis and an effusion, highly suspicious for septic coxitis. Urgent aspiration and surgical drainage (arthrotomy) are required to prevent catastrophic destruction of the cartilaginous femoral head.

Question 2004

Topic: Pediatric Hip

A 3-week-old neonate presents with fever, irritability, and decreased spontaneous movement of the right lower extremity. Clinical examination reveals pain upon passive range of motion of the right hip. Ultrasound shows a joint effusion. What is the most appropriate next step in management?

. Intravenous antibiotics and close observation
. MRI of the right hip with contrast
. Ultrasound-guided hip aspiration and urgent surgical drainage
. Closed reduction and spica casting
. Pavlik harness application

Correct Answer & Explanation

. Ultrasound-guided hip aspiration and urgent surgical drainage

Explanation

Septic coxitis in a neonate is an orthopedic emergency presenting as pseudoparalysis. Immediate ultrasound-guided aspiration followed by urgent surgical debridement is required to prevent rapid femoral head destruction.

Question 2005

Topic: Pediatric Hip
A 2-week-old neonate presents with irritability, poor feeding, and pseudoparalysis of the left lower extremity. Examination shows pain with passive range of motion of the left hip. If left untreated, which of the following is the most likely catastrophic complication specific to this joint in this age group?
. Malignant transformation
. Slipped capital femoral epiphysis
. Complete destruction of the femoral head and neck
. Premature closure of the triradiate cartilage
. Development of Legg-Calvé-Perthes disease

Correct Answer & Explanation

. Complete destruction of the femoral head and neck

Explanation

Septic arthritis of the hip in a neonate is a surgical emergency. Delayed treatment rapidly leads to complete destruction of the cartilaginous femoral anlage (femoral head and neck) due to proteolytic enzymes and compromised intracapsular blood supply.

Question 2006

Topic: Pediatric Hip

A 13-year-old obese male presents with a 3-week history of left groin pain and a limp. On examination, as the left hip is passively flexed, it obligatorily externally rotates. Radiographs confirm a slipped capital femoral epiphysis (SCFE). Relative to the capital femoral epiphysis, in which direction is the femoral neck (metaphysis) typically displaced in this condition?

. Posterior and inferior
. Anterior and superior
. Posterior and superior
. Anterior and inferior
. Medial and inferior

Correct Answer & Explanation

. Anterior and superior

Explanation

Correct Answer: Anterior and superiorIn a Slipped Capital Femoral Epiphysis (SCFE), the capital femoral epiphysis remains anatomically seated within the acetabulum while the femoral neck (metaphysis) displaces. Because the epiphysis effectively 'slips' posterior and inferior relative to the neck, the biomechanical reality is that the femoral neck displaces anterior and superior relative to the epiphysis. This creates the classic external rotation deformity seen clinically.

Question 2007

Topic: Pediatric Hip

A 3-month-old female is being treated with a Pavlik harness for developmental dysplasia of the hip (DDH). During a follow-up visit, the parents report that the infant has stopped kicking her leg on the treated side. On examination, there is an absence of active knee extension. This complication is most likely due to which of the following positioning errors?

. Excessive hip abduction
. Inadequate hip abduction
. Excessive hip flexion
. Inadequate hip flexion
. Excessive hip internal rotation

Correct Answer & Explanation

. Excessive hip flexion

Explanation

Correct Answer: Excessive hip flexionThe Pavlik harness is used to treat DDH by maintaining the hips in flexion and abduction. However, improper application can lead to severe complications. Excessive hip flexion (typically >120 degrees) can compress the femoral nerve against the inguinal ligament, leading to a transient femoral nerve palsy, which presents as an inability to actively extend the knee. Conversely, excessive hip abduction places the medial circumflex femoral artery at risk, potentially causing avascular necrosis (AVN) of the femoral head.

Question 2008

Topic: Pediatric Hip

A 3-month-old female is being treated with a Pavlik harness for developmental dysplasia of the hip (DDH). During a follow-up visit, the physician notes that the infant is no longer actively extending her knee on the treated side. Which of the following positioning errors in the harness is the most likely cause of this complication?

. Excessive hip abduction
. Inadequate hip abduction
. Excessive hip flexion
. Inadequate hip flexion
. Excessive knee flexion

Correct Answer & Explanation

. Excessive hip flexion

Explanation

Correct Answer: CThe Pavlik harness maintains the hip in flexion and abduction. Excessive hip flexion (typically greater than 120 degrees) can cause compression of the femoral nerve against the inguinal ligament, leading to a transient femoral nerve palsy. This presents clinically as an inability to actively extend the knee due to quadriceps weakness. Conversely, excessive abduction is associated with avascular necrosis (AVN) of the femoral head.

Question 2009

Topic: Pediatric Hip

A 3-month-old female is being treated with a Pavlik harness for developmental dysplasia of the hip (DDH). During a follow-up visit, the parents report that the infant has stopped kicking her right leg. On examination, there is an absence of active knee extension on the right side. This complication is most likely due to which of the following improper harness adjustments?

. Excessive abduction of the hip
. Inadequate abduction of the hip
. Excessive flexion of the hip
. Inadequate flexion of the hip
. Excessive internal rotation of the hip

Correct Answer & Explanation

. Excessive flexion of the hip

Explanation

Correct Answer: CThe Pavlik harness is the standard initial treatment for DDH in infants under 6 months. Proper positioning is crucial. Excessive flexion of the hip (caused by anterior straps being too tight) can compress the femoral nerve against the inguinal ligament, leading to a transient femoral nerve palsy. This manifests clinically as decreased kicking and absent active knee extension. Conversely, excessive abduction (posterior straps too tight) increases the risk of avascular necrosis of the femoral head.

Question 2010

Topic: Pediatric Hip

Developmental dysplasia of the hip (DDH) has several known risk factors, including breech presentation. What is the primary biomechanical mechanism by which breech positioning in utero increases the risk of DDH?

. Increased maternal relaxin crossing the placenta
. Forced hip extension and adduction restricting normal acetabular development
. Direct trauma to the greater trochanter during delivery
. Decreased amniotic fluid volume causing generalized joint contractures
. Asymmetric tension on the iliopsoas tendon

Correct Answer & Explanation

. Forced hip extension and adduction restricting normal acetabular development

Explanation

Correct Answer: Forced hip extension and adduction restricting normal acetabular developmentBreech presentation forces the fetal hips into extreme flexion and limits abduction (often forcing adduction or extension depending on the exact breech type, but primarily restricting the normal flexed/abducted posture). This mechanical restriction prevents the femoral head from properly seating and stimulating the development of a deep, concentric acetabulum.

Question 2011

Topic: Pediatric Hip

A 13-year-old obese boy complains of a 3-week history of right thigh and knee pain. He walks with an antalgic gait and has obligate external rotation of the right hip during passive flexion. Which of the following is the most appropriate initial management?

. Immediate physical therapy for hip range of motion
. Non-weight-bearing strictly and urgent in situ percutaneous pinning
. Closed reduction and spica cast application
. Open reduction and internal fixation through an anterior approach
. Observation with serial radiographs

Correct Answer & Explanation

. Non-weight-bearing strictly and urgent in situ percutaneous pinning

Explanation

The patient has a slipped capital femoral epiphysis (SCFE) characterized by obligate external rotation with hip flexion. Immediate non-weight-bearing and urgent in situ percutaneous pinning is required to prevent further slippage and minimize AVN risk.

Question 2012

Topic: Pediatric Hip

A 4-month-old female infant is diagnosed with developmental dysplasia of the hip (DDH) after an ultrasound shows an alpha angle of 45 degrees. The infant is placed in a Pavlik harness. Which nerve is most at risk of palsy if the harness causes excessive hip flexion?

. Sciatic nerve
. Femoral nerve
. Obturator nerve
. Superior gluteal nerve
. Lateral femoral cutaneous nerve

Correct Answer & Explanation

. Femoral nerve

Explanation

The Pavlik harness must be properly adjusted to avoid complications. Excessive hip flexion beyond 100-110 degrees places the infant at risk for femoral nerve palsy, while excessive abduction risks avascular necrosis of the femoral head.

Question 2013

Topic: Pediatric Hip

A 12-year-old boy presents with an acute-on-chronic stable slipped capital femoral epiphysis (SCFE) of the left hip. Under which of the following circumstances is prophylactic pinning of the contralateral asymptomatic hip most strongly indicated?

. The patient is male
. The patient has a body mass index greater than the 95th percentile
. The patient has underlying panhypopituitarism
. The patient is exactly 12 years of age
. The patient has radiographic retroversion of the acetabulum

Correct Answer & Explanation

. The patient has underlying panhypopituitarism

Explanation

Prophylactic pinning of the contralateral hip is strongly indicated in patients with endocrine disorders, such as panhypopituitarism, hypothyroidism, or renal osteodystrophy. These patients have a significantly higher risk of developing bilateral SCFE compared to the idiopathic population.

Question 2014

Topic: Pediatric Hip

A 6-month-old female with developmental dysplasia of the hip (DDH) fails to achieve stable reduction after 4 weeks of compliant Pavlik harness treatment. What is the most appropriate next step in management?

. Continue Pavlik harness for an additional 4 weeks
. Transition to a rigid abduction orthosis (e.g., Ilfeld splint)
. Closed reduction and spica casting under general anesthesia
. Open reduction and spica casting
. Varus derotational osteotomy of the proximal femur

Correct Answer & Explanation

. Closed reduction and spica casting under general anesthesia

Explanation

If a Pavlik harness fails to reduce the hip after 3 to 4 weeks, it must be discontinued to prevent "Pavlik harness disease" (posterior acetabular wear and worsening dysplasia). The standard next step for a 6-month-old is a closed reduction and spica casting under anesthesia.

Question 2015

Topic: Pediatric Hip

A 13-year-old obese boy presents with acute on chronic groin pain and an inability to bear weight. Radiographs show a severe slipped capital femoral epiphysis. Following in situ pinning, he develops severe stiffness and pain with any hip motion. Radiographs now show symmetric joint space narrowing. What is the most likely complication?

. Avascular necrosis
. Chondrolysis
. Femoral neck fracture
. Deep space infection
. Screw cut-out

Correct Answer & Explanation

. Chondrolysis

Explanation

Chondrolysis is characterized by acute onset of severe stiffness and joint space narrowing after SCFE, particularly associated with unrecognized penetrating hardware. It leads to profound, rapid loss of articular cartilage and a painfully stiff hip.

Question 2016

Topic: Pediatric Hip
Children with Trichorhinophalangeal Syndrome (TRPS) Type I are at an increased risk of developing which of the following hip pathologies, which frequently mimics a distinct pediatric orthopedic condition?
. Slipped capital femoral epiphysis
. Legg-Calvé-Perthes-like avascular necrosis of the femoral head
. Developmental dysplasia of the hip with frank dislocation
. Coxa vara due to a primary ossification defect
. Recurrent transient synovitis of the hip

Correct Answer & Explanation

. Legg-Calvé-Perthes-like avascular necrosis of the femoral head

Explanation

Patients with TRPS commonly develop early-onset degenerative changes and avascular necrosis-like fragmentation of the femoral head. These radiographic and clinical findings closely mimic Legg-Calvé-Perthes disease, necessitating routine clinical and radiographic hip screening.

Question 2017

Topic: Pediatric Hip

A 12-year-old boy presents with short stature, a bulbous nose, and sparse scalp hair. Radiographs of his hands demonstrate cone-shaped epiphyses in the phalanges. Which of the following orthopedic hip conditions is strongly associated with this genetic syndrome?

. Protrusio acetabuli
. Slipped capital femoral epiphysis
. Coxa vara
. Legg-Calve-Perthes-like changes
. Femoroacetabular impingement

Correct Answer & Explanation

. Legg-Calve-Perthes-like changes

Explanation

This patient has Trichorhinophalangeal syndrome type 1 (TRPS1). Along with cone-shaped epiphyses of the phalanges, these patients frequently develop premature osteoarthritis of the hip secondary to Legg-Calve-Perthes-like avascular necrosis changes.

Question 2018

Topic: Pediatric Hip
Which of the following combinations of clinical and radiographic findings best distinguishes Trichorhinophalangeal syndrome (TRPS) Type I from Legg-Calvé-Perthes disease when evaluating a child with hip pain?
. Unilateral hip involvement with normal hand radiographs
. Bilateral severe coxarthrosis, sparse scalp hair, and cone-shaped epiphyses in the hands
. Slipped capital femoral epiphysis with associated generalized osteosclerosis
. Unilateral femoral head fragmentation with multiple osteochondromas
. Acetabular dysplasia with an absent clavicle

Correct Answer & Explanation

. Bilateral severe coxarthrosis, sparse scalp hair, and cone-shaped epiphyses in the hands

Explanation

TRPS Type I often presents with early, severe bilateral hip joint destruction that can mimic Legg-Calvé-Perthes. It is distinguished by syndromic features including sparse hair, a bulbous nose, and cone-shaped phalangeal epiphyses.

Question 2019

Topic: Pediatric Hip
A 12-year-old girl is diagnosed with TRPS1 based on facial features, sparse hair, and brachydactyly. She complains of persistent hip pain. Radiographs of her pelvis are most likely to demonstrate which of the following?
. Bilateral coxa vara with fragmented capital femoral epiphyses
. Protrusio acetabuli with severe osteopenia
. Ankylosis of the sacroiliac joints
. Coxa valga with subluxation of the femoral head
. Sclerotic 'rugger-jersey' appearance of the lumbar vertebrae

Correct Answer & Explanation

. Bilateral coxa vara with fragmented capital femoral epiphyses

Explanation

Patients with TRPS commonly develop severe, premature osteoarthritis of the hips. In childhood, this often manifests as bilateral epiphyseal fragmentation, flattening of the femoral head, and coxa vara, closely mimicking severe Legg-Calvé-Perthes disease.

Question 2020

Topic: Pediatric Hip
A 10-year-old male with known Trichorhinophalangeal syndrome (TRPS) presents with a painless limp and restricted hip abduction. Which of the following hip pathologies is frequently associated with TRPS type I and most likely explains his symptoms?
. Slipped capital femoral epiphysis
. Legg-Calvé-Perthes-like avascular necrosis
. Developmental dysplasia of the hip
. Femoroacetabular impingement (cam type)
. Coxa vara from subtrochanteric pseudofractures

Correct Answer & Explanation

. Legg-Calvé-Perthes-like avascular necrosis

Explanation

Patients with Trichorhinophalangeal syndrome (TRPS) frequently develop hip abnormalities that closely mimic Legg-Calvé-Perthes disease. This includes avascular necrosis-like changes and subsequent flattening of the femoral head (coxa plana).

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