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Pediatric Hip MCQs

Practice Set 2 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 21

Topic: Pediatric Hip

A 6-month-old girl is diagnosed with developmental dysplasia of the hip (DDH) and has failed a proper 3-week trial of a Pavlik harness, with the hip remaining dislocated. What is the most appropriate next step in management?

. Continue Pavlik harness for an additional 4 weeks
. Switch to a rigid abduction orthosis (e.g., Ilfeld splint)
. Closed reduction and spica casting
. Immediate open reduction and capsulorrhaphy
. Pelvic osteotomy

Correct Answer & Explanation

. Closed reduction and spica casting

Explanation

If a Pavlik harness fails to achieve reduction within 3 to 4 weeks, it should be abandoned to prevent 'Pavlik harness disease' (damage to the posterior acetabular wall). The next appropriate step is closed reduction and spica casting under general anesthesia.

Question 22

Topic: Pediatric Hip

In which of the following patients presenting with a unilateral slipped capital femoral epiphysis (SCFE) is prophylactic pinning of the contralateral hip most strongly indicated?

. A 12-year-old boy with a BMI of 30
. An 11-year-old girl with idiopathic SCFE
. A 10-year-old boy with renal osteodystrophy
. A 14-year-old boy with an acute-on-chronic SCFE
. A 13-year-old girl with an ipsilateral retroverted acetabulum

Correct Answer & Explanation

. A 10-year-old boy with renal osteodystrophy

Explanation

Prophylactic pinning of the contralateral hip is strongly recommended in patients with endocrine or metabolic disorders (e.g., renal osteodystrophy, hypothyroidism) due to a very high rate of subsequent contralateral slips.

Question 23

Topic: Pediatric Hip
A 7-year-old boy is diagnosed with Legg-Calvé-Perthes disease. Which of the following describes the most critical prognostic factors for long-term hip deformity?
. Age at onset and lateral pillar classification
. Gender and extent of medial pillar collapse
. Body mass index and epiphyseal height
. Initial range of motion and presence of crescent sign

Correct Answer & Explanation

. Age at onset and lateral pillar classification

Explanation

The most important prognostic factors in Legg-Calvé-Perthes disease are the age at clinical presentation (worse outcomes if >8 years) and the Herring lateral pillar classification. Preservation of the lateral pillar height corresponds to better long-term sphericity of the femoral head.

Question 24

Topic: Pediatric Hip
A 5-year-old patient with Legg-Calvé-Perthes disease has lateral pillar B involvement. He has 15% epiphyseal extrusion. Treatment should consist of:
. Observation
. Femoral osteotomy
. Iliac osteotomy
. Combined femoral and iliac osteotomy
. External fixation

Correct Answer & Explanation

. Observation

Explanation

Patients who have Legg-Calvé-Perthes disease with onset before 6 years of age have a good prognosis unless they have lateral pillar involvement in the B/C border or C categories.

Question 25

Topic: Pediatric Hip
Which of the following characteristics is more commonly found in patients with Meyer dysplasia than in patients with Legg-Calvé-Perthes disease?
. Bilateral involvement
. Asynchronous onset
. Metaphyseal widening
. Epiphyseal extrusion
. Later degenerative change

Correct Answer & Explanation

. Bilateral involvement

Explanation

Meyer dysplasia is a rare condition that affects children before age 4. A characteristic of the condition includes delayed ossification of the epiphyses, which eventually develop normal ossification. Meyer dysplasia is synchronous, meaning that both heads have symmetrical involvement unlike Legg-Calvé-Perthes disease. Meyer dysplasia is usually bilateral, in contrast to Legg-Calvé-Perthes disease, which is bilateral in fewer than 10% of patients. There is no metaphyseal widening and no treatment is indicated.

Question 26

Topic: Pediatric Hip



A 12-year-old boy presents with an altered gait and thigh pain. If the underlying diagnosis is Slipped Capital Femoral Epiphysis (SCFE), what is the anatomical direction of the epiphyseal slip relative to the femoral neck?

. Anterior and superior
. Anterior and inferior
. Posterior and superior
. Posterior and inferior
. Directly medial

Correct Answer & Explanation

. Posterior and inferior

Explanation

In SCFE, the capital femoral epiphysis typically slips posteriorly and inferiorly relative to the metaphysis of the femoral neck. This displacement leads to the characteristic externally rotated and shortened posture of the affected limb.

Question 27

Topic: Pediatric Hip

During an open reduction of a Developmentally Dysplastic Hip (DDH) via a medial (Ludloff) approach in an 11-month-old, which structure is directly released to allow access to the joint and facilitate reduction?

. Gluteus medius
. Iliopsoas tendon
. Sartorius
. Tensor fasciae latae
. Rectus femoris

Correct Answer & Explanation

. Iliopsoas tendon

Explanation

The medial approach allows direct access to the medial structures blocking reduction, primarily requiring the release of the iliopsoas tendon. This approach avoids disruption of the abductors but carries a risk of injury to the medial circumflex femoral artery.

Question 28

Topic: Pediatric Hip

A 4-month-old infant in a Pavlik harness for DDH develops an inability to actively extend the knee. This complication is most likely due to:

. Excessive hip abduction
. Inadequate hip abduction
. Excessive hip flexion
. Inadequate hip flexion
. Straps causing direct pressure on the fibular neck

Correct Answer & Explanation

. Excessive hip flexion

Explanation

Hyperflexion of the hip in a Pavlik harness can cause compression of the femoral nerve against the inguinal ligament. This leads to an iatrogenic femoral nerve palsy, manifesting clinically as poor active knee extension.

Question 29

Topic: Pediatric Hip
Which of the following is considered the most significant poor prognostic factor in Legg-Calvé-Perthes disease?
. Male gender
. Bilateral involvement
. Age at onset greater than 8 years
. Presence of a positive Galeazzi sign
. Associated mild obesity

Correct Answer & Explanation

. Age at onset greater than 8 years

Explanation

Older age at presentation (typically > 8 years) is a major poor prognostic factor in Legg-Calvé-Perthes disease. Older patients have less remaining time for femoral head remodeling before physeal closure, increasing the risk of early osteoarthritis.

Question 30

Topic: Pediatric Hip

A 12-year-old obese boy presents with a 3-week history of left knee pain and an antalgic gait. Examination shows obligatory external rotation of the left hip during flexion. Which of the following is the most appropriate initial management?

. Non-weight bearing with crutches and urgent in situ pinning
. MRI of the left knee
. Physical therapy for hip strengthening
. Closed reduction and spica casting
. Capsulotomy and surgical dislocation

Correct Answer & Explanation

. Non-weight bearing with crutches and urgent in situ pinning

Explanation

This patient has a Slipped Capital Femoral Epiphysis (SCFE), presenting typically with knee pain and obligatory external rotation during hip flexion. Initial management requires strict non-weight bearing to prevent further slip, followed by urgent in situ pinning.

Question 31

Topic: Pediatric Hip

Which of the following is an absolute contraindication to the use of a Pavlik harness for the treatment of developmental dysplasia of the hip (DDH)?

. Age less than 6 weeks
. Bilateral hip dislocation
. Teratologic hip dislocation
. Reducible Barlow-positive hip
. Ultrasound showing alpha angle of 45 degrees

Correct Answer & Explanation

. Teratologic hip dislocation

Explanation

Teratologic hip dislocations (associated with conditions like arthrogryposis or spina bifida) are rigid and irreducible with a Pavlik harness, representing an absolute contraindication. Pavlik harness treatment in these cases risks prolonged immobilization without success and potential iatrogenic injury.

Question 32

Topic: Pediatric Hip
In the lateral pillar classification of Legg-Calvé-Perthes disease, which radiographic parameter is evaluated to determine the prognosis?
. The extent of medial epiphyseal involvement
. The degree of fragmentation of the central pillar
. The height of the lateral portion of the capital femoral epiphysis
. The severity of metaphyseal cysts
. The alpha angle of the acetabulum

Correct Answer & Explanation

. The height of the lateral portion of the capital femoral epiphysis

Explanation

The Herring lateral pillar classification evaluates the height of the lateral third (lateral pillar) of the capital femoral epiphysis relative to its original height during the fragmentation stage. Preservation of lateral pillar height correlates with a better long-term prognosis.

Question 33

Topic: Pediatric Hip

Patients who have had a unilateral slipped capital femoral epiphysis (SC FE) are at what odds of a contralateral slip compared to the general population:

. 2 times
. 20 times
. 200 times
. 2,000 times
. 20,000 times

Correct Answer & Explanation

. 2,000 times

Explanation

Patients who have presented with a unilateral SC FE are at approximately 2,000 times the risk of a contralateral slip compared to the general population. The risk of a contralateral slip in a juvenile is approximately 1/10,000, which provides justification for prophylactic pinning of a second side if a surgeon thinks it is warranted.

Question 34

Topic: Pediatric Hip

A 6-year-old boy presents with a painless limp. Radiographs demonstrate sclerosis and fragmentation of the proximal femoral epiphysis. Which of the following factors carries the worst prognosis for this condition?

. Age of onset less than 6 years
. Loss of internal rotation
. Lateral pillar C classification
. Male sex
. Catterall group I

Correct Answer & Explanation

. Lateral pillar C classification

Explanation

In Legg-Calve-Perthes disease, the Lateral Pillar classification is strongly prognostic. Lateral Pillar C (greater than 50% loss of lateral pillar height) has the worst prognosis.

Question 35

Topic: Pediatric Hip

A 12-year-old obese boy presents with a 3-week history of left groin pain and a limp. On examination, as the left hip is flexed, it obligatorily externally rotates. Radiographs are shown.

What is the most appropriate definitive management?

. Spica cast immobilization
. In situ pinning with a single cannulated screw
. Closed reduction and casting
. Proximal femoral osteotomy
. Core decompression

Correct Answer & Explanation

. In situ pinning with a single cannulated screw

Explanation

The presentation is classic for a Slipped Capital Femoral Epiphysis (SCFE). The gold standard treatment for a stable SCFE is in situ pinning with a single cannulated screw to prevent further slippage.

Question 36

Topic: Pediatric Hip

A 6-year-old boy presents with a painless limp of 2 months' duration. His hip range of motion reveals decreased abduction and internal rotation. A radiograph reveals sclerosis and fragmentation of the proximal femoral epiphysis. What is the most likely diagnosis?

. Transient synovitis
. Septic arthritis
. Legg-Calve-Perthes disease
. Slipped capital femoral epiphysis
. Juvenile idiopathic arthritis

Correct Answer & Explanation

. Legg-Calve-Perthes disease

Explanation

Legg-Calve-Perthes disease typically presents in children aged 4-8 with a painless or mildly painful limp. Radiographs show avascular necrosis of the capital femoral epiphysis.

Question 37

Topic: Pediatric Hip

A 4-week-old female infant is brought to the clinic for a routine check-up. Barlow and Ortolani maneuvers are positive on the left side. Ultrasound confirms developmental dysplasia of the hip (DDH). What is the initial treatment of choice?

. Pavlik harness
. Rigid abduction orthosis
. Closed reduction and spica casting
. Open reduction and spica casting
. Observation

Correct Answer & Explanation

. Pavlik harness

Explanation

The Pavlik harness is the gold standard initial treatment for DDH in infants under 6 months of age, maintaining the hip in flexion and abduction.

Question 38

Topic: Pediatric Hip
An 8-year-old boy presents with a persistent limp. Radiographs demonstrate a fragmented proximal femoral epiphysis. Which of the following factors is most predictive of the final radiographic outcome in Legg-Calvé-Perthes disease?
. Gender of the patient
. Body mass index
. Age at clinical onset
. Duration of initial symptoms
. Presence of knee pain

Correct Answer & Explanation

. Age at clinical onset

Explanation

Age at clinical onset is the most significant prognostic factor in Legg-Calvé-Perthes disease. Patients presenting before the age of 6 to 8 years generally have a much higher potential for remodeling and a better final radiographic outcome.

Question 39

Topic: Pediatric Hip

An 8-month-old girl presents with developmental dysplasia of the hip (DDH) that has failed Pavlik harness treatment. A closed reduction and spica casting is planned. Which of the following is considered the most significant extra-articular block to closed reduction in this age group?

. Inverted limbus
. Iliopsoas tendon
. Pulvinar
. Ligamentum teres
. Transverse acetabular ligament

Correct Answer & Explanation

. Iliopsoas tendon

Explanation

The iliopsoas tendon is typically the most significant extra-articular block to reduction in DDH, often causing an hourglass constriction of the hip capsule. The other listed options are intra-articular blocks.

Question 40

Topic: Pediatric Hip

A 12-year-old obese boy presents with right knee pain and an antalgic gait. Hip radiographs

show a stable slipped capital femoral epiphysis (SCFE). He is treated with a single in-situ screw. What is the most common long-term complication of his underlying condition?

. Chondrolysis
. Avascular necrosis of the femoral head
. Femoroacetabular impingement
. Subtrochanteric fracture
. Slipped capital femoral epiphysis of the contralateral hip within 1 week

Correct Answer & Explanation

. Femoroacetabular impingement

Explanation

Even after successful in-situ fixation, the residual metaphyseal prominence of the proximal femur often leads to cam-type femoroacetabular impingement (FAI). Avascular necrosis is a higher risk in unstable SCFE.

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