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Pediatric Hip MCQs

Practice Set 22 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 421

Topic: Pediatric Hip

A 9-year-old girl reports the immediate onset of severe groin pain and the inability to walk after tripping on a curb. Examination reveals marked hip pain with passive range of motion. A radiograph is shown in Figure 21. Regardless of treatment, what is the most common complication following this injury?

Pediatrics Board Review 2004: High-Yield MCQs (Set 2) - Figure 28

. Chondrolysis
. Osteochondritis dissecans of the femoral head
. Osteonecrosis of the femoral head
. Nonunion
. Coxa magna

Correct Answer & Explanation

. Osteonecrosis of the femoral head

Explanation

The patient has an unstable slipped capital femoral epiphysis (SCFE). According to the classification system based on physeal stability, an unstable SCFE is one in which the patient is unable to walk, even with crutches. Ishemic necrosis, or osteonecrosis, of the femoral head is the most devastating complication of SCFE. One study found a 47% incidence of ischemic necrosis following unstable slips. This complication is most likely the result of vascular injury associated with initial femoral head displacement rather than the result of either tamponade from joint effusion or gentle repositioning prior to stabilization. Chondrolysis is a relatively uncommon complication following treatment of SCFE. This complication has been associated with persistent penetration of the hip joint with screws or pins used to stabilize the femoral head or with spica cast immobilization. There are no reports to suggest that osteochondritis dissecans, nonunion, or coxa magna follows treatment of SCFE. Loder RT, Richards BS, Shapiro PS, et al: Acute slipped capital epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-1140.

Question 422

Topic: Pediatric Hip

Figure 54 shows the preoperative radiograph of a 45-year-old woman who is considering total hip arthroplasty with her orthopaedic surgeon. What femoral characteristic is a typical concern in this patient?

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 4) - Figure 13

. Osteopenia
. Excessive anteversion
. Excessive varus
. Excessive bowing
. Stove-pipe femur

Correct Answer & Explanation

. Excessive anteversion

Explanation

Developmental dysplasia of the hip (DDH) leads to early arthritis of the hip as seen in this patient. Although DDH is believed to mostly affect the acetabulum, most patients with DDH also have anatomic aberrations of the femur. Using three-dimensional computer models generated by reconstruction of CT scans, dysplastic femurs were shown to have shorter necks and smaller, straighter canals than the controls. The shape of the canal became more abnormal with increasing subluxation. The studies also have shown that the primary deformity of the dysplastic femur is rotational, with an increase in anteversion of 5 degrees to 16 degrees, depending on the degree of subluxation of the hip. The rotational deformity of the dysplastic femur arises within the diaphysis between the lesser trochanter and the isthmus and is not attributable to a torsional deformity of the metaphysis. Osteopenia is not a concern in a patient with an excellent cortical index (thick cortices and narrow canal). Femoral varus or bowing of the femur is not a typical finding in patients with DDH. Noble PC, Kamaric E, Sugano N, et al: Three-dimensional shape of the dysplastic femur: Implications for THR. Clin Orthop 2003;417:27-40.

Question 423

Topic: Pediatric Hip

A 5-month-old girl with arthrogryposis has a limb-length discrepancy. Examination and radiographs reveal unilateral hip dislocation. Management should consist of

. a Pavlik harness.
. observation.
. closed reduction and a spica cast.
. open reduction and femoral shortening.
. open reduction.

Correct Answer & Explanation

. open reduction.

Explanation

In this age group of patients with arthrogryposis, open reduction through a medial approach is generally recommended. Open reduction through an anterior approach is reserved for patients in which a medial approach has failed or for older patients who require simultaneous femoral shortening and/or pelvic osteotomy. Closed treatment of unilateral hip dislocation in association with arthrogryposis is rarely successful. In bilateral hip dislocation associated with arthrogrypsis, the consensus is that the hips are best left unreduced because of the difficulty in obtaining excellent clinical and radiographic results bilaterally. Staheli LT, Chew DE, Elliot JS, Mosca VS: Management of hip dislocations in children with arthrogryposis. J Pediatr Orthop 1987;7:681-685. Szoke G, Staheli LT, Jaffe K, Hall JG: Medial-approach open reduction of hip dislocation in amyoplasia-type arthrogryposis. J Pediatr Orthop 1996;16:127-130.

Question 424

Topic: Pediatric Hip

Figure 10 shows the radiograph of a 7-year-old patient who has a bilateral Trendelenburg limp and limited range of hip motion but no pain. His work-up should include

Orthopedic Surgery Board Review 2026 | High-Yield MCQs - Set 2 - Figure 77

. a skeletal survey.
. genetic evaluation.
. cardiac evaluation.
. coagulation studies.
. MRI of the hips.

Correct Answer & Explanation

. a skeletal survey.

Explanation

The radiograph shows bilateral flattening of the femoral heads with mottling and "fragmentation" suggestive of Legg-Calve-Perthes disease. However, when these changes occur bilaterally and are symmetric, multiple epiphyseal dysplasia or spondyloepiphyseal dysplasia should be suspected. Skeletal survey will show irregularity of the secondary ossification centers. With these conditions, there is no true osteonecrosis and no evidence that orthotic or surgical "containment" will alter the outcome of progressive degenerative arthritis. Cardiac anomalies and coagulopathies are not associated with the epiphyseal dysplasias. Crossan JF, Wynne-Davies R, Fulford GE: Bilateral failure of the capital femoral epiphysis: Bilateral Perthes disease, multiple epiphyseal dysplasia, pseudoachondroplasia, and spondyloepiphyseal dysplasia congenita and tarda. J Pediatr Orthop 1983;3:297-301.

Question 425

Topic: Pediatric Hip
A 7-year-old patient has had a painless limp for several months. Examination reveals pain and spasm with internal rotation, and abduction is limited to 10 degrees on the involved side. Management consists of 1 week of bed rest and traction, followed by an arthrogram. A maximum abduction/internal rotation view is shown in Figure 40a, and abduction and adduction views are shown in Figures 40b and 40c. The studies are most consistent with
. Catterall II involvement.
. tubercular synovitis.
. Herring type A involvement.
. hinge abduction.
. osteochondritis dissecans.

Correct Answer & Explanation

. hinge abduction.

Explanation

The radiographs show classic hinge abduction. The diagnostic feature is the failure of the lateral epiphysis to slide under the acetabular edge with abduction, and the abduction view shows medial dye pooling because of distraction of the hip joint. Persistent hinge abduction has been shown to prevent femoral head remodeling by the acetabulum. Radiographic changes are characteristic of severe involvement with Legg-Calve-Perthes disease. The Catterall classification cannot be well applied without a lateral radiograph, but this degree of involvement would likely be considered a grade III or IV. Because the lateral pillar is involved, this condition would be classified as type C using the Herring lateral pillar classification scheme.

Question 426

Topic: Pediatric Hip

Figure 26 shows the radiograph of an otherwise healthy Caucasian 5-year-old boy who has a painless limp. What is the best treatment option?

Pediatrics 2007 Practice Questions: Set 3 (Solved) - Figure 8

. Shelf procedure
. Salter osteotomy
. Chiari osteotomy
. Varus derotation osteotomy
. Physical therapy and range-of-motion exercises

Correct Answer & Explanation

. Physical therapy and range-of-motion exercises

Explanation

The prognosis of Legg-Perthes disease in children younger than age 6 years is good. There is no indication that surgical treatment will improve the outcome. Range-of-motion exercises to prevent contracture may be helpful. Herring JA, Kim HT, Browne R: Legg-Calve-Perthes disease: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am 2004;86:2121-2134.

Question 427

Topic: Pediatric Hip

Figures 20a and 20b show the radiographs of an obese 15-year-old boy who has severe left groin pain and is unable to bear weight following a minor injury. Treatment should consist of

. fixation with one or two screws.
. cast immobilization.
. manipulative reduction with single screw fixation.
. in situ fixation with multiple screws.
. open epiphyseodesis.

Correct Answer & Explanation

. in situ fixation with multiple screws.

Explanation

The radiographs and history are consistent with an acute unstable slipped capital femoral epiphysis. Aronson and Loder documented an increased rate of osteonecrosis associated with manipulative reduction. They recommended bed rest with skin traction to allow the synovitis to resolve, followed by in situ pinning. They noted, however, that many of these slips reduced with anesthesia and positioning on a fracture table. Biomechanic studies have shown a slight increased resistance to shear stress when two screws are used, but it is unknown if this is significant in the clinical setting. Open epiphyseodesis does not provide postoperative stability; therefore, adjunctive fixation or immobilization is required. Numerous studies have noted the inadvisability of using multiple screws. Casting has a high rate of complications, including chondrolysis and progression of the slip. Aronson DD, Loder RT: Treatment of the unstable (acute) slipped capital femoral epiphysis. Clin Orthop 1996;322:99-110. Karol LA, Doane RM, Cornicelli SF, Zak PA, Haut RC, Manoli A II: Single versus double screw fixation for treatment of slipped capital femoral epiphysis: A biomechanical analysis. J Pediatr Orthop 1992;12:741-745.

Question 428

Topic: Pediatric Hip

A 15-year-old girl who swims the breaststroke has had hip pain after training excessively for a national level competition. Based on the MRI scans shown in Figures 5a through 5c, what is the most likely diagnosis?

. Femoral neck stress fracture
. External rotator muscle tear
. Slipped capital femoral epiphysis
. Superior acetabular labral tear
. Acetabular dysplasia

Correct Answer & Explanation

. External rotator muscle tear

Explanation

The MRI scans reveal open physes but no evidence of a slipped capital femoral epiphysis, labral tear, or acetabular dysplasia. The femoral neck does not show evidence of a fracture. The muscle tear seen on the right side lies near the musculotendinous junction of the external rotators of the hip at the level of the lesser trochanter, representing the obturator externus. This is consistent with the forced motion required for the breaststroke kick. Grote K, Lincoln TL, Gamble JG: Hip adductor injury in competitive swimmers. Am J Sports Med 2004;32:104-108.

Question 429

Topic: Pediatric Hip

Figure 36 shows the radiograph of a 14-year-old boy who has been treated in the past for Perthes' disease with an abduction brace. He now has hip pain that limits his activity, and nonsteroidal anti-inflammatory drugs have failed to provide relief. What is the most appropriate treatment?

Pediatrics Board Review 2007: High-Yield MCQs (Set 4) - Figure 6

. Proximal femoral varus osteotomy
. Salter innominate osteotomy
. Distal transfer of the greater trochanter
. Shelf acetabuloplasty
. Hip arthrodesis

Correct Answer & Explanation

. Shelf acetabuloplasty

Explanation

Several authors have reported good success in relieving pain with shelf acetabuloplasty. This patient's Perthes' disease is in the healed phase; therefore, proximal femoral varus and Salter innominate osteotomies aimed at improving containment are not indicated. The medial one half of the patient's femoral head is markedly deformed, and rotating it into a weight-bearing position with proximal femoral valgus osteotomy is unlikely to relieve pain. Hip arthrodesis can always be performed as a salvage procedure if the shelf acetabuloplasty fails. Daly K, Bruce C, Catterall A: Lateral shelf acetabuloplasty in Perthes' disease: A review of the end of growth. J Bone Joint Surg Br 1999;81:380-384.

Question 430

Topic: Pediatric Hip

A 53-year-old man with a history of severe left hip pain has a significant limp that is the result of a 5-cm limb-length discrepancy. An AP radiograph is shown in Figure 48. The underlying etiology is most likely related to a history of

Anatomy Board Review 2002: High-Yield MCQs (Set 4) - Figure 10

. septic arthritis.
. slipped capital femoral epiphysis.
. femoral head fracture (Pipkin I).
. developmental dysplasia of the hip.
. Legg-Calve-Perthes disease.

Correct Answer & Explanation

. Legg-Calve-Perthes disease.

Explanation

Radiographic abnormalities such as coxa magna, coxa breva secondary to growth arrest, and coxa plana and acetabular deformities are associated with healed Legg-Calve-Perthes disease. Femoral heads that were flat yet congruent with the acetabulum are at risk for disabling arthritis in the sixth decade of life in 50% of these untreated patients. As the normal ball-and-socket joint deforms to a flattened cylinder, the hip loses abduction and rotation capability, while retaining flexion and extension potential. If the femoral head is flat and is not concentric with the acetabulum, early severe arthritis occurs. Hinge abduction and anterior impingement are known sequelae of a flat, incongruent femoral head.

Question 431

Topic: Pediatric Hip

Figures 39a and 39b show the current radiographs of an 8-year-old girl who has had pain in the left thigh for the past 3 months. She was recently diagnosed with hypothyroidism and started treatment 1 week ago. Examination reveals a mild abductor deficiency limp on the left side. She lacks 30 degrees internal rotation on the left hip compared with the right hip. Management should consist of

. abductor muscle strengthening.
. a left 1-1/2 hip spica cast.
. closed reduction and pinning of the left hip.
. symptomatic treatment with crutch walking and nonsteroidal anti-inflammatory drugs.
. in situ pinning of both hips.

Correct Answer & Explanation

. in situ pinning of both hips.

Explanation

The radiographs confirm a slipped capital femoral epiphysis of the left hip, as well as a widened growth plate on the contralateral hip. This is considered a stable slip because the patient is able to walk. Treatment options for stable slips include in situ pinning, bone graft epiphysiodesis, and in some centers severe slips are treated with primary osteotomy and epiphyseal fixation. Percutaneous in situ fixation is the most popular and widely used method of treatment. This juvenile patient has an endocrine condition and a widened growth plate on the right side; therefore, strong consideration should be given to pinning the contralateral hip "pre-slip." Muscle strengthening, hip spica casting, and closed reduction have no place in the primary treatment of a stable slipped capital femoral epiphysis. Loder RT, Richards BS, Shapiro PS, et al: Acute slipped capital femoral epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-1140. Loder R, Wittenberg B, DeSilva G: Slipped capital femoral epiphysis associated with endocrine disorders. J Pediatr Orthop 1995;15:349-356.

Question 432

Topic: Pediatric Hip

A 5-year-old boy has had right hip pain and a limp for the past 3 months. Examination of the right hip reveals irritability and restricted abduction and internal rotation. AP and lateral radiographs of the hips are shown in Figures 31a and 31b. Initial management should consist of

. a Salter innominate osteotomy.
. a shelf acetabuloplasty.
. a varus femoral osteotomy.
. symptomatic treatment, including traction, activity modification, and nonsteroidal anti-inflammatory drugs.
. abduction bracing.

Correct Answer & Explanation

. symptomatic treatment, including traction, activity modification, and nonsteroidal anti-inflammatory drugs.

Explanation

A favorable prognosis can be expected in up to 70% of children with Legg-Calve-Perthes disease who are younger than age 6 years. Containment treatment has not been shown to alter the outcome in this age group. The goals of treatment in this patient are to reduce pain (synovitis), restore motion, and improve function. Symptomatic treatment modalities include bed rest, traction, crutches, activity modification, and nonsteroidal anti-inflammatory drugs. Herring JA: The treatment of Legg-Calve-Perthes disease: A critical review of the literature. J Bone Joint Surg Am 1994;76:448-458.

Question 433

Topic: Pediatric Hip

Figures 8a and 8b show the current radiographs of a 10-year-old boy with a hip disorder who was treated with an abduction orthosis 3 years ago. If no further remodeling occurs, what is the most likely prognosis?

. The patient is at risk for repeated episodes of ischemic necrosis.
. The patient is at high risk for deep venous thrombosis.
. No further problems will develop on the involved side.
. Accelerated onset of degenerative arthritis will develop on the involved side in the fifth or sixth decade of life.
. Epiphyseodesis will be required on the involved side.

Correct Answer & Explanation

. Accelerated onset of degenerative arthritis will develop on the involved side in the fifth or sixth decade of life.

Explanation

The radiographs show a child with Legg-Calve-Perthes disease (LCPD) that has healed. Deformity (asphericity) of the femoral head is evident, but the femoral head and acetabulum are congruous. Stulberg and associates found that hips with aspherical congruity at skeletal maturity functioned well until the fifth or sixth decade of life. Similarly, another study found that degenerative arthritis caused deteriorating hip function after age 40 years in patients with this degree of residual deformity. Repeated episodes of ischemic necrosis are unlikely. Although some studies suggested coagulation abnormalities such as protein C and S deficiencies in children with LCPD, other studies failed to show any evidence of inherited thrombophila in most children with this disorder. There are no studies to suggest growth acceleration occurs following LCPD. Stulberg SD, Cooperman DR, Wallenstein R: The natural history of Legg-Calve-Perthes disease. J Bone Joint Surg Am 1984;66:479-489.

Question 434

Topic: Pediatric Hip

A 40-year-old man has had hip pain with increased activity over the past year. Examination reveals restriction of motion and tenderness with combined hip flexion, adduction, and internal rotation. An AP radiograph is shown in Figure 34. What is the most likely diagnosis?

Anatomy 2008 Practice Questions: Set 3 (Solved) - Figure 12

. Developmental dysplasia of the hip
. Osteonecrosis
. Perthes disease
. Pseudogout
. Femoral acetabular impingement

Correct Answer & Explanation

. Femoral acetabular impingement

Explanation

Femoral acetabular impingement (FAI) is a pathologic entity leading to pain, reduced range of motion in flexion and internal rotation, and development of secondary arthritis of the hip. There are two types of FAI: cam impingement and pincher impingement. Cam impingement is seen when a nonspherical femoral head produces a cam effect when the prominent portion to the femoral head rotates into the joint. This mechanism produces shear forces that damage articular cartilage. Radiographs reveal early joint degeneration and flattening of the head neck junction (the so-called "pistol grip deformity") as seen in this image. The pincher type of impingement involves abnormal contact between the femoral head neck junction and the acetabulum, in the presence of a spherical femoral head. Beall DP, Sweet CF, Martin HD, et al: Imaging findings of femoraoacetabular impingement syndrome. Skeletal Radiol 2005;34:691-701.

Question 435

Topic: Pediatric Hip

Figure 42 shows the radiograph of a 12-year-old boy who has a limp and pain in the left hip with athletic activity. Examination reveals decreased abduction and internal rotation of the left hip, with pain at the extremes of motion and a 1-cm limb-length discrepancy. Management should consist of

Pediatrics 2001 Practice Questions: Set 3 (Solved) - Figure 25

. total hip arthroplasty.
. innominate osteotomy.
. varus osteotomy of the proximal femur.
. valgus osteotomy of the proximal femur.
. a shoe lift.

Correct Answer & Explanation

. valgus osteotomy of the proximal femur.

Explanation

The radiograph shows changes that are most consistent with Legg-Calve Perthes disease. Valgus extension osteotomy is the salvage procedure of choice in patients with late symptomatic Perthes disease with severe joint incongruity. Prerequisites for valgus extension osteotomy include an adequate range of hip adduction and proof of improved congruity in the new position. Total hip arthroplasty is not a good alternative in the young patient. Varus osteotomy would further shorten the extremity and place a flattened portion of the femoral head in the acetabulum. A prerequisite of the innominate osteotomy is a congruent reduction. Skaggs DL, Tolo VT: Legg-Calve-Perthes disease. J Am Acad Orthop Surg 1996;4:9-16.

Question 436

Topic: Pediatric Hip

A 13-year-old obese male complains of left knee pain and a limp for 3 weeks. Radiographs are provided:

He is able to bear weight with crutches. During physical examination, as the affected hip is passively flexed, into which position will the limb obligately deviate?

. Internal rotation
. External rotation
. Adduction
. Extension
. Abduction

Correct Answer & Explanation

. External rotation

Explanation

In slipped capital femoral epiphysis (SCFE), the proximal femoral epiphysis displaces posteriorly and inferiorly relative to the femoral neck. This altered anatomy leads to an obligate external rotation of the thigh during passive hip flexion, a classic physical examination finding.

Question 437

Topic: Pediatric Hip

In the evaluation of Slipped Capital Femoral Epiphysis (SCFE), which of the following scenarios is a widely accepted indication for prophylactic in situ pinning of the contralateral, asymptomatic hip?

. Age greater than 14 years in males with a unilateral SCFE
. Unilateral SCFE in an obese child with normal endocrinology
. Presence of an underlying endocrine disorder, such as renal osteodystrophy
. Klein's line intersecting the epiphysis bilaterally on initial radiograph
. Bone age advanced for chronologic age

Correct Answer & Explanation

. Presence of an underlying endocrine disorder, such as renal osteodystrophy

Explanation

Prophylactic pinning of the contralateral hip in a unilateral SCFE presentation is indicated in patients who are at exceptionally high risk for developing a subsequent contralateral slip. Accepted indications include the presence of endocrinopathies (such as hypothyroidism, panhypopituitarism, and renal osteodystrophy), prior radiation therapy, or young age (females < 10, males < 12) at the time of initial presentation. Bone age that is delayed (not advanced) is a risk factor.

Question 438

Topic: Pediatric Hip

A 10-year-old boy presents with a unilateral stable Slipped Capital Femoral Epiphysis (SCFE). In addition to treating the affected hip, the surgeon considers prophylactic in situ pinning of the contralateral hip. Which of the following conditions is the strongest indication for prophylactic fixation?

. Male sex
. Age greater than 14 years
. Hypothyroidism
. Body Mass Index (BMI) in the 85th percentile
. Presentation with a stable SCFE slip angle of 20 degrees

Correct Answer & Explanation

. Hypothyroidism

Explanation

Prophylactic pinning of the contralateral hip in SCFE is highly recommended in patients with endocrine disorders (e.g., hypothyroidism, growth hormone deficiency, renal osteodystrophy) due to the significantly higher risk of bilateral involvement. Other indications for prophylactic pinning include young age (< 10 years for boys) and unreliability for follow-up.

Question 439

Topic: Pediatric Hip
A 12-year-old male with a BMI > 95th percentile presents with hip pain and is diagnosed with a Slipped Capital Femoral Epiphysis (SCFE). Which of the following is the strongest indication for prophylactic in situ pinning of the asymptomatic contralateral hip?
. Age greater than 14 years at presentation
. Presence of a moderate slip angle (30-50 degrees) on the affected side
. Underlying endocrinopathy, such as hypothyroidism
. Male sex and African American descent
. History of prior hip trauma

Correct Answer & Explanation

. Underlying endocrinopathy, such as hypothyroidism

Explanation

Prophylactic pinning of the contralateral hip in SCFE is controversial but is strongly indicated in patients with underlying endocrinopathies (e.g., hypothyroidism, growth hormone deficiency) or renal osteodystrophy. These conditions dramatically increase the risk of bilateral involvement. Other indications include inability to follow up, radiation therapy, and open triradiate cartilage (though age and triradiate status are debated, endocrinopathy is universally agreed upon).

Question 440

Topic: Pediatric Hip

A 12-year-old obese male presents with left knee pain and a limp. Physical examination demonstrates obligate external rotation of the left hip during passive flexion. He is diagnosed with a stable Slipped Capital Femoral Epiphysis (SCFE) and undergoes in situ pinning with a single cannulated screw. What is the most common long-term complication of this treated condition?

. Avascular necrosis (AVN)
. Chondrolysis
. Femoral-acetabular impingement (FAI)
. Slipped contralateral epiphysis
. Subtrochanteric fracture

Correct Answer & Explanation

. Femoral-acetabular impingement (FAI)

Explanation

Femoral-acetabular impingement (FAI), specifically cam-type impingement, is the most common complication after in situ pinning of a SCFE. The prominent anterior metaphysis created by the posterior slip abuts the acetabular rim during flexion and internal rotation. AVN is a dreaded complication but is much more common in unstable SCFE. Chondrolysis is associated with unrecognized joint penetration by the hardware.

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