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Pediatric Hip MCQs

Practice Set 69 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 1361

Topic: Pediatric Hip

An 8-year-old boy presents with a progressive limp and hip pain. Radiographs demonstrate sclerosis and fragmentation of the proximal femoral epiphysis consistent with Legg-Calve-Perthes disease. Which of the following radiographic findings in the lateral pillar classification is most predictive of a poor long-term outcome?

. More than 50% loss of lateral pillar height
. Involvement of the medial pillar only
. A subchondral radiolucent line (Crescent sign)
. Metaphyseal cysts
. A V-shaped radiolucency in the lateral epiphysis (Gage sign)

Correct Answer & Explanation

. More than 50% loss of lateral pillar height

Explanation

The Lateral Pillar (Herring) classification is highly prognostic in Legg-Calve-Perthes disease. Group C, defined as greater than 50% collapse of the lateral pillar, is associated with the worst outcomes, often leading to early osteoarthritis, particularly in children over 8 years old.

Question 1362

Topic: Pediatric Hip

An 11-year-old girl with end-stage renal disease and renal osteodystrophy undergoes in situ percutaneous pinning for a left slipped capital femoral epiphysis (SCFE). Her right hip is completely asymptomatic and radiographically normal. What is the most appropriate management for the right hip?

. Observation with serial radiographs every 6 months
. Prophylactic in situ percutaneous pinning
. Prophylactic spica cast application
. Core decompression of the femoral neck
. Physeal bar resection

Correct Answer & Explanation

. Prophylactic in situ percutaneous pinning

Explanation

Patients with endocrinopathies, such as renal osteodystrophy or hypothyroidism, have an exceptionally high risk of developing bilateral SCFE. Prophylactic pinning of the contralateral asymptomatic hip is strongly recommended in these specific patient populations.

Question 1363

Topic: Pediatric Hip

A 13-year-old obese male presents with a 2-day history of severe right thigh pain and inability to bear weight after a minor trip. Examination shows obligatory external rotation of the right hip with flexion.

According to the Loder classification, which of the following criteria defines an 'unstable' slipped capital femoral epiphysis (SCFE)?

. Slip angle greater than 50 degrees
. Inability to ambulate with or without crutches
. Presence of a significant joint effusion on ultrasound
. Duration of symptoms less than 3 weeks
. Development of early chondrolysis

Correct Answer & Explanation

. Inability to ambulate with or without crutches

Explanation

The Loder classification divides SCFE into stable and unstable based on the patient's ability to bear weight. An unstable SCFE is defined by the inability to ambulate even with crutches, regardless of the duration of symptoms. This classification is clinically highly relevant because unstable SCFE has a significantly higher rate of avascular necrosis (AVN) approaching 50%.

Question 1364

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, it is noted that the anterior straps are adjusted too tightly, causing excessive hip flexion. This specific positioning error places the child at greatest risk for which of the following complications?

. Avascular necrosis of the femoral head
. Femoral nerve palsy
. Sciatic nerve palsy
. Obturator nerve palsy
. Inferior dislocation of the hip

Correct Answer & Explanation

. Femoral nerve palsy

Explanation

In the Pavlik harness, excessive hip flexion (typically > 120 degrees) can impinge the femoral nerve against the inguinal ligament, leading to a femoral nerve palsy (evident by loss of active knee extension/quadriceps function). Conversely, excessive abduction (posterior straps too tight) increases the risk of avascular necrosis (AVN) of the femoral head.

Question 1365

Topic: Pediatric Hip

A 13-year-old obese male presents with left groin pain and an obligatory external rotation of the hip during active flexion. An AP pelvis radiograph is obtained.

What is the most appropriate management for a stable presentation of this condition?

. Spica casting
. In situ single screw fixation
. Closed reduction and multiple pinning
. Imhauser osteotomy
. Open reduction and internal fixation via surgical dislocation

Correct Answer & Explanation

. In situ single screw fixation

Explanation

The presentation is classic for a Slipped Capital Femoral Epiphysis (SCFE). The gold standard treatment for a stable SCFE is in situ fixation across the physis with a single cannulated screw.

Question 1366

Topic: Pediatric Hip

A 12-year-old obese male presents with a 2-week history of left thigh pain and an antalgic limp. Examination reveals obligate external rotation with passive hip flexion. A radiograph is shown

. He is diagnosed with a Slipped Capital Femoral Epiphysis (SCFE). Which of the following is the strongest indication for prophylactic pinning of the contralateral asymptomatic hip?

. Male sex
. Modified Oxford bone age score of 20
. Initial presentation with acute slip
. Presence of an endocrine disorder (e.g., hypothyroidism)
. Body mass index in the 99th percentile

Correct Answer & Explanation

. Presence of an endocrine disorder (e.g., hypothyroidism)

Explanation

Prophylactic pinning of the contralateral hip in SCFE is highly recommended for patients with an underlying endocrine disorder (such as hypothyroidism, panhypopituitarism, or renal osteodystrophy), as they have a significantly higher risk of a subsequent bilateral slip. A low modified Oxford bone age score (<16), denoting skeletal immaturity, is also a relative indication, but a score of 20 indicates skeletal maturity.

Question 1367

Topic: Pediatric Hip

A 6-month-old female with developmental dysplasia of the hip (DDH) has failed 4 weeks of compliant Pavlik harness treatment. An ultrasound

reveals the hip remains persistently dislocated. What is the most appropriate next step in her management?

. Continue the Pavlik harness for an additional 4 weeks
. Switch to an abduction orthosis (e.g., Ilfeld splint)
. Closed reduction under anesthesia and spica casting
. Open reduction and femoral shortening osteotomy
. Varus derotational osteotomy (VDRO)

Correct Answer & Explanation

. Closed reduction under anesthesia and spica casting

Explanation

If a Pavlik harness fails to achieve reduction of a dislocated hip after 3 to 4 weeks of compliant use, it should be abandoned to prevent "Pavlik harness disease" (damage to the posterior acetabulum). The definitive next step in management for a 6-month-old is a closed reduction under general anesthesia, usually accompanied by an arthrogram and adductor tenotomy, followed by spica casting.

Question 1368

Topic: Pediatric Hip

A 13-year-old obese boy is brought to the emergency department strictly unable to bear weight on his left leg after a minor slip. Radiographs confirm a severe, unstable slipped capital femoral epiphysis (SCFE).

He undergoes urgent single-screw in situ fixation. Which of the following is the most feared and highest-risk complication specifically associated with an unstable SCFE compared to a stable SCFE?

. Chondrolysis
. Osteonecrosis (Avascular necrosis) of the femoral head
. Subtrochanteric femur fracture
. Slipped capital femoral epiphysis of the contralateral hip
. Deep vein thrombosis

Correct Answer & Explanation

. Osteonecrosis (Avascular necrosis) of the femoral head

Explanation

An unstable SCFE is defined clinically by the inability of the patient to ambulate, even with crutches. Unstable slips carry a profoundly higher risk of osteonecrosis (avascular necrosis) of the femoral head (ranging from 20% to nearly 50%), whereas AVN is exceedingly rare in stable SCFE. Chondrolysis is another complication but is classically associated with unrecognized pin joint penetration.

Question 1369

Topic: Pediatric Hip

A 13-year-old boy with a slipped capital femoral epiphysis (SCFE) cannot bear weight even with crutches. According to the Loder classification, this is an unstable SCFE. What is the most significant risk associated with an unstable SCFE compared to a stable SCFE?

. Chondrolysis
. Avascular necrosis (AVN)
. Femoral-acetabular impingement (FAI)
. Premature physeal closure
. Contralateral slip

Correct Answer & Explanation

. Avascular necrosis (AVN)

Explanation

An unstable SCFE (inability to bear weight with or without crutches) has a significantly higher risk of avascular necrosis (up to nearly 50%) compared to a stable SCFE, which has an AVN rate close to 0%.

Question 1370

Topic: Pediatric Hip

A 4-year-old child presents with an antalgic gait and pain in the right hip. Radiographs show flattening and increased density of the right femoral epiphysis. What is the most appropriate initial management?

. Immediate surgical pinning
. Observation and activity modification with crutches
. Total hip arthroplasty
. Steroid injections
. Casting in abduction

Correct Answer & Explanation

. Observation and activity modification with crutches

Explanation

This presentation is classic for Legg-Calve-Perthes disease (LCPD), an idiopathic avascular necrosis of the femoral head. For a 4-year-old, the primary goal is to maintain containment of the femoral head within the acetabulum to allow for remodeling and prevent deformity. While there are various treatment strategies depending on the extent and stage, in most young children, observation and activity modification (often with protected weight-bearing via crutches) is the initial approach for mild cases or early stages, allowing for revascularization and remodeling. Surgical pinning is for SCFE. Total hip arthroplasty is for end-stage arthritis. Steroid injections are not indicated. Casting in abduction (e.g., Petrie cast) may be used for more severe cases or older children to contain the femoral head, but not as the initial generalized approach for all LCPD.

Question 1371

Topic: Pediatric Hip

Which of the following is a classic radiographic sign of Developmental Dysplasia of the Hip (DDH) in an infant older than 3 months?

. Shenton's line disruption
. Increased acetabular index
. Lester's sign
. Ossification of the femoral head
. Perkins' line intersection

Correct Answer & Explanation

. Shenton's line disruption

Explanation

Shenton's line (a curved line formed by the medial aspect of the femoral neck and the inferior border of the superior pubic ramus) disruption is a classic radiographic sign of hip dislocation or subluxation in DDH. An increased acetabular index (angle formed by the acetabular roof and a horizontal line through the triradiate cartilage) indicates acetabular dysplasia. Lester's sign is not a recognized orthopedic sign. Ossification of the femoral head typically begins around 3-6 months and is not a direct sign of DDH, although delayed ossification can be associated. Perkins' line (vertical line from the lateral aspect of the acetabulum) helps define quadrants for femoral head position, but disruption of Shenton's line is a direct indicator of subluxation/dislocation.

Question 1372

Topic: Pediatric Hip

Which type of orthosis is most commonly used to manage developmental dysplasia of the hip (DDH) in an infant up to 6 months of age?

. Hip spica cast
. Pavlik harness
. Abduction brace
. Knee-ankle-foot orthosis (KAFO)
. Scottish Rite brace

Correct Answer & Explanation

. Pavlik harness

Explanation

The Pavlik harness is the most commonly used and effective orthosis for managing developmental dysplasia of the hip (DDH) in infants up to 6 months of age (and sometimes up to 9 months). It holds the hips in flexion and abduction, allowing for gradual reduction and development of the acetabulum. A hip spica cast is typically used for older infants or those who fail Pavlik harness treatment. Abduction braces are used for older children or after cast removal. KAFOs and Scottish Rite braces are for different orthopedic conditions.

Question 1373

Topic: Pediatric Hip
A 13-year-old obese male presents with a several-week history of left hip pain and a limping gait. He denies any specific trauma. On examination, he holds his left hip in external rotation and has decreased internal rotation and abduction. What is the most likely diagnosis and the immediate management?
. Legg-Calvé-Perthes disease; bed rest and NSAIDs
. Developmental dysplasia of the hip; Pavlik harness
. Transient synovitis; observation
. Slipped capital femoral epiphysis; non-weight bearing and urgent surgical pinning in situ
. Septic arthritis; urgent joint aspiration and antibiotics

Correct Answer & Explanation

. Slipped capital femoral epiphysis; non-weight bearing and urgent surgical pinning in situ

Explanation

This presentation (obese adolescent, hip pain, limping, external rotation, limited internal rotation/abduction) is classic for Slipped Capital Femoral Epiphysis (SCFE). SCFE is an orthopedic emergency because further slippage can occur. Immediate management involves making the patient strictly non-weight bearing on the affected side and urgent surgical pinning in situ to stabilize the growth plate and prevent further displacement. Legg-Calvé-Perthes typically affects younger children (4-8 years). DDH is infantile. Transient synovitis is self-limiting but less likely with these exam findings. Septic arthritis would present with acute, severe pain and fever.

Question 1374

Topic: Pediatric Hip
A 6-year-old boy presents with a painless limp and restricted hip motion, particularly abduction and internal rotation, for several months. Radiographs show fragmentation and flattening of the femoral epiphysis. What is the primary goal of treatment for Legg-Calvé-Perthes disease?
. To relieve pain with NSAIDs
. To prevent femoral head avascular necrosis
. To maintain femoral head sphericity and containment within the acetabulum
. To accelerate revascularization of the femoral head
. To perform an urgent surgical osteotomy

Correct Answer & Explanation

. To maintain femoral head sphericity and containment within the acetabulum

Explanation

The primary goal of treatment for Legg-Calvé-Perthes disease is to maintain the sphericity of the femoral head and achieve containment within the acetabulum. This helps to prevent femoral head collapse and subsequent premature osteoarthritis. While pain relief and revascularization are aspects of care, they are secondary to the overall goal of preserving the joint's shape and function. Urgent osteotomy is reserved for specific indications or failures of conservative management.

Question 1375

Topic: Pediatric Hip
A 4-year-old child presents with a sudden onset of hip pain and a limp. He has a low-grade fever but is otherwise well. Labs show mild elevation of ESR/CRP. Hip range of motion is mildly restricted, but he is able to bear some weight. What is the most likely diagnosis?
. Septic arthritis
. Legg-Calvé-Perthes disease
. Slipped capital femoral epiphysis (SCFE)
. Transient synovitis of the hip
. Juvenile idiopathic arthritis

Correct Answer & Explanation

. Transient synovitis of the hip

Explanation

This presentation (sudden onset limp and hip pain, low-grade fever, mild lab elevations, ability to bear some weight) is classic for transient synovitis of the hip, which is a benign, self-limiting inflammatory condition. Septic arthritis would present with much more severe pain, inability to bear weight, and higher inflammatory markers. Perthes and SCFE have more insidious onset and different age groups (Perthes 4-8, SCFE adolescent). JIA is a chronic condition.

Question 1376

Topic: Pediatric Hip

A 6-month-old infant is diagnosed with a dislocated hip due to Developmental Dysplasia of the Hip (DDH). After successful closed reduction, what is the MOST appropriate next step in management?

. Immediate full weight-bearing and physical therapy
. Long-term hip abduction bracing for 6-12 months
. Open reduction and internal fixation to secure reduction
. Spica cast immobilization for 6-12 weeks
. Observation with monthly clinical exams

Correct Answer & Explanation

. Spica cast immobilization for 6-12 weeks

Explanation

After successful closed reduction of a dislocated hip in DDH (typically for infants aged 6-18 months, or older infants where Pavlik harness failed), the hip is immobilized in a spica cast for typically 6-12 weeks to maintain the reduction and allow for acetabular remodeling. This is crucial for long-term stability. Long-term bracing might follow the cast, but cast immobilization is the immediate next step post-reduction. Open reduction is for irreducible dislocations.

Question 1377

Topic: Pediatric Hip

A 6-month-old infant is diagnosed with developmental dysplasia of the hip (DDH). Physical examination reveals a positive Barlow test and Galeazzi sign. Radiographs show a dislocated left hip. What is the most appropriate initial treatment?

. Immediate open reduction and spica cast
. Pavlik harness
. Closed reduction under anesthesia and spica cast
. Observation with serial ultrasounds
. Referral for triple osteotomy

Correct Answer & Explanation

. Pavlik harness

Explanation

For an infant diagnosed with DDH at 6 months of age, a Pavlik harness is the gold standard initial treatment for reducible hips. The Barlow test indicates reducibility. The Pavlik harness holds the hips in flexion and abduction, promoting femoral head seating and acetabular development. Open reduction or closed reduction with spica cast is typically reserved for older infants, failed harness treatment, or irreducible hips. Observation is inappropriate for a dislocated hip. Triple osteotomy is for older children with persistent dysplasia.

Question 1378

Topic: Pediatric Hip

A 3-month-old infant presents for a routine check-up. The pediatrician notes asymmetric thigh folds and a positive Ortolani test on the left hip. What is the most appropriate next step in management?

. Reassure the parents and observe for 3 months.
. Order a plain radiograph of the pelvis.
. Refer for immediate orthopedic consultation and likely Pavlik harness application.
. Start physical therapy exercises for hip strengthening.
. Obtain an MRI of the hip.

Correct Answer & Explanation

. Refer for immediate orthopedic consultation and likely Pavlik harness application.

Explanation

A positive Ortolani test in a 3-month-old infant indicates a reducible dislocated hip, which is a definitive sign of developmental dysplasia of the hip (DDH). Given the age and positive clinical finding, immediate orthopedic consultation and Pavlik harness application are the most appropriate steps. The Pavlik harness is highly effective for DDH when initiated early, especially before 6 months of age. Reassurance and observation are inappropriate for a dislocated hip. Plain radiographs are less reliable for cartilaginous hips in infants younger than 4-6 months, where ultrasound is preferred, but the clinical exam is diagnostic here. Physical therapy is not the primary treatment for a dislocated hip. MRI is usually reserved for complex cases or failed harness treatment.

Question 1379

Topic: Pediatric Hip

A 12-year-old boy, overweight, presents with a 3-week history of right hip and knee pain, particularly when walking. Examination shows a painful limp, limited internal rotation, and abduction of the hip. What is the most appropriate initial diagnostic imaging?

. MRI of the hip to rule out avascular necrosis.
. AP and frog-leg lateral radiographs of both hips.
. Ultrasound of the hip to check for effusion.
. CT scan of the pelvis.
. Plain radiographs of the knee.

Correct Answer & Explanation

. AP and frog-leg lateral radiographs of both hips.

Explanation

This clinical scenario (overweight adolescent with hip and knee pain, painful limp, limited internal rotation) is highly suspicious for Slipped Capital Femoral Epiphysis (SCFE). SCFE requires urgent diagnosis and treatment to prevent further slip and complications. The most appropriate initial diagnostic imaging is AP and frog-leg lateral radiographs of BOTH hips. This is crucial because SCFE can be bilateral (even if asymptomatic on the other side) and a frog-leg lateral view is essential to visualize the slip, which may not be obvious on the AP view. MRI is more sensitive but often not needed initially for diagnosis. Ultrasound and CT are typically not first-line for SCFE diagnosis. Plain radiographs of the knee would likely be normal given the hip pathology, but hip pain often refers to the knee.

Question 1380

Topic: Pediatric Hip
A 10-year-old boy presents with a 3-week history of right hip pain and a limp, without antecedent trauma. Physical examination reveals limited internal rotation and abduction of the right hip. Radiographs show sclerosis and flattening of the right femoral epiphysis. What is the most likely diagnosis?
. Slipped Capital Femoral Epiphysis (SCFE)
. Developmental Dysplasia of the Hip (DDH)
. Transient synovitis
. Legg-Calvé-Perthes disease (LCPD)
. Septic arthritis

Correct Answer & Explanation

. Legg-Calvé-Perthes disease (LCPD)

Explanation

The age (peak incidence 4-10 years), presentation (atraumatic hip pain, limp), and radiographic findings (sclerosis, flattening of the femoral epiphysis) are classic for Legg-Calvé-Perthes disease (LCPD), which is idiopathic avascular necrosis of the femoral head. SCFE typically occurs in older, obese adolescents. DDH is usually diagnosed in infancy. Transient synovitis is acute and self-limiting. Septic arthritis would present with more acute, severe pain, fever, and systemic signs.

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