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Pediatric Hip MCQs

Practice Set 70 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 1381

Topic: Pediatric Hip

A 4-year-old child presents with a Galeazzi sign (apparent shortening of one thigh with hips and knees flexed) and unequal skin folds in the groin. What is the most appropriate initial diagnostic imaging study?

. Plain radiographs of the pelvis
. MRI of the hips
. CT scan of the pelvis
. Ultrasound of the hips
. Bone scintigraphy

Correct Answer & Explanation

. Plain radiographs of the pelvis

Explanation

The clinical signs (Galeazzi sign, unequal skin folds) are suggestive of Developmental Dysplasia of the Hip (DDH). In children under 4-6 months, ultrasound is the preferred imaging modality because the femoral head is largely cartilaginous and not ossified, making X-rays unreliable. However, for a 4-year-old, ossification is sufficient, and plain radiographs of the pelvis (AP and frog-leg lateral views) are the primary initial diagnostic imaging study to assess hip morphology, acetabular index, and femoral head position. MRI and CT are typically reserved for surgical planning or more complex cases. Bone scintigraphy is not indicated for DDH.

Question 1382

Topic: Pediatric Hip

A 10-year-old male presents with a painful limp and limited internal rotation of the hip. Radiographs show a widening of the physis and posterior and inferior displacement of the femoral head relative to the femoral neck. Which of the following conditions is most likely, and what is the standard management?

. Developmental Dysplasia of the Hip (DDH); typically managed with Pavlik harness.
. Legg-Calve-Perthes disease; managed with containment bracing.
. Slipped Capital Femoral Epiphysis (SCFE); requiring surgical pinning in situ.
. Transient synovitis; managed with rest and NSAIDs.
. Juvenile Idiopathic Arthritis; managed with anti-inflammatory medication.

Correct Answer & Explanation

. Slipped Capital Femoral Epiphysis (SCFE); requiring surgical pinning in situ.

Explanation

The clinical presentation (painful limp, limited internal rotation) and radiographic findings (widening of physis, posterior/inferior displacement of femoral head) are classic for Slipped Capital Femoral Epiphysis (SCFE). SCFE is a condition of adolescence where the growth plate weakens and the epiphysis slips off the metaphysis. It is an orthopedic emergency to prevent further slip and avascular necrosis, requiring immediate surgical pinning in situ. The other conditions have different presentations and management strategies.

Question 1383

Topic: Pediatric Hip

A 5-year-old child presents with a limp, hip pain, and restricted hip abduction and internal rotation. Radiographs show increased density (sclerosis) and fragmentation of the femoral head epiphysis. What is the most likely diagnosis?

. Transient synovitis.
. Septic arthritis.
. Slipped Capital Femoral Epiphysis (SCFE).
. Legg-Calve-Perthes disease.
. Developmental Dysplasia of the Hip (DDH).

Correct Answer & Explanation

. Legg-Calve-Perthes disease.

Explanation

The clinical picture (limp, hip pain, restricted motion in a young child) combined with radiographic findings of increased density and fragmentation of the femoral head epiphysis is classic for Legg-Calve-Perthes disease. This condition is idiopathic avascular necrosis of the femoral head. Transient synovitis is self-limiting inflammation without radiographic changes. Septic arthritis would present acutely with fever and severe pain. SCFE occurs in older children/adolescents with epiphyseal slip. DDH is a developmental abnormality of the hip joint.

Question 1384

Topic: Pediatric Hip

A 1-year-old infant is diagnosed with a dislocated hip on routine screening examination. Ortolani and Barlow tests are positive. Radiographs confirm developmental dysplasia of the hip (DDH). Which of the following is the most appropriate initial management?

. Open reduction and spica cast.
. Pavlik harness.
. Observation with regular follow-up.
. Femoral osteotomy.
. Physical therapy.

Correct Answer & Explanation

. Pavlik harness.

Explanation

For infants diagnosed with Developmental Dysplasia of the Hip (DDH), particularly those with a dislocated but reducible hip as indicated by positive Ortolani and Barlow tests, the Pavlik harness is the most appropriate initial management. It is a soft abduction brace that encourages hip flexion and abduction, allowing the hip to reduce spontaneously and stabilize. Open reduction is for older children or failed harness treatment. Observation is only for mild dysplasia. Osteotomy is a reconstructive procedure for older children. Physical therapy alone is insufficient.

Question 1385

Topic: Pediatric Hip
A 4-year-old child presents with a limp and right hip pain that started insidiously. X-rays show fragmentation and collapse of the right femoral head epiphysis. What is the most likely diagnosis?
. Septic arthritis of the hip.
. Developmental dysplasia of the hip (DDH).
. Slipped capital femoral epiphysis (SCFE).
. Legg-Calvé-Perthes disease.
. Transient synovitis.

Correct Answer & Explanation

. Legg-Calvé-Perthes disease.

Explanation

The clinical presentation (limp, hip pain, insidious onset in a young child) combined with radiographic findings of fragmentation and collapse of the femoral head epiphysis is classic for Legg-Calvé-Perthes disease, which is avascular necrosis of the femoral head in children. Septic arthritis has an acute onset with systemic signs. DDH is a developmental abnormality. SCFE typically affects older, obese adolescents. Transient synovitis is a self-limiting inflammatory condition with normal X-rays.

Question 1386

Topic: Pediatric Hip
A 10-year-old obese male presents with a painful limp and external rotation of the affected leg, which worsens with activity. Radiographs show a widening and irregularity of the physis, with posterior and inferior displacement of the femoral head relative to the femoral neck. What is the most likely diagnosis?
. Legg-Calvé-Perthes disease.
. Transient synovitis of the hip.
. Septic arthritis of the hip.
. Developmental dysplasia of the hip (DDH).
. Slipped capital femoral epiphysis (SCFE).

Correct Answer & Explanation

. Slipped capital femoral epiphysis (SCFE).

Explanation

The presentation of a painful limp, external rotation deformity, and classic radiographic findings (widening/irregularity of physis, posterior/inferior displacement of femoral head) in an obese adolescent male is pathognomonic for Slipped Capital Femoral Epiphysis (SCFE). Legg-Calvé-Perthes disease affects younger children and involves fragmentation/collapse of the femoral head. Transient synovitis is self-limiting and has normal X-rays. Septic arthritis presents acutely with fever and systemic signs. DDH is a neonatal/infant condition.

Question 1387

Topic: Pediatric Hip
A 7-year-old child presents with a limp, hip pain, and limited internal rotation and abduction of the hip. Radiographs show epiphyseal displacement of the femoral head. What is the most likely diagnosis?
. Developmental dysplasia of the hip (DDH)
. Legg-Calvé-Perthes disease
. Septic arthritis of the hip
. Slipped capital femoral epiphysis (SCFE)
. Transient synovitis

Correct Answer & Explanation

. Slipped capital femoral epiphysis (SCFE)

Explanation

Slipped Capital Femoral Epiphysis (SCFE) typically presents in pre-adolescent or adolescent children (around 10-16 years old, though can be younger) with obesity, hip or knee pain, and a characteristic limited internal rotation and obligate external rotation with hip flexion. Radiographs show posterior and inferior displacement of the femoral epiphysis relative to the metaphysis. Legg-Calvé-Perthes disease affects a younger age group (4-8 years) and involves avascular necrosis of the femoral head. DDH is a neonatal/infantile condition. Septic arthritis presents with acute onset of severe pain, fever, and systemic signs. Transient synovitis is a self-limiting inflammatory condition with less severe symptoms.

Question 1388

Topic: Pediatric Hip

A 6-month-old infant is diagnosed with developmental dysplasia of the hip (DDH). The Ortolani and Barlow tests are negative. Ultrasonography shows acetabular dysplasia but a reducible hip. What is the most appropriate initial treatment?

. Observation
. Spica cast
. Open reduction
. Pavlik harness
. Traction

Correct Answer & Explanation

. Pavlik harness

Explanation

For infants diagnosed with developmental dysplasia of the hip (DDH) that is reducible and not dislocated (Graf Type IIa or IIb), the Pavlik harness is the most appropriate initial treatment. It maintains the hip in a position of flexion and abduction, promoting acetabular development. A spica cast or open reduction is used for irreducible or dislocated hips, or when Pavlik harness fails. Observation is inappropriate for a diagnosed reducible DDH. Traction is rarely used as primary treatment for DDH.

Question 1389

Topic: Pediatric Hip
A 2-year-old child presents with a new onset limp and refusal to bear weight. Radiographs of the lower extremities are normal. Physical examination is unremarkable except for mild pain with internal rotation of the right hip. Laboratory studies show a normal white blood cell count and slightly elevated ESR (25 mm/hr). What is the most likely diagnosis?
. Septic arthritis of the hip
. Transient synovitis of the hip
. Osteomyelitis of the femur
. Legg-Calvé-Perthes disease
. Slipped capital femoral epiphysis (SCFE)

Correct Answer & Explanation

. Transient synovitis of the hip

Explanation

This presentation (young child, limp, refusal to bear weight, normal radiographs, mild pain on hip motion, slightly elevated ESR) is highly consistent with transient synovitis of the hip. It is a diagnosis of exclusion and the most common cause of hip pain in children aged 3-10. Septic arthritis would present with higher fever, more severe pain, marked elevation of inflammatory markers, and severe limitation of motion. Osteomyelitis would typically show more focal pain and later radiographic changes. Legg-Calvé-Perthes disease is avascular necrosis of the femoral head, presenting with a limp but usually in an older age group (4-8 years) and characteristic radiographic changes. SCFE is typically in pre-adolescents/adolescents and has distinct radiographic findings.

Question 1390

Topic: Pediatric Hip

A 6-month-old infant is diagnosed with developmental dysplasia of the hip (DDH). The Ortolani and Barlow tests are negative, but there is asymmetry of the thigh folds and limited hip abduction. What is the most appropriate initial treatment?

. Observation with close follow-up
. Pavlik harness
. Spica cast
. Open reduction and internal fixation
. Traction followed by casting

Correct Answer & Explanation

. Pavlik harness

Explanation

For an infant diagnosed with DDH between birth and 6-9 months, especially with reducible instability or limited abduction (even if Ortolani/Barlow are negative at this age due to soft tissue contracture), a Pavlik harness is the gold standard initial treatment. It maintains the hips in flexion and abduction, promoting proper acetabular development. Observation is insufficient for true DDH. Spica cast or open reduction are used for older infants, failed harness treatment, or irreducible hips.

Question 1391

Topic: Pediatric Hip

Which of the following is the hallmark radiological sign for a slipped capital femoral epiphysis (SCFE)?

. Increased femoral neck-shaft angle
. Decreased epiphyseal height
. Absence of Klein's line crossing the lateral part of the femoral epiphysis
. Widening of the physis with metaphyseal sclerosis
. Bone fragmentation and collapse of the femoral head

Correct Answer & Explanation

. Absence of Klein's line crossing the lateral part of the femoral epiphysis

Explanation

The hallmark radiological sign for SCFE is a failure of Klein's line (a line drawn along the superior border of the femoral neck) to intersect the lateral portion of the femoral epiphysis on an AP pelvic radiograph. Normally, Klein's line should cross at least a portion of the epiphysis. Widening of the physis with metaphyseal sclerosis can be seen, but the relationship with Klein's line is more definitive. Increased neck-shaft angle is not specific, and bone fragmentation/collapse suggests AVN, not acute SCFE.

Question 1392

Topic: Pediatric Hip
Which of the following conditions is characterized by a gradual onset of hip pain in an obese adolescent, often presenting with a painful limp and limited internal rotation and abduction?
. Legg-Calvé-Perthes disease
. Transient synovitis of the hip
. Septic arthritis
. Slipped capital femoral epiphysis (SCFE)
. Juvenile idiopathic arthritis

Correct Answer & Explanation

. Slipped capital femoral epiphysis (SCFE)

Explanation

Slipped capital femoral epiphysis (SCFE) classically presents in obese adolescents (typically 10-16 years old) with a gradual onset of hip or knee pain, a painful limp, and characteristic limited internal rotation and abduction of the hip. Legg-Calvé-Perthes disease occurs in younger children (4-8 years). Transient synovitis is acute and resolves. Septic arthritis is acute with systemic signs. Juvenile idiopathic arthritis has a more chronic inflammatory presentation.

Question 1393

Topic: Pediatric Hip

A 12-year-old obese male presents with a slipped capital femoral epiphysis (SCFE). Which of the following best describes the typical anatomical direction of epiphyseal displacement relative to the femoral neck?

. Anterior and superior
. Anterior and inferior
. Posterior and superior
. Posterior and inferior
. Directly posterior

Correct Answer & Explanation

. Posterior and inferior

Explanation

In a slipped capital femoral epiphysis, the epiphysis typically displaces posteriorly and inferiorly relative to the femoral neck metaphysis. Conversely, the metaphysis translates anteriorly and superiorly.

Question 1394

Topic: Pediatric Hip

When treating developmental dysplasia of the hip (DDH) in an infant with a Pavlik harness, excessive hyperflexion of the hip (greater than 120 degrees) increases the risk of which iatrogenic complication?

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

Correct Answer & Explanation

. Femoral nerve palsy

Explanation

Excessive flexion (>120 degrees) in a Pavlik harness puts the patient at risk for a femoral nerve palsy due to compression of the nerve against the inguinal ligament. Excessive abduction, on the other hand, risks avascular necrosis.

Question 1395

Topic: Pediatric Hip

A 6-year-old boy is diagnosed with Legg-Calve-Perthes disease (LCPD). According to the Herring lateral pillar classification, which radiographic feature is the most critical determinant of a poor prognosis (Herring Group C)?

. Sclerosis of the anterior pillar
. Greater than 50% loss of lateral pillar height
. Less than 50% loss of lateral pillar height
. Central pillar fragmentation only
. Presence of a subchondral crescent sign

Correct Answer & Explanation

. Greater than 50% loss of lateral pillar height

Explanation

The Herring lateral pillar classification heavily dictates prognosis in LCPD based on AP pelvic radiographs in the fragmentation stage. Group C, defined by >50% loss of lateral pillar height, portends the worst prognosis with the highest risk of permanent femoral head deformity.

Question 1396

Topic: Pediatric Hip

A 4-month-old infant is being treated with a Pavlik harness for developmental dysplasia of the hip (DDH). During follow-up, the mother notes the child is no longer actively extending the knee on the treated side. Which of the following harness malpositioning errors is the most likely cause?

. Excessive hip abduction
. Excessive hip adduction
. Excessive hip flexion
. Insufficient hip flexion
. Insufficient hip abduction

Correct Answer & Explanation

. Excessive hip flexion

Explanation

Placing the hip in excessive flexion within a Pavlik harness can compress the femoral nerve against the inguinal ligament. This results in a transient femoral nerve palsy, evident by a lack of active knee extension.

Question 1397

Topic: Pediatric Hip

Prophylactic in situ pinning of the contralateral asymptomatic hip is most strongly indicated in a patient presenting with a unilateral slipped capital femoral epiphysis (SCFE) and which of the following concurrent conditions?

. Morbid obesity
. Hypothyroidism
. Attention-deficit/hyperactivity disorder
. Type 1 diabetes mellitus
. Down syndrome

Correct Answer & Explanation

. Hypothyroidism

Explanation

Patients with SCFE secondary to endocrine disorders (e.g., hypothyroidism, panhypopituitarism) or renal osteodystrophy have an exceptionally high risk of bilateral involvement. Prophylactic pinning of the contralateral hip is strongly recommended in these cases.

Question 1398

Topic: Pediatric Hip

A 6-week-old female infant is undergoing ultrasound evaluation for developmental dysplasia of the hip (DDH). The Graf alpha angle is measured at 52 degrees. What does this measurement indicate?

. A normal, mature hip
. A physiologically immature hip expected to normalize without intervention
. A dysplastic hip requiring treatment
. A completely dislocated hip resting outside the labrum
. An artifact of incorrect probe positioning

Correct Answer & Explanation

. A dysplastic hip requiring treatment

Explanation

An alpha angle less than 60 degrees indicates a shallow bony acetabular roof and is considered abnormal. An angle of 52 degrees falls into the dysplastic category (Graf type IIc or worse) and generally warrants treatment with a Pavlik harness.

Question 1399

Topic: Pediatric Hip

In Legg-Calve-Perthes disease, the lateral pillar classification is highly prognostic of long-term head shape outcomes. According to Herring's lateral pillar classification, a Type B hip is characterized radiographically by which of the following?

. No radiolucency or collapse of the lateral pillar
. >50% maintenance of the lateral pillar height
. <50% maintenance of the lateral pillar height
. Complete collapse of the lateral pillar with lateral extrusion
. Central pillar collapse with structurally intact medial and lateral pillars

Correct Answer & Explanation

. <50% maintenance of the lateral pillar height

Explanation

Herring's lateral pillar classification assesses the height of the lateral portion of the capital femoral epiphysis on an AP pelvis radiograph during the fragmentation phase. Type A involves no lateral pillar involvement. Type B involves >50% maintenance of lateral pillar height. Type C involves <50% maintenance of lateral pillar height. Type B/C border cases have a specific prognostic significance.

Question 1400

Topic: Pediatric Hip

A 13-year-old obese male presents with right groin pain and a limp for 3 weeks. On physical examination, as his right hip is passively flexed, it falls into obligatory external rotation. He is unable to bear weight on the right leg, even with the use of crutches. Which of the following is the most accurate statement regarding his condition?

. This is a stable slipped capital femoral epiphysis (SCFE) and carries a low risk of avascular necrosis.
. The definition of an unstable SCFE is based entirely on the radiographic slip angle being greater than 50 degrees.
. Prophylactic pinning of the contralateral hip is universally required regardless of age or endocrine status.
. This is an unstable SCFE, which carries an increased risk of avascular necrosis (up to 50%).
. The primary blood supply at risk during closed reduction of this condition is the artery of the ligamentum teres.

Correct Answer & Explanation

. This is an unstable SCFE, which carries an increased risk of avascular necrosis (up to 50%).

Explanation

The patient's presentation of obligatory external rotation with hip flexion is classic for Slipped Capital Femoral Epiphysis (SCFE). The inability to bear weight, even with crutches, defines an unstable SCFE according to Loder's classification. Unstable SCFE carries a significantly higher risk of avascular necrosis (AVN), historically ranging from 20% to 50%, compared to nearly 0% in stable SCFE.

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