Menu

Pediatric Upper Extremity & Spine MCQs

Practice Set 1 of 33

This practice set contains high-yield board review questions covering key concepts in Pediatric Upper Extremity & Spine. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 1

Topic: Pediatric Upper Extremity & Spine

A 12-year-old elite baseball pitcher presents with chronic medial elbow pain. Radiographs demonstrate widening and fragmentation of the medial epicondyle apophysis. What biomechanical forces are primarily responsible for this condition?

. Valgus overload causing medial tension and lateral compression
. Varus overload causing medial compression and lateral tension
. Hyperextension causing posterior impingement
. Hyperflexion causing anterior capsular strain
. Direct traumatic impact to the medial epicondyle

Correct Answer & Explanation

. Valgus overload causing medial tension and lateral compression

Explanation

Little League elbow encompasses several conditions caused by repetitive valgus overload during throwing. This creates tension forces on the medial structures (causing medial epicondyle apophysitis) and compressive forces on the lateral structures.

Question 2

Topic: Pediatric Upper Extremity & Spine

A 6-year-old girl falls from the monkey bars and sustains an extension-type supracondylar humerus fracture. After closed reduction and percutaneous pinning, she is unable to flex the interphalangeal joint of her thumb and the distal interphalangeal joint of her index finger. Which nerve is most likely injured?

. Ulnar nerve
. Radial nerve
. Anterior interosseous nerve (AIN)
. Posterior interosseous nerve (PIN)
. Musculocutaneous nerve

Correct Answer & Explanation

. Anterior interosseous nerve (AIN)

Explanation

The anterior interosseous nerve (AIN) is the most commonly injured nerve in extension-type supracondylar humerus fractures. Injury results in the inability to make an 'OK' sign due to weakness of the flexor pollicis longus and the flexor digitorum profundus to the index finger.

Question 3

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with an extension-type displaced supracondylar humerus fracture (Gartland Type III). He is unable to flex the interphalangeal joint of his thumb or the distal interphalangeal joint of his index finger. Which nerve is most likely injured?
. Posterior interosseous nerve
. Ulnar nerve
. Anterior interosseous nerve
. Musculocutaneous nerve
. Superficial radial nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

The anterior interosseous nerve (AIN), a branch of the median nerve, is the most commonly injured nerve in extension-type supracondylar humerus fractures. It provides motor innervation to the flexor pollicis longus and the flexor digitorum profundus of the index and middle fingers.

Question 4

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains an extension-type supracondylar humerus fracture. Upon presentation, he is unable to flex the interphalangeal joint of his thumb or the distal interphalangeal joint of his index finger. Which nerve is most likely injured?

. Ulnar nerve
. Radial nerve
. Anterior interosseous nerve
. Posterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

The anterior interosseous nerve (AIN) is the most commonly injured nerve in extension-type supracondylar humerus fractures. Injury presents with the inability to form an "OK" sign due to weakness of the FPL and FDP to the index finger.

Question 5

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarcheal girl is diagnosed with Adolescent Idiopathic Scoliosis. Radiographs demonstrate a Risser 0 stage and a right thoracic curve measuring 34 degrees. What is the most appropriate next step in management?

. Observation with radiographs in 6 months
. Physical therapy focusing on core strengthening
. Thoracolumbosacral orthosis (TLSO) bracing
. Posterior spinal fusion
. Anterior vertebral body tethering

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing

Explanation

Bracing is indicated for skeletally immature patients (Risser 0-2) presenting with curve magnitudes between 25 and 45 degrees. A TLSO is the standard of care to prevent curve progression in this demographic.

Question 6

Topic: Pediatric Upper Extremity & Spine

In the Lenke classification for adolescent idiopathic scoliosis, a lumbar modifier of "B" indicates that the Center Sacral Vertical Line (CSVL) falls:

. Medial to the pedicles of the apical lumbar vertebra
. Between the medial border of the pedicle and the lateral margin of the apical vertebral body
. Lateral to the apical vertebral body completely
. Exactly through the center of the apical vertebra
. Through the apex of the thoracic curve

Correct Answer & Explanation

. Between the medial border of the pedicle and the lateral margin of the apical vertebral body

Explanation

In the Lenke classification, a "B" modifier means the CSVL falls between the medial aspect of the concave pedicle and the lateral margin of the apical lumbar vertebral body. "A" is between the pedicles, and "C" is entirely medial to the body.

Question 7

Topic: Pediatric Upper Extremity & Spine

Which Risser stage corresponds to complete ossification and fusion of the iliac apophysis to the ilium, indicating skeletal maturity?

. Risser 1
. Risser 3
. Risser 4
. Risser 5
. Risser 0

Correct Answer & Explanation

. Risser 5

Explanation

Risser 5 indicates complete capping and fusion of the iliac apophysis to the ilium, signaling the end of spinal growth. Risser 1-4 correspond to the progressive lateral-to-medial ossification of the apophysis.

Question 8

Topic: Pediatric Upper Extremity & Spine

A 13-year-old female presents with a 25-degree right thoracic scoliosis curve. Radiographs show ossification over the lateral 50% of the iliac apophysis, but it has not reached the medial half. What is her Risser grade?

. Risser 1
. Risser 2
. Risser 3
. Risser 4
. Risser 5

Correct Answer & Explanation

. Risser 2

Explanation

Risser 2 indicates ossification of 25% to 50% of the iliac apophysis. Risser 1 is 0-25%, Risser 3 is 50-75%, Risser 4 is 75-100% (without fusion), and Risser 5 is complete fusion of the apophysis to the ilium.

Question 9

Topic: Pediatric Upper Extremity & Spine

A 16-year-old female is diagnosed with adolescent idiopathic scoliosis. Her Cobb angle is 35 degrees, and she is pre-menarchal with a Risser stage of 1. What is the most appropriate management?

. Observation with follow-up radiographs in 1 year
. Thoracolumbosacral orthosis (TLSO) bracing
. Poster spinal fusion
. Anterior spinal tethering
. Epidural steroid injections

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing

Explanation

Bracing is indicated in growing adolescents (Risser 0-2) with progressive curves or curves measuring 25 to 45 degrees. A TLSO aims to halt curve progression during the remaining growth spurt.

Question 10

Topic: Pediatric Upper Extremity & Spine

A patient presents with a spinal cord injury following a severe trauma. Sensation is preserved below the level of injury including the S4-S5 dermatomes, but there is no voluntary motor function in the lower extremities. Anal sphincter tone is absent, but deep anal sensation is present. Which ASIA Impairment Scale (AIS) grade does this represent?

. ASIA A
. ASIA B
. ASIA C
. ASIA D
. ASIA E

Correct Answer & Explanation

. ASIA B

Explanation

ASIA B represents a sensory incomplete injury where sensation is preserved below the neurologic level (including S4-S5), but motor function is completely lost. The presence of deep anal sensation confirms the incomplete sensory status.

Question 11

Topic: Pediatric Upper Extremity & Spine

In a 14-year-old patient diagnosed with Scheuermann's kyphosis, which of the following scenarios is the most appropriate indication for initiating treatment with a Milwaukee brace?

. A 30-degree flexible curve
. A 60-degree rigid curve with anterior wedging
. An 85-degree rigid curve with intractable back pain
. A 45-degree curve in a patient with a Risser 5 status
. A 20-degree rigid curve

Correct Answer & Explanation

. A 60-degree rigid curve with anterior wedging

Explanation

Extension bracing is indicated for skeletally immature patients presenting with a kyphotic curve between 50 and 75 degrees. Curves exceeding 75 degrees often require surgical correction, while mature patients or mild curves are managed symptomatically.

Question 12

Topic: Pediatric Upper Extremity & Spine

In evaluating a 12-year-old female with adolescent idiopathic scoliosis (AIS), which of the following combinations of factors represents the highest risk for curve progression?

. Risser 4 stage, post-menarchal, 20-degree curve
. Risser 0 stage, pre-menarchal, 35-degree curve
. Risser 2 stage, post-menarchal, 15-degree curve
. Risser 5 stage, post-menarchal, 45-degree curve
. Male sex, Risser 3 stage, 25-degree curve

Correct Answer & Explanation

. Risser 0 stage, pre-menarchal, 35-degree curve

Explanation

The risk of curve progression in AIS is highest in patients with significant remaining growth (pre-menarchal, Risser 0-1) and larger magnitude curves (>25-30 degrees) at the time of presentation.

Question 13

Topic: Pediatric Upper Extremity & Spine

The Lenke classification system for Adolescent Idiopathic Scoliosis (AIS) utilizes a sagittal modifier. Which specific radiographic measurement determines this modifier?

. T1-T5 kyphosis
. T5-T12 kyphosis
. T10-L2 kyphosis
. L1-S1 lordosis

Correct Answer & Explanation

. T5-T12 kyphosis

Explanation

The Lenke sagittal thoracic modifier is determined by measuring the kyphosis between T5 and T12. It is classified as hypokyphotic (-), normal (N), or hyperkyphotic (+).

Question 14

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal girl is diagnosed with adolescent idiopathic scoliosis. Her physical examination reveals a right thoracic prominence. Radiographs show a right thoracic curve with a Cobb angle of 34 degrees and a Risser stage of 1. What is the most appropriate management?

. Observation with radiographs every 6 months
. Physical therapy and spinal manipulation
. Prescription of a Thoracolumbosacral orthosis (TLSO)
. Posterior spinal fusion with instrumentation
. Anterior release and fusion

Correct Answer & Explanation

. Prescription of a Thoracolumbosacral orthosis (TLSO)

Explanation

Bracing is indicated for skeletally immature patients (Risser 0-2, premenarchal) with an idiopathic curve between 25 and 45 degrees. A TLSO brace effectively alters the natural history of curve progression in this high-risk population.

Question 15

Topic: Pediatric Upper Extremity & Spine

Which of the following parameters indicates the highest risk for curve progression in a 12-year-old female with adolescent idiopathic scoliosis?

. Risser grade 4
. Closed triradiate cartilage
. Menarche onset 2 years prior
. Risser grade 0 with open triradiate cartilage
. A single thoracic curve of 15 degrees

Correct Answer & Explanation

. Risser grade 4

Explanation

The risk of curve progression in adolescent idiopathic scoliosis is highest during the peak height velocity. A Risser grade of 0 combined with an open triradiate cartilage indicates significant remaining skeletal growth, placing the patient at maximum risk.

Question 16

Topic: Pediatric Upper Extremity & Spine
A 12-year-old premenarcheal female with adolescent idiopathic scoliosis presents with a right thoracic curve measuring 32 degrees on standing AP radiographs. Her Risser stage is 0. What is the most appropriate evidence-based recommendation for her treatment?
. Observation with radiographs in 6 months
. Physical therapy focusing on core strengthening
. Posterior spinal fusion
. Thoracolumbosacral orthosis (TLSO) brace wear for 18-23 hours a day
. Nighttime-only bending brace

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) brace wear for 18-23 hours a day

Explanation

This patient has significant remaining growth (premenarcheal, Risser 0) and a curve between 25 and 45 degrees. According to the BRAIST trial, rigid bracing (like a TLSO) for at least 18 hours per day is indicated and highly effective at preventing progression to surgery.

Question 17

Topic: Pediatric Upper Extremity & Spine

According to the Lenke Classification system for Adolescent Idiopathic Scoliosis, what specific radiographic criterion officially defines a 'structural' minor curve on side-bending films?

. A residual coronal curve of greater than or equal to 25 degrees
. A residual coronal curve of greater than or equal to 10 degrees
. Apical vertebral rotation of Grade II or higher
. A rigid kyphosis greater than 40 degrees
. Failure of the apical vertebra to cross the midline

Correct Answer & Explanation

. A residual coronal curve of greater than or equal to 25 degrees

Explanation

In the Lenke classification system, a minor curve is considered structural if the residual curve on a maximum supine side-bending radiograph remains greater than or equal to 25 degrees, or if the regional kyphosis is +20 degrees or greater.

Question 18

Topic: Pediatric Upper Extremity & Spine

A 13-year-old pre-menarchal girl presents with a right thoracic adolescent idiopathic scoliosis measuring 32 degrees. Her Risser stage is 0, and her Sanders bone age corresponds to stage 2. What is the most appropriate, evidence-based management strategy?

. Observation with radiographs every 6 months
. Schroth physical therapy alone
. Thoracolumbosacral orthosis (TLSO) for 18-23 hours daily
. Nighttime-only bending brace
. Posterior spinal fusion

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) for 18-23 hours daily

Explanation

For a skeletally immature patient (Risser 0-2) with a progressive idiopathic curve between 25 and 40 degrees, the BRAIS study demonstrated that TLSO bracing for at least 18 hours a day significantly decreases the risk of progression to surgery.

Question 19

Topic: Pediatric Upper Extremity & Spine

A 13-year-old female with Marfan syndrome presents with a progressive 35-degree thoracic scoliosis. Regarding the management of her spinal deformity, which of the following statements is most accurate?

. Bracing is highly effective and rarely fails
. The curve is typically less responsive to bracing compared to adolescent idiopathic scoliosis
. Bracing is contraindicated due to aortic root fragility
. Posterior spinal fusion alone is contraindicated
. Her curve is likely to resolve spontaneously with growth

Correct Answer & Explanation

. The curve is typically less responsive to bracing compared to adolescent idiopathic scoliosis

Explanation

Scoliosis in Marfan syndrome is often more rigid and less responsive to conservative treatment (bracing) than adolescent idiopathic scoliosis (AIS), frequently progressing to require surgical intervention.

Question 20

Topic: Pediatric Upper Extremity & Spine

A 13-year-old male presents with adolescent idiopathic scoliosis. He has a 40-degree left thoracic curve. Neurological examination is completely normal. Why is a total spine MRI indicated for this patient?

. To measure the pedicle width for screws
. Left-sided thoracic curves have a higher incidence of neural axis abnormalities
. It is standard of care for all AIS patients
. To evaluate for pulmonary hypoplasia
. Males have a higher incidence of dural ectasia

Correct Answer & Explanation

. Left-sided thoracic curves have a higher incidence of neural axis abnormalities

Explanation

Atypical curve patterns, such as a left-sided thoracic curve in adolescent idiopathic scoliosis, carry a higher risk of underlying neural axis abnormalities (e.g., syringomyelia, Chiari malformation). MRI is indicated even with a completely normal neurological exam.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page