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Pediatric Upper Extremity & Spine MCQs

Practice Set 12 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 221

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls onto an outstretched hand and sustains a Gartland Type III supracondylar humerus fracture. On examination, his hand is pink but pulseless, with brisk capillary refill. What is the most appropriate initial management?
. Immediate CT angiogram of the upper extremity
. Urgent open exploration of the brachial artery
. Closed reduction and percutaneous pinning
. Application of a splint in 90 degrees of flexion
. Observation and elevation for 24 hours

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

A pink, pulseless hand in the setting of a displaced supracondylar fracture is typically due to brachial artery kinking or vasospasm. The first step is urgent closed reduction and percutaneous pinning, which relieves the traction on the vessel and frequently restores the palpable pulse.

Question 222

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a completely displaced supracondylar humerus fracture. After closed reduction and percutaneous pinning, the hand remains pink with a capillary refill of 1.5 seconds, but the radial pulse is absent. What is the most appropriate next step in management?

. Immediate exploration of the brachial artery
. Perform a brachial angiogram
. Remove the pins and re-reduce the fracture
. Observe and document neurovascular status
. Perform a sympathetic nerve block

Correct Answer & Explanation

. Observe and document neurovascular status

Explanation

In a well-perfused, pink hand with brisk capillary refill but an absent pulse after reduction, collateral circulation is sufficient. Immediate surgical exploration is only indicated if the hand is dysvascular (pale and pulseless).

Question 223

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with a Gartland type III supracondylar humerus fracture. After closed reduction and percutaneous pinning, the hand is pink and well-perfused but the radial pulse is completely absent. What is the most appropriate next step in management?
. Immediate arteriogram
. Immediate vascular exploration
. Remove the pins and extend the elbow
. Local warming of the extremity
. Observation and pulse oximetry monitoring

Correct Answer & Explanation

. Observation and pulse oximetry monitoring

Explanation

A pulseless, pink hand after reduction of a pediatric supracondylar fracture indicates adequate collateral perfusion. Observation is the standard of care, as the pulse typically returns within a few days once swelling subsides.

Question 224

Topic: Pediatric Upper Extremity & Spine
In a Paediatric Trauma scenario, a 6-year-old presents with a Gartland Type III supracondylar humeral fracture. The hand is pink but pulseless. Following closed reduction and percutaneous pinning, the hand remains pink and pulseless. What is the most appropriate next step?
. Immediate exploration of the brachial artery
. Observe and admit for 24 hours with elevation
. Perform an immediate forearm fasciotomy
. Remove the pins and attempt open reduction
. Order a CT angiogram before deciding on further management

Correct Answer & Explanation

. Observe and admit for 24 hours with elevation

Explanation

For a 'pink, pulseless' hand after satisfactory reduction and stabilization of a paediatric supracondylar fracture, the standard protocol is close observation. Collateral circulation is adequate for tissue viability, and the pulse often returns within 24-48 hours.

Question 225

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with a completely displaced, extension-type supracondylar humerus fracture (Gartland Type III). On initial examination, the hand is pale, pulseless, and cool. After a gentle closed reduction and percutaneous pinning in the OR, the hand becomes pink, warm, and has a capillary refill of 1.5 seconds, but the radial pulse remains absent on Doppler. What is the most appropriate next step in management?
. Immediate open exploration of the brachial artery in the antecubital fossa
. Perform an intraoperative formal angiogram
. Observation and hospital admission for close serial neurovascular monitoring
. Remove the pins, slightly extend the elbow, and repin the fracture
. Perform a prophylactic volar forearm fasciotomy

Correct Answer & Explanation

. Observation and hospital admission for close serial neurovascular monitoring

Explanation

The management of a 'pink, pulseless' hand following the successful reduction and pinning of a pediatric supracondylar humerus fracture is observation. If the hand is well-perfused (warm, pink, brisk capillary refill < 2 seconds), the limb is viable. The absence of a palpable or Doppler pulse is typically due to localized vasospasm, which resolves over hours to days. Emergent vascular exploration is indicated if the hand remains 'pale and pulseless' (poorly perfused) after reduction.

Question 226

Topic: Pediatric Upper Extremity & Spine
A 5-year-old child sustains a Gartland type III supracondylar humerus fracture. Post-injury examination reveals an isolated anterior interosseous nerve (AIN) palsy. What is the most characteristic clinical finding associated with this specific nerve injury?
. Inability to cross the fingers
. Weakness of thumb interphalangeal (IP) joint and index finger distal interphalangeal (DIP) joint flexion
. Inability to extend the wrist
. Numbness over the volar aspect of the index finger
. Weakness of the abductor pollicis brevis

Correct Answer & Explanation

. Weakness of thumb interphalangeal (IP) joint and index finger distal interphalangeal (DIP) joint flexion

Explanation

The anterior interosseous nerve (AIN) is the most commonly injured nerve in extension-type supracondylar humerus fractures. The AIN is a pure motor nerve that innervates the flexor pollicis longus (FPL), the radial half of the flexor digitorum profundus (FDP to the index and middle fingers), and the pronator quadratus. An AIN palsy presents with weakness in flexing the thumb IP joint and index finger DIP joint, clinically resulting in the inability to form an 'OK' sign. Because it is purely motor, there is no sensory deficit.

Question 227

Topic: Pediatric Upper Extremity & Spine
A 6-year-old child arrives at the trauma bay with a severely displaced Gartland type III supracondylar humerus fracture. On initial assessment, the hand is pulseless and pale. Following prompt closed reduction and percutaneous pinning in the operating room, the radial pulse remains unpalpable, but the hand becomes warm, pink, and has a capillary refill of 2 seconds. What is the most appropriate next step in management?
. Immediate exploration of the brachial artery
. CT angiography of the upper extremity
. Removal of pins and open reduction
. Observation and hospital admission for serial neurovascular checks
. Administration of intra-arterial vasodilators

Correct Answer & Explanation

. Observation and hospital admission for serial neurovascular checks

Explanation

In the setting of a supracondylar humerus fracture, if the hand is 'pulseless but pink' (perfused via collateral circulation) following an adequate reduction and stabilization, the standard of care is close observation and hospital admission. Immediate vascular exploration is indicated if the hand remains 'pulseless and pale' (ischemic) despite reduction.

Question 228

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with a Gartland type III supracondylar humerus fracture. On initial presentation, his hand is 'pink and pulseless', with brisk capillary refill but an absent radial pulse. He is taken immediately to the operating room for closed reduction and percutaneous pinning. Post-operatively in the recovery room, his hand remains pink with brisk capillary refill, but the radial pulse remains absent. What is the most appropriate next step in management?
. Immediate removal of the pins and open reduction
. Perform a CT angiogram of the upper extremity
. Vascular exploration of the brachial artery
. Admission, elevation, and close clinical observation
. Prophylactic fasciotomies of the forearm

Correct Answer & Explanation

. Admission, elevation, and close clinical observation

Explanation

The management of a 'pink, pulseless' hand following a well-reduced and pinned pediatric supracondylar humerus fracture is admission and close clinical observation. Studies show that perfusion is adequate due to collateral circulation, and the radial pulse often returns within a few days as vasospasm resolves. Vascular exploration is strictly indicated if the hand becomes 'white and pulseless' (ischemic) after reduction.

Question 229

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl is undergoing a posterior spinal fusion for a Lenke type 1A adolescent idiopathic scoliosis. During the rod rotation maneuver, motor evoked potentials (MEPs) drop by 80% bilaterally in the lower extremities, while somatosensory evoked potentials (SSEPs) remain at baseline. The anesthesiologist confirms that the mean arterial pressure (MAP) is currently 90 mmHg and no paralytics have been administered. What is the most appropriate immediate surgical step?

. Administer high-dose intravenous methylprednisolone
. Release all corrective forces and remove the rods
. Perform an immediate Stagnara wake-up test
. Wait 15 minutes to allow for neurological accommodation
. Perform a rapid multi-level laminectomy for decompression

Correct Answer & Explanation

. Release all corrective forces and remove the rods

Explanation

An isolated drop in MEPs indicates anterior spinal cord (motor tract) compromise. The standard protocol for intraoperative neuromonitoring changes is to first rule out anesthetic causes and optimize hemodynamics (maintaining MAP > 85 mmHg). Since the MAP is already optimized and no paralytics were given, the most appropriate immediate surgical step is to undo the mechanical maneuver that caused the deficit, which involves releasing corrective forces and removing the rods.

Question 230

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents to the emergency department after falling off monkey bars. Radiographs demonstrate a completely displaced, extension-type supracondylar humerus fracture with no bony contact between the proximal and distal fragments. Upon closed reduction in the operating room, the surgeon notes the medial periosteal hinge is intact. According to the Gartland classification, what type of fracture is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type III

Explanation

Gartland Classification: Type I = non-displaced. Type II = displaced with intact posterior cortex. Type III = completely displaced with no cortical contact (though a medial or lateral periosteal hinge may remain intact, dictating displacement direction). Type IV = complete multidirectional instability due to complete periosteal disruption (diagnosed intraoperatively).

Question 231

Topic: Pediatric Upper Extremity & Spine

In the Lenke classification system for adolescent idiopathic scoliosis, a Type 1 (Main Thoracic) curve pattern is defined strictly by which of the following parameters regarding structurality?

. The main thoracic curve is structural; proximal thoracic and thoracolumbar/lumbar curves are non-structural.
. The double thoracic curves are both structural; the thoracolumbar/lumbar curve is non-structural.
. The main thoracic and thoracolumbar/lumbar curves are both structural.
. All three curves (proximal thoracic, main thoracic, thoracolumbar/lumbar) are structural.
. The thoracolumbar/lumbar curve is the major structural curve; the main thoracic curve is non-structural.

Correct Answer & Explanation

. The main thoracic curve is structural; proximal thoracic and thoracolumbar/lumbar curves are non-structural.

Explanation

According to the Lenke classification, a Type 1 curve is defined by a main thoracic major curve that is structural, while the proximal thoracic and the thoracolumbar/lumbar curves are minor and non-structural (bending out to < 25 degrees).

Question 232

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains a completely displaced (Gartland Type III) supracondylar humerus fracture. On initial presentation in the emergency department, his hand is warm and well-perfused (pink), but the radial pulse is absent on palpation and Doppler ultrasound. What is the most appropriate next step in management?
. Immediate surgical exploration of the brachial artery
. CT angiography of the upper extremity
. Urgent closed reduction and percutaneous pinning
. Application of a long arm cast in 90 degrees of flexion
. Observation and elevation for 24 hours

Correct Answer & Explanation

. Urgent closed reduction and percutaneous pinning

Explanation

The standard of care for a 'pulseless, pink' hand in the setting of a displaced pediatric supracondylar humerus fracture is urgent closed reduction and percutaneous pinning (CRPP). Realigning the fracture relieves the tethering, kinking, or spasm of the brachial artery over the proximal fragment, often restoring the pulse. Vascular exploration is indicated if the hand is 'pulseless and pale' (ischemic) before or after reduction.

Question 233

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with a Gartland Type III extension-type supracondylar humerus fracture. On initial exam, the hand is pink but lacks a palpable radial pulse. Following emergent closed reduction and percutaneous pinning in the operating room, the hand remains pink and pulseless, but capillary refill is brisk (<2 seconds). What is the most appropriate next step in management?
. Immediate removal of pins and transition to open reduction
. Emergent anterior approach for brachial artery exploration
. Observation and admission for 24-48 hours
. Doppler ultrasound of the radial artery in the PACU
. Formal angiography of the upper extremity

Correct Answer & Explanation

. Observation and admission for 24-48 hours

Explanation

The management of a 'pink, pulseless' hand after satisfactory reduction and pinning of a pediatric supracondylar humerus fracture is observation. The brisk capillary refill indicates adequate collateral perfusion. Vascular exploration is strictly indicated if the hand is 'white and pulseless' (ischemic) after reduction.

Question 234

Topic: Pediatric Upper Extremity & Spine

In adolescent idiopathic scoliosis (AIS), curve progression is a primary concern guiding treatment. Based on natural history studies, which of the following patients has the highest statistical risk of curve progression?

. A 15-year-old female, Risser 4, with a 35-degree curve
. A 13-year-old male, Risser 2, with a 25-degree curve
. A 12-year-old female, Risser 0, with a 25-degree curve
. A 14-year-old female, Risser 3, with a 20-degree curve
. A 16-year-old male, Risser 5, with a 45-degree curve

Correct Answer & Explanation

. A 12-year-old female, Risser 0, with a 25-degree curve

Explanation

The risk of curve progression in AIS is highest in patients who are female, have a lower Risser stage (indicating significant remaining skeletal growth), and present with larger initial curves (>20 degrees) before skeletal maturity. A 12-year-old female at Risser 0 with a 25-degree curve has a progression risk exceeding 60-80%.

Question 235

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy falls from monkey bars and sustains a widely displaced, extension-type supracondylar humerus fracture. On initial presentation in the emergency department, his hand is pale and pulseless. What is the most appropriate next step in management?

. Immediate CT angiography of the upper extremity
. Open anterior approach for exploration of the brachial artery
. Urgent closed reduction and percutaneous pinning in the operating room
. Application of a warm compress and observation for 2 hours
. Administration of intravenous heparin

Correct Answer & Explanation

. Urgent closed reduction and percutaneous pinning in the operating room

Explanation

A pale, pulseless hand in the setting of a displaced supracondylar humerus fracture is a surgical emergency. The immediate next step is urgent closed reduction and percutaneous pinning in the OR. Often, realignment of the fracture unkinks the brachial artery and restores perfusion. Routine angiography delays necessary reduction.

Question 236

Topic: Pediatric Upper Extremity & Spine

In the Lenke classification system for adolescent idiopathic scoliosis, a minor curve is defined as 'structural' (and therefore requires inclusion in the surgical fusion construct) if it meets which of the following criteria?

. The Cobb angle remains greater than or equal to 10 degrees on supine side-bending radiographs
. The Cobb angle remains greater than or equal to 25 degrees on supine side-bending radiographs
. Apical vertebral translation is greater than 1 cm
. Nash-Moe rotation is Grade 2 or higher
. The curve flexibility is less than 50% of the standing coronal Cobb angle

Correct Answer & Explanation

. The Cobb angle remains greater than or equal to 25 degrees on supine side-bending radiographs

Explanation

The Lenke classification defines a minor curve as structural if its Cobb angle remains at or above 25 degrees on maximal supine side-bending radiographs. Additionally, for thoracic curves, a regional kyphosis of +20 degrees or more (T2-T5 for proximal thoracic, T10-L2 for thoracolumbar/lumbar) also qualifies the curve as structural regardless of the side-bending coronal Cobb angle. Structural minor curves must be included in the arthrodesis.

Question 237

Topic: Pediatric Upper Extremity & Spine
An infant is born with a unilateral radial clubhand (radial longitudinal deficiency). The consulting geneticist suspects a systemic syndrome. Physical examination reveals an absent thumb on the affected side. Which of the following syndromes is strictly characterized by the presence of a thumb despite radial deficiency, making it clinically distinguishable from the others?
. Holt-Oram syndrome
. Fanconi anemia
. VACTERL association
. Thrombocytopenia-absent radius (TAR) syndrome
. Roberts syndrome

Correct Answer & Explanation

. Thrombocytopenia-absent radius (TAR) syndrome

Explanation

Thrombocytopenia-absent radius (TAR) syndrome is unique among the conditions associated with radial longitudinal deficiency because the thumb is classically present, whereas in Holt-Oram syndrome, Fanconi anemia, and VACTERL association, the thumb is typically hypoplastic or absent.

Question 238

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents to the emergency department with a completely displaced, extension-type supracondylar humerus fracture (Gartland Type III). On physical examination, he is unable to flex the interphalangeal (IP) joint of his thumb and the distal interphalangeal (DIP) joint of his index finger. Which of the following neurological structures is most likely injured?
. Ulnar nerve
. Radial nerve
. Posterior interosseous nerve
. Anterior interosseous nerve
. Musculocutaneous 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. Injury manifests as an inability to flex the IP joint of the thumb (FPL) and the DIP joint of the index finger (FDP), preventing the patient from making an 'A-OK' sign.

Question 239

Topic: Pediatric Upper Extremity & Spine

When evaluating an adolescent idiopathic scoliosis (AIS) patient using the Lenke classification system, structural characteristics of the curves dictate the curve type (1-6). If a patient has a structural main thoracic curve and a structural proximal thoracic curve, but the thoracolumbar curve bends out to 10 degrees on side-bending films (non-structural), what is the correct Lenke curve type?

. Lenke Type 1 (Main Thoracic)
. Lenke Type 2 (Double Thoracic)
. Lenke Type 3 (Double Major)
. Lenke Type 4 (Triple Major)
. Lenke Type 5 (Thoracolumbar/Lumbar)

Correct Answer & Explanation

. Lenke Type 5 (Thoracolumbar/Lumbar)

Explanation

The Lenke classification for AIS is based on identifying structural curves (defined as a curve >= 25 degrees on coronal side-bending films or > 20 degrees of kyphosis on the sagittal film). Lenke Type 1 is a structural main thoracic curve only. Lenke Type 2 (Double Thoracic) has a structural proximal thoracic curve and a structural main thoracic curve, while the thoracolumbar curve is non-structural. Lenke Type 3 is a structural MT and structural TL/L. Lenke 4 has all three structural. Lenke 5 is structural TL/L only.

Question 240

Topic: Pediatric Upper Extremity & Spine

A 25-year-old soccer player is undergoing anterior cruciate ligament (ACL) reconstruction. The surgeon considers an anterolateral ligament (ALL) reconstruction for residual pivot shift. Which of the following accurately describes the anatomic attachment sites of the ALL?

. Originates anterior to the lateral epicondyle and inserts on Gerdy's tubercle
. Originates posterior and proximal to the lateral epicondyle and inserts midway between Gerdy's tubercle and the fibular head
. Originates on the popliteus sulcus and inserts on the fibular head
. Originates anterior and distal to the lateral epicondyle and inserts on the anterior horn of the lateral meniscus
. Originates at the lateral supracondylar ridge and inserts on the fibular styloid

Correct Answer & Explanation

. Originates posterior and proximal to the lateral epicondyle and inserts midway between Gerdy's tubercle and the fibular head

Explanation

The anterolateral ligament (ALL) originates slightly posterior and proximal to the lateral femoral epicondyle and inserts on the proximal tibia midway between Gerdy's tubercle and the fibular head. It acts as an important secondary restraint to internal tibial rotation.

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