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Pediatric Upper Extremity & Spine MCQs

Practice Set 16 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 301

Topic: Pediatric Upper Extremity & Spine
A 5-year-old boy sustains a type III extension supracondylar humerus fracture. After closed reduction and percutaneous pinning, the hand is noted to be pink but lacks a palpable radial pulse. Doppler confirms a monophasic signal at the wrist. What is the most appropriate next step in management?
. Immediate exploration of the brachial artery
. Removal of all pins and open reduction
. Observation and elevation
. Stellate ganglion block
. Arteriography

Correct Answer & Explanation

. Observation and elevation

Explanation

A pink, pulseless hand following adequate closed reduction and pinning of a supracondylar humerus fracture indicates sufficient collateral circulation. Observation is the recommended management, as pulses typically return over several days.

Question 302

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal girl presents with adolescent idiopathic scoliosis. Radiographs demonstrate a right thoracic curve of 32 degrees. Her Risser stage is 0. What is the most appropriate management?

. Observation with repeat radiographs in 6 months
. TLSO bracing
. Posterior spinal fusion
. Anterior vertebral body tethering
. Physical therapy (Schroth method) alone

Correct Answer & Explanation

. Observation with repeat radiographs in 6 months

Explanation

Bracing in adolescent idiopathic scoliosis is indicated for curves between 25 and 40 degrees in skeletally immature patients (Risser 0-2). The goal of the TLSO brace is to halt progression, not to correct the existing deformity.

Question 303

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a completely displaced extension-type supracondylar humerus fracture. On initial presentation, his hand is pink but the radial pulse is absent. Following closed reduction and percutaneous pinning, the hand remains pink and well-perfused, but the radial pulse is still non-palpable. What is the most appropriate next step in management?

. Immediate vascular exploration
. Perform a sympathetic block
. Close observation with pulse oximetry
. Remove the pins and open the fracture
. Angiography of the upper extremity

Correct Answer & Explanation

. Immediate vascular exploration

Explanation

A pink, pulseless hand following adequate reduction of a supracondylar humerus fracture should be managed with close clinical observation. Vascular exploration is indicated only if the hand is persistently cold, pale, and poorly perfused after reduction.

Question 304

Topic: Pediatric Upper Extremity & Spine

A 5-year-old boy sustains a completely displaced extension-type supracondylar fracture of the humerus. On examination, the hand is pink and warm, but the radial pulse is absent. After urgent closed reduction and percutaneous pinning, the hand remains pink and warm, but the radial pulse remains non-palpable. What is the most appropriate next step?

. Immediate vascular exploration
. Arteriography
. Observation and admission
. Administration of intra-arterial vasodilators
. Revision of the reduction

Correct Answer & Explanation

. Immediate vascular exploration

Explanation

In a pulseless, pink, and well-perfused hand following a completely displaced supracondylar fracture, observation is the standard of care if perfusion remains intact after reduction and pinning. Vascular exploration is reserved for a pulseless, white (ischemic) hand.

Question 305

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarchal girl presents with adolescent idiopathic scoliosis. Radiographs demonstrate a right thoracic curve of 55 degrees and a Risser stage of 0. Which of the following is the most appropriate treatment?

. Observation with repeat radiographs in 6 months
. Thoracolumbosacral orthosis (TLSO) for 23 hours a day
. Nighttime bending brace
. Posterior spinal fusion with instrumentation
. Anterior tethering procedure

Correct Answer & Explanation

. Observation with repeat radiographs in 6 months

Explanation

A curve of 55 degrees in a skeletally immature patient (Risser 0, premenarchal) has a very high risk of progression. Posterior spinal fusion with instrumentation is the standard treatment for curves >50 degrees.

Question 306

Topic: Pediatric Upper Extremity & Spine

A 5-year-old boy sustains a completely displaced, extension-type supracondylar humerus fracture. Upon presentation, his hand is pink and well-perfused, but the radial pulse is absent. Following closed reduction and percutaneous pinning, the fracture is perfectly aligned, but the radial pulse remains absent while the hand remains pink. What is the most appropriate next step in management?

. Immediate exploration of the brachial artery
. Removal of the pins and open reduction
. Observation and hospital admission for close neurovascular monitoring
. Performance of a sympathectomy
. Obtain an urgent CT angiogram of the upper extremity

Correct Answer & Explanation

. Immediate exploration of the brachial artery

Explanation

In a 'pulseless, pink' hand following adequate reduction and stabilization of a supracondylar humerus fracture, observation is appropriate. Collateral circulation provides adequate perfusion, and the brachial artery spasm usually resolves over 24-48 hours.

Question 307

Topic: Pediatric Upper Extremity & Spine

A 12-year-old girl presents with adolescent idiopathic scoliosis. She is pre-menarchal. Her Risser sign is 1. Radiographs show a right thoracic curve of 34 degrees. What is the most widely accepted standard of care?

. Observation only
. Physical therapy with the Schroth method as monotherapy
. Full-time wear of a thoracolumbosacral orthosis (TLSO)
. Nighttime-only bending brace
. Posterior spinal fusion

Correct Answer & Explanation

. Observation only

Explanation

Bracing (typically full-time TLSO) is indicated for skeletally immature patients (Risser 0-2) with curves between 25 and 45 degrees. The goal of bracing is to halt progression, not to correct the curve.

Question 308

Topic: Pediatric Upper Extremity & Spine

A 13-year-old boy with adolescent idiopathic scoliosis presents with an atypical curve pattern (a sharp left-sided thoracic curve). He also reports mild headaches. Which of the following is the most appropriate next step in evaluating this patient?

. Perform a CT scan of the chest
. Obtain an MRI of the entire neuraxis
. Schedule immediate posterior spinal fusion
. Measure leg length discrepancy with scanograms
. Prescribe a nighttime brace

Correct Answer & Explanation

. Perform a CT scan of the chest

Explanation

Atypical curve patterns, such as a left thoracic curve in AIS, are considered 'red flags' for underlying intraspinal pathology (e.g., syringomyelia, Chiari malformation, tethered cord). An MRI of the entire neuraxis is mandatory to rule out these anomalies.

Question 309

Topic: Pediatric Upper Extremity & Spine

A 13-year-old girl with adolescent idiopathic scoliosis (AIS) presents for evaluation. Her menarche was 6 months ago. Radiographs reveal a right thoracic curve of 35 degrees and a Risser stage of 0. What is the most appropriate management?

. Observation with radiographs in 6 months
. Nighttime bending brace alone
. Full-time thoracolumbosacral orthosis (TLSO) bracing
. Posterior spinal fusion
. Anterior spinal tethering

Correct Answer & Explanation

. Observation with radiographs in 6 months

Explanation

Full-time bracing is indicated for skeletally immature patients (Risser 0-2) with progressive curves between 25 and 45 degrees. At 35 degrees with significant remaining growth potential, a TLSO is the standard of care to prevent curve progression.

Question 310

Topic: Pediatric Upper Extremity & Spine

A 5-year-old boy sustains a severe extension-type supracondylar humerus fracture. On presentation, his hand is warm and pink, but the radial pulse is not palpable. After closed reduction and percutaneous pinning, the hand remains well-perfused with an oxygen saturation of 99%, but the pulse remains non-palpable. What is the next best step in management?

. Immediate exploration of the brachial artery
. Fasciotomy of the forearm
. Observation and hospital admission for close monitoring
. Removal of the pins and open reduction
. CT angiography of the upper extremity

Correct Answer & Explanation

. Immediate exploration of the brachial artery

Explanation

A pulseless but well-perfused (pink) hand after reduction and pinning of a supracondylar fracture should be closely observed. Collateral circulation is typically adequate, and the pulse often returns over time; surgical exploration is reserved for a pulseless, pale, and poorly perfused hand.

Question 311

Topic: Pediatric Upper Extremity & Spine
A 6-year-old girl sustains an extension-type Gartland III supracondylar humerus fracture. Upon initial clinical evaluation, 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?
. Anterior interosseous nerve
. Radial nerve
. Ulnar nerve
. Posterior 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 fractures. An AIN palsy presents with the inability to form an 'OK' sign due to weakness of the flexor pollicis longus and flexor digitorum profundus to the index finger.

Question 312

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarcheal girl (Risser 0) presents with adolescent idiopathic scoliosis. Radiographs demonstrate a right thoracic curve of 32 degrees. What is the most appropriate treatment recommendation?

. Observation with repeat radiographs in 6 months
. Physical therapy and core strengthening
. TLSO bracing for 16-23 hours per day
. Nighttime-only bending brace
. Posterior spinal fusion

Correct Answer & Explanation

. Observation with repeat radiographs in 6 months

Explanation

Bracing is indicated for skeletally immature patients (Risser 0-2) with a curve between 25 and 40 degrees. A TLSO worn for 16 to 23 hours a day is the most effective nonsurgical method to halt curve progression.

Question 313

Topic: Pediatric Upper Extremity & Spine

A 12-year-old girl with adolescent idiopathic scoliosis (AIS) presents with a right thoracic curve. She is premenarcheal, Risser 0, and her curve measures 35 degrees on standing PA radiograph. Which of the following is the most appropriate next step in management?

. Observation with clinical follow-up in 6 months
. Thoracolumbosacral orthosis (TLSO) bracing for 16-23 hours per day
. Nighttime only bending brace
. Posterior spinal fusion
. Physical therapy and core strengthening

Correct Answer & Explanation

. Observation with clinical follow-up in 6 months

Explanation

Bracing is indicated for skeletally immature patients (Risser 0-2) with AIS curves between 25 and 45 degrees. A TLSO worn for 16-23 hours daily has been shown to significantly decrease the risk of curve progression to the surgical threshold.

Question 314

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarcheal girl presents for evaluation of a spinal deformity. She is Risser 0. Standing posteroanterior and lateral radiographs of the spine reveal a right thoracic curve of 36 degrees and normal sagittal alignment. Which of the following is the most appropriate treatment recommendation?

. Observation with repeat radiographs in 6 months
. Full-time wear of a thoracolumbosacral orthosis (TLSO)
. Nighttime bending brace only
. Posterior spinal fusion with instrumentation
. Anterior vertebral body tethering

Correct Answer & Explanation

. Observation with repeat radiographs in 6 months

Explanation

Indications for bracing in adolescent idiopathic scoliosis (AIS) include a curve magnitude between 25 and 45 degrees in a skeletally immature patient (Risser 0-2, premenarcheal or less than 1 year postmenarcheal). A full-time TLSO has been shown in multicenter randomized trials (e.g., BrAIST) to significantly decrease the progression of curves to the surgical threshold.

Question 315

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains a supracondylar fracture of the humerus. Radiographs demonstrate a Gartland Type III fracture with posteromedial displacement of the distal fragment. Which of the following neurologic deficits is most likely to be present?
. Weakness of thumb interphalangeal joint flexion and index finger distal interphalangeal joint flexion
. Inability to extend the metacarpophalangeal joints of the fingers and thumb
. Decreased sensation over the volar aspect of the little finger
. Inability to abduct and adduct the fingers
. Weakness of elbow flexion and forearm supination

Correct Answer & Explanation

. Inability to extend the metacarpophalangeal joints of the fingers and thumb

Explanation

In a supracondylar humerus fracture with posteromedial displacement of the distal fragment, the proximal fragment displaces anterolaterally. This places the radial nerve at risk of tenting or laceration as it passes through the lateral intermuscular septum. Radial nerve palsy presents with wrist drop and inability to extend the fingers and thumb at the MCP joints. Conversely, posterolateral displacement puts the anterior interosseous nerve (AIN) at risk.

Question 316

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy presents with a completely displaced posteromedial supracondylar humerus fracture. Based on the direction of displacement, which nerve is at highest risk of injury?

. Median nerve
. Ulnar nerve
. Radial nerve
. Anterior interosseous nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Median nerve

Explanation

Supracondylar humerus fractures are the most common elbow fractures in children. Posteromedial displacement is the most common pattern of an extension-type supracondylar humerus fracture. In this pattern, the distal fragment goes posteromedially, causing the proximal fragment to displace anterolaterally. The radial nerve is located anterolaterally and is tethered at the lateral intermuscular septum, making it the most vulnerable structure to injury by the proximal fragment spike. The anterior interosseous nerve (AIN) is most commonly injured in posterolateral displacement.

Question 317

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy falls from monkey bars and sustains a completely displaced, extension-type supracondylar humerus fracture. On arrival at the emergency department, his hand is pink and warm with brisk capillary refill, but no radial pulse is palpable. What is the next best step in management?

. Immediate open exploration of the brachial artery
. Closed reduction and percutaneous pinning followed by observation
. Immediate MR Angiography
. Prophylactic fasciotomies of the forearm
. Stellate ganglion block

Correct Answer & Explanation

. Immediate open exploration of the brachial artery

Explanation

In the setting of a displaced supracondylar humerus fracture with a 'pulseless but pink' (well-perfused) hand, the initial management is urgent closed reduction and percutaneous pinning (CRPP). The pulse often returns following anatomical alignment of the fracture. If the hand remains pink and well-perfused after CRPP, observation is the appropriate management. Open vascular exploration is indicated if the hand is dysvascular (pulseless, white, and cold) before or after reduction.

Question 318

Topic: Pediatric Upper Extremity & Spine

A 5-year-old boy sustains a Gartland type III extension-type supracondylar humerus fracture. On initial presentation, his hand is pink but pulseless. Following a satisfactory closed reduction and percutaneous pinning, the hand remains pink with brisk capillary refill, but the radial pulse remains unpalpable. What is the most appropriate next step in management?

. Immediate anterior vascular exploration
. Observation and hospital admission for 24 to 48 hours
. Emergent formal arteriography
. Removal of the pins and application of a long-arm cast
. Prophylactic fasciotomy of the forearm

Correct Answer & Explanation

. Immediate anterior vascular exploration

Explanation

A "pink, pulseless" hand following adequate reduction and pinning of a supracondylar fracture generally has adequate collateral circulation and can be safely observed. The pulse typically returns within a few days, avoiding the need for immediate vascular exploration.

Question 319

Topic: Pediatric Upper Extremity & Spine

A 5-year-old boy sustains a completely displaced, extension-type supracondylar humerus fracture. On presentation, the hand is pink and warm, but the radial pulse is absent. After urgent closed reduction and percutaneous pinning, the hand remains pink and warm, and the pulse remains absent. What is the most appropriate next step in management?

. Urgent exploration of the brachial artery
. Observation and admission for close neurovascular monitoring
. Immediate arterial bypass grafting
. Angiography of the upper extremity
. Removal of pins and open reduction

Correct Answer & Explanation

. Urgent exploration of the brachial artery

Explanation

A 'pulseless pink hand' after reduction of a supracondylar fracture indicates adequate collateral perfusion. Observation and close monitoring are appropriate, as the pulse often returns within a few days to weeks.

Question 320

Topic: Pediatric Upper Extremity & Spine

When evaluating the adequacy of a closed reduction for a pediatric supracondylar humerus fracture, Baumann's angle is primarily used to assess:

. Sagittal plane rotation
. Coronal plane angulation (varus/valgus)
. Flexion/extension of the distal fragment
. Anterior humeral line intersection
. Humeral version

Correct Answer & Explanation

. Sagittal plane rotation

Explanation

Baumann's angle is used to evaluate coronal plane alignment. It helps ensure correct reduction and prevent cubitus varus deformity.

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