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Pediatric Upper Extremity & Spine MCQs

Practice Set 17 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 321

Topic: Pediatric Upper Extremity & Spine

A 4-year-old falls on an outstretched hand. Radiographs show a supracondylar humerus fracture with an intact posterior cortex but an anterior humeral line that passes anterior to the capitellum. How is this fracture classified?

. Gartland Type I
. Gartland Type II
. Gartland Type III
. Gartland Type IV
. Flexion-type fracture

Correct Answer & Explanation

. Gartland Type I

Explanation

A Gartland Type II fracture is characterized by displacement (extension) with an intact posterior hinge (cortex). The anterior humeral line will pass anterior to the middle third of the capitellum.

Question 322

Topic: Pediatric Upper Extremity & Spine

Which of the following is true regarding flexion-type supracondylar humerus fractures compared to extension-type fractures?

. They are more common, accounting for 70% of cases
. They require the elbow to be immobilized in full flexion to maintain reduction
. They are more likely to require open reduction due to entrapped periosteum or muscle
. They are most commonly associated with anterior interosseous nerve injuries
. The distal fragment is displaced posteriorly relative to the humerus

Correct Answer & Explanation

. They are more common, accounting for 70% of cases

Explanation

Flexion-type supracondylar fractures frequently require open reduction because the reduction is often blocked by interposed tissue. They are immobilized in relative extension, and the ulnar nerve is most commonly injured.

Question 323

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a severe extension-type supracondylar humerus fracture (Gartland Type III). On examination, he cannot 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
. Posterior interosseous nerve
. Anterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Ulnar 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 presents as an inability to form the 'A-OK' sign due to weakness of the flexor pollicis longus and flexor digitorum profundus.

Question 324

Topic: Pediatric Upper Extremity & Spine

A 5-year-old boy presents with a Gartland Type III supracondylar humerus fracture. The hand is pink, but the radial pulse is absent. After a satisfactory closed reduction and percutaneous pinning, the hand remains pink and well-perfused, but the radial pulse remains absent. What is the most appropriate next step in management?

. Immediate exploration of the brachial artery
. Administration of intra-arterial vasodilators
. Observation and hospital admission for close neurovascular monitoring
. Removal of pins and open reduction
. Perform a forearm fasciotomy

Correct Answer & Explanation

. Immediate exploration of the brachial artery

Explanation

In a 'pink, pulseless' hand after satisfactory reduction of a supracondylar fracture, capillary refill indicates adequate collateral circulation. The standard of care is careful observation and hospital admission; surgical exploration is generally reserved for a white, pulseless hand.

Question 325

Topic: Pediatric Upper Extremity & Spine

When stabilizing a Gartland Type III supracondylar humerus fracture with percutaneous pins, a surgeon debates between placing crossed pins (medial and lateral) versus two lateral divergent pins. What is the primary biomechanical and clinical trade-off of using a crossed-pin configuration?

. Decreased torsional stability but lower risk of ulnar nerve injury
. Increased torsional stability but higher risk of ulnar nerve injury
. Decreased varus stability but lower risk of radial nerve injury
. Increased varus stability but higher risk of radial nerve injury
. Equivalent biomechanics to lateral pins but higher nonunion rate

Correct Answer & Explanation

. Decreased torsional stability but lower risk of ulnar nerve injury

Explanation

Crossed pinning provides superior torsional stability compared to isolated lateral pinning. However, the placement of a medial pin carries an increased, albeit small, iatrogenic risk to the ulnar nerve.

Question 326

Topic: Pediatric Upper Extremity & Spine

A 5-year-old girl sustains a Gartland type III supracondylar humerus fracture. After a successful closed reduction and percutaneous pinning in the operating room, her hand is warm and well-perfused with brisk capillary refill, but the radial pulse remains non-palpable. What is the most appropriate management?

. Immediate vascular surgical exploration
. Arteriography
. Sympathetic nerve block
. Observe and admit for close neurovascular monitoring
. Immediate open reduction and internal fixation

Correct Answer & Explanation

. Immediate vascular surgical exploration

Explanation

A "pink, pulseless" hand after successful reduction and pinning of a supracondylar fracture indicates adequate collateral circulation. Current guidelines recommend observation and close inpatient monitoring rather than immediate vascular exploration.

Question 327

Topic: Pediatric Upper Extremity & Spine

An 8-year-old boy is brought to the clinic 2 years after undergoing closed reduction and percutaneous pinning of a Gartland III supracondylar humerus fracture. The parents are concerned about the cosmetic appearance of his arm, which shows a marked cubitus varus deformity. What is the most common cause of this deformity?

. Growth arrest of the medial capitellum
. Malreduction of coronal tilt or rotation at the time of surgery
. Overgrowth of the lateral condyle
. Unrecognized concomitant lateral condyle fracture
. Ulnar nerve entrapment

Correct Answer & Explanation

. Growth arrest of the medial capitellum

Explanation

Cubitus varus following a supracondylar fracture is almost always secondary to malunion rather than growth arrest. Failure to adequately correct medial impaction or residual internal rotation at the time of initial reduction leads to this common cosmetic deformity.

Question 328

Topic: Pediatric Upper Extremity & Spine

During preoperative planning for percutaneous pinning of a Gartland type III supracondylar humerus fracture, the biomechanical properties of different pin configurations are reviewed. Compared to two divergent lateral pins, a crossed-pin configuration (one medial, one lateral) provides statistically significant increased resistance to which of the following forces?

. Torsional forces
. Valgus stress
. Varus stress
. Extension forces
. Flexion forces

Correct Answer & Explanation

. Torsional forces

Explanation

Biomechanical studies have consistently shown that crossed pins offer superior resistance to torsional forces compared to two lateral pins. However, lateral pins are often preferred clinically to eliminate the risk of iatrogenic ulnar nerve injury associated with medial pin placement.

Question 329

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a Gartland type III extension-type supracondylar humerus fracture. On presentation, his hand is pink and warm, but the radial pulse is nonpalpable. After closed reduction and percutaneous pinning, the hand remains pink and warm, but the pulse is still absent. What is the most appropriate next step in management?

. Immediate vascular surgery consultation for brachial artery exploration
. Observation and admission for 24 hours
. Remove the pins and attempt open reduction
. Perform an anterior compartment fasciotomy
. Obtain an emergent CT angiogram

Correct Answer & Explanation

. Immediate vascular surgery consultation for brachial artery exploration

Explanation

A "pink, pulseless" hand after reduction of a supracondylar fracture typically indicates adequate collateral circulation. The standard of care is close clinical observation rather than immediate surgical exploration if perfusion is adequate.

Question 330

Topic: Pediatric Upper Extremity & Spine

A 7-year-old boy presents with a severely displaced supracondylar humerus fracture. The overlying skin on the anterior distal arm exhibits a distinct dimple or "pucker" sign. This finding strongly suggests interposition of which of the following structures?

. Triceps brachii
. Brachioradialis
. Brachialis muscle
. Biceps tendon
. Brachial artery

Correct Answer & Explanation

. Triceps brachii

Explanation

An anterior skin pucker sign indicates that the proximal fracture fragment has penetrated the brachialis muscle and is tethering the deep dermis. This often makes closed reduction difficult and suggests a higher risk of neurovascular entrapment.

Question 331

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a completely displaced Gartland type III extension-type supracondylar humerus fracture. On initial presentation, his hand is pink but the radial pulse is not palpable. Following urgent closed reduction and percutaneous pinning, the fracture is anatomically aligned, but the hand remains pink and pulseless. Capillary refill is less than 2 seconds. What is the most appropriate management?

. Immediate exploration of the brachial artery
. Observation and admission for close neurovascular monitoring
. Perform a CT angiogram of the upper extremity
. Remove the pins and attempt an open reduction
. Perform an immediate forearm fasciotomy

Correct Answer & Explanation

. Immediate exploration of the brachial artery

Explanation

A pink, pulseless hand post-reduction of a supracondylar humerus fracture with adequate perfusion (capillary refill < 2 seconds) should be observed. Collateral circulation is typically sufficient, and surgical exploration is reserved for hands that become or remain pale and poorly perfused after reduction.

Question 332

Topic: Pediatric Upper Extremity & Spine

In the evaluation of Adolescent Idiopathic Scoliosis using the Lenke classification, specific radiographic criteria are used to determine if a minor curve is structural. Which of the following findings correctly defines a proximal thoracic minor curve as structural?

. Cobb angle greater than 25 degrees on the standing PA radiograph
. Residual Cobb angle of 25 degrees or greater on a side-bending radiograph
. Thoracic kyphosis (T2-T5) of 10 degrees or greater
. Apical vertebral translation greater than 2.5 cm
. An axial rotation of Grade II or greater by Nash-Moe criteria

Correct Answer & Explanation

. Cobb angle greater than 25 degrees on the standing PA radiograph

Explanation

In the Lenke classification, a minor proximal thoracic or main thoracic curve is considered structural if the residual Cobb angle is >= 25 degrees on a side-bending radiograph, or if the regional kyphosis is >= 20 degrees.

Question 333

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal girl has a right thoracic curve of 32 degrees on standing posteroanterior radiographs. Her Risser stage is 0. What is the most appropriate management?

. Observation with repeated radiographs in 6 months
. Physical therapy focusing on Schroth exercises
. Full-time TLSO bracing
. Nighttime-only bending brace
. Posterior spinal fusion

Correct Answer & Explanation

. Observation with repeated radiographs in 6 months

Explanation

Bracing is indicated for immature patients (Risser 0-2, premenarchal) with an idiopathic curve between 25 and 40 degrees. A full-time TLSO brace is the standard of care to prevent curve progression to surgical magnitude.

Question 334

Topic: Pediatric Upper Extremity & Spine

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

. Observe and admit for serial neurovascular checks
. Immediate open exploration of the brachial artery
. Perform a brachial artery angiogram
. Remove pins and hyper-extend the elbow
. Consult vascular surgery for immediate bypass

Correct Answer & Explanation

. Observe and admit for serial neurovascular checks

Explanation

In a pulseless but well-perfused (pink) hand following reduction and pinning of a supracondylar humerus fracture, observation is recommended as collateral circulation is adequate. Exploration is indicated if the hand is pulseless and white (poorly perfused).

Question 335

Topic: Pediatric Upper Extremity & Spine

Which of the following factors represents the highest risk for curve progression in a 12-year-old girl with Adolescent Idiopathic Scoliosis (AIS)?

. Risser 0 with an open triradiate cartilage
. Risser 2 with a closed triradiate cartilage
. Menarche 1 year ago
. Double major curve of 20 degrees
. Lumbar curve of 25 degrees

Correct Answer & Explanation

. Risser 0 with an open triradiate cartilage

Explanation

Peak height velocity and maximal curve progression occur just before or during Risser 0 and open triradiate cartilages. An open triradiate cartilage is a strong predictor of high remaining growth potential and curve progression.

Question 336

Topic: Pediatric Upper Extremity & Spine

In the Lenke classification for Adolescent Idiopathic Scoliosis, a curve is considered "structural" if it fails to reduce to less than what Cobb angle on side-bending radiographs?

. 15 degrees
. 20 degrees
. 25 degrees
. 30 degrees
. 40 degrees

Correct Answer & Explanation

. 15 degrees

Explanation

According to the Lenke classification, a minor curve is structural if the Cobb angle is 25 degrees or greater on a side-bending radiograph, or if there is kyphosis of +20 degrees or more across the region.

Question 337

Topic: Pediatric Upper Extremity & Spine

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

. Observation with standing radiographs in 6 months
. Thoracolumbosacral orthosis (TLSO) bracing
. Physical therapy and Schroth exercises alone
. Posterior spinal fusion
. Anterior vertebral body tethering

Correct Answer & Explanation

. Observation with standing radiographs in 6 months

Explanation

Bracing is strictly indicated for skeletally immature patients (Risser 0-2, premenarchal) with curves between 25 and 45 degrees. The primary goal of a TLSO brace is to halt curve progression to a surgical magnitude during the rapid adolescent growth spurt.

Question 338

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a completely displaced posteromedial supracondylar humerus fracture. On presentation, the hand is pink and warm, but the radial pulse is absent. Capillary refill is 2 seconds. What is the most appropriate initial management?

. Urgent closed reduction and percutaneous pinning
. Immediate CT angiography of the upper extremity
. Open exploration of the brachial artery
. Application of a long arm cast in 120 degrees of flexion
. Observation and admission for neurovascular checks

Correct Answer & Explanation

. Urgent closed reduction and percutaneous pinning

Explanation

A "pulseless, pink" hand in the setting of a completely displaced supracondylar humerus fracture indicates adequate collateral perfusion. The immediate next step is urgent closed reduction and percutaneous pinning, which often restores the pulse by removing pressure from the brachial artery.

Question 339

Topic: Pediatric Upper Extremity & Spine

A 13-year-old female with adolescent idiopathic scoliosis presents for routine evaluation. Radiographs reveal a 22-degree right thoracic curve. Evaluation of the iliac apophysis demonstrates ossification covering the anterior 75% of the iliac crest, but not yet reaching the posterior superior iliac spine (PSIS). What Risser stage does this represent?

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

Correct Answer & Explanation

. Risser 1

Explanation

The Risser classification evaluates skeletal maturity based on the ossification of the iliac apophysis. Risser 3 corresponds to ossification covering 50% to 75% of the iliac crest. Risser 4 covers 75% to 100%, and Risser 5 indicates complete fusion to the ilium.

Question 340

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a completely displaced, extension-type supracondylar humerus fracture. On presentation, the hand is pink but the radial pulse is absent. After successful closed reduction and percutaneous pinning, the hand remains pink and capillary refill is brisk, but the radial pulse remains unpalpable. What is the most appropriate next step?

. Immediate vascular exploration
. Arteriography
. Remove pins and reposition the fracture
. Close clinical observation
. Sympathetic nerve block

Correct Answer & Explanation

. Immediate vascular exploration

Explanation

In a pulseless, pink hand following adequate reduction and pinning of a supracondylar fracture, the extremity has adequate collateral perfusion. Close clinical observation is recommended as the palpable pulse often returns gradually without surgical exploration.

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