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Pediatric Upper Extremity & Spine MCQs

Practice Set 18 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 341

Topic: Pediatric Upper Extremity & Spine

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

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

Correct Answer & Explanation

. Observation with repeat radiographs in 6 months

Explanation

Bracing is definitively indicated in a growing child (Risser 0-2, premenarchal) with an idiopathic curve measuring 25 to 45 degrees. Evidence shows it significantly decreases the likelihood of curve progression to the surgical threshold.

Question 342

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl with adolescent idiopathic scoliosis presents for follow-up. Standing full-spine radiographs show a right thoracic curve of 55 degrees. She is post-menarchal and Risser 4. What is the most appropriate treatment recommendation?

. Continuation of TLSO bracing until Risser 5
. Posterior spinal fusion
. Anterior vertebral body tethering
. Night-time only bracing
. Observation with radiographs in 1 year

Correct Answer & Explanation

. Continuation of TLSO bracing until Risser 5

Explanation

In a skeletally mature or nearly mature adolescent (Risser 4), a thoracic curve of 50 degrees or more is highly likely to continue progressing into adulthood. Surgical correction with posterior spinal fusion is the standard indication.

Question 343

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a widely displaced extension-type supracondylar humerus fracture. After closed reduction and percutaneous pinning, the hand is pink and warm, but the radial pulse remains nonpalpable. Capillary refill is less than 2 seconds. What is the most appropriate next step?

. Remove the pins and re-reduce the fracture
. Perform an immediate brachial artery exploration
. Perform a CT angiogram of the upper extremity
. Admit for observation and arm elevation
. Consult vascular surgery for a bypass graft

Correct Answer & Explanation

. Remove the pins and re-reduce the fracture

Explanation

A "pink, pulseless" hand after anatomic reduction and pinning of a supracondylar humerus fracture typically indicates vascular spasm. It is best managed with close observation and elevation, as collateral circulation is adequate.

Question 344

Topic: Pediatric Upper Extremity & Spine

An 11-year-old girl presents with adolescent idiopathic scoliosis. Standing radiographs reveal a right thoracic curve measuring 35 degrees. She is premenarchal and has a Risser stage of 0. What is the most appropriate management?

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

Correct Answer & Explanation

. Observation with repeat radiographs in 6 months

Explanation

Bracing is indicated for skeletally immature patients (Risser 0-2, premenarchal) who present with an idiopathic scoliotic curve between 25 and 45 degrees to prevent curve progression.

Question 345

Topic: Pediatric Upper Extremity & Spine

Brace treatment for adolescent idiopathic scoliosis is generally most effective and indicated for which of the following patient profiles?

. A Risser 4 patient with a 30-degree curve
. A Risser 0 patient with a 35-degree curve
. A Risser 1 patient with a 55-degree curve
. A Risser 5 patient with a 20-degree curve
. A Risser 0 patient with an 15-degree curve

Correct Answer & Explanation

. A Risser 4 patient with a 30-degree curve

Explanation

Bracing in adolescent idiopathic scoliosis is indicated for skeletally immature patients (Risser 0-2) with progressive curves between 25 and 45 degrees. Curves over 45 degrees usually require surgery, while non-progressive curves under 25 degrees are observed.

Question 346

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a completely displaced supracondylar humerus fracture. Upon arrival, his hand is pink but the radial pulse is absent. Following closed reduction and percutaneous pinning, the hand remains pink but the pulse is still not palpable. What is the next best step in management?

. Immediate open exploration of the brachial artery
. Perform a vascular bypass graft
. Remove the pins and hyperflex the elbow
. Admit for observation with the arm slightly elevated
. Perform an immediate forearm fasciotomy

Correct Answer & Explanation

. Immediate open exploration of the brachial artery

Explanation

In a "pink, pulseless" hand after anatomical reduction and pinning of a supracondylar humerus fracture, observation is recommended as collateral circulation is adequate. Routine exploration is not indicated unless the hand becomes cool and pale.

Question 347

Topic: Pediatric Upper Extremity & Spine

According to the Bracing in Adolescent Idiopathic Scoliosis Trial (BRAIST), a rigid thoracolumbosacral orthosis is most effective at preventing curve progression to surgical thresholds when worn for a minimum of how many hours per day?

. 8 hours
. 12 hours
. 14 hours
. 18 hours
. 23 hours

Correct Answer & Explanation

. 8 hours

Explanation

The BRAIST trial established a clear dose-response relationship for bracing in adolescent idiopathic scoliosis, demonstrating highly significant clinical success in preventing surgery when braces are worn for 18 or more hours daily.

Question 348

Topic: Pediatric Upper Extremity & Spine

A 5-year-old girl falls from monkey bars and sustains a widely displaced, extension-type supracondylar humerus fracture. On examination, the hand is pink and well-perfused, but the radial pulse is absent. What is the most appropriate next step in management?

. Urgent open exploration of the brachial artery
. Immediate Doppler ultrasound of the upper extremity
. Urgent closed reduction and percutaneous pinning
. Application of a long arm cast in 120 degrees of flexion
. Observation and elevation for 24 hours

Correct Answer & Explanation

. Urgent open exploration of the brachial artery

Explanation

A 'pink, pulseless' hand after a supracondylar fracture indicates adequate collateral circulation. The next step is urgent closed reduction and percutaneous pinning. The pulse often returns after reduction; vascular exploration is only indicated if the hand becomes or remains dysvascular (white and pulseless) after reduction.

Question 349

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarcheal female presents for scoliosis screening. Radiographs demonstrate a 32-degree right thoracic curve. Her Risser stage is 0. What is the most appropriate management?

. Observation with follow-up radiographs in 1 year
. Physical therapy focusing on core strengthening
. Prescription of a thoracolumbosacral orthosis (TLSO) for 16-23 hours daily
. Nighttime-only bending brace
. Posterior spinal fusion with instrumentation

Correct Answer & Explanation

. Observation with follow-up radiographs in 1 year

Explanation

This patient has adolescent idiopathic scoliosis (AIS) with a curve between 25 and 45 degrees and significant growth remaining (premenarcheal, Risser 0). The standard of care to prevent curve progression is full-time bracing (TLSO) for 16 to 23 hours a day.

Question 350

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy falls from monkey bars and sustains a widely displaced extension-type supracondylar humerus fracture. Examination reveals an absent radial pulse but a warm, pink hand. After closed reduction and percutaneous pinning, the hand remains warm and pink, but the pulse remains absent. What is the next best step in management?

. Immediate exploration of the brachial artery
. Arteriography
. Observation and admission for neurovascular checks
. Removal of pins and open reduction
. Prophylactic forearm fasciotomy

Correct Answer & Explanation

. Immediate exploration of the brachial artery

Explanation

A "pink, pulseless" hand after anatomical reduction and pinning of a supracondylar humerus fracture typically indicates adequate collateral circulation. Observation is indicated as the pulse often returns within a few days; vascular exploration is reserved for a pale, pulseless hand.

Question 351

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl with adolescent idiopathic scoliosis (AIS) has a right thoracic curve of 55 degrees and a left lumbar curve of 30 degrees. On side-bending radiographs, the lumbar curve reduces to 10 degrees. According to the Lenke classification, what type of curve pattern is this, and what is the recommended surgical approach?

. Lenke 1: Selective thoracic fusion
. Lenke 2: Double thoracic fusion
. Lenke 3: Thoracic and lumbar fusion
. Lenke 5: Selective lumbar fusion
. Lenke 6: Thoracolumbar/lumbar fusion

Correct Answer & Explanation

. Lenke 1: Selective thoracic fusion

Explanation

This is a Lenke 1 (main thoracic) curve pattern, because the lumbar curve is nonstructural (bends out to less than 25 degrees). The standard surgical management is a selective thoracic fusion, which spares the lumbar spine to preserve spinal mobility.

Question 352

Topic: Pediatric Upper Extremity & Spine

A 13-year-old girl with adolescent idiopathic scoliosis presents for evaluation. Radiographs reveal a right thoracic curve of 35 degrees. Her Risser sign is 1, and she is premenarcheal. What is the most appropriate management?

. Observation with serial radiographs every 6 months
. Part-time nighttime bracing
. Full-time TLSO bracing
. Posterior spinal fusion
. Anterior tethering procedure

Correct Answer & Explanation

. Observation with serial radiographs every 6 months

Explanation

Full-time bracing (TLSO) is indicated for immature patients (Risser 0-2, premenarcheal) with idiopathic curves between 25 and 45 degrees. It has been shown to significantly decrease the risk of curve progression to the surgical threshold.

Question 353

Topic: Pediatric Upper Extremity & Spine

A 12-year-old girl presents with adolescent idiopathic scoliosis. She has a 20-degree right thoracic curve. She has not reached menarche. Which of the following radiographic parameters indicates the highest risk for curve progression?

. Closed triradiate cartilage
. Risser grade 0
. Risser grade 4
. Apical vertebral rotation of Grade 1
. Curve magnitude of 15 degrees

Correct Answer & Explanation

. Closed triradiate cartilage

Explanation

A Risser grade of 0 indicates that ossification of the iliac apophysis has not yet begun, implying significant remaining spinal growth. This is the strongest radiographic predictor for curve progression in adolescent idiopathic scoliosis.

Question 354

Topic: Pediatric Upper Extremity & Spine

A 13-year-old girl is evaluated for scoliosis. Radiographs show a 32-degree right thoracic curve. She is premenarchal, and her Risser grade is 1.

What is the most appropriate management?

. Physical therapy and observation
. Thoracolumbosacral orthosis (TLSO)
. Posterior spinal fusion
. Anterior spinal tethering
. Nighttime bending brace only

Correct Answer & Explanation

. Physical therapy and observation

Explanation

Bracing is indicated for skeletally immature patients (Risser 0-2) presenting with curve magnitudes between 25 and 45 degrees. A TLSO brace aims to halt curve progression during the adolescent growth spurt.

Question 355

Topic: Pediatric Upper Extremity & Spine

In the Lenke classification system for Adolescent Idiopathic Scoliosis, a proximal thoracic curve is defined as structural if the residual Cobb angle on a side-bending radiograph is at least:

. 10 degrees
. 15 degrees
. 20 degrees
. 25 degrees
. 30 degrees

Correct Answer & Explanation

. 10 degrees

Explanation

The Lenke classification defines a structural curve as one having a residual Cobb angle of 25 degrees or greater on lateral side-bending radiographs, or a regional kyphosis of 20 degrees or more.

Question 356

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal girl (Risser 0) is diagnosed with Adolescent Idiopathic Scoliosis. Her standing radiographs reveal a right thoracic curve of 32 degrees. Neurologic exam is normal. What is the most appropriate management?

. Observation with 6-month radiographic follow-up
. Initiation of physical therapy and Schroth exercises alone
. Thoracolumbosacral orthosis (TLSO) bracing
. Posterior spinal instrumentation and fusion
. Anterior vertebral body tethering

Correct Answer & Explanation

. Observation with 6-month radiographic follow-up

Explanation

In a growing child (Risser 0-2) with an adolescent idiopathic scoliosis curve measuring between 25 and 45 degrees, TLSO bracing is indicated to halt curve progression. A landmark trial (BrAIST) showed bracing significantly decreases the likelihood of progression to surgery.

Question 357

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl is diagnosed with a 45-degree right thoracic scoliosis. She is premenarcheal, Risser 0, and has open triradiate cartilages on pelvic radiographs. Without treatment, what is the estimated risk of her curve progressing to greater than 50 degrees?

. < 10%
. 20 - 30%
. 40 - 50%
. 60 - 70%
. > 90%

Correct Answer & Explanation

. < 10%

Explanation

Curve progression risk is based on remaining growth and curve magnitude. A premenarcheal, Risser 0 patient with a curve already at 45 degrees has an extremely high risk (approaching 100%) of progressing beyond surgical thresholds.

Question 358

Topic: Pediatric Upper Extremity & Spine

In evaluating a 12-year-old girl with adolescent idiopathic scoliosis, which of the following combinations of factors indicates the highest risk for curve progression?

. Risser stage 4 and a 20-degree curve
. Premenarchal status and a 30-degree curve
. Risser stage 0 and a 15-degree curve
. Postmenarchal status and a 40-degree curve
. Risser stage 2 and a 25-degree curve

Correct Answer & Explanation

. Risser stage 4 and a 20-degree curve

Explanation

Peak height velocity occurs just prior to menarche, making premenarchal status a critical risk factor for progression. A 30-degree curve in a rapidly growing premenarchal girl has the highest risk of progression among the choices provided.

Question 359

Topic: Pediatric Upper Extremity & Spine

A 55-year-old man who underwent previous Harrington rod instrumentation for adolescent idiopathic scoliosis now presents with forward-leaning posture, back pain, and thigh fatigue.

What is the primary pathophysiologic mechanism for his thigh fatigue?

. L4 nerve root compression
. Hip flexor contracture
. Compensatory hip extension and knee flexion
. Ischial bursitis
. Femoral nerve stretch

Correct Answer & Explanation

. L4 nerve root compression

Explanation

Flatback syndrome results in a loss of lumbar lordosis and a positive sagittal vertical axis. Patients compensate by extending their hips and flexing their knees, leading to rapid quadriceps and hamstring fatigue.

Question 360

Topic: Pediatric Upper Extremity & Spine

In the Lenke classification for adolescent idiopathic scoliosis, a curve is considered 'structural' if it lacks flexibility on side-bending radiographs. What residual Cobb angle on side-bending defines a structural curve?

. 10 degrees or greater
. 15 degrees or greater
. 20 degrees or greater
. 25 degrees or greater
. 30 degrees or greater

Correct Answer & Explanation

. 10 degrees or greater

Explanation

In the Lenke classification system, a minor curve is defined as structural if it does not bend down to less than 25 degrees (i.e., remains 25 degrees or greater) on coronal side-bending radiographs.

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