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Pediatric Upper Extremity & Spine MCQs

Practice Set 2 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 21

Topic: Pediatric Upper Extremity & Spine

Six months ago, an 11-year-old premenarchal girl with adolescent idiopathic scoliosis had a right thoracic curve from T5 to T12 measuring 20°. Her physical examination was normal. She returned to the office and a standing posteroanterior radiograph demonstrates a 28° right thoracic curve from T5 to T12; she is Risser stage 0. A lateral radiograph shows a thoracic kyphosis of 10°. At this time, you recommend:

. Repeat radiograph in 6 months
. Thoracic flexibility exercises
. Full-time use of a thoracolumbosacral orthosis
. Electrical stimulation
. Posterior spinal fusion with instrumentation

Correct Answer & Explanation

. Full-time use of a thoracolumbosacral orthosis

Explanation

In skeletally immature patients with adolescent idiopathic scoliosis and curves approaching 30° with documented progression, bracing may be effective at preventing further progression of the curve. Risk of progression in adolescent idiopathic scoliosis is related to curve magnitude and remaining growth potential. The risk of further progression in this patient is 68%, and bracing is indicated. Electrical stimulation and physical therapy have not been shown to affect the natural history of scoliosis. Surgery may be indicated in patients with more severe curves. In the sagittal plane, hypokyphosis is usually present in adolescent idiopathic scoliosis.

Question 22

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a completely displaced, extension-type supracondylar humerus fracture. After closed reduction and percutaneous pinning with two lateral pins, you notice the anterior interosseous nerve (AIN) is non-functional. What is the most common physical finding of AIN palsy?

. Inability to extend the IP joint of the thumb
. Inability to flex the IP joint of the thumb and the DIP joint of the index finger
. Decreased sensation over the volar aspect of the index finger
. Inability to spread the fingers
. Wrist drop

Correct Answer & Explanation

. Inability to flex the IP joint of the thumb and the DIP joint of the index finger

Explanation

The AIN innervates the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) to the index finger. Palsy results in the inability to make an "OK" sign (flexion of thumb IP and index DIP joints).

Question 23

Topic: Pediatric Upper Extremity & Spine

A 5-year-old boy sustains a completely displaced supracondylar humerus fracture. On examination, the hand is pink and well-perfused but the radial pulse is absent. What is the next best step in management?

. Immediate open vascular exploration
. Closed reduction and percutaneous pinning followed by reassessment
. CT angiography of the upper extremity
. Application of a long arm cast in 120 degrees of flexion
. Observation for 24 hours before intervention

Correct Answer & Explanation

. Closed reduction and percutaneous pinning followed by reassessment

Explanation

For a pulseless, pink, and well-perfused hand associated with a supracondylar fracture, the initial step is urgent closed reduction and pinning. If the hand remains pink and perfused post-reduction despite an absent pulse, close observation without immediate exploration is standard practice.

Question 24

Topic: Pediatric Upper Extremity & Spine

A 6-year-old girl sustains a severely displaced extension-type supracondylar humerus fracture. On presentation, her hand is well-perfused and pink, but the radial pulse is absent. What is the most appropriate initial management?

. Immediate open exploration of the brachial artery
. Observation and admission for 24 hours
. Urgent closed reduction and percutaneous pinning
. CT angiography of the upper extremity
. Prophylactic forearm fasciotomy

Correct Answer & Explanation

. Urgent closed reduction and percutaneous pinning

Explanation

In a 'pulseless, pink' hand following a supracondylar fracture, the collateral circulation is intact. The standard of care is urgent closed reduction and percutaneous pinning, which often restores the palpable pulse.

Question 25

Topic: Pediatric Upper Extremity & Spine

A 3-year-old boy falls on his upper extremity and shows sign of pain. His radiograph only shows a posterior fat pad sign of the elbow. What is the most likely diagnosis:

. Nursemaid elbow
. Elbow sprain
. Supracondylar humerus fracture
. Proximal ulna fracture
. Lateral condyle fracture

Correct Answer & Explanation

. Supracondylar humerus fracture

Explanation

A positive posterior fat pad sign is more suspicious for occult fracture than an anterior fat pad sign because flexing the elbow normally may elevate the anterior but not the posterior fat pad. A positive posterior fat pad sign is most likely to represent an undisplaced supracondylar fracture of the distal humerus, followed by proximal ulna, lateral conydle, and radial neck fracture. A nursemaid elbow is a diagnosis of exclusion and should be used only when the mechanism is one of traction rather than compression.

Question 26

Topic: Pediatric Upper Extremity & Spine

Which of the following is not an indication to urgently treat a supracondylar humerus fracture:

. Antecubital ecchymosis
. Firm compartments
. Associated forearm fracture
. Poor perfusion
. Medial comminution

Correct Answer & Explanation

. Medial comminution

Explanation

Medial comminution is an indication of potential bony instability but does not convey any increased vascular risk. All of the other indications convey a vascular risk, and treatment should not be delayed.

Question 27

Topic: Pediatric Upper Extremity & Spine

An 8-year-old boy presents with an isolated pediatric lateral condyle fracture of the humerus. Radiographs show a Milch Type II fracture with 3 mm of displacement. What is the most appropriate management?

. Long arm cast in supination
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation
. Excision of the fragment
. Observation with serial weekly radiographs

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

Lateral condyle fractures displaced greater than 2 mm have a high rate of nonunion due to synovial fluid bathing the fracture and the pull of the extensor origin. Therefore, open reduction and internal fixation (ORIF) is indicated.

Question 28

Topic: Pediatric Upper Extremity & Spine

A 12-year-old baseball pitcher presents with chronic medial elbow pain. Radiographs reveal widening of the medial epicondylar apophysis. The biomechanical mechanism responsible for this condition is primarily:

. Valgus overload
. Varus overload
. Hyperextension stress
. Hyperflexion stress
. Direct posterior impact

Correct Answer & Explanation

. Valgus overload

Explanation

Little League Elbow encompasses medial epicondyle apophysitis caused by repetitive valgus overload during the late cocking and early acceleration phases of throwing. This places massive tensile stress on the medial structures.

Question 29

Topic: Pediatric Upper Extremity & Spine

A newborn is diagnosed with bilateral radial clubhands. Which of the following laboratory investigations is most critical to perform early to rule out a potentially fatal condition associated with this deformity?

. Renal function panel
. Complete blood count and chromosomal breakage studies
. Liver function tests
. Serum calcium and phosphate
. Sweat chloride test

Correct Answer & Explanation

. Complete blood count and chromosomal breakage studies

Explanation

Fanconi anemia is a life-threatening aplastic anemia associated with radial clubhand. A CBC and chromosomal breakage test (diepoxybutane test) are critical early screening tools to detect this condition.

Question 30

Topic: Pediatric Upper Extremity & Spine
A newborn has absent radii bilaterally, but both thumbs are distinctly present and well-formed. Blood tests reveal profound thrombocytopenia. This clinical picture is most characteristic of which syndrome?
. Holt-Oram syndrome
. TAR syndrome
. Fanconi anemia
. VACTERL association
. Roberts syndrome

Correct Answer & Explanation

. TAR syndrome

Explanation

Thrombocytopenia-Absent Radius (TAR) syndrome classically presents with bilateral absence of the radii but preservation of the thumbs. This differentiates it from other causes of radial dysplasia where the thumbs are typically absent or hypoplastic.

Question 31

Topic: Pediatric Upper Extremity & Spine

A 13-year-old gymnast sustains a dislocated elbow with an associated medial epicondyle fracture. Following closed reduction of the elbow joint, what is the absolute indication for open reduction and internal fixation of the medial epicondyle?

. Displacement greater than 2 mm
. Ulnar nerve neurapraxia
. Incarceration of the medial epicondyle fragment within the joint
. High demand athletic status
. Dominant arm involvement

Correct Answer & Explanation

. Incarceration of the medial epicondyle fragment within the joint

Explanation

Incarceration of the medial epicondyle within the ulnohumeral joint after an attempted closed reduction is an absolute indication for surgical extraction and internal fixation. Most other criteria are relative indications depending on the surgeon and patient demands.

Question 32

Topic: Pediatric Upper Extremity & Spine

A 5-year-old sustains a completely displaced supracondylar humerus fracture. On arrival, the hand is pink but the radial pulse is absent. After successful closed reduction and pinning, the hand remains pink and warm with a capillary refill of 2 seconds, but the pulse remains absent. What is the most appropriate next step?

. Immediate vascular exploration
. Fasciotomy of the forearm
. Observation with close continuous clinical monitoring
. Local intra-arterial vasodilators
. Angiography

Correct Answer & Explanation

. Observation with close continuous clinical monitoring

Explanation

A "pink, pulseless" hand after a well-reduced supracondylar fracture indicates adequate collateral circulation. Current AAOS guidelines support close observation rather than immediate vascular exploration in this scenario.

Question 33

Topic: Pediatric Upper Extremity & Spine

When attempting closed reduction of a typical extension-type supracondylar fracture of the humerus with medial comminution, which position of the forearm is utilized to tension the intact medial periosteal hinge and prevent varus malalignment?

. Maximum supination
. Maximum pronation
. Neutral rotation
. Palmar flexion
. Ulnar deviation

Correct Answer & Explanation

. Maximum pronation

Explanation

Pronation of the forearm tightens the medial periosteal hinge. This helps close the lateral fracture gap and prevents cubitus varus deformity, which is the most common cosmetic complication of medial comminution.

Question 34

Topic: Pediatric Upper Extremity & Spine

Flexion-type supracondylar fractures of the distal humerus in children are characterized by which of the following when compared to extension-type injuries:

. Younger age at presentation
. Higher risk of ulnar nerve injury
. Higher risk of anterior interosseous nerve injury
. Lower risk of needing open reduction
. Greater frequency of occurrence

Correct Answer & Explanation

. Higher risk of ulnar nerve injury

Explanation

Flexion-type supracondylar fractures of the distal humerus in children include the following characteristics: Frequency is less than one-tenth as that of extension-type supracondylar fractures Tend to occur in older children Lower risk of anterior interosseous nerve injury Higher risk of ulnar nerve injury More often require open reduction

Question 35

Topic: Pediatric Upper Extremity & Spine
A newborn is noted to have a foreshortened right forearm with the hand deviated radially and an absent thumb. Which of the following systemic conditions is NOT typically associated with this deformity?
. TAR syndrome
. Holt-Oram syndrome
. VACTERL association
. Fanconi anemia
. Neurofibromatosis type 1

Correct Answer & Explanation

. Neurofibromatosis type 1

Explanation

Radial clubhand (radial longitudinal deficiency) is associated with TAR, Holt-Oram, VACTERL, and Fanconi anemia. Neurofibromatosis type 1 is classically associated with anterolateral tibial bowing, not radial clubhand.

Question 36

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal female (Risser 0) is diagnosed with adolescent idiopathic scoliosis. Her right thoracic curve measures 32 degrees. What is the most appropriate management?

. Observation with radiographs every 12 months
. Physical therapy for core strengthening
. Full-time TLSO bracing
. Posterior spinal fusion
. Anterior tethering procedure

Correct Answer & Explanation

. Full-time TLSO bracing

Explanation

Bracing is indicated for growing children (Risser 0-2, premenarchal) with curves between 25 and 40 degrees. It is also indicated for documented progression of >5 degrees in curves of 20-25 degrees.

Question 37

Topic: Pediatric Upper Extremity & Spine

A 12-year-old girl is diagnosed with adolescent idiopathic scoliosis (AIS). She is premenarchal, Risser stage 0, and has a right thoracic curve of 35 degrees. What is the most appropriate management?

. Observation with radiographs every 6 months
. Thoracolumbosacral orthosis (TLSO) bracing
. Posterior spinal fusion
. Anterior tethering procedure
. Physical therapy alone

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing

Explanation

In a skeletally immature patient (Risser 0, premenarchal) with an AIS curve between 25 and 45 degrees, bracing is indicated to prevent curve progression.

Question 38

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy presents with a displaced extension-type supracondylar humerus fracture. After anatomic closed reduction and percutaneous pinning, the radial pulse is absent, but the hand remains warm and pink with brisk capillary refill. What is the most appropriate next step in management?

. Immediate exploration of the brachial artery
. Observation with strict pulse oximetry monitoring
. Immediate removal of all pins and open reduction
. Prophylactic fasciotomy of the forearm
. Immediate CT angiogram of the upper extremity

Correct Answer & Explanation

. Observation with strict pulse oximetry monitoring

Explanation

A 'pulseless, pink' hand following an adequate reduction and pinning of a supracondylar fracture indicates sufficient collateral circulation. Standard management is close observation and monitoring, as the pulse often returns over several days.

Question 39

Topic: Pediatric Upper Extremity & Spine

Risk factors for superior mesenteric artery syndrome after adolescent idiopathic scoliosis surgery include all of the following except:

. Decreased correction of thoracic curve with preoperative bending
. Body mass index (BMI) below the 25th percentile
. Lenke lumbar modifier B or C
. Staged surgical correction
. Use of iliac crest bone graft

Correct Answer & Explanation

. Body mass index (BMI) below the 25th percentile

Explanation

Superior mesenteric artery syndrome occurs more often in patients with decreased BMI, larger and stiffer thoracic curves, lumbar apical translation of Lenke B or C , and two staged procedures.

Question 40

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a severely displaced extension-type supracondylar humerus fracture. On examination, he has a completely absent radial pulse, but his hand is warm, pink, and has a capillary refill of less than 2 seconds. What is the most appropriate next step in management?

. Immediate open exploration of the brachial artery
. Preoperative CT angiogram of the upper extremity
. Urgent closed reduction and percutaneous pinning
. Observation in a splint for 24 hours
. Doppler ultrasound of the radial artery

Correct Answer & Explanation

. Urgent closed reduction and percutaneous pinning

Explanation

A pulseless but well-perfused (pink and warm) hand following a supracondylar humerus fracture is usually due to brachial artery kinking or spasm. The immediate treatment of choice is urgent closed reduction and percutaneous pinning, after which perfusion is reassessed.

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