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Pediatric Upper Extremity & Spine MCQs

Practice Set 20 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 381

Topic: Pediatric Upper Extremity & Spine

A 5-year-old girl falls from the monkey bars and sustains a Gartland type III extension-type supracondylar humerus fracture.

On presentation, she has a pulseless, pink hand. After prompt closed reduction and percutaneous pinning, her hand remains warm and pink with a capillary refill of 2 seconds, but the radial pulse is still non-palpable. What is the most appropriate next step in management?

. Immediate open exploration of the brachial artery
. Observation with admission for close neurovascular monitoring
. Urgent CT angiography of the upper extremity
. Removal of the pins and open reduction of the fracture
. Prophylactic volar forearm fasciotomy

Correct Answer & Explanation

. Observation with admission for close neurovascular monitoring

Explanation

A pulseless, pink hand is a well-recognized clinical scenario following a displaced supracondylar humerus fracture. If the hand remains well-perfused (pink, warm, brisk capillary refill) after anatomical reduction and stabilization, collateral circulation is adequate. The standard of care is to admit the patient for close observation and serial neurovascular checks. Open vascular exploration is indicated if the hand is pulseless AND poorly perfused (pale/white) after reduction.

Question 382

Topic: Pediatric Upper Extremity & Spine
A 13-year-old premenarchal girl (Risser 0) presents for evaluation of a spinal deformity. Neurological examination is completely normal. Standing PA spine radiograph reveals a right thoracic curve measuring 35 degrees. What is the most appropriate next step in management?
. Observation with repeat radiographs in 6 months
. Schroth physical therapy method alone
. Prescription of a rigid thoracolumbosacral orthosis (TLSO)
. Posterior spinal fusion with pedicle screws
. Magnetically controlled growing rods (MCGR)

Correct Answer & Explanation

. Prescription of a rigid thoracolumbosacral orthosis (TLSO)

Explanation

This patient has Adolescent Idiopathic Scoliosis (AIS). She has significant remaining growth potential (premenarchal, Risser 0) and a curve magnitude between 25 and 45 degrees. According to the Bracing in Adolescent Idiopathic Scoliosis Trial (BRAIST) criteria, the standard of care for a skeletally immature patient with a curve of this magnitude is a rigid brace (e.g., TLSO) worn for at least 18 hours a day to prevent curve progression to surgical magnitude (>50 degrees).

Question 383

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl presents with adolescent idiopathic scoliosis (AIS). Upright radiographs demonstrate a right thoracic curve of 55 degrees and a left lumbar curve of 35 degrees. On supine side-bending radiographs, the thoracic curve reduces to 40 degrees, and the lumbar curve reduces to 15 degrees. The T2-T5 kyphosis is +15 degrees. According to the Lenke classification, what type of curve pattern does she have?

. Type 1 (Main Thoracic)
. Type 2 (Double Thoracic)
. Type 3 (Double Major)
. Type 5 (Thoracolumbar/Lumbar)
. Type 6 (Thoracolumbar/Lumbar-Main Thoracic)

Correct Answer & Explanation

. Type 1 (Main Thoracic)

Explanation

The Lenke classification system defines structural curves based on their flexibility. A minor curve is considered non-structural if it bends out to less than 25 degrees on side-bending films and has normal sagittal alignment. In this patient, the lumbar curve reduces to 15 degrees (non-structural), and the T2-T5 kyphosis is normal (not structural). Thus, only the main thoracic curve is structural, classifying this as a Lenke Type 1 (Main Thoracic) curve.

Question 384

Topic: Pediatric Upper Extremity & Spine

A 6-year-old girl falls from monkey bars and sustains a widely displaced, extension-type supracondylar humerus fracture. On initial presentation, she has no palpable radial pulse, but the hand is warm, pink, and has a brisk capillary refill of less than 2 seconds. She is taken urgently to the operating room, where an anatomic closed reduction is achieved and stabilized with three divergent lateral pins. After pinning, the hand remains pink and warm, but the radial pulse remains absent. What is the most appropriate next step in management?

. Immediate vascular surgery consultation for brachial artery exploration
. Remove the pins and perform an open reduction of the fracture
. Observation and admission for close neurovascular monitoring
. Immediate CT angiography of the upper extremity
. Administration of intra-arterial vasodilators

Correct Answer & Explanation

. Observation and admission for close neurovascular monitoring

Explanation

The management of a 'pulseless, pink' hand following adequate reduction and pinning of a supracondylar humerus fracture is observation and close monitoring. The pink color and brisk capillary refill indicate that collateral circulation is providing adequate perfusion to the hand. Routine vascular exploration is not indicated unless the hand becomes cool, pale, and ischemic (a 'pulseless, white' hand) after reduction.

Question 385

Topic: Pediatric Upper Extremity & Spine

A 12-year-old female presents to the clinic with an adolescent idiopathic scoliosis (AIS) right thoracic curve of 28 degrees. When counseling her parents about the risk of curve progression, you explain the concept of peak height velocity (PHV). Which of the following maturity indicators most closely corresponds to the peak velocity of growth in a patient with AIS?

. Closure of the triradiate cartilage
. Onset of menarche
. Risser stage 3
. Sanders maturity stage 3 (digital skeletal age)
. Transition from Risser stage 4 to 5

Correct Answer & Explanation

. Sanders maturity stage 3 (digital skeletal age)

Explanation

The peak height velocity (PHV) represents the phase of maximum linear growth and is the period of highest risk for curve progression in AIS. It typically occurs just before menarche. The Sanders maturity scale, which assesses the ossification of hand epiphyses, identifies Stage 3 (adolescent rapid-early) and Stage 4 (adolescent rapid-late) as the exact periods correlating with PHV. Triradiate cartilage closure is closely associated but Sanders 3 is the most precise indicator of the peak.

Question 386

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy falls from the monkey bars and sustains a widely displaced, extension-type supracondylar humerus fracture. On presentation to the emergency department, his hand is pink and warm with brisk capillary refill, but the radial pulse is absent. Neurological examination reveals weakness in flexing the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger. What is the most appropriate next step in management?

. Immediate open reduction and internal fixation
. Closed reduction and percutaneous pinning, followed by mandatory vascular exploration if the pulse remains absent
. Closed reduction and percutaneous pinning; if the hand remains pink and warm, observation is indicated
. CT angiography of the affected upper extremity
. Urgent vascular bypass grafting

Correct Answer & Explanation

. Closed reduction and percutaneous pinning; if the hand remains pink and warm, observation is indicated

Explanation

This patient has a "pink, pulseless" hand associated with a displaced supracondylar humerus fracture, along with an anterior interosseous nerve (AIN) palsy. The standard of care is urgent closed reduction and percutaneous pinning (CRPP). If the hand remains pink and well-perfused (warm with good capillary refill) after reduction, observation without vascular exploration is the accepted management, even if the radial pulse does not immediately return. Vascular exploration is indicated only if the hand becomes or remains white/ischemic after reduction.

Question 387

Topic: Pediatric Upper Extremity & Spine

A 6-year-old girl sustains a severely displaced, extension-type supracondylar humerus fracture. On initial presentation in the emergency department, her hand is pale and pulseless. Following urgent closed reduction and percutaneous pinning in the operating room, the fracture is anatomically aligned, but the hand remains pale, cold, and pulseless after 15 minutes of observation. What is the next most appropriate step in management?

. Observe the hand overnight for improvement in collateral circulation
. Perform an immediate anterior vascular exploration of the brachial artery
. Administer intravenous heparin and obtain a vascular surgery consult
. Remove the pins, flex the elbow to 120 degrees, and repin
. Perform a rapid sequence Doppler ultrasound

Correct Answer & Explanation

. Perform an immediate anterior vascular exploration of the brachial artery

Explanation

A pulseless, pale (white) hand following anatomical reduction and stabilization of a supracondylar humerus fracture is an absolute indication for immediate anterior vascular exploration. The brachial artery may be incarcerated in the fracture site, kinked, or transected. A pulseless but well-perfused (pink, warm) hand can often be closely observed, but a pale and pulseless hand mandates surgical exploration to restore perfusion and prevent ischemic contracture.

Question 388

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal female (Risser stage 0) presents with adolescent idiopathic scoliosis. Standing posteroanterior radiographs reveal a primary right thoracic curve measuring 32 degrees and a compensatory left lumbar curve of 20 degrees. What is the most appropriate management recommendation?

. Observation with repeat standing radiographs in 6 months
. Full-time wear of a nighttime bending brace
. Posterior spinal fusion with pedicle screw instrumentation
. Full-time wear of a thoracolumbosacral orthosis (TLSO)
. Intensive physical therapy and core strengthening program

Correct Answer & Explanation

. Full-time wear of a thoracolumbosacral orthosis (TLSO)

Explanation

The indications for bracing in Adolescent Idiopathic Scoliosis (AIS) are a growing child (Risser 0-2, premenarchal or < 1 year postmenarchal) with a curve between 25 and 40 degrees, or curve progression of > 5 degrees over 6 months in a curve initially measuring 20-29 degrees. Because this patient is Risser 0 with significant growth remaining and a 32-degree curve, full-time bracing with a TLSO (typically prescribed for 16-23 hours/day) is indicated. The BrAIST trial confirmed full-time bracing decreases the risk of curve progression to surgical magnitude.

Question 389

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy presents with a completely displaced, extension-type supracondylar humerus fracture. 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 pulse remains absent. What is the most appropriate next step?

. Immediate open exploration of the brachial artery
. Perform a CT angiogram of the upper extremity
. Remove the pins and attempt a second closed reduction
. Admit for 24-48 hours of observation with serial vascular checks
. Administer intravenous heparin and discharge home

Correct Answer & Explanation

. Admit for 24-48 hours of observation with serial vascular checks

Explanation

A "pulseless, pink" hand after reduction and pinning of a supracondylar fracture indicates adequate collateral circulation. Observation is the standard of care, as most radial pulses return within 24 to 48 hours without needing surgical exploration.

Question 390

Topic: Pediatric Upper Extremity & Spine
A 6-year-old girl sustains a Gartland type III supracondylar humerus fracture. On emergency department presentation, she has a 'pink, pulseless' hand with a normal neurologic examination. Capillary refill is less than 2 seconds. What is the most appropriate initial management?
. Immediate open vascular exploration and bypass
. Prompt closed reduction and percutaneous pinning followed by vascular reassessment
. CT angiography of the upper extremity prior to any intervention
. Application of a warm blanket and elevation for 24 hours
. Immediate fasciotomy of the forearm to prevent compartment syndrome

Correct Answer & Explanation

. Prompt closed reduction and percutaneous pinning followed by vascular reassessment

Explanation

For a 'pink, pulseless' hand in a displaced pediatric supracondylar humerus fracture, the initial step is prompt closed reduction and percutaneous pinning. Vascular exploration is indicated only if the hand becomes poorly perfused (white/cool) after reduction.

Question 391

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy falls from the monkey bars and sustains a completely displaced posteromedial supracondylar humerus fracture. On examination, the hand is pink and warm, but the radial pulse is absent. After closed reduction and percutaneous pinning, the hand remains pink and warm, and the radial pulse remains nonpalpable. What is the most appropriate next step?

. Urgent open exploration of the brachial artery
. Immediate angiography of the upper extremity
. Observation and hospital admission for neurovascular checks
. Administration of intravenous heparin
. Immediate removal of the pins and transition to open reduction

Correct Answer & Explanation

. Observation and hospital admission for neurovascular checks

Explanation

In a "pink, pulseless" hand following adequate reduction and stabilization of a supracondylar humerus fracture, collateral circulation is sufficient for distal perfusion. Close observation is recommended, as the pulse typically returns within several days without the need for urgent arterial exploration.

Question 392

Topic: Pediatric Upper Extremity & Spine
A 6-year-old girl sustains a Gartland type III extension-type supracondylar humerus fracture. On examination, she has a pulseless but pink, well-perfused hand. After closed reduction and percutaneous pinning, the hand remains pink and warm, but the radial pulse remains unpalpable. What is the most appropriate next step?
. Immediate vascular exploration
. Observe and admit for 24-48 hours
. Perform a sympathetic block
. Remove the pins and re-reduce the fracture
. Obtain an emergent CT angiogram

Correct Answer & Explanation

. Observe and admit for 24-48 hours

Explanation

A pulseless, pink, well-perfused hand after anatomical reduction and pinning of a supracondylar humerus fracture can be observed. Collateral circulation is adequate, and the radial pulse often returns within a few days due to relief of vasospasm.

Question 393

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains a Gartland type III extension supracondylar humerus fracture. On examination, the hand is pink and warm, but the radial pulse is not palpable. What is the most appropriate initial management?
. Immediate open vascular exploration
. Closed reduction and percutaneous pinning followed by vascular reassessment
. Computed tomography angiography (CTA) to localize the arterial injury
. Open reduction and internal fixation via an anterior approach
. Administration of intravenous heparin and observation

Correct Answer & Explanation

. Closed reduction and percutaneous pinning followed by vascular reassessment

Explanation

For a pink, pulseless hand associated with a supracondylar humerus fracture, the initial treatment is urgent closed reduction and percutaneous pinning. Vascular exploration is reserved for a persistently white, pulseless hand post-reduction.

Question 394

Topic: Pediatric Upper Extremity & Spine
A 5-year-old boy sustains a Gartland type III extension supracondylar humerus fracture. On initial presentation, his hand is pale, pulseless, and cool. Urgent closed reduction and percutaneous pinning are performed. Post-operatively, the hand becomes pink with brisk capillary refill, but the radial pulse remains non-palpable. What is the most appropriate next step in management?
. Immediate surgical exploration of the brachial artery
. Arteriography of the upper extremity
. Administration of systemic tissue plasminogen activator (tPA)
. Close observation and continuous pulse oximetry monitoring
. Immediate removal of the pins and conversion to open reduction

Correct Answer & Explanation

. Close observation and continuous pulse oximetry monitoring

Explanation

A pulseless, pink hand following reduction of a pediatric supracondylar humerus fracture indicates adequate collateral circulation. Close observation with continuous pulse oximetry is the standard of care. Surgical exploration is only indicated if the hand remains pale, pulseless, and poorly perfused after anatomical reduction.

Question 395

Topic: Pediatric Upper Extremity & Spine
A 5-year-old boy falls from the monkey bars and sustains a widely displaced Gartland type III supracondylar humerus fracture. On evaluation in the emergency department, his hand is warm and well-perfused (pink), but he has an absent radial pulse. What is the most appropriate initial management?
. Immediate open vascular exploration with a vascular surgeon
. Emergent closed reduction and percutaneous pinning
. CT angiography to definitively localize the arterial injury
. Observation with the arm continuously elevated above the heart
. Open reduction and internal fixation with medial and lateral plates

Correct Answer & Explanation

. Emergent closed reduction and percutaneous pinning

Explanation

In a pediatric patient with a displaced supracondylar humerus fracture and a 'pink, pulseless' hand, collateral circulation is maintaining limb viability. The initial management is emergent closed reduction and percutaneous pinning. The brachial artery is frequently tethered, kinked, or entrapped over the fracture fragments, and anatomical reduction usually restores the pulse. Angiography delays treatment, and open vascular exploration is reserved for a 'white, pulseless' hand that does not improve after reduction.

Question 396

Topic: Pediatric Upper Extremity & Spine

A 14-year-old female presents with Adolescent Idiopathic Scoliosis. Radiographs demonstrate a main thoracic curve of 55 degrees and a lumbar curve of 35 degrees. On dynamic side-bending films, the lumbar curve corrects to 15 degrees. The proximal thoracic curve measures 20 degrees and corrects to 10 degrees on side bending.

According to the Lenke classification system, what is the curve type?

. Type 1 (Main Thoracic)
. Type 2 (Double Thoracic)
. Type 3 (Double Major)
. Type 5 (Thoracolumbar/Lumbar)
. Type 6 (Thoracolumbar/Lumbar-Main Thoracic)

Correct Answer & Explanation

. Type 1 (Main Thoracic)

Explanation

In the Lenke classification, a curve is considered 'structural' if it fails to correct to <25 degrees on side-bending films. Here, the main thoracic curve is 55 degrees (major curve). The proximal thoracic corrects to 10 degrees (<25, so non-structural) and the lumbar curve corrects to 15 degrees (<25, so non-structural). Because only the Main Thoracic curve is structural, this is a Lenke Type 1 curve.

Question 397

Topic: Pediatric Upper Extremity & Spine
A 13-year-old premenarchal female presents with a right thoracic curve. She has not had her first menstrual period and is Risser stage 0. Standing PA radiograph shows a Cobb angle of 35 degrees. According to the Bracing in Adolescent Idiopathic Scoliosis Trial (BRAIST), what is the most appropriate management for this patient?
. Observation with repeat radiographs in 6 months
. Thoracolumbosacral orthosis (TLSO) bracing for 18-23 hours per day
. Night-time bending brace only
. Posterior spinal fusion
. Physiotherapy and core strengthening exercises as primary definitive treatment

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing for 18-23 hours per day

Explanation

The patient is a skeletally immature female (Risser 0, premenarchal) with an Adolescent Idiopathic Scoliosis (AIS) curve in the bracing threshold range (25 to 45 degrees). The BRAIST study conclusively demonstrated that high-hour TLSO bracing (18-23 hours/day) significantly decreases the progression of high-risk curves to the surgical threshold (>50 degrees) compared to observation.

Question 398

Topic: Pediatric Upper Extremity & Spine
A 12-year-old premenarchal girl presents with an asymmetric Adam's forward bending test. Standing scoliosis radiographs reveal a right thoracic curve measuring 32 degrees with an apex at T8. Her Risser stage is 0, and the tri-radiate cartilages are open. What is the most appropriate management for this patient?
. Observation with repeat radiographs in 6 months
. Thoracolumbosacral orthosis (TLSO) bracing
. Posterior spinal fusion with instrumentation
. Anterior vertebral body tethering
. Physical therapy focusing on core strengthening

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing

Explanation

The patient has Adolescent Idiopathic Scoliosis (AIS). Indications for bracing in AIS include an actively growing child (Risser 0-2, premenarchal or <1 year postmenarchal) with a curve between 25 and 40 degrees. Bracing (such as a TLSO for > 18 hours per day) has been shown in the BRAIST trial to significantly decrease the rate of curve progression to the surgical threshold (≥ 50 degrees). Observation alone is appropriate for curves < 25 degrees, while surgery is generally reserved for curves > 45-50 degrees.

Question 399

Topic: Pediatric Upper Extremity & Spine

In the evaluation of Adolescent Idiopathic Scoliosis (AIS) using the Lenke classification system, a proximal thoracic curve is considered "structural" and must be included in the fusion construct if the Cobb angle on the side-bending radiograph is at least:

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

Correct Answer & Explanation

. 25 degrees

Explanation

In the Lenke classification system for AIS, a minor curve is considered structural if it does not bend out to less than 25 degrees on side-bending radiographs, or if there is local kyphosis of +20 degrees or more across that region. Identifying structural minor curves is critical for determining the proper levels for spinal fusion.

Question 400

Topic: Pediatric Upper Extremity & Spine

A 12-year-old girl is evaluated for a spinal deformity. Radiographs demonstrate a right thoracic curve of 25 degrees. She has not yet reached menarche. Her Risser stage is 0, and her Sanders bone age stage is 2. Which of the following factors is most predictive of curve progression in this patient?

. Apical vertebral rotation
. Peak height velocity
. Family history of scoliosis
. Curve magnitude and remaining skeletal growth
. Presence of back pain

Correct Answer & Explanation

. Curve magnitude and remaining skeletal growth

Explanation

The risk of curve progression in adolescent idiopathic scoliosis is primarily determined by two main factors: the magnitude of the curve at presentation and the amount of remaining skeletal growth. Remaining growth is assessed using indicators such as Risser stage, menarcheal status, and Sanders bone age. A 25-degree curve in a pre-menarcheal girl with a Risser stage of 0 has a high risk of progression, and bracing is typically indicated.

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