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Pediatric Upper Extremity & Spine MCQs

Practice Set 21 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 401

Topic: Pediatric Upper Extremity & Spine

An 11-year-old girl is evaluated for scoliosis. She is premenarchal. Radiographs demonstrate a right thoracic curve with a Cobb angle of 32 degrees. Her Risser stage is 0. What is the most appropriate recommendation?

. Observation with repeat radiographs in 6 months
. Physical therapy focusing on core strengthening
. Full-time thoracolumbosacral orthosis (TLSO) bracing
. Nighttime bending brace alone
. Posterior spinal instrumentation and fusion

Correct Answer & Explanation

. Full-time thoracolumbosacral orthosis (TLSO) bracing

Explanation

This patient has adolescent idiopathic scoliosis (AIS) with a high risk of curve progression due to her significant skeletal immaturity (premenarchal, Risser 0) and curve magnitude (32 degrees). The BrAIST (Bracing in Adolescent Idiopathic Scoliosis Trial) study definitively showed that full-time bracing (at least 16-18 hours per day) significantly decreases the progression of high-risk curves to the surgical threshold (curves between 25 and 45 degrees in skeletally immature patients).

Question 402

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents to the emergency department after falling off monkey bars. Radiographs reveal a Gartland Type III extension supracondylar humerus fracture with posteromedial displacement of the distal fragment. Which of the following neurologic deficits is most likely to be observed on physical examination?
. Inability to flex the interphalangeal joint of the thumb
. Inability to extend the metacarpophalangeal joints of the fingers
. Weakness in spreading the fingers against resistance
. Numbness over the volar aspect of the little finger
. Weakness of the flexor carpi ulnaris

Correct Answer & Explanation

. Inability to extend the metacarpophalangeal joints of the fingers

Explanation

In an extension-type supracondylar fracture of the humerus, the distal fragment is displaced posteriorly. If the distal fragment is displaced posteromedially, the proximal fragment acts as a lateral spike, which puts the radial nerve at the highest risk of injury. A radial nerve palsy presents with the inability to extend the wrist and metacarpophalangeal joints. Posterolateral displacement of the distal fragment puts the median nerve (particularly the anterior interosseous nerve) and brachial artery at risk due to the medial spike of the proximal fragment.

Question 403

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls on an outstretched hand and sustains a supracondylar humerus fracture. A radiograph reveals a completely displaced extension-type (Gartland Type III) fracture. On physical examination in the emergency department, an anterior interosseous nerve (AIN) palsy is diagnosed. Which of the following clinical findings is most likely present to confirm this diagnosis?
. Inability to flex the wrist with ulnar deviation
. Inability to flex the distal interphalangeal joint of the index finger
. Inability to extend the interphalangeal joint of the thumb
. Loss of sensation over the volar aspect of the index finger
. Inability to abduct the fingers against resistance

Correct Answer & Explanation

. Inability to flex the distal interphalangeal joint of the index finger

Explanation

Anterior interosseous nerve (AIN) palsy is the most common neurologic injury associated with extension-type supracondylar humerus fractures. The AIN is a pure motor branch of the median nerve that innervates the flexor pollicis longus (FPL), the flexor digitorum profundus (FDP) to the index and middle fingers, and the pronator quadratus. Clinically, it presents as an inability to make the 'A-OK' sign due to weakness in flexing the distal interphalangeal joint of the index finger and the interphalangeal joint of the thumb. It does not cause sensory deficits.

Question 404

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls from the monkey bars and sustains a completely displaced, extension-type supracondylar humerus fracture. On arrival, his hand is pink but the radial pulse is absent. Capillary refill is brisk (< 2 seconds). Following closed reduction and percutaneous pinning, the hand remains pink with brisk capillary refill, but the radial pulse remains unpalpable. What is the next best step in management?
. Immediate exploration of the brachial artery
. Removal of pins and open reduction
. Observation and admission for 24-48 hours
. Urgent CT angiography of the upper extremity
. Prophylactic volar fasciotomy of the forearm

Correct Answer & Explanation

. Observation and admission for 24-48 hours

Explanation

The management of a 'pink, pulseless' hand following a well-reduced and pinned supracondylar humerus fracture is observation. Because perfusion is clinically adequate (pink color, brisk capillary refill), the collateral circulation is sufficient to sustain the limb. Vascular exploration is indicated only if the hand becomes white and pulseless (ischemia) after reduction, which suggests brachial artery entrapment or severe intimal injury without adequate collateral flow.

Question 405

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains a Gartland type III extension-type supracondylar humerus fracture. On initial evaluation in the emergency department, the hand is pink and warm with brisk capillary refill, but the radial pulse is not palpable. After emergent closed reduction and percutaneous pinning in the operating room, the fracture is anatomically aligned, but the radial pulse remains absent. The hand remains warm and pink. What is the most appropriate next step in management?
. Immediate open exploration of the brachial artery
. Observation with continuous clinical monitoring
. CT angiography of the upper extremity
. Removal of the pins and transition to a long arm cast
. Prophylactic forearm fasciotomies

Correct Answer & Explanation

. Observation with continuous clinical monitoring

Explanation

The management of a 'pulseless, pink hand' following a supracondylar humerus fracture involves urgent closed reduction and percutaneous pinning (CRPP) to restore anatomy and potentially release a kinked or entrapped brachial artery. If the hand remains pink and well-perfused (capillary refill <2 seconds) after anatomic reduction and stabilization, despite an absent palpable pulse, the standard of care is observation and continuous monitoring. Many of these hands have adequate collateral circulation. Open exploration of the brachial artery is indicated if the hand becomes or remains 'pulseless and white' (ischemic) after reduction.

Question 406

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 in the emergency department, his hand is pink and warm, but the radial pulse is not palpable. He is taken emergently to the operating room. After successful closed reduction and percutaneous pinning, the hand remains pink with brisk capillary refill, but the radial pulse is still absent on Doppler ultrasound. What is the most appropriate next step in management?

. Immediate vascular exploration
. Close observation with hospital admission
. Emergent arteriography
. Removal of the pins and transition to open reduction
. Administration of systemic intravenous heparin

Correct Answer & Explanation

. Close observation with hospital admission

Explanation

The management of a 'pulseless, pink hand' after a supracondylar humerus fracture reduction is close clinical observation. As long as the hand remains well-perfused (warm, pink, capillary refill < 2 seconds), adequate collateral circulation is present. Vascular exploration is indicated only if the hand becomes dysvascular (white, cold, prolonged capillary refill) after reduction, or if there is a loss of a previously palpable pulse following reduction.

Question 407

Topic: Pediatric Upper Extremity & Spine
A 5-year-old girl falls from monkey bars and sustains a Gartland type III supracondylar humerus fracture. On presentation to the emergency department, her hand is pink and well-perfused with a capillary refill of 2 seconds, but the radial pulse is not palpable. She undergoes emergent closed reduction and percutaneous pinning. In the recovery room, her hand remains pink and warm, but the radial pulse remains absent on palpation and Doppler ultrasound. What is the most appropriate next step in management?
. Immediate exploration of the brachial artery
. Computed tomography angiography of the upper extremity
. Observation with close clinical monitoring
. Immediate removal of pins and open reduction
. Forearm fasciotomy

Correct Answer & Explanation

. Observation with close clinical monitoring

Explanation

The management of the 'pulseless, pink hand' following a pediatric supracondylar humerus fracture is observation. If the hand remains well-perfused (pink, warm, capillary refill < 2 seconds) after closed reduction and pinning, the collateral circulation is sufficient, and arterial exploration or advanced imaging is not indicated. The brachial artery may be in spasm or have a small intimal tear that will often resolve or remodel without ischemic consequence. Arterial exploration is strictly indicated if the hand is 'white and pulseless' (ischemic) after reduction and pinning.

Question 408

Topic: Pediatric Upper Extremity & Spine

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

. Immediate vascular exploration
. Observation with ward monitoring
. Removal of pins and hyperflexion of the elbow
. Prophylactic forearm fasciotomy
. CT angiography

Correct Answer & Explanation

. Observation with ward monitoring

Explanation

A "pink, pulseless" hand after reduction of a supracondylar humerus fracture indicates adequate collateral perfusion. The standard of care is close observation and admission, as the pulse often returns within 24 to 48 hours without surgical exploration.

Question 409

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy falls from monkey bars and sustains a completely displaced, extension-type supracondylar fracture of the humerus. On examination, the hand is pink and warm, but the radial pulse is non-palpable. What is the most appropriate initial management?

. Immediate open exploration of the brachial artery
. Closed reduction and percutaneous pinning
. CT angiography of the upper extremity
. Splinting in 90 degrees of flexion and observation
. Application of a long arm cast in full extension

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

For a pulseless but well-perfused (pink) hand following a supracondylar humerus fracture, the standard of care is urgent closed reduction and percutaneous pinning. The pulse frequently returns after the fracture is anatomically reduced.

Question 410

Topic: Pediatric Upper Extremity & Spine

A 6-year-old girl sustains a severely displaced extension-type supracondylar humerus fracture. After closed reduction and percutaneous pinning in the operating room, her hand is pink and well-perfused, but the radial pulse remains non-palpable. A biphasic Doppler signal is present at the wrist. What is the most appropriate management?

. Immediate exploration of the brachial artery
. Observation and admission for close neurovascular checks
. Angiography of the upper extremity
. Removal of the pins and open reduction
. Administration of intravenous heparin

Correct Answer & Explanation

. Observation and admission for close neurovascular checks

Explanation

A 'pink, pulseless' hand after reduction and pinning of a supracondylar fracture with good capillary refill and Doppler signals should be observed closely. Vascular exploration is indicated only if the hand becomes pale and poorly perfused (white and pulseless).

Question 411

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarchal female with Adolescent Idiopathic Scoliosis presents with a right thoracic curve of 32 degrees. Her Risser stage is 0, and her Sanders maturity scale is 2. What is the most appropriate treatment recommendation?

. Observation with radiographs in 6 months
. Physical therapy alone
. Full-time TLSO bracing
. Posterior spinal fusion
. Anterior vertebral body tethering

Correct Answer & Explanation

. Full-time TLSO bracing

Explanation

Bracing is indicated for skeletally immature patients (Risser 0-2, premenarchal) with an AIS curve between 25 and 45 degrees. A TLSO brace worn 16-23 hours a day decreases the risk of curve progression to a surgical threshold.

Question 412

Topic: Pediatric Upper Extremity & Spine

A 5-year-old girl sustains a severely displaced extension-type supracondylar humerus fracture. On presentation, her hand is warm and pink, but the radial pulse is not palpable. 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 exploration
. Observe and admit for 24-48 hours
. Perform a CT angiogram
. Remove the pins and perform an open reduction
. Administer intravenous heparin

Correct Answer & Explanation

. Observe and admit for 24-48 hours

Explanation

In a pulseless but pink and well-perfused hand following reduction and pinning of a supracondylar fracture, observation is recommended. The collateral circulation is adequate, and the radial pulse often returns within a few days due to the resolution of vasospasm.

Question 413

Topic: Pediatric Upper Extremity & Spine

A 6-year-old girl sustains a severely displaced extension-type supracondylar humerus fracture. After closed reduction and percutaneous pinning, the hand is pink but lacks a palpable radial pulse. Capillary refill is less than 2 seconds. What is the most appropriate next step in management?

. Immediate exploration of the brachial artery
. Intravenous heparin infusion
. Removal of pins and open reduction
. Observation with close neurovascular monitoring
. Compartment fasciotomies

Correct Answer & Explanation

. Observation with close neurovascular monitoring

Explanation

A "pink, pulseless" hand after reduction and pinning of a supracondylar humerus fracture with adequate perfusion (capillary refill < 2 seconds) should be observed closely. Vascular exploration is indicated if the hand becomes pale and dysvascular after an anatomic reduction.

Question 414

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. Capillary refill is less than 2 seconds. What is the most appropriate next step in management?

. Immediate open vascular exploration
. Closed reduction and percutaneous pinning, then reassess perfusion
. Doppler ultrasound of the brachial artery
. Angiography of the upper extremity
. Application of a long arm cast in 120 degrees of flexion

Correct Answer & Explanation

. Closed reduction and percutaneous pinning, then reassess perfusion

Explanation

The pulseless, pink hand is a well-described clinical scenario in completely displaced supracondylar humerus fractures. The most appropriate initial step is urgent closed reduction and percutaneous pinning, followed by reassessment of the vascular status.

Question 415

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains an extension-type Gartland III supracondylar humerus fracture. Examination reveals weakness in flexing the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger. Which nerve is most likely injured?
. Radial nerve
. Ulnar nerve
. Anterior interosseous nerve
. Posterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

The anterior interosseous nerve (AIN) is the most commonly injured nerve in extension-type supracondylar humerus fractures. Injury presents with an inability to form the "A-OK" sign.

Question 416

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal girl presents with adolescent idiopathic scoliosis. Her primary thoracic curve measures 25 degrees. Her Risser stage is 0. What is her approximate risk of curve progression to greater than 50 degrees?

. 10%
. 20%
. 40%
. 68%
. 90%

Correct Answer & Explanation

. 68%

Explanation

In a patient with Risser stage 0-1 and a curve of 20 to 29 degrees, the risk of curve progression is approximately 68%. Bracing is strongly indicated in this scenario.

Question 417

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a completely displaced, extension-type supracondylar humerus fracture. On arrival, the hand is pink and well-perfused, but the radial pulse is absent. What is the most appropriate next step in management?

. Immediate exploration of the brachial artery
. Urgent CT angiography
. Closed reduction and percutaneous pinning, followed by observation if perfusion remains intact
. Open reduction and internal fixation with prophylactic fasciotomies
. Application of a hyperflexion cast

Correct Answer & Explanation

. Closed reduction and percutaneous pinning, followed by observation if perfusion remains intact

Explanation

For a 'pink, pulseless' hand associated with a supracondylar humerus fracture, the initial treatment is urgent closed reduction and percutaneous pinning. If the hand remains well-perfused after pinning, vascular exploration is not indicated, and the patient can be closely observed.

Question 418

Topic: Pediatric Upper Extremity & Spine
A 5-year-old girl falls from monkey bars and sustains a widely displaced, extension-type Gartland III supracondylar humerus fracture. On initial evaluation, the hand is pink and warm, but the radial pulse is not palpable. What is the most appropriate initial management?
. Closed reduction and percutaneous pinning, followed by reassessment of the pulse
. Immediate open exploration of the brachial artery
. Urgent CT angiography of the upper extremity
. Prophylactic forearm fasciotomies
. Observation in a long arm cast for 24 hours

Correct Answer & Explanation

. Closed reduction and percutaneous pinning, followed by reassessment of the pulse

Explanation

A "pulseless, pink" hand in the setting of a displaced supracondylar fracture should be managed with prompt closed reduction and percutaneous pinning (CRPP). Routine exploration is not required unless the hand becomes poorly perfused (white) after reduction.

Question 419

Topic: Pediatric Upper Extremity & Spine

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

. Immediate exploration of the brachial artery
. Observation and admission for close clinical monitoring
. Stat Doppler ultrasound of the radial artery
. Emergent upper extremity arteriography
. Removal of the pins and immediate re-reduction

Correct Answer & Explanation

. Observation and admission for close clinical monitoring

Explanation

A pulseless but pink and well-perfused hand following adequate reduction and pinning of a supracondylar humerus fracture is an indication for close clinical observation and admission. Vascular exploration is only indicated if the hand remains white, cool, and poorly perfused after reduction.

Question 420

Topic: Pediatric Upper Extremity & Spine
A 5-year-old girl sustains a Gartland type III supracondylar humerus fracture. Following closed reduction and percutaneous pinning, the radial pulse is not palpable, but her hand is warm and pink with a capillary refill time of 2 seconds. What is the most appropriate next step?
. Immediate exploration of the brachial artery
. Removal of all pins and open reduction
. Perform an upper extremity angiogram
. Observation and hospital admission
. Fasciotomy of the forearm

Correct Answer & Explanation

. Observation and hospital admission

Explanation

A 'pink, pulseless' hand after reduction and pinning of a supracondylar fracture indicates adequate collateral perfusion. Current AAOS guidelines recommend close observation for 24-48 hours rather than routine surgical exploration.

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