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Pediatric Upper Extremity & Spine MCQs

Practice Set 22 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 421

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarchal girl presents with adolescent idiopathic scoliosis. Radiographs demonstrate a right thoracic curve of 32 degrees. Her Risser stage is 0. What is the most appropriate management?

. Observation with radiographs every 6 months
. Thoracolumbosacral orthosis (TLSO) for 18 hours per day
. Nighttime-only bending brace
. Posterior spinal fusion
. Anterior vertebral body tethering

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) for 18 hours per day

Explanation

Bracing is indicated for skeletally immature patients (Risser 0-2, premenarchal) with an idiopathic scoliotic curve between 25 and 45 degrees. A TLSO worn for at least 18 hours per day has been shown to significantly decrease the risk of progression to surgery.

Question 422

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy falls from monkey bars and sustains a significantly displaced extension-type supracondylar humerus fracture. On presentation, his hand is pink but the radial pulse is absent. The fracture is closed reduced and pinned, and the hand remains pink, but the radial pulse remains absent. Capillary refill is brisk. What is the most appropriate next step?

. Immediate exploration of the brachial artery
. CT angiography of the upper extremity
. Release of the pins and repositioning of the fracture
. Observation and admission for neurovascular checks
. Open reduction via an anterior approach

Correct Answer & Explanation

. Observation and admission for neurovascular checks

Explanation

A 'pink, pulseless hand' following closed reduction and pinning of a supracondylar humerus fracture with good capillary refill indicates adequate collateral perfusion. Observation is the standard of care, as most pulses return within a few days and ischemic complications in this setting are exceedingly rare.

Question 423

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, the hand is pink but the radial pulse is not palpable. Capillary refill is less than 2 seconds. What is the most appropriate next step?

. Immediate exploration of the brachial artery
. Release of the anterior compartment of the forearm
. Removal of the pins and open reduction
. Observation and close clinical monitoring
. Administration of intravenous heparin

Correct Answer & Explanation

. Observation and close clinical monitoring

Explanation

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

Question 424

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a completely displaced, extension-type supracondylar humerus fracture. Upon arrival, his hand is pink but pulseless, and he has a dense anterior interosseous nerve (AIN) palsy. Following closed reduction and percutaneous pinning, the hand remains pink and pulseless. What is the most appropriate next step in management?

. Immediate vascular exploration
. Close observation and admission for 24-48 hours
. Removal of pins and re-reduction of the fracture
. Emergent color duplex ultrasonography
. Open reduction and internal fixation

Correct Answer & Explanation

. Close observation and admission for 24-48 hours

Explanation

A 'pink, pulseless hand' after a satisfactory reduction and pinning of a supracondylar humerus fracture should be admitted and observed closely. Vascular exploration is generally indicated only if the hand is poorly perfused (white and pulseless) after reduction.

Question 425

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarchal girl presents for evaluation of a spinal deformity. Radiographs reveal a right thoracic adolescent idiopathic scoliosis (AIS) curve measuring 35 degrees. Her Risser stage is 0. What is the most appropriate management?

. Observation with radiographs in 6 months
. Schroth physical therapy method alone
. Thoracolumbosacral orthosis (TLSO) bracing
. Posterior spinal fusion with pedicle screws
. Anterior vertebral body tethering

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing

Explanation

Bracing is indicated for skeletally immature patients (Risser 0-2, premenarchal) with an AIS curve between 25 and 40 degrees. A TLSO brace worn for at least 18 hours a day has been shown to significantly reduce the risk of progression to a surgical magnitude.

Question 426

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a displaced supracondylar humerus fracture. Post-reduction, he is unable to form an "OK" sign with his thumb and index finger. The affected nerve innervates which of the following muscle groups?

. Flexor pollicis longus, flexor digitorum profundus (index and middle), and pronator quadratus
. Flexor pollicis brevis, flexor digitorum superficialis, and pronator teres
. Flexor carpi radialis, flexor pollicis longus, and flexor digitorum profundus (ring and small)
. Abductor pollicis longus, extensor pollicis brevis, and supinator
. Flexor digitorum profundus (all digits) and pronator quadratus

Correct Answer & Explanation

. Flexor pollicis longus, flexor digitorum profundus (index and middle), and pronator quadratus

Explanation

The inability to form the "OK" sign indicates an Anterior Interosseous Nerve (AIN) palsy. The AIN is a motor branch of the median nerve that innervates the flexor pollicis longus, the radial half of the flexor digitorum profundus, and the pronator quadratus.

Question 427

Topic: Pediatric Upper Extremity & Spine

A 12-year-old Little League pitcher complains of progressively worsening medial elbow pain. Radiographs demonstrate widening of the medial epicondyle apophysis without significant displacement. What is the most appropriate initial management?

. Ulnar collateral ligament reconstruction
. Ulnar collateral ligament repair with internal bracing
. Complete cessation of throwing for 4 to 6 weeks
. Physical therapy with continued throwing at lower velocities
. Intra-articular corticosteroid injection

Correct Answer & Explanation

. Complete cessation of throwing for 4 to 6 weeks

Explanation

Medial epicondyle apophysitis (Little League Elbow) in a skeletally immature throwing athlete is an overuse injury. The most critical initial treatment is complete cessation of throwing (rest) for 4 to 6 weeks, followed by a gradual return-to-throwing program.

Question 428

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a completely displaced extension-type supracondylar humerus fracture. Prior to reduction, the hand is pink but pulseless. After closed reduction and percutaneous pinning, the hand remains pink and pulseless with capillary refill of 2 seconds. What is the next best step in management?

. Immediate open vascular exploration.
. CT angiography of the upper extremity.
. Observation with close clinical monitoring.
. Removal of the pins and attempting a second closed reduction.
. Prophylactic volar forearm fasciotomy.

Correct Answer & Explanation

. Observation with close clinical monitoring.

Explanation

A 'pink, pulseless' hand following an anatomic reduction of a supracondylar humerus fracture indicates adequate collateral perfusion. Close observation is indicated, as routine vascular exploration is unnecessary unless the hand becomes pale and poorly perfused.

Question 429

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal girl is evaluated for adolescent idiopathic scoliosis. Radiographs demonstrate a 35-degree right thoracic curve, and her Risser stage is 0. What is the most appropriate management?

. Observation with repeat standing radiographs in 6 months.
. Schroth physical therapy as the primary standalone treatment.
. Thoracolumbosacral orthosis (TLSO) bracing.
. Posterior spinal fusion with pedicle screw instrumentation.
. Vertebral body tethering.

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing.

Explanation

In a skeletally immature patient (Risser 0-2, premenarchal) with an adolescent idiopathic scoliosis curve between 25 and 40 degrees, rigid bracing (TLSO) is the standard of care to halt curve progression and reduce the need for surgery.

Question 430

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, she cannot flex her thumb interphalangeal joint or index finger distal interphalangeal joint. What is the most likely injured nerve structure?

. 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 fractures. It innervates the flexor pollicis longus and the flexor digitorum profundus to the index finger.

Question 431

Topic: Pediatric Upper Extremity & Spine

A 12-year-old girl with adolescent idiopathic scoliosis presents with a right thoracic curve. She has not reached menarche and her Risser stage is 0. Her curve measures 35 degrees. What is the most appropriate management?

. Observation with serial radiographs every 6 months
. Physical therapy and core strengthening
. TLSO bracing
. Posterior spinal fusion
. Anterior tethering

Correct Answer & Explanation

. TLSO bracing

Explanation

In a skeletally immature patient (premenarchal, Risser 0-2) with a progressive curve between 25 and 45 degrees, bracing is the standard of care to prevent further progression.

Question 432

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains an extension-type Gartland III supracondylar humerus fracture. Upon initial presentation, the hand is pink but pulseless. After anatomical closed reduction and percutaneous pinning, the hand remains pink and well-perfused, but the radial pulse remains absent. What is the next best step?
. Observe and admit for serial neurovascular examinations
. Remove the pins and attempt closed reduction again
. Immediate exploration of the brachial artery
. Perform a CT angiogram
. Administer a sympathetic nerve block

Correct Answer & Explanation

. Observe and admit for serial neurovascular examinations

Explanation

A pink, pulseless hand after an anatomic reduction of a supracondylar fracture indicates adequate collateral perfusion. The standard of care is close observation, as the pulse often returns spontaneously within 24 to 48 hours without the need for vascular exploration.

Question 433

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarchal girl (Risser stage 0) is diagnosed with a right thoracic adolescent idiopathic scoliosis measuring 35 degrees on standing radiographs. What is the most appropriate initial management?

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

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing

Explanation

TLSO bracing is indicated for skeletally immature patients (Risser 0-2) with adolescent idiopathic scoliosis curves between 25 and 45 degrees. Bracing effectively halts curve progression and reduces the need for surgical intervention when compliance is high.

Question 434

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 lacks a palpable radial pulse. Following closed reduction and percutaneous pinning, the fracture is anatomically aligned, but the radial pulse remains absent while the hand remains warm and pink. What is the most appropriate next step in management?

. Immediate exploration of the brachial artery
. Arteriography of the upper extremity
. Observation and admission for close neurovascular monitoring
. Application of a warm compress to the antecubital fossa
. Removal of pins and open reduction

Correct Answer & Explanation

. Observation and admission for close neurovascular monitoring

Explanation

For a pink, pulseless hand following anatomic reduction and pinning of a supracondylar humerus fracture, close clinical observation is the standard of care. Arterial exploration is indicated if the hand becomes pale and poorly perfused.

Question 435

Topic: Pediatric Upper Extremity & Spine

A 6-year-old girl sustains a severely displaced extension-type supracondylar humerus fracture. On initial presentation, her hand is pink and warm, but the radial pulse is absent. After 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
. Fasciotomy of the forearm
. Observation and admission for close monitoring
. Angiography
. Open reduction and internal fixation

Correct Answer & Explanation

. Observation and admission for close monitoring

Explanation

A "pulseless, pink hand" following anatomical reduction and pinning of a supracondylar humerus fracture can be safely observed if perfusion is clinically adequate (capillary refill <2 seconds). Vascular exploration is indicated only if the hand becomes dysvascular (cool, pale) after reduction.

Question 436

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal girl presents with a right thoracic curve measuring 32 degrees. Her Risser stage is 0. What is the most appropriate management?

. Observation with radiographs in 6 months
. Thoracolumbosacral orthosis (TLSO) bracing for 16-23 hours/day
. Posterior spinal fusion
. Night-time only bending brace
. Schroth physical therapy exercises alone

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing for 16-23 hours/day

Explanation

In a skeletally immature patient (premenarchal, Risser 0-2) with an AIS curve between 25 and 45 degrees, TLSO bracing for a minimum of 16-18 hours per day is indicated to prevent curve progression.

Question 437

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a completely displaced extension-type supracondylar humerus fracture. Examination shows an inability to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger. Which nerve is most likely injured?

. Anterior interosseous nerve
. Posterior interosseous nerve
. Ulnar nerve
. Superficial radial 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. It innervates the flexor pollicis longus and flexor digitorum profundus to the index and middle fingers.

Question 438

Topic: Pediatric Upper Extremity & Spine
A 5-year-old girl presents with a Gartland type III supracondylar humerus fracture. On initial examination, her hand is pink but lacks a palpable radial pulse. Following closed reduction and percutaneous pinning, the hand remains well-perfused and pink, but the radial pulse is still absent on palpation and Doppler. What is the most appropriate next step in management?
. Observation and hospital admission for close neurovascular monitoring
. Immediate arteriography
. Open exploration of the brachial artery
. Removal of the percutaneous pins and re-reduction
. Prophylactic fasciotomy of the forearm

Correct Answer & Explanation

. Observation and hospital admission for close neurovascular monitoring

Explanation

A "pink, pulseless" hand following adequate reduction and pinning of a supracondylar fracture typically has sufficient collateral circulation and should be observed. Open vascular exploration is indicated if the hand remains "white and pulseless" after reduction.

Question 439

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, warm, and has brisk capillary refill, but the radial pulse is absent on palpation and Doppler. What is the most appropriate next step in management?

. Immediate CT angiography of the upper extremity
. Open exploration of the brachial artery in the emergency department
. Urgent closed reduction and percutaneous pinning
. Emergent forearm fasciotomies
. Observation and repeat vascular examination in 24 hours

Correct Answer & Explanation

. Urgent closed reduction and percutaneous pinning

Explanation

A pulseless but well-perfused (pink) hand associated with a supracondylar humerus fracture should initially be managed with urgent closed reduction and percutaneous pinning. Vascular exploration is only indicated if the hand becomes poorly perfused (white/ischemic) after reduction.

Question 440

Topic: Pediatric Upper Extremity & Spine

A 5-year-old boy falls from monkey bars and sustains a widely displaced extension-type supracondylar humerus fracture. On presentation, his hand is pink and warm, but the radial pulse is absent. After prompt closed reduction and percutaneous pinning, the hand remains pink and warm, but the radial pulse is still absent. Doppler signal is present in the radial artery. Management should consist of:

. Immediate vascular exploration
. Observation and admission for 24 hours
. Arteriography
. Local thrombolytic therapy
. Revision of the closed reduction

Correct Answer & Explanation

. Observation and admission for 24 hours

Explanation

In a pink, pulseless hand following reduction of a supracondylar humerus fracture, observation is the standard of care as collateral circulation is adequate. Vascular exploration is indicated if the hand is white and pulseless after reduction.

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