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Pediatric Upper Extremity & Spine MCQs

Practice Set 23 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 441

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl with adolescent idiopathic scoliosis presents with a right thoracic curve of 55 degrees and a left lumbar curve of 35 degrees. On bending films, the lumbar curve reduces to 15 degrees. The apical vertebral translation of the thoracic curve is 4 cm and the lumbar curve is 1 cm. What is the correct Lenke classification curve type for this patient?

. Type 1 (Main Thoracic)
. Type 2 (Double Thoracic)
. Type 3 (Double Major)
. Type 4 (Triple Major)
. Type 5 (Thoracolumbar/Lumbar)

Correct Answer & Explanation

. Type 1 (Main Thoracic)

Explanation

Lenke Type 1 curves have a structural main thoracic curve and a nonstructural lumbar curve. A lumbar curve that bends out to 25 degrees or less is considered nonstructural.

Question 442

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls from monkey bars and sustains a Gartland type III supracondylar humerus fracture. On presentation, his hand is warm and pink, but the radial pulse is absent. After urgent closed reduction and percutaneous pinning, the hand remains pink and well-perfused, but the pulse is still absent by Doppler. What is the most appropriate next step?
. Immediate vascular exploration
. Observe with close admission monitoring
. Perform a CT angiogram
. Remove the pins and perform open reduction
. Perform a forearm fasciotomy

Correct Answer & Explanation

. Observe with close admission monitoring

Explanation

A "pulseless pink" hand after anatomic reduction and pinning of a supracondylar humerus fracture indicates adequate collateral perfusion. Observation is the standard of care, as the pulse often returns within 24 to 48 hours.

Question 443

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl with adolescent idiopathic scoliosis (AIS) has a right thoracic curve of 48 degrees and a Risser stage of 0. She has not reached menarche. What is the most appropriate recommendation?

. Observation with repeat radiographs in 6 months
. Thoracolumbosacral orthosis (TLSO) bracing for 18 hours a day
. Nighttime bending brace
. Posterior spinal fusion
. Anterior vertebral body tethering

Correct Answer & Explanation

. Posterior spinal fusion

Explanation

This patient has a curve approaching 50 degrees and has significant remaining growth potential (Risser 0, premenarchal). Surgery (posterior spinal fusion) is indicated for curves greater than 45-50 degrees to prevent continued progression into adulthood.

Question 444

Topic: Pediatric Upper Extremity & Spine
A 5-year-old boy falls from the monkey bars and sustains a Gartland type III extension supracondylar humerus fracture. Examination shows 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), a branch of the median nerve, is the most commonly injured nerve in extension-type supracondylar humerus fractures. It innervates the flexor pollicis longus and the flexor digitorum profundus to the index finger.

Question 445

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarchal female (Risser 0) presents with right thoracic adolescent idiopathic scoliosis. Standing radiographs reveal a Cobb angle of 32 degrees. What is the most appropriate recommended treatment?

. Observation with follow-up radiographs in 6 months
. Intensive physical therapy utilizing the Schroth method alone
. 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 an AIS curve of 25 to 45 degrees. Bracing has been proven to significantly decrease the risk of curve progression to the surgical threshold.

Question 446

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with a Gartland type III supracondylar humerus fracture. The hand is pink but pulseless. After closed reduction and percutaneous pinning, the hand remains pink and pulseless. What is the most appropriate next step in management?
. Immediate vascular exploration
. Observation with close monitoring
. Administration of IV heparin
. Removal of the pins and open reduction
. Angiography

Correct Answer & Explanation

. Observation with close monitoring

Explanation

In a pediatric supracondylar humerus fracture with a pink, pulseless hand after anatomical reduction and pinning, observation for 24-48 hours is indicated. The collateral circulation is adequate to perfuse the hand, and vascular exploration is not immediately required.

Question 447

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls from monkey bars and sustains a Gartland Type III supracondylar humerus fracture. On examination, the radial pulse is absent, but the hand is warm, pink, and has a capillary refill of less than 2 seconds. After prompt closed reduction and percutaneous pinning, the pulse remains absent but the hand remains well-perfused. What is the most appropriate next step?
. Immediate open exploration of the brachial artery
. Angiography to localize the arterial injury
. Observation and admission for neurovascular monitoring
. Removal of the pins and open reduction
. Administration of thrombolytics

Correct Answer & Explanation

. Observation and admission for neurovascular monitoring

Explanation

A "pulseless but pink" hand following reduction and pinning of a supracondylar fracture indicates adequate collateral circulation. Current guidelines recommend close observation and monitoring rather than immediate surgical exploration.

Question 448

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a completely displaced posterolateral supracondylar humerus fracture. Upon presentation, he has a pulseless but well-perfused (pink) hand. Closed reduction and percutaneous pinning are performed, achieving an anatomic reduction. Postoperatively, the hand remains pink but the radial pulse is still absent. What is the most appropriate management?

. Immediate open exploration of the brachial artery
. Observation and hospital admission for close neurovascular monitoring
. Color duplex ultrasound of the brachial artery
. CT angiography of the upper extremity
. Removal of pins and open reduction

Correct Answer & Explanation

. Observation and hospital admission for close neurovascular monitoring

Explanation

In a pulseless, pink hand following anatomic reduction and pinning of a supracondylar fracture, observation is the standard of care. Collateral circulation provides adequate perfusion; open exploration is indicated only for a pulseless, pale (ischemic) hand after reduction.

Question 449

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains a completely displaced (Gartland Type III) posteromedial supracondylar humerus fracture. On examination, the hand is pink and warm, but the radial pulse is absent. After anatomical closed reduction and percutaneous pinning, the hand remains pink and the pulse remains absent. What is the next best step?
. Immediate open exploration of the brachial artery
. Immediate CT angiography
. Observation and admission for close neurovascular monitoring
. Removal of pins and open reduction
. Administration of intravenous heparin

Correct Answer & Explanation

. Observation and admission for close neurovascular monitoring

Explanation

A "pulseless, pink" hand after a well-reduced supracondylar fracture usually indicates adequate collateral circulation. Current guidelines recommend close observation over immediate vascular exploration, provided the limb remains well-perfused.

Question 450

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarcheal girl with a Risser stage of 0 presents with a right thoracic adolescent idiopathic scoliosis (AIS). Her curve measures 30 degrees. Which of the following represents the most appropriate management?

. Observation with radiographs in 6 months
. Immediate posterior spinal fusion
. Full-time Thoracolumbosacral Orthosis (TLSO) bracing
. Nighttime bending brace only
. Vertebral body tethering

Correct Answer & Explanation

. Full-time Thoracolumbosacral Orthosis (TLSO) bracing

Explanation

In an immature patient (Risser 0, premenarcheal) with an AIS curve between 25 and 40 degrees, full-time TLSO bracing is indicated to halt progression. Observation is inappropriate given her high risk for rapid curve worsening.

Question 451

Topic: Pediatric Upper Extremity & Spine
A 6-year-old girl sustains a displaced Gartland III supracondylar humerus fracture. On examination, the radial pulse is absent, but the hand is warm, pink, and has capillary refill under 2 seconds. What is the most appropriate initial management?
. Immediate open exploration of the brachial artery
. Observation and splinting in 90 degrees of flexion
. CT angiogram of the upper extremity
. Urgent closed reduction and percutaneous pinning
. Immediate administration of intravenous heparin

Correct Answer & Explanation

. Urgent closed reduction and percutaneous pinning

Explanation

A pulseless, pink hand indicates adequate collateral circulation. The most appropriate initial step is urgent closed reduction and percutaneous pinning, which frequently restores the palpable pulse.

Question 452

Topic: Pediatric Upper Extremity & Spine

A 14-year-old premenarchal girl (Risser 0) presents with adolescent idiopathic scoliosis. Standing radiographs demonstrate a right thoracic curve of 35 degrees. What is the recommended treatment?

. Observation with clinical follow-up in 1 year
. Physical therapy focusing on the Schroth method alone
. TLSO bracing for 16 to 23 hours a day
. Posterior spinal fusion with pedicle screws
. Anterior vertebral body tethering

Correct Answer & Explanation

. TLSO bracing for 16 to 23 hours a day

Explanation

In a growing child (Risser 0-2) with an adolescent idiopathic scoliosis curve measuring between 25 and 45 degrees, TLSO bracing for a minimum of 16-18 hours daily is the standard of care to prevent progression.

Question 453

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a completely displaced extension-type supracondylar humerus fracture. On presentation, his hand is pale, pulseless, and cold. After rapid closed reduction and percutaneous pinning, his hand becomes warm and pink, with a capillary refill of 2 seconds, but the radial pulse remains absent. What is the most appropriate next step in management?

. Immediate exploration of the brachial artery
. Perform an upper extremity angiogram
. Administer intravenous heparin
. Observe and admit for 24 to 48 hours
. Remove the pins and perform an open reduction

Correct Answer & Explanation

. Observe and admit for 24 to 48 hours

Explanation

A pulseless but well-perfused (pink) hand after closed reduction of a supracondylar fracture typically results from arterial vasospasm or non-occlusive tethering. Observation is the standard of care, as collateral circulation is adequate and the pulse usually returns within a few days.

Question 454

Topic: Pediatric Upper Extremity & Spine

A 5-year-old girl falls on an outstretched hand and sustains a lateral condyle fracture of the humerus with 1 mm of displacement. She is treated in a long-arm cast. At her 4-week follow-up, radiographs show delayed union but no change in displacement. What is the most appropriate management?

. Immediate open reduction and internal fixation
. Closed reduction and percutaneous pinning
. Continue cast immobilization for an additional 2 to 4 weeks
. Remove the cast and begin aggressive physical therapy
. Perform an MRI to assess the cartilaginous hinge

Correct Answer & Explanation

. Continue cast immobilization for an additional 2 to 4 weeks

Explanation

Minimally displaced lateral condyle fractures often exhibit delayed radiographic union. If there is no further displacement, extending cast immobilization for up to 6 to 8 weeks total is appropriate and usually results in successful union.

Question 455

Topic: Pediatric Upper Extremity & Spine

An 8-year-old boy presents with a displaced extension-type supracondylar humerus fracture. The hand is pink but the radial pulse is absent before and after closed reduction and percutaneous pinning. The hand remains warm and well-perfused. What is the most appropriate next step?

. Immediate vascular exploration
. Removal of pins and open reduction
. Observation and admission for neurovascular monitoring
. Brachial artery angiography
. Fasciotomy of the forearm

Correct Answer & Explanation

. Observation and admission for neurovascular monitoring

Explanation

In a pink, pulseless hand following a well-reduced and pinned supracondylar humerus fracture, collateral circulation is adequate to perfuse the hand. The standard of care is close observation and hospital admission rather than immediate vascular exploration.

Question 456

Topic: Pediatric Upper Extremity & Spine

A

14-year-old girl is evaluated for scoliosis. Radiographs reveal a right thoracic curve of 42 degrees. Her Risser stage is 0 and she is premenarchal. What is the most appropriate next step in management?

. Observation with radiographs in 6 months
. Physical therapy and core strengthening
. Custom Thoracolumbosacral orthosis (TLSO) bracing
. Posterior spinal fusion
. Anterior spinal tethering

Correct Answer & Explanation

. Custom Thoracolumbosacral orthosis (TLSO) bracing

Explanation

Bracing is indicated for skeletally immature patients (Risser 0-2) with adolescent idiopathic scoliosis who have a curve between 25 and 45 degrees. A TLSO brace worn 18-23 hours a day significantly decreases the risk of curve progression to the surgical threshold.

Question 457

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal female presents with a right thoracic curve measuring 48 degrees on a standing PA radiograph. She is Risser 0 and has a Sanders skeletal maturity stage of 2. What is the most appropriate management?

. Observation with clinical follow-up in 6 months
. Thoracolumbosacral orthosis (TLSO) bracing full-time
. Nighttime bending brace
. Posterior spinal fusion
. Anterior spinal tethering

Correct Answer & Explanation

. Posterior spinal fusion

Explanation

Posterior spinal fusion is indicated for adolescent idiopathic scoliosis curves greater than 45-50 degrees. Highly immature patients (Risser 0, premenarchal) with curves of this magnitude have a near 100% risk of progression and require surgical intervention.

Question 458

Topic: Pediatric Upper Extremity & Spine

A 12-year-old girl is diagnosed with adolescent idiopathic scoliosis. She is premenarcheal with a Risser stage of 0. Standing radiographs reveal a right thoracic curve of 35 degrees. What is the most appropriate next step in management?

. Observation with radiographs every 6 months
. Physical therapy emphasizing core strengthening
. Full-time rigid thoracolumbosacral orthosis (TLSO) bracing
. Posterior spinal fusion
. Anterior vertebral body tethering

Correct Answer & Explanation

. Full-time rigid thoracolumbosacral orthosis (TLSO) bracing

Explanation

Bracing is indicated for skeletally immature patients (Risser 0-2) with curves between 25 and 45 degrees. A full-time rigid TLSO significantly decreases the risk of curve progression to the surgical threshold.

Question 459

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarchal girl (Risser 0) is diagnosed with adolescent idiopathic scoliosis. Her right thoracic curve measures 34 degrees. What is the most appropriate next step in management?

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

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing 18 hours per day

Explanation

Bracing is indicated for skeletally immature patients (Risser 0-2) with a curve between 25 and 45 degrees. A dose-response relationship exists, and wearing a TLSO for at least 18 hours daily significantly decreases the risk of curve progression to the surgical threshold.

Question 460

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarcheal female presents with a right thoracic prominence. Radiographs reveal an adolescent idiopathic scoliosis (AIS) curve of 32 degrees. Her Risser stage is 1. What is the most appropriate management?

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

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing

Explanation

Bracing is indicated for patients with Adolescent Idiopathic Scoliosis who are skeletally immature (Risser 0-2, premenarcheal) with a curve magnitude between 25 and 45 degrees. It significantly decreases the risk of curve progression to the surgical threshold.

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