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Pediatric Upper Extremity & Spine MCQs

Practice Set 25 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 481

Topic: Pediatric Upper Extremity & Spine
A 7-year-old child presents 5 days after a fall with a displaced (Gartland Type III) supracondylar humerus fracture. The elbow is significantly swollen and tense, with a palpable but diminished radial pulse. Capillary refill in the fingers is delayed to 4 seconds, and he has pain with passive finger extension. Neurological examination of the median, ulnar, and radial nerves is intact. What is the most urgent management step?
. Immediate closed reduction and percutaneous pinning.
. Order a CT angiogram to assess vascular compromise.
. Observation with elevation and analgesia, reassessing pulses and neurological status.
. Emergency open reduction and internal fixation with vascular exploration.
. Initiate a diagnostic elbow arthrogram.

Correct Answer & Explanation

. Emergency open reduction and internal fixation with vascular exploration.

Explanation

This child presents with a Gartland Type III supracondylar humerus fracture with clear signs of impending vascular compromise: diminished radial pulse, delayed capillary refill, and severe pain with passive finger extension (suggestive of compartment syndrome, though pain is the earliest and most reliable sign). The swelling and delayed presentation (5 days) increase the risk. While closed reduction and pinning is the usual treatment for Gartland III, the presence of critical vascular compromise (pulselessness or diminished pulse with signs of ischemia) mandates immediate surgical intervention. For delayed presentations with severe swelling and vascular compromise, open reduction, vascular exploration (to assess for brachial artery entrapment or injury), and then fixation is often necessary. A CT angiogram delays critical intervention. Observation is contraindicated. An arthrogram is not indicated for vascular compromise.

Question 482

Topic: Pediatric Upper Extremity & Spine

Which of the following describes the 'columns' of the distal humerus, critical for surgical planning?

. The medial and lateral epicondyles
. The anterior and posterior cortices of the humeral shaft
. The medial and lateral supracondylar ridges extending to the articular surface
. The capitellum and trochlea
. The anterior and posterior synovial compartments

Correct Answer & Explanation

. The medial and lateral supracondylar ridges extending to the articular surface

Explanation

The concept of medial and lateral columns is fundamental to the surgical management of distal humerus fractures. These columns consist of the medial and lateral supracondylar ridges that extend distally to articulate with the forearm bones. The articular surface (capitellum and trochlea) forms the 'tie arch' between these columns. Restoring the length, alignment, and rotation of these columns, and then reducing the articular fragments, is central to achieving stable fixation. The epicondyles are part of the columns, but not the columns themselves. The other options describe different anatomical parts or concepts.

Question 483

Topic: Pediatric Upper Extremity & Spine

Which specific intra-articular fracture pattern often requires meticulous direct articular visualization and fine fragment reduction, sometimes necessitating a separate mini-approach, due to its common association with instability?

. Type A supracondylar fracture
. Type B1 lateral condyle fracture
. Type C3 comminuted bicondylar fracture
. Capitellar fracture (e.g., Bryan and Morrey Type I)
. Simple medial epicondyle avulsion

Correct Answer & Explanation

. Capitellar fracture (e.g., Bryan and Morrey Type I)

Explanation

Capitellar fractures (e.g., Bryan and Morrey Type I) are intra-articular coronal shear fractures of the capitellum. They are notoriously unstable and require meticulous direct articular visualization and often a separate mini-approach (e.g., lateral paratricipital or via a posterior approach with osteotomy) to achieve anatomical reduction and stable fixation (often with headless compression screws or small plates). They are often missed or underestimated on plain radiographs. Type A supracondylar and medial epicondyle avulsions are less complex articular injuries. C3 is complex overall, but capitellar itself is a distinct challenge.

Question 484

Topic: Pediatric Upper Extremity & Spine

In the surgical management of adolescent idiopathic scoliosis (AIS), what is the primary goal of instrumentation and fusion?

. To eliminate all spinal curvature
. To prevent further progression of the curve
. To restore normal spinal flexibility
. To decompress any neural elements
. To correct the rib hump deformity

Correct Answer & Explanation

. To prevent further progression of the curve

Explanation

The primary goal of surgical instrumentation and fusion in AIS is to prevent further progression of the curve and to achieve a balanced spine. While some correction of the curve and the rib hump is achieved, the aim is not to eliminate all curvature or restore normal flexibility (as fusion limits motion). Decompression is not typically the primary goal in AIS unless there's neurological compromise, which is rare.

Question 485

Topic: Pediatric Upper Extremity & Spine

A 35-year-old male presents with progressive intrinsic muscle weakness in his right hand and numbness involving the ring and small fingers. He recalls sustaining an elbow injury at age 5 that was treated non-operatively in a cast. Physical examination reveals a prominent cubitus valgus deformity of the right elbow. What was the most likely pediatric elbow injury this patient sustained?

. Extension-type supracondylar humerus fracture
. Medial epicondyle fracture
. Radial neck fracture
. Lateral condyle fracture of the humerus
. Monteggia fracture-dislocation

Correct Answer & Explanation

. Lateral condyle fracture of the humerus

Explanation

The classic presentation of a missed or non-united lateral condyle fracture of the humerus in childhood is the gradual development of a cubitus valgus deformity over years. This valgus stretching of the ulnar nerve behind the medial epicondyle leads to a 'tardy ulnar nerve palsy' decades later, manifesting as intrinsic hand weakness and sensory changes in the ulnar nerve distribution.

Question 486

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents to the emergency department after falling off a swing. He has a visibly deformed right elbow. Examination reveals an obviously swollen, cool, and pale hand with diminished radial pulse. Capillary refill is >3 seconds. Radiographs confirm a displaced, comminuted supracondylar humerus fracture (Gartland Type III extension type). What is the immediate priority after initial assessment and analgesia?
. Emergent CT angiography to assess vascular injury.
. Closed reduction and percutaneous pinning.
. Exploration of the brachial artery and repair.
. Immediate traction in the emergency department.
. Application of a long arm splint and observation.

Correct Answer & Explanation

. Closed reduction and percutaneous pinning.

Explanation

This is a critical scenario indicating a displaced supracondylar humerus fracture with signs of vascular compromise (cool, pale hand, diminished radial pulse, poor capillary refill). The first and most critical orthopedic intervention is an attempt at gentle closed reduction and percutaneous pinning (Option 1). Often, the vascular compromise is due to kinking or spasm of the brachial artery over the displaced fracture fragments. Reduction of the fracture can restore blood flow by decompressing the artery. If the pulse does not return after successful reduction and pinning, then an emergent vascular exploration (Option 2) is warranted. CT angiography (Option 0) is not the immediate priority; the clinical signs are sufficient for urgent action. Traction (Option 3) alone is not the definitive management. Splinting and observation (Option 4) is contraindicated with vascular compromise.

Question 487

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl is diagnosed with Adolescent Idiopathic Scoliosis. Her current Cobb angle is 48 degrees, and she has a Risser sign of 3. She experiences mild back pain after prolonged standing but denies any neurological symptoms. Her skeletal maturity is nearing completion. What is the most appropriate management recommendation?

. Observation with serial radiographs every 6-12 months.
. Bracing with a thoracolumbosacral orthosis (TLSO).
. Surgical correction with posterior spinal fusion.
. Referral for chiropractic manipulation.
. Physical therapy focused on core strengthening and flexibility.

Correct Answer & Explanation

. Surgical correction with posterior spinal fusion.

Explanation

The standard indication for surgical correction of Adolescent Idiopathic Scoliosis (AIS) is a Cobb angle greater than 45-50 degrees. This patient has a 48-degree curve and a Risser sign of 3, indicating some remaining growth potential, which means the curve could still progress. Given the magnitude of the curve and the patient's age and Risser sign, surgical correction with posterior spinal fusion (Option C) is the most appropriate management to prevent further progression and improve alignment. Observation (Option A) is for smaller curves (<20-25 degrees). Bracing (Option B) is typically recommended for progressive curves between 25-45 degrees in skeletally immature patients to prevent progression, but it is less effective for curves already >45 degrees or nearing skeletal maturity. Chiropractic manipulation (Option D) and physical therapy (Option E) are not proven to correct or halt the progression of AIS curves of this magnitude.

Question 488

Topic: Pediatric Upper Extremity & Spine
A newborn infant presents with severe radial deviation of both wrists. Radiographs confirm bilateral absent radii. Physical examination reveals that the thumbs are present bilaterally. Laboratory evaluation shows a profoundly low platelet count. Which of the following is the most likely diagnosis?
. Fanconi anemia
. Holt-Oram syndrome
. VACTERL association
. TAR (Thrombocytopenia-Absent Radius) syndrome
. Cornelia de Lange syndrome

Correct Answer & Explanation

. TAR (Thrombocytopenia-Absent Radius) syndrome

Explanation

TAR (Thrombocytopenia-Absent Radius) syndrome is classically characterized by the absence of the radius with the preservation of the thumb. This critical clinical feature distinguishes TAR syndrome from Fanconi anemia and Holt-Oram syndrome, where an absent radius is almost universally accompanied by an absent or severely hypoplastic thumb.

Question 489

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains a severe Gartland Type III supracondylar humerus fracture. Upon arrival, his hand is pale and pulseless. After closed reduction and percutaneous pinning, the radial pulse remains unpalpable, but the hand becomes pink, warm, and has a capillary refill of less than 2 seconds. What is the next best step in management?
. Immediate exploration of the brachial artery
. Observation, admission, and close monitoring for 24-48 hours
. Administration of intravenous heparin
. Immediate removal of pins and transition to open reduction
. Emergent CT angiography

Correct Answer & Explanation

. Observation, admission, and close monitoring for 24-48 hours

Explanation

The 'pink, pulseless hand' after reduction of a supracondylar humerus fracture is a well-known clinical entity. If the hand is well-perfused (pink, warm, strong capillary refill), the lack of a palpable radial pulse is likely due to arterial spasm rather than a complete irreversible occlusion or transection. The standard of care is admission, elevation, and close monitoring for 24-48 hours. Immediate surgical exploration is indicated only if the hand remains 'white and pulseless' after a proper reduction.

Question 490

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains a Gartland type III extension supracondylar humerus fracture. On presentation, his hand is pink and warm, but the radial pulse is non-palpable. Urgent closed reduction and percutaneous pinning are performed. Postoperatively, the fracture is anatomically aligned on fluoroscopy, but the radial pulse remains absent. Capillary refill is 2 seconds and the hand remains warm. What is the most appropriate management?
. Immediate exploration of the brachial artery in the antecubital fossa.
. Perform a CT angiogram of the upper extremity.
. Observation and hospital admission for close serial neurovascular monitoring.
. Remove the pins and open the fracture anteriorly to clear the neurovascular bundle.
. Prescribe intravenous heparin and obtain a vascular surgery consult.

Correct Answer & Explanation

. Observation and hospital admission for close serial neurovascular monitoring.

Explanation

The management of a 'pulseless pink hand' following anatomical closed reduction and pinning of a pediatric supracondylar humerus fracture is close observation. The hand's pink color, warmth, and brisk capillary refill indicate that collateral circulation is sufficient to perfuse the extremity despite a presumed brachial artery vasospasm or non-occlusive intimal flap. Immediate vascular exploration is strictly indicated if the hand becomes dysvascular (white, cold, absent capillary refill) after reduction.

Question 491

Topic: Pediatric Upper Extremity & Spine
A newborn male presents with bilateral radial longitudinal deficiency (absent radii and absent thumbs). A chromosomal breakage test using diepoxybutane is positive. If left untreated, what is the most common cause of mortality associated with this patient's underlying diagnosis?
. Congenital heart failure
. End-stage renal disease
. Bone marrow failure
. Tracheoesophageal fistula complications
. Severe immunodeficiency

Correct Answer & Explanation

. Bone marrow failure

Explanation

The patient's clinical presentation (radial clubhand) combined with a positive chromosomal breakage test using diepoxybutane (DEB) or mitomycin C definitively diagnoses Fanconi anemia. Fanconi anemia is an autosomal recessive condition that leads to progressive pancytopenia and bone marrow failure, which is the most common cause of mortality in these patients. It is critical to differentiate it from other causes of radial longitudinal deficiency, such as Holt-Oram (cardiac), TAR syndrome (thrombocytopenia but thumbs are present), and VACTERL.

Question 492

Topic: Pediatric Upper Extremity & Spine
A 6-year-old girl sustains an extension-type Gartland III supracondylar humerus fracture. Examination reveals an inability to actively flex 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 (AIN)
. Posterior interosseous nerve (PIN)
. Musculocutaneous nerve

Correct Answer & Explanation

. Anterior interosseous nerve (AIN)

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 an 'OK' sign due to weakness of the flexor pollicis longus and flexor digitorum profundus to the index finger.

Question 493

Topic: Pediatric Upper Extremity & Spine
What is the primary cause of cubitus varus deformity following closed reduction and percutaneous pinning of a Gartland type III supracondylar humerus fracture?
. Epiphyseal growth arrest of the lateral capitellum
. Inadequate correction of internal rotation and medial comminution
. Over-tightening of the lateral entry pin
. Iatrogenic ulnar nerve entrapment
. Avascular necrosis of the trochlea

Correct Answer & Explanation

. Inadequate correction of internal rotation and medial comminution

Explanation

Cubitus varus after supracondylar humerus fractures is primarily a cosmetic deformity resulting from malunion. It specifically occurs due to the failure to adequately reduce internal rotation and correct coronal tilt in the presence of medial column comminution.

Question 494

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with a displaced Gartland type III supracondylar humerus fracture. After closed reduction and percutaneous pinning, the hand is pink, warm, and has a capillary refill of 2 seconds, but the radial pulse remains absent on Doppler ultrasound. What is the most appropriate next step in management?
. Immediate open vascular exploration
. Observation and admission for 24-48 hours
. Administration of intravenous heparin
. Removal of the pins and open reduction
. Emergent volar fasciotomy

Correct Answer & Explanation

. Observation and admission for 24-48 hours

Explanation

A 'pulseless, pink' hand following successful reduction and pinning of a supracondylar fracture indicates adequate collateral perfusion. Observation is the standard of care, as the pulse typically returns over hours to days without the need for acute vascular exploration.

Question 495

Topic: Pediatric Upper Extremity & Spine

A 12-year-old elite baseball pitcher presents with medial elbow pain that worsens during the acceleration phase of throwing. Radiographs demonstrate widening of the medial epicondyle apophysis. Which muscle group is the primary deforming force contributing to this condition?

. Extensor carpi radialis brevis and longus
. Triceps brachii and anconeus
. Biceps brachii and brachialis
. Flexor-pronator mass
. Brachioradialis and supinator

Correct Answer & Explanation

. Flexor-pronator mass

Explanation

'Little League Elbow' is a traction apophysitis of the medial epicondyle caused by repetitive valgus overload during throwing. The primary deforming forces pulling on the medial epicondyle apophysis are the flexor-pronator mass and the ulnar collateral ligament.

Question 496

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls from monkey bars and sustains a completely displaced, extension-type supracondylar humerus fracture (Gartland Type III). Radiographs show the distal fragment is displaced posteromedially. Which of the following peripheral nerves is at highest risk of injury with this specific displacement pattern?
. Median nerve
. Anterior interosseous nerve (AIN)
. Radial nerve
. Ulnar nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Radial nerve

Explanation

In a posteromedially displaced supracondylar fracture, the proximal fragment displaces anterolaterally, commonly piercing the brachialis muscle and tenting or injuring the radial nerve. Posterolateral displacement endangers the anterior interosseous nerve (AIN).

Question 497

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents after falling from monkey bars with an extension-type Gartland III supracondylar humerus fracture. Examination reveals weak index finger flexion and absent flexion of the IP joint of the thumb. 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. It is evaluated by checking the patient's ability to make an "OK" sign, requiring flexion of the thumb IP and index DIP joints.

Question 498

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with a Gartland type III extension-type supracondylar humerus fracture. Examination reveals a pink, pulseless hand with intact capillary refill. Following closed reduction and percutaneous pinning, the radial pulse remains absent, but the hand remains pink and well-perfused. What is the most appropriate next step in management?
. Immediate exploration of the brachial artery via an anterior approach.
. Removal of the pins and open reduction via a posterior triceps-sparing approach.
. Observation and admission for continuous pulse oximetry and neurovascular checks.
. Emergent CT angiography of the upper extremity to localize the vascular lesion.
. Administration of systemic tissue plasminogen activator (tPA).

Correct Answer & Explanation

. Observation and admission for continuous pulse oximetry and neurovascular checks.

Explanation

In a pediatric supracondylar humerus fracture, a pink, pulseless hand following adequate closed reduction and pinning indicates sufficient collateral circulation. Current AAOS guidelines recommend close observation and admission rather than routine immediate vascular exploration, provided the hand remains well-perfused.

Question 499

Topic: Pediatric Upper Extremity & Spine

Which of the following conditions is most strongly associated with adolescent idiopathic scoliosis progression?

. Male gender
. Risser sign 5
. Curve magnitude > 20 degrees at presentation
. Age greater than 16 years
. Menarche status (post-menarche)

Correct Answer & Explanation

. Curve magnitude > 20 degrees at presentation

Explanation

The most significant factors for progression of adolescent idiopathic scoliosis are curve magnitude at presentation (curves > 20 degrees are more likely to progress than smaller curves), skeletal immaturity (lower Risser sign), and premenarchal status in females. Female gender is associated with higher progression rates and need for intervention. Risser sign 5 indicates skeletal maturity, at which point progression risk is minimal. Younger age and pre-menarche are risk factors for progression.

Question 500

Topic: Pediatric Upper Extremity & Spine

A 7-year-old boy falls off monkey bars and sustains a supracondylar humerus fracture. On presentation, he has a pulseless but warm and pink hand with intact motor function. Radiographs confirm a displaced extension-type supracondylar fracture. What is the MOST appropriate initial management?

. Observation and repeat neurovascular exam
. Closed reduction and percutaneous pinning (CRPP)
. Open reduction and internal fixation (ORIF)
. Splinting in extension and referral to orthopedics
. Immediate surgical exploration of the brachial artery

Correct Answer & Explanation

. Closed reduction and percutaneous pinning (CRPP)

Explanation

A pulseless but perfused hand in the setting of a supracondylar humerus fracture, particularly after a traumatic event, often indicates vascular spasm or kinking rather than a complete transection. The initial management is urgent closed reduction and percutaneous pinning (CRPP) to restore anatomical alignment and decompress the brachial artery. If the pulse does not return after successful reduction and pinning, or if signs of ischemia develop, then surgical exploration of the brachial artery becomes necessary. Observation is inappropriate, and ORIF is typically reserved for irreducible fractures. Splinting in extension could worsen the neurovascular status.

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