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Pediatric Upper Extremity & Spine MCQs

Practice Set 26 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 501

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl is diagnosed with adolescent idiopathic scoliosis with a 35-degree thoracic curve (Cobb angle). She is still skeletally immature (Risser 0). What is the MOST appropriate initial management?

. Observation with serial radiographs every 6 months
. Milwaukee brace application
. Spinal fusion surgery
. Physical therapy and core strengthening exercises
. Chiropractic adjustments

Correct Answer & Explanation

. Milwaukee brace application

Explanation

For adolescent idiopathic scoliosis, the management depends on the curve magnitude and skeletal maturity. For curves between 25-40 degrees in a skeletally immature patient (Risser 0-2), bracing (e.g., Boston brace or TLSO) is the most appropriate initial treatment to prevent progression. Observation is for smaller curves (<25 degrees) or skeletally mature patients. Spinal fusion is typically reserved for curves >45-50 degrees or progressive curves despite bracing. Milwaukee brace is generally outdated compared to modern TLSOs.

Question 502

Topic: Pediatric Upper Extremity & Spine

A 12-year-old female presents with progressive thoracic spinal deformity. Radiographs show a right thoracic curve measuring 45 degrees, with significant vertebral rotation. She is Risser 0. What is the most appropriate management?

. Observation and serial radiographs every 6 months
. Bracing with a thoracolumbosacral orthosis (TLSO)
. Posterior spinal fusion
. Anterior vertebral body tethering (VBT)
. Physical therapy and stretching exercises

Correct Answer & Explanation

. Posterior spinal fusion

Explanation

For adolescent idiopathic scoliosis, a curve magnitude of 45 degrees in a skeletally immature patient (Risser 0 indicates significant growth remaining) is typically an indication for surgical intervention, most commonly posterior spinal fusion. Bracing is generally recommended for curves between 25-45 degrees in growing patients to prevent progression, but a 45-degree curve at Risser 0 has a high likelihood of progression beyond 50 degrees, warranting surgery. Observation is for curves <25 degrees. VBT is a growth modulation technique, but a 45-degree curve may be pushing its limits, and posterior fusion is more definitive for this magnitude. Physical therapy does not typically prevent progression of structural scoliosis.

Question 503

Topic: Pediatric Upper Extremity & Spine

A 3-year-old child presents with a painful, swollen elbow after being pulled up by the hand by an adult. The child holds the arm pronated and slightly flexed, refusing to use it. Radiographs are normal. What is the most likely diagnosis?

. Supracondylar humerus fracture
. Lateral condyle fracture
. Radial head subluxation (nursemaid's elbow)
. Olecranon fracture
. Septic elbow arthritis

Correct Answer & Explanation

. Radial head subluxation (nursemaid's elbow)

Explanation

The classic presentation of a child (typically 1-4 years old) with a painful arm held in pronation and flexion after a sudden pull on the hand, with normal radiographs, is highly suggestive of a radial head subluxation, commonly known as 'nursemaid's elbow.' This occurs when the annular ligament slips over the radial head and becomes trapped in the radiohumeral joint. Fractures would typically be visible on X-ray, and septic arthritis would present with fever and more systemic signs.

Question 504

Topic: Pediatric Upper Extremity & Spine

What is the primary goal of surgical treatment for adolescent idiopathic scoliosis (AIS) with curves greater than 45-50 degrees?

. Elimination of all back pain.
. Correction of cosmetic deformity and prevention of curve progression.
. Complete normalization of spinal alignment.
. Improvement of pulmonary function only.
. Prevention of neurological deficits.

Correct Answer & Explanation

. Correction of cosmetic deformity and prevention of curve progression.

Explanation

The primary goal of surgical treatment for adolescent idiopathic scoliosis (AIS) with significant curves (typically >45-50 degrees in skeletally immature or >50 degrees in mature patients) is to correct the cosmetic deformity and, most importantly, prevent further curve progression. Curves exceeding 50 degrees in adults tend to progress throughout life and can eventually lead to significant back pain and pulmonary compromise. While pain improvement can occur, it is not the primary indication for surgery. Complete normalization of spinal alignment is generally not achievable or necessary. Pulmonary function improvement is a secondary benefit, especially in very severe curves. Prevention of neurological deficits is a concern during surgery, but not the primary indication for elective correction of AIS.

Question 505

Topic: Pediatric Upper Extremity & Spine
A 5-year-old child sustains a supracondylar humerus fracture (Gartland Type III) after a fall. Examination reveals a pale, pulseless hand. What is the most appropriate emergent management?
. Immediate closed reduction and percutaneous pinning.
. Observation and repeat vascular assessment in 1 hour.
. Open reduction and internal fixation with vascular exploration.
. Angiography to localize the vascular injury.
. Administer IV fluids and heparin.

Correct Answer & Explanation

. Immediate closed reduction and percutaneous pinning.

Explanation

A supracondylar humerus fracture with signs of vascular compromise (pale, pulseless hand) is an orthopedic emergency. The most appropriate emergent management is immediate closed reduction of the fracture and percutaneous pinning. Often, reduction of the fracture itself can restore arterial flow by relieving mechanical compression of the brachial artery. If the pulse does not return after successful reduction and pinning, then further investigation (e.g., Doppler ultrasound, formal angiography) and vascular exploration would be necessary. Observation is contraindicated in an ischemic limb. Open reduction and vascular exploration are secondary steps if closed reduction fails to restore perfusion. Administering fluids and heparin is supportive but not definitive.

Question 506

Topic: Pediatric Upper Extremity & Spine

What is the most accurate statement regarding the assessment of respiratory function in a patient with severe adolescent idiopathic scoliosis (AIS) undergoing surgical correction?

. Pulmonary function tests (PFTs) are rarely needed as respiratory complications are uncommon.
. Forced vital capacity (FVC) is the most sensitive predictor of postoperative respiratory complications.
. Surgical correction always leads to immediate and significant improvement in lung function.
. Patients with preoperative FVC < 40% are at highest risk for significant postoperative respiratory morbidity.
. Routine arterial blood gas (ABG) analysis is sufficient to assess respiratory reserve.

Correct Answer & Explanation

. Patients with preoperative FVC < 40% are at highest risk for significant postoperative respiratory morbidity.

Explanation

In severe AIS, preoperative pulmonary function tests are crucial. Patients with a forced vital capacity (FVC) less than 40% of predicted are considered to be at highest risk for significant postoperative respiratory morbidity and potential respiratory failure. While FVC is an important parameter, it's not themostsensitive predictor as others like forced expiratory volume in 1 second (FEV1) and FEV1/FVC ratio are also important. Surgical correction can improve lung function, but not always immediately or significantly, and it carries its own risks. PFTs are definitely needed for assessment, and ABG provides snapshot information, not a comprehensive assessment of reserve.

Question 507

Topic: Pediatric Upper Extremity & Spine
A 7-year-old boy presents with a supracondylar humerus fracture (Gartland Type III). Initial radiographs show significant displacement and rotation. Which neurovascular structure is most commonly at risk in this type of fracture?
. Radial nerve.
. Ulnar nerve.
. Median nerve and brachial artery.
. Axillary nerve.
. Musculocutaneous nerve.

Correct Answer & Explanation

. Median nerve and brachial artery.

Explanation

Gartland Type III supracondylar humerus fractures are severely displaced and rotated, putting the median nerve and brachial artery at significant risk of injury due to their close proximity to the distal humerus. The radial nerve is also at risk but less commonly than the median nerve/brachial artery. Ulnar nerve injury is less common in extension-type supracondylar fractures but can occur with flexion-type fractures or during surgical manipulation. Axillary and musculocutaneous nerves are not typically injured in this fracture pattern.

Question 508

Topic: Pediatric Upper Extremity & Spine

What is the primary indication for surgical treatment of scoliosis in adolescents?

. Cobb angle greater than 20 degrees
. Progressive curve despite bracing
. Back pain refractory to conservative management
. Cosmetic deformity, regardless of curve magnitude
. Curve greater than 45-50 degrees in a skeletally immature patient

Correct Answer & Explanation

. Curve greater than 45-50 degrees in a skeletally immature patient

Explanation

The primary indication for surgical correction of adolescent idiopathic scoliosis (AIS) is a progressive curve greater than 45-50 degrees in a skeletally immature patient, or a curve greater than 50-60 degrees in a skeletally mature patient. This threshold is chosen because curves of this magnitude are likely to progress even after skeletal maturity and can lead to significant pulmonary compromise or trunk imbalance. While progression despite bracing and refractory pain are considerations, the specific Cobb angle threshold in an immature patient is a critical surgical indication. Cosmetic deformity alone is not a primary medical indication for surgery unless it is associated with a severe curve.

Question 509

Topic: Pediatric Upper Extremity & Spine

A 10-year-old female presents with progressive scoliosis. Her Risser sign is 1. Her Cobb angle measures 35 degrees. She is still growing rapidly. What is the most appropriate management strategy?

. Observation with serial radiographs every 6-12 months.
. Referral for spinal fusion surgery.
. Bracing.
. Physical therapy focusing on core strengthening.
. Pain management with NSAIDs.

Correct Answer & Explanation

. Bracing.

Explanation

For adolescent idiopathic scoliosis (AIS), the management depends on the magnitude of the curve and the patient's skeletal maturity. For curves between 25 and 45 degrees in a growing child (Risser 0-2), bracing is indicated to prevent curve progression. A Cobb angle of 35 degrees with a Risser 1 indicates significant growth remaining and a curve at risk for progression. Observation is typically for curves <25 degrees or skeletally mature patients with curves <45 degrees. Spinal fusion is generally reserved for curves >45-50 degrees or progressive curves despite bracing. Physical therapy can be adjunctive but not a primary treatment for curve progression. NSAIDs are for pain, not curve correction.

Question 510

Topic: Pediatric Upper Extremity & Spine
In the management of a displaced supracondylar humerus fracture (Gartland Type III) in a child, which of the following is the most critical immediate concern after reduction?
. Prevention of cubitus varus deformity
. Assessment for median nerve entrapment
. Monitoring for compartment syndrome and vascular compromise
. Achieving stable pin fixation
. Minimizing radiation exposure during fluoroscopy

Correct Answer & Explanation

. Monitoring for compartment syndrome and vascular compromise

Explanation

For a displaced supracondylar humerus fracture, especially after reduction and pinning, the most critical immediate concern is monitoring for compartment syndrome and vascular compromise (Volkmann's ischemic contracture). Swelling and potential injury to the brachial artery (often associated with Gartland Type III) can lead to devastating consequences if not recognized and treated promptly. While the other options are important, they are secondary to limb viability. Cubitus varus is a cosmetic deformity, median nerve entrapment is a concern but less immediately catastrophic, stable pinning is a goal of the procedure, and radiation exposure is a general surgical concern but not the most critical immediate post-op concern in terms of patient safety.

Question 511

Topic: Pediatric Upper Extremity & Spine

A 4-year-old boy falls from a height and sustains a supracondylar humerus fracture. He presents with a pulseless but warm and pink hand. What is the immediate next step in management after initial stabilization and pain control?

. Observation and repeat pulse check in 30 minutes
. Immediate surgical exploration of the brachial artery
. Closed reduction and percutaneous pinning
. Angiography to assess vascular injury
. Application of a coaptation splint

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

In a supracondylar humerus fracture with a pulseless but perfused (warm, pink, good capillary refill) hand, the immediate priority after initial stabilization is gentle closed reduction and percutaneous pinning. Often, the pulse will return with reduction of the fracture and relief of mechanical obstruction/kinking of the brachial artery. If the pulse does not return after successful reduction, then further vascular workup (angiography) or surgical exploration is indicated. Immediate exploration without attempting reduction is usually not necessary unless there are signs of overt ischemia (cold, pale hand) or a hard sign of vascular injury. Observation is inappropriate for a pulseless extremity.

Question 512

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with a displaced Gartland Type III supracondylar humerus fracture. On initial presentation, his hand is pink, but the radial pulse is absent. The patient is taken emergently to the OR. After anatomic closed reduction and percutaneous pinning, the hand remains pink, warm, and well-perfused (capillary refill < 2 seconds), but the radial pulse remains absent by Doppler. What is the most appropriate next step in management?
. Immediate open exploration of the brachial artery
. Intraoperative CT angiogram
. Observation with close clinical monitoring and admission
. Removal of the pins and conversion to open reduction
. Emergent fasciotomy of the forearm compartments

Correct Answer & Explanation

. Observation with close clinical monitoring and admission

Explanation

A 'pulseless, pink' hand following reduction and pinning of a pediatric supracondylar humerus fracture suggests adequate collateral circulation despite probable brachial artery spasm, kinking, or intimal injury. Current guidelines recommend close observation and hospital admission for a pulseless but well-perfused (pink) hand after definitive fracture stabilization. Routine vascular exploration is not indicated unless the hand becomes poorly perfused (white, cool, capillary refill > 3 seconds), in which case open exploration of the artery would be warranted.

Question 513

Topic: Pediatric Upper Extremity & Spine
A 5-year-old boy presents after falling from the monkey bars with a significantly swollen, deformed elbow. Radiographs show an extension-type Gartland III supracondylar humerus fracture. Which of the following physical exam findings indicates the most commonly injured nerve in this fracture pattern?
. Inability to make the "A-OK" sign
. Loss of sensation over the dorsal first web space
. Inability to cross the index and middle fingers
. Weakness with elbow flexion and supination
. Loss of sensation over the volar tip of the small finger

Correct Answer & Explanation

. Inability to make the "A-OK" sign

Explanation

The anterior interosseous nerve (AIN), a branch of the median nerve, is the most commonly injured nerve in extension-type supracondylar humerus fractures. Injury to the AIN results in weakness of the flexor pollicis longus and flexor digitorum profundus to the index finger, presenting as an inability to form the "A-OK" sign.

Question 514

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal female presents with a right thoracic scoliosis curve of 35 degrees. Her Risser stage is 0. Which combination of factors indicates the highest risk for curve progression in adolescent idiopathic scoliosis?

. Male gender, mature skeletal age, single lumbar curve
. Female gender, premenarchal status, single thoracic curve
. Female gender, premenarchal status, double curve pattern
. Male gender, postmenarchal equivalent status, double curve pattern
. Female gender, mature skeletal age, single thoracic curve

Correct Answer & Explanation

. Female gender, premenarchal status, double curve pattern

Explanation

Risk factors for progression in adolescent idiopathic scoliosis (AIS) include female gender (females are up to 10 times more likely to have curves progress to surgical magnitude), substantial remaining skeletal growth (premenarchal status, open triradiate cartilage, Risser 0), and double curve patterns.

Question 515

Topic: Pediatric Upper Extremity & Spine
A newborn is diagnosed with a unilateral radial longitudinal deficiency (radial club hand) characterized by an absent radius (Type IV). Before proceeding with any orthopedic interventions, which of the following screening tests is most critical for determining the patient's immediate survival risk?
. Renal ultrasound
. Non-contrast head CT
. Chromosomal breakage testing
. Upper extremity angiography
. Electrocardiogram

Correct Answer & Explanation

. Chromosomal breakage testing

Explanation

Radial longitudinal deficiency is highly associated with systemic conditions such as VACTERL, Holt-Oram, TAR syndrome, and Fanconi anemia. Fanconi anemia, an autosomal recessive disorder leading to fatal aplastic anemia, carries the highest mortality risk if undetected. Screening is performed using a chromosomal breakage test (diepoxybutane test).

Question 516

Topic: Pediatric Upper Extremity & Spine

A 4-year-old boy undergoes open reduction and internal fixation of a displaced Milch Type II lateral condyle fracture of the humerus. Which of the following is the most common complication associated with this injury and its treatment?

. Avascular necrosis of the trochlea
. Cubitus varus
. Nonunion
. Lateral spur formation (lateral condylar overgrowth)
. Ulnar nerve palsy

Correct Answer & Explanation

. Avascular necrosis of the trochlea

Explanation

Lateral spur formation, or lateral condylar overgrowth, is the most common complication of a lateral condyle fracture, occurring in up to 50-70% of cases. It causes a cosmetic bump on the lateral elbow but rarely restricts motion or causes functional deficits. While nonunion and tardy ulnar nerve palsy (due to cubitus valgus) are classic severe complications of a missed or poorly treated lateral condyle fracture, lateral overgrowth is far more frequent.

Question 517

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal female (Risser 0) presents with a right thoracic adolescent idiopathic scoliosis. Her curve measures 22 degrees on a standing PA radiograph. What is the approximate risk of curve progression to greater than 30 degrees?

. 10%
. 20%
. 40%
. 68%
. 95%

Correct Answer & Explanation

. 10%

Explanation

According to the Lonstein and Carlson progression formula and established general guidelines for Adolescent Idiopathic Scoliosis, a patient who is highly immature (Risser 0-2, premenarchal) with a curve measuring between 20-29 degrees has approximately a 68% risk of curve progression. This warrants close observation or initiation of bracing.

Question 518

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls from the monkey bars and sustains a Gartland Type III supracondylar humerus fracture. Upon initial evaluation, his hand is pale and pulseless. After prompt closed reduction and percutaneous pinning in the operating room, the hand becomes warm and pink, with a capillary refill of less than 2 seconds, but the radial pulse remains unpalpable. What is the next best step in management?
. Immediate open vascular exploration of the brachial artery
. Removal of the pins, extension of the elbow to 30 degrees, and re-evaluation
. Admit the patient for close inpatient observation and neurovascular monitoring
. Administration of intra-arterial vasodilators (e.g., papaverine)
. Perform an immediate forearm fasciotomy

Correct Answer & Explanation

. Admit the patient for close inpatient observation and neurovascular monitoring

Explanation

The management of the 'pink, pulseless hand' following reduction of a supracondylar humerus fracture is a well-established algorithm. If the hand is well-perfused (pink, warm, good capillary refill) after adequate reduction and stabilization, collateral circulation is sufficient. The standard of care is to admit the patient for close neurovascular monitoring (observation) rather than pursuing immediate vascular exploration, as the brachial artery is often in spasm and recanalizes over time.

Question 519

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls from the monkey bars and sustains a Gartland type III supracondylar humerus fracture. Upon arrival in the emergency department, his hand is pink but the radial pulse is absent. After closed reduction and percutaneous pinning in the operating room, the hand remains pink and well-perfused with brisk capillary refill, but the pulse remains absent via Doppler. What is the most appropriate next step in management?
. Immediate vascular surgery consultation for brachial artery exploration
. Removal of pins and transition to open reduction
. Observation and hospital admission for close neurovascular monitoring
. Perform a CT angiogram of the upper extremity
. Administer intravenous heparin and systemic vasodilators

Correct Answer & Explanation

. Observation and hospital admission for close neurovascular monitoring

Explanation

In the setting of a 'pink, pulseless' hand following the closed reduction and pinning of a supracondylar humerus fracture, the most appropriate management is observation and close monitoring (admission). As long as the hand remains well-perfused (capillary refill < 2 seconds, warm, pink), surgical vascular exploration is not indicated because collateral circulation is adequate. Routine angiogram or empirical exploration in a well-perfused hand is unnecessary and potentially harmful.

Question 520

Topic: Pediatric Upper Extremity & Spine
A newborn is noted to have severe radial deviation of the right wrist, an absent right thumb, and shortening of the right forearm. Radiographs reveal an absent radius. To rule out the most life-threatening associated condition, which of the following screening tests should be ordered initially?
. Renal ultrasound
. Echocardiogram
. Chromosomal breakage test (Diepoxybutane test)
. Complete blood count (CBC) with peripheral smear
. Whole-spine MRI

Correct Answer & Explanation

. Chromosomal breakage test (Diepoxybutane test)

Explanation

Radial longitudinal deficiency (radial clubhand) is strongly associated with several systemic syndromes including VACTERL, TAR (Thrombocytopenia-Absent Radius), Holt-Oram, and Fanconi anemia. Fanconi anemia is the most life-threatening because it leads to fatal aplastic anemia and a high risk of malignancies (leukemia). The definitive screening test is chromosomal breakage analysis induced by diepoxybutane (DEB). A CBC may be normal in the neonatal period before marrow failure manifests, making it an insufficient screen.

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