Menu

Pediatric Upper Extremity & Spine MCQs

Practice Set 27 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 521

Topic: Pediatric Upper Extremity & Spine
A 5-year-old boy presents with an extension-type Gartland III supracondylar humerus fracture after a fall. On examination, his hand is well-perfused (pink) with brisk capillary refill, but the radial pulse is absent. What is the most appropriate initial management?
. Immediate open vascular exploration
. Urgent closed reduction and percutaneous pinning, followed by reassessment
. CT angiography of the upper extremity
. Prophylactic forearm fasciotomy
. Admission for elevation and observation in a splint

Correct Answer & Explanation

. Urgent closed reduction and percutaneous pinning, followed by reassessment

Explanation

The presentation of a 'pink, pulseless' hand with a displaced supracondylar fracture dictates urgent closed reduction and percutaneous pinning (CRPP) as the initial step. Often, the pulse returns after reduction removes the tethering or kinking of the brachial artery. If the hand remains pink and well-perfused after CRPP, observation is appropriate even if the pulse remains absent. Open exploration is indicated for a 'white, pulseless' hand that does not improve after reduction.

Question 522

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains a completely displaced, extension-type supracondylar humerus fracture (Gartland Type III). Upon presentation, his hand is pale and pulseless. Following closed reduction and percutaneous pinning in the operating room, the hand becomes warm and pink with a capillary refill of 2 seconds, but the radial pulse remains unpalpable. What is the most appropriate next step in management?
. Immediate exploration of the brachial artery
. Removal of pins and open reduction
. Observation and hospital admission for neurovascular checks
. Immediate sympathectomy
. Application of a hyperflexion cast

Correct Answer & Explanation

. Observation and hospital admission for neurovascular checks

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 frequently returns within a few days.

Question 523

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls from monkey bars and sustains a widely displaced posterolateral Gartland type III supracondylar humerus fracture. Which of the following neurologic deficits is most likely to be observed on physical examination?
. Inability to extend the wrist and digits
. Inability to actively flex the distal interphalangeal joint of the index finger
. Decreased sensation over the dorsal first web space
. Inability to abduct and adduct the fingers
. Decreased sensation over the volar small finger

Correct Answer & Explanation

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

Explanation

Posterolateral displacement in supracondylar humerus fractures places the anterior interosseous nerve (AIN) at the greatest risk. AIN palsy presents with an inability to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger (the "OK" sign).

Question 524

Topic: Pediatric Upper Extremity & Spine
A 5-year-old girl undergoes closed reduction and percutaneous pinning for a Gartland type III supracondylar humerus fracture. Postoperatively, the radial pulse is completely absent, but her hand is warm, pink, and demonstrates brisk capillary refill (<2 seconds). What is the most appropriate management?
. Immediate exploration of the brachial artery
. Emergent fasciotomy of the forearm
. Observation with close monitoring and elevation
. Emergent angiography of the upper extremity
. Removal of all pins and conversion to open reduction

Correct Answer & Explanation

. Observation with close monitoring and elevation

Explanation

A "pink, pulseless" hand after anatomic reduction and stabilization of a supracondylar humerus fracture indicates adequate collateral circulation. The standard of care is close clinical observation, as the pulse typically returns within a few days due to resolution of vasospasm.

Question 525

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a severe extension-type supracondylar humerus fracture. On examination, the hand is pink and warm with normal capillary refill, but the radial pulse is not palpable.

What is the most appropriate initial management?

. Immediate open vascular exploration
. Urgent closed reduction and percutaneous pinning, followed by reassessment of perfusion
. CT angiography to identify arterial injury before any fracture manipulation
. Application of a long arm cast in 120 degrees of flexion
. Observation in the emergency department for 24 hours to allow for vasospasm resolution

Correct Answer & Explanation

. Immediate open vascular exploration

Explanation

For a 'pulseless, pink hand' associated with a supracondylar humerus fracture, the standard of care is urgent closed reduction and percutaneous pinning (CRPP). If the hand remains pink and well-perfused post-reduction, routine vascular exploration is unnecessary.

Question 526

Topic: Pediatric Upper Extremity & Spine

In the Lenke classification system for Adolescent Idiopathic Scoliosis (AIS), a proximal thoracic curve is considered 'structural' if it meets which of the following radiographic criteria?

. Residual curve >= 10 degrees on side bending
. Residual curve >= 15 degrees on side bending
. Residual curve >= 25 degrees on side bending
. Residual curve >= 35 degrees on side bending
. Flexible curve resolving to 0 degrees on side bending

Correct Answer & Explanation

. Residual curve >= 10 degrees on side bending

Explanation

According to the Lenke classification for AIS, minor curves are considered 'structural' if they do not bend out to less than 25 degrees on supine maximum side-bending radiographs (i.e., residual curve >= 25 degrees). For a proximal thoracic curve, another criterion for being structural is a regional kyphosis (T2-T5) of >= 20 degrees.

Question 527

Topic: Pediatric Upper Extremity & Spine

In the Lenke classification system for Adolescent Idiopathic Scoliosis (AIS), determining whether a curve is 'structural' or 'non-structural' is crucial for deciding which curves must be included in the fusion construct. To classify the Proximal Thoracic (PT) curve as structural, which of the following radiographic criteria must be met?

. The side-bending Cobb angle must be > 10 degrees OR T10-L2 kyphosis > 10 degrees.
. The side-bending Cobb angle must be > 35 degrees OR T2-T5 kyphosis > 10 degrees.
. The side-bending Cobb angle must be >= 25 degrees OR T5-T12 kyphosis >= +20 degrees.
. The side-bending Cobb angle must be >= 25 degrees OR T2-T5 kyphosis >= +20 degrees.
. The side-bending Cobb angle must be >= 15 degrees OR T10-L2 kyphosis >= +15 degrees.

Correct Answer & Explanation

. The side-bending Cobb angle must be > 10 degrees OR T10-L2 kyphosis > 10 degrees.

Explanation

In the Lenke classification, a minor curve is considered structural if it lacks adequate flexibility or is regionally kyphotic. Specifically, for the Proximal Thoracic (PT) curve, the criteria to be structural are a residual Cobb angle of >= 25 degrees on maximum side-bending radiographs OR regional kyphosis between T2 and T5 of >= +20 degrees. If either criterion is met, the PT curve is structural and generally must be included in the fusion construct.

Question 528

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal female with a Risser 0 score presents with an adolescent idiopathic scoliosis right thoracic curve of 32 degrees. Based on the BrAIST trial, what is the most appropriate management?

. Observation with 6-month serial radiographs
. Nighttime-only bending brace
. Thoracolumbosacral orthosis (TLSO) bracing for a minimum of 18 hours per day
. Posterior spinal fusion
. Anterior vertebral body tethering

Correct Answer & Explanation

. Observation with 6-month serial radiographs

Explanation

The BrAIST trial definitively showed that bracing significantly decreases the progression of high-risk AIS curves to the surgical threshold. Wearing a TLSO brace for at least 18 hours daily was highly correlated with treatment success.

Question 529

Topic: Pediatric Upper Extremity & Spine
A 12-year-old premenarchal female presents with an adolescent idiopathic scoliosis right thoracic curve of 25 degrees. Her Risser stage is 0. According to the Lonstein and Carlson criteria, what is her approximate risk of curve progression to a surgical magnitude (>50 degrees)?
. < 10%
. 20-30%
. 40-50%
. 68%
. > 90%

Correct Answer & Explanation

. 68%

Explanation

In a premenarchal female who is Risser 0 with an AIS curve between 20 and 29 degrees, the risk of curve progression is exceptionally high, calculated to be approximately 68% by Lonstein and Carlson.

Question 530

Topic: Pediatric Upper Extremity & Spine
A neonate presents with bilateral shortened forearms, radially deviated hands, and absent radii on radiographs. Interestingly, both thumbs are present and appear structurally normal. Which of the following genetic syndromes is most likely in this patient?
. Holt-Oram syndrome
. Fanconi anemia
. VATER association
. Thrombocytopenia-absent radius (TAR) syndrome
. VACTERL syndrome

Correct Answer & Explanation

. Thrombocytopenia-absent radius (TAR) syndrome

Explanation

Thrombocytopenia-absent radius (TAR) syndrome is uniquely characterized by bilateral absence of the radii but with preservation of the thumbs. In other syndromes associated with radial longitudinal deficiency (such as Fanconi anemia, Holt-Oram, and VACTERL), if the radius is absent or hypoplastic, the thumb is also typically absent or hypoplastic.

Question 531

Topic: Pediatric Upper Extremity & Spine
A newborn presents with bilateral absent radii and severely radially deviated hands. Examination reveals that both thumbs are perfectly formed and present. An echocardiogram is normal. Laboratory tests reveal severe thrombocytopenia. Which genetic mutation is most likely responsible for this child's syndrome?
. RBM8A
. TBX5
. FANCA
. SALL4
. FGFR2

Correct Answer & Explanation

. RBM8A

Explanation

The child has Thrombocytopenia-Absent Radius (TAR) syndrome, which is unique among the radial longitudinal deficiencies because the thumbs are present. This distinguishes it from Fanconi anemia (FANCA) and Holt-Oram syndrome (TBX5), where thumbs are typically absent or hypoplastic. TAR syndrome is caused by a microdeletion at 1q21.1 affecting the RBM8A gene.

Question 532

Topic: Pediatric Upper Extremity & Spine
A newborn presents with radial clubhand and an absent thumb. Echocardiography reveals an atrial septal defect. Hematologic workup is normal. What is the most likely diagnosis?
. Fanconi anemia
. Holt-Oram syndrome
. TAR syndrome
. VACTERL association
. Apert syndrome

Correct Answer & Explanation

. Holt-Oram syndrome

Explanation

Holt-Oram syndrome is an autosomal dominant condition characterized by radial longitudinal deficiency and congenital heart defects, most commonly atrial septal defects (ASD) or ventricular septal defects (VSD). Unlike Fanconi anemia, bone marrow function is normal.

Question 533

Topic: Pediatric Upper Extremity & Spine
A newborn presents with bilateral absent radii and absent thumbs (radial clubhands). Before considering any surgical intervention, which of the following is an absolute mandatory hematologic screening test?
. Hemoglobin electrophoresis
. Peripheral blood smear
. Chromosomal breakage testing with diepoxybutane
. Factor VIII assay
. Bone marrow biopsy

Correct Answer & Explanation

. Chromosomal breakage testing with diepoxybutane

Explanation

Radial clubhand can be associated with multiple syndromes, notably Fanconi anemia, Holt-Oram, TAR, and VACTERL. Fanconi anemia is a fatal aplastic anemia if unrecognized, and surgery is contraindicated until it is ruled out. Chromosomal breakage testing using diepoxybutane (DEB) or mitomycin C is the gold standard for diagnosis.

Question 534

Topic: Pediatric Upper Extremity & Spine
A newborn is evaluated for an absent right thumb and a radially deviated right wrist. Radiographs confirm complete absence of the radius. Which of the following diagnostic tests is most critical to perform next to rule out a potentially fatal associated condition?
. Renal ultrasound
. Echocardiogram
. Chromosomal breakage analysis
. Complete blood count with smear
. Cranial ultrasound

Correct Answer & Explanation

. Chromosomal breakage analysis

Explanation

Radial longitudinal deficiency with an absent thumb is strongly associated with Fanconi anemia, Holt-Oram syndrome, and VACTERL. Fanconi anemia involves fatal aplastic anemia if undiagnosed, and chromosomal breakage analysis (using diepoxybutane) is the definitive screening test. TAR syndrome typically presents with a preserved thumb.

Question 535

Topic: Pediatric Upper Extremity & Spine
A 5-year-old boy sustains a fall on an outstretched hand and presents with a completely displaced, extension-type supracondylar humerus fracture with no cortical contact (Gartland Type III). Which of the following peripheral nerve injuries is most commonly associated with this specific fracture pattern?
. Radial nerve
. Ulnar nerve
. Anterior interosseous nerve (AIN)
. Median nerve (excluding AIN)
. 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. It typically presents with weakness of the flexor pollicis longus and flexor digitorum profundus to the index finger, resulting in an inability to make an "OK" sign.

Question 536

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains a Gartland type III extension-type supracondylar humerus fracture. Following prompt closed reduction and percutaneous pinning, the hand remains 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 exploration of the brachial artery
. CT angiography of the upper extremity
. Observation and hospital admission
. Removal of the pins and open reduction

Correct Answer & Explanation

. Observation and hospital admission

Explanation

A 'pink, pulseless' hand following reduction of a supracondylar fracture indicates adequate collateral perfusion. Observation is the standard of care, as the pulse often returns within a few days.

Question 537

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains an extension-type Gartland III supracondylar humerus fracture that is posterolaterally displaced. Which nerve is at the highest risk of injury, and what is its classic clinical manifestation?
. Ulnar nerve; weak finger abduction
. Radial nerve; inability to extend the wrist
. Anterior interosseous nerve; inability to flex the IP joint of the thumb and DIP of the index finger
. Median nerve; complete loss of sensation over the thenar eminence
. Musculocutaneous nerve; weak elbow flexion

Correct Answer & Explanation

. Anterior interosseous nerve; inability to flex the IP joint of the thumb and DIP of the index finger

Explanation

Posterolateral displacement of the distal fragment causes the proximal metaphyseal spike to displace anteromedially, jeopardizing the median nerve and its branch, the anterior interosseous nerve (AIN). AIN injury results in inability to make an "OK" sign.

Question 538

Topic: Pediatric Upper Extremity & Spine

A 13-year-old Risser 1 female presents with a right thoracic curve of 35 degrees. What is the most appropriate management?

. Observation with repeat radiographs in 6 months
. Physical therapy and core strengthening
. Part-time (nighttime only) bracing
. Full-time TLSO bracing (at least 18 hours/day)
. Posterior spinal fusion

Correct Answer & Explanation

. Observation with repeat radiographs in 6 months

Explanation

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

Question 539

Topic: Pediatric Upper Extremity & Spine

During correction of an adolescent idiopathic scoliosis deformity, there is a sudden and sustained loss of motor evoked potentials (MEPs) bilaterally, while somatosensory evoked potentials (SSEPs) remain at baseline. The patient's mean arterial pressure (MAP) is currently 85 mmHg. What is the most appropriate immediate step in management?

. Perform an immediate wake-up test before altering the surgical construct
. Increase the depth of inhalational anesthesia to reduce metabolic demand
. Administer high-dose intravenous methylprednisolone
. Release distraction and loosen the deformity correction immediately
. Continue the procedure as SSEP preservation ensures sensory tract viability

Correct Answer & Explanation

. Perform an immediate wake-up test before altering the surgical construct

Explanation

Isolated loss of MEPs with intact SSEPs suggests an anterior cord issue affecting the motor tracts, often due to mechanical stretch or ischemia. After informing the surgeon, optimizing hemodynamics (MAP > 85-90), and ensuring there is no technical/anesthetic failure, the immediate surgical step is to release the corrective distraction forces. Waiting to perform a wake-up test or continuing the procedure wastes critical time during which ischemic injury can become permanent.

Question 540

Topic: Pediatric Upper Extremity & Spine

When applying the Lenke classification system for adolescent idiopathic scoliosis, a minor curve must be included in the surgical fusion construct if it is deemed 'structural'. What radiographic criterion defines a structural minor curve in the coronal plane?

. Cobb angle > 10 degrees on side-bending radiographs
. Cobb angle > 25 degrees on side-bending radiographs
. Cobb angle > 20 degrees on standing radiographs
. Apical vertebral translation > 2 cm
. Nash-Moe rotation > Grade 2

Correct Answer & Explanation

. Cobb angle > 10 degrees on side-bending radiographs

Explanation

In the Lenke classification, a minor curve is considered structural if it fails to bend out to less than 25 degrees on dynamic supine side-bending radiographs, or if there is kyphosis of at least +20 degrees across that region.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page