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Pediatric Upper Extremity & Spine MCQs

Practice Set 28 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 541

Topic: Pediatric Upper Extremity & Spine
A 6-year-old male sustains a Gartland type III supracondylar humerus fracture. On presentation, his hand is pink and warm, but the radial pulse is absent. After a successful closed reduction and percutaneous pinning, the hand remains pink and warm with brisk capillary refill, but the radial pulse remains unpalpable. What is the most appropriate next step in management?
. Immediate open exploration of the brachial artery
. Observation with close clinical monitoring for 24 to 48 hours
. Emergent CT angiography of the upper extremity
. Administration of intravenous heparin
. Prophylactic fasciotomy of the volar forearm

Correct Answer & Explanation

. Observation with close clinical monitoring for 24 to 48 hours

Explanation

The management of the 'pink, pulseless hand' following reduction of a supracondylar humerus fracture is a well-tested topic. If the hand remains well-perfused (pink, warm, capillary refill < 2 seconds) despite the absence of a palpable pulse, the collateral circulation is sufficient. The most appropriate next step is observation with close monitoring. Open vascular exploration or angiography is reserved for the 'white, pulseless hand' that remains dysvascular after fracture reduction.

Question 542

Topic: Pediatric Upper Extremity & Spine

In the Lenke classification for adolescent idiopathic scoliosis, a proximal thoracic curve is defined as a 'structural' minor curve if its side-bending Cobb angle fails to correct below what threshold?

. 10 degrees
. 15 degrees
. 20 degrees
. 25 degrees
. 30 degrees

Correct Answer & Explanation

. 10 degrees

Explanation

The Lenke classification system dictates that a minor curve is considered 'structural' if the Cobb angle remains greater than or equal to 25 degrees on coronal side-bending radiographs. If it reduces to less than 25 degrees, it is considered nonstructural. For proximal thoracic curves, a T2-T5 kyphosis of >20 degrees is also a criterion for structural definition, but the coronal bending threshold is 25 degrees.

Question 543

Topic: Pediatric Upper Extremity & Spine
A 6-year-old girl falls from monkey bars and sustains a Gartland Type III extension-type supracondylar humerus fracture. On arrival, her hand is pink and warm, but she lacks a palpable radial pulse. Capillary refill is brisk (<2 seconds). Which of the following is the most appropriate initial management for this patient?
. Urgent closed reduction and percutaneous pinning, followed by reassessment of the pulse
. Immediate vascular surgical consultation for arterial exploration
. CT angiogram of the upper extremity
. Immediate open reduction through an anterior approach
. Observation in a splint overnight to allow swelling to decrease

Correct Answer & Explanation

. Urgent closed reduction and percutaneous pinning, followed by reassessment of the pulse

Explanation

A 'pink, pulseless' hand is a classic clinical scenario in pediatric supracondylar humerus fractures, commonly due to kinking, spasm, or tethering of the brachial artery. The accepted initial management is urgent closed reduction and percutaneous pinning. Often, the pulse returns once the fracture is reduced. If the hand remains well-perfused (pink) despite no palpable pulse after reduction, observation is acceptable. Immediate exploration is reserved for a 'white, pulseless' hand that does not improve after reduction.

Question 544

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with a completely displaced, extension-type (Gartland III) supracondylar humerus fracture. His hand is pink but pulseless. After prompt closed reduction and percutaneous pinning in the OR, his hand remains pink and pulseless. What is the most appropriate next step in management?
. Immediate vascular exploration
. CT angiography of the upper extremity
. Remove the pins, re-reduce, and repin
. Close observation with continuous pulse oximetry and serial exams
. Prophylactic forearm fasciotomy

Correct Answer & Explanation

. Close observation with continuous pulse oximetry and serial exams

Explanation

A 'pink, pulseless' hand after adequate reduction and pinning of a pediatric supracondylar humerus fracture indicates adequate collateral perfusion. The standard of care is close clinical observation, as the radial pulse typically returns within a few days.

Question 545

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls off monkey bars and sustains a widely displaced extension-type supracondylar humerus fracture (Gartland Type III). During neurological examination, he is unable to actively flex his thumb interphalangeal joint and the distal interphalangeal joint of his 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), a purely motor branch of the median nerve, is the most commonly injured nerve in extension-type supracondylar humerus fractures (often tented over the proximal fragment). Clinically, it presents with an inability to make the 'A-OK' sign due to weakness of the flexor pollicis longus (thumb IP flexion) and the flexor digitorum profundus to the index finger (index DIP flexion).

Question 546

Topic: Pediatric Upper Extremity & Spine
A 12-year-old premenarchal female is evaluated for a right thoracic prominence. Standing radiographs reveal a main thoracic curve of 32 degrees. Her Risser stage is 0. Based on the Bracing in Adolescent Idiopathic Scoliosis Trial (BRAIST), which of the following factors has the most significant dose-dependent correlation with the success of bracing in preventing curve progression to surgical thresholds?
. The exact magnitude of the initial curve below 35 degrees
. The patient's Body Mass Index (BMI)
. The hours of daily brace wear
. The specific use of a Milwaukee brace over a TLSO
. The presence of an underlying positive family history

Correct Answer & Explanation

. The hours of daily brace wear

Explanation

The BRAIST trial established high-level evidence that bracing significantly decreases the progression of high-risk curves to the threshold for surgery. The success of bracing is highly correlated with compliance in a dose-dependent manner; greater hours of daily brace wear (especially >12.9 hours) yield significantly higher success rates.

Question 547

Topic: Pediatric Upper Extremity & Spine

A 14-year-old female with Adolescent Idiopathic Scoliosis is being evaluated for surgery.

Radiographs demonstrate a main thoracic curve of 55 degrees and a lumbar curve of 35 degrees. On lateral bending films, the main thoracic curve corrects to 30 degrees, while the lumbar curve corrects to 15 degrees. According to the Lenke classification, what type of curve is this?

. Lenke 1 (Main Thoracic)
. Lenke 2 (Double Thoracic)
. Lenke 3 (Double Major)
. Lenke 5 (Thoracolumbar/Lumbar)
. Lenke 6 (Thoracolumbar/Lumbar - Main Thoracic)

Correct Answer & Explanation

. Lenke 1 (Main Thoracic)

Explanation

In the Lenke classification, structural criteria define the curve type. A curve is non-structural if it bends to less than 25 degrees. Here, the lumbar curve bends to 15 degrees (non-structural), while the main thoracic curve remains > 25 degrees (structural). Thus, this is a Lenke 1 (Main Thoracic) curve.

Question 548

Topic: Pediatric Upper Extremity & Spine
A newborn presents with a severe right radial clubhand. Examination shows an absent thumb and radial deviation of the wrist. An echocardiogram reveals an atrial septal defect (ASD). Which of the following syndromes best fits this clinical picture?
. Fanconi anemia
. Holt-Oram syndrome
. Thrombocytopenia-Absent Radius (TAR) syndrome
. VACTERL association
. Klippel-Trenaunay syndrome

Correct Answer & Explanation

. Holt-Oram syndrome

Explanation

Holt-Oram syndrome is an autosomal dominant condition characterized by upper extremity anomalies (often radial ray deficiencies, including absent thumb) and congenital heart defects, most commonly an ASD or VSD. In contrast, TAR syndrome features an absent radius but a PRESENT thumb. Fanconi anemia involves bone marrow failure and requires chromosomal breakage testing. VACTERL includes vertebral, anal, cardiac, tracheoesophageal, renal, and limb anomalies, but Holt-Oram is specifically defined by the heart-hand connection.

Question 549

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl is diagnosed with adolescent idiopathic scoliosis (AIS). Her Lenke classification is 1AN. Which of the following best describes the structural characteristics of her curve?

. Main thoracic curve is structural, proximal thoracic and thoracolumbar/lumbar are non-structural.
. Double major curve with a structural main thoracic and structural thoracolumbar/lumbar curve.
. Triple major curve with structural proximal thoracic, main thoracic, and thoracolumbar curves.
. Main thoracic curve is structural with a positive sagittal modifier (kyphosis > 40 degrees).
. Thoracolumbar/lumbar curve is structural, main thoracic is non-structural.

Correct Answer & Explanation

. Main thoracic curve is structural, proximal thoracic and thoracolumbar/lumbar are non-structural.

Explanation

Lenke 1 curves are main thoracic structural curves with non-structural proximal thoracic and thoracolumbar curves. The "A" modifier indicates the lumbar apex falls between the pedicles, and "N" designates normal thoracic kyphosis.

Question 550

Topic: Pediatric Upper Extremity & Spine

A newborn is noted to have a missing thumb and severe radial deviation of the wrist. Radiographs confirm radial clubhand. Which of the following screening tests is most appropriate to rule out a potentially fatal associated condition?

. Renal ultrasound
. Chromosomal breakage analysis with diepoxybutane
. Echocardiogram
. Spinal MRI
. Thyroid function tests

Correct Answer & Explanation

. Renal ultrasound

Explanation

Radial clubhand is strongly associated with Fanconi anemia, a life-threatening aplastic anemia syndrome. It is screened via chromosomal breakage analysis using clastogenic agents like diepoxybutane (DEB).

Question 551

Topic: Pediatric Upper Extremity & Spine

A 7-year-old boy sustains a completely displaced extension-type supracondylar humerus fracture. Upon examination, he is unable to flex the interphalangeal joint of his thumb or the distal interphalangeal joint of his index finger. Which nerve is most likely injured?

. Radial nerve
. Ulnar nerve
. Posterior interosseous nerve
. Anterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Radial nerve

Explanation

The Anterior Interosseous Nerve (AIN) is the most frequently injured nerve in extension-type supracondylar fractures. Clinically, AIN palsy presents as the inability to form an 'OK' sign due to weakness of the flexor pollicis longus and flexor digitorum profundus to the index finger.

Question 552

Topic: Pediatric Upper Extremity & Spine
A 5-year-old child sustains a completely displaced extension-type Gartland III supracondylar fracture of the humerus. Which of the following clinical findings is most specific for testing the most commonly injured nerve in this fracture pattern?
. Inability to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger
. Numbness over the dorsal first web space
. Inability to extend the metacarpophalangeal joints of the fingers
. Weakness in spreading the fingers apart against resistance
. Numbness over the volar tip of the little finger

Correct Answer & Explanation

. Inability to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger

Explanation

The anterior interosseous nerve (AIN) is the most commonly injured nerve in extension-type supracondylar humerus fractures. It is a pure motor nerve that innervates the FPL, the FDP to the index and middle fingers, and the pronator quadratus. Weakness is evaluated by the 'OK' sign, which corresponds to the inability to actively flex the IP joint of the thumb and the DIP joint of the index finger.

Question 553

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with a completely displaced, extension-type supracondylar humerus fracture (Gartland Type III). On examination, his hand is pink, warm, and has a brisk capillary refill, but the radial pulse is completely absent by palpation and Doppler. What is the most appropriate initial management?
. Immediate open exploration of the brachial artery in the antecubital fossa
. Urgent closed reduction and percutaneous pinning without immediate vascular exploration
. Application of a long arm cast in 120 degrees of elbow flexion to restore the pulse
. CT angiography of the upper extremity to map the vascular injury
. Prophylactic fasciotomy of the volar forearm

Correct Answer & Explanation

. Urgent closed reduction and percutaneous pinning without immediate vascular exploration

Explanation

This is a classic 'pink, pulseless' hand scenario in a pediatric supracondylar humerus fracture. The limb is well-perfused via collateral circulation, but the main brachial artery is kinked or in spasm over the fracture site. The standard of care is urgent closed reduction and percutaneous pinning. In the vast majority of cases, anatomic reduction relieves the kinking, and the pulse returns. If the hand remains pink and well-perfused post-reduction despite an absent pulse, observation is appropriate. Open exploration is indicated only if the hand is persistently 'pale and pulseless' after reduction.

Question 554

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents to the emergency department after falling from monkey bars. He has a visibly deformed left elbow. Radiographs confirm a displaced, posteromedial Gartland Type III supracondylar humerus fracture. On examination, the hand is pink and capillary refill is less than 2 seconds, but the radial pulse is completely non-palpable. What is the most appropriate next step in management?
. Immediate vascular surgery consultation for open brachial artery exploration
. Emergent closed reduction and percutaneous pinning
. CT angiography of the upper extremity to map the vascular injury
. Observation with strict elevation and cast application in 120 degrees of flexion
. Application of a warming blanket and repeated pulse checks every 4 hours

Correct Answer & Explanation

. Emergent closed reduction and percutaneous pinning

Explanation

The clinical presentation of a 'pink, pulseless hand' in the setting of a displaced pediatric supracondylar humerus fracture represents a vascular urgency. The brachial artery is often kinked or tethered over the proximal fracture fragment rather than transected. The standard of care is to proceed emergently to the operating room for closed reduction and percutaneous pinning (CRPP).

Question 555

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a completely displaced extension-type supracondylar humerus fracture. Which associated nerve deficit is most characteristic of this specific injury pattern?

. Inability to abduct the fingers
. Inability to extend the wrist
. Inability to flex the interphalangeal joint of the thumb and distal interphalangeal joint of the index finger
. Inability to extend the metacarpophalangeal joints
. Decreased sensation over the anatomical snuffbox

Correct Answer & Explanation

. Inability to abduct the fingers

Explanation

The anterior interosseous nerve (AIN) is the most commonly injured nerve in extension-type supracondylar humerus fractures. Injury to the AIN manifests as motor weakness in the flexor pollicis longus and the flexor digitorum profundus to the index finger.

Question 556

Topic: Pediatric Upper Extremity & Spine
A 5-year-old child sustains a Gartland type III supracondylar humerus fracture. On presentation, the hand is pink but pulseless. Following closed reduction and percutaneous pinning, the hand remains pink and pulseless. What is the most appropriate next step in management?
. Observation and hospital admission
. Immediate CT angiogram
. Open exploration of the brachial artery
. Removal of the K-wires and open reduction
. Intra-arterial papaverine injection

Correct Answer & Explanation

. Observation and hospital admission

Explanation

In a pink, pulseless hand following adequate reduction and pinning of a supracondylar fracture, observation is recommended as collateral circulation is sufficient. Vascular exploration is indicated only if the hand becomes pale or ischemic.

Question 557

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with a Gartland type III supracondylar humerus fracture. His hand is pink but the radial pulse is absent. Following closed reduction and percutaneous pinning, the hand remains pink and pulseless. What is the most appropriate next step in management?
. Immediate exploration of the brachial artery
. Observation and admission for serial neurovascular checks
. Angiography of the upper extremity
. Removal of pins and open reduction
. Perform a forearm fasciotomy

Correct Answer & Explanation

. Observation and admission for serial neurovascular checks

Explanation

A pink, pulseless hand after reduction and pinning of a supracondylar humerus fracture indicates it is well-perfused through collateral circulation. The standard of care is close observation, as the pulse often returns within 24 to 48 hours.

Question 558

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 remains pink and pulseless. What is the next best step in management?

. Immediate vascular exploration
. Doppler ultrasound of the brachial artery
. Observation and admission for 48 hours
. Administration of IV heparin
. Removal of pins and open reduction

Correct Answer & Explanation

. Immediate vascular exploration

Explanation

A pink, pulseless hand following adequate reduction and pinning of a supracondylar humerus fracture indicates sufficient collateral circulation. Observation for 24-48 hours is indicated as pulses often return; immediate exploration is reserved for a white, pulseless hand.

Question 559

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls off monkey bars and sustains an extension-type Gartland III supracondylar humerus fracture. On evaluation in the ER, his hand is pink but the radial pulse is absent. The patient is taken emergently to the OR for closed reduction and percutaneous pinning. Post-operatively, the limb remains well-perfused (pink) with brisk capillary refill, but the radial pulse remains non-palpable. What is the most appropriate next step in management?
. Immediate open exploration of the brachial artery
. CT Angiography of the upper extremity
. Observation and hospital admission for close monitoring
. Immediate removal of the pins and re-reduction of the fracture
. Prophylactic forearm fasciotomy

Correct Answer & Explanation

. Observation and hospital admission for close monitoring

Explanation

A 'pink, pulseless' hand following reduction of a supracondylar humerus fracture is a well-recognized clinical scenario. Provided that the hand is definitively warm, pink, and has capillary refill < 2 seconds, collateral circulation is deemed adequate. The recommended management is observation and close monitoring for 24-48 hours. Open exploration is indicated only for a 'white, pulseless' hand or if signs of ischemia develop.

Question 560

Topic: Pediatric Upper Extremity & Spine

A 35-year-old male with a severe traumatic brain injury develops massive heterotopic ossification (HO) around his right elbow following a supracondylar humerus fracture, resulting in complete ankylosis. What is the optimal criteria and timing for surgical excision of the heterotopic bone to maximize range of motion and minimize the risk of recurrence?

. Excision at 6 weeks post-injury, prior to complete maturation
. Excision at 3 months, regardless of radiographic appearance
. Excision when there is radiographic evidence of mature trabeculae, normal serum alkaline phosphatase, and neurological stability
. Immediate excision upon initial detection of fluffy calcifications on X-ray
. Excision is contraindicated in patients with TBI due to a 100% recurrence rate

Correct Answer & Explanation

. Excision at 6 weeks post-injury, prior to complete maturation

Explanation

Surgical excision of heterotopic ossification (HO) is technically demanding and carries a risk of recurrence. The classic criteria for safe excision include 1) neurologic recovery or stability, 2) normal serum alkaline phosphatase levels, and 3) radiographic evidence of mature bone with a clear trabecular pattern and sharp cortical margins. Historically, waiting 12-18 months was recommended, but modern literature suggests earlier excision (typically around 6 months) is safe as long as the bone appears radiographically mature and the patient is neurologically stable. Postoperative prophylaxis with radiation or indomethacin is critical.

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