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Pediatric Upper Extremity & Spine MCQs

Practice Set 29 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 561

Topic: Pediatric Upper Extremity & Spine

A 12-year-old baseball pitcher presents with chronic medial elbow pain. Radiographs demonstrate widening and fragmentation of the medial epicondyle apophysis. Which specific biomechanical force is the primary driver of this condition, commonly known as "Little League Elbow"?

. Valgus overload during the acceleration phase of throwing
. Varus overload during the deceleration phase of throwing
. Axial compression during the cocking phase
. Direct impact to the medial epicondyle
. Hyperextension during follow-through

Correct Answer & Explanation

. Valgus overload during the acceleration phase of throwing

Explanation

"Little League Elbow" represents a medial epicondyle apophysitis caused by repetitive valgus stress during the late cocking and early acceleration phases of pitching. This creates immense tension on the medial structures, causing microtrauma to the open apophysis.

Question 562

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl with Adolescent Idiopathic Scoliosis (AIS) undergoes posterior spinal fusion. Postoperatively, the surgeon evaluates the correction using the Lenke classification criteria. According to the Lenke classification, which of the following determines if a proximal thoracic curve is considered 'structural'?

. A Cobb angle > 25 degrees on side-bending radiographs
. Apical vertebral rotation of grade II or higher on standing AP radiograph
. A Cobb angle > 10 degrees on side-bending radiographs
. Thoracic kyphosis (T2-T5) of > +20 degrees
. Presence of a rib hump > 15 degrees on forward bending test

Correct Answer & Explanation

. A Cobb angle > 25 degrees on side-bending radiographs

Explanation

In the Lenke classification for AIS, a minor curve is defined as 'structural' if it fails to correct to <25 degrees on voluntary side-bending radiographs. For the proximal and main thoracic regions, a regional kyphosis of > +20 degrees also defines the curve as structural.

Question 563

Topic: Pediatric Upper Extremity & Spine
A 5-year-old boy presents with a displaced Gartland type III supracondylar humerus fracture. On examination, the hand is pink and well-perfused, but the radial pulse is absent. Which of the following is the most appropriate initial management?
. Immediate open vascular exploration with saphenous vein grafting
. Urgent CT angiography of the upper extremity
. Urgent closed reduction and percutaneous pinning
. Application of warm compresses and observation for 24 hours
. Closed reduction and application of a long arm cast in 120 degrees of flexion

Correct Answer & Explanation

. Urgent closed reduction and percutaneous pinning

Explanation

A pulseless, pink hand in a pediatric supracondylar fracture should first be managed with urgent closed reduction and percutaneous pinning. Vascular status typically normalizes once the fracture is reduced, relieving the kink or tether on the brachial artery.

Question 564

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents to the emergency department after falling from monkey bars. He has a severely displaced, completely off-ended extension-type supracondylar humerus fracture (Gartland Type III). On examination, his hand is warm and pink, capillary refill is less than 2 seconds, but there is no palpable radial pulse. What is the most appropriate next step in management?
. Immediate operative exploration of the brachial artery
. Stat CT angiography of the upper extremity
. Urgent closed reduction and percutaneous pinning in the operating room
. Application of a long arm cast in 120 degrees of flexion and close observation
. Administration of systemic thrombolytics and heparin

Correct Answer & Explanation

. Urgent closed reduction and percutaneous pinning in the operating room

Explanation

The patient has a "pink, pulseless" hand in the setting of a Gartland III supracondylar fracture. The brachial artery is frequently kinked, tethered, or placed in spasm over the proximal fracture fragment rather than completely transected. The standard of care for a pink, pulseless hand is to proceed urgently to the operating room for closed reduction and percutaneous pinning (CRPP) of the fracture. In the vast majority of cases, reduction of the fracture relieves the vascular kinking and restores the pulse. Vascular exploration is only indicated if the hand remains pulseless and becomes poorly perfused (cold/white) after successful fracture reduction and pinning.

Question 565

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy is brought to the emergency department after falling off monkey bars. Radiographs reveal a completely displaced extension-type supracondylar humerus fracture (Gartland Type III). On examination, the child's hand is warm and pink with brisk capillary refill, but the radial pulse is not palpable. What is the most appropriate initial management?
. Immediate open exploration of the brachial artery by vascular surgery
. Urgent closed reduction and percutaneous pinning, followed by reassessment of perfusion
. CT angiography to localize the level of vascular intimal injury prior to any intervention
. Observation for 24 hours in a splint to allow for vascular spasm resolution
. Application of a long arm cast in 120 degrees of hyperflexion to compress the fracture

Correct Answer & Explanation

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

Explanation

For a 'pulseless, pink hand' in the setting of a displaced supracondylar humerus fracture, the standard of care is urgent closed reduction and percutaneous pinning (CRPP). The pulselessness is often due to kinking, compression, or spasm of the brachial artery over the fracture fragments. Reduction usually restores flow. If the hand remains pink and well-perfused post-reduction, even without a palpable pulse, close observation is recommended over routine surgical exploration.

Question 566

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls off monkey bars and presents to the emergency department with a Gartland Type III extension-type supracondylar humerus fracture. Radiographs indicate that the distal fracture fragment is severely posterolaterally displaced. Based on this specific displacement pattern, which neurologic structure is at the greatest risk of injury from the proximal fragment?
. Ulnar nerve
. Radial nerve
. Anterior interosseous nerve (AIN) / Median nerve
. Posterior interosseous nerve (PIN)
. Musculocutaneous nerve

Correct Answer & Explanation

. Anterior interosseous nerve (AIN) / Median nerve

Explanation

In extension-type supracondylar humerus fractures, the displacement of the distal fragment dictates the location of the sharp proximal fragment. If the distal fragment goes posterolaterally, the proximal fragment is driven anteromedially. This anteromedial spike puts the median nerve (and its anterior interosseous branch) and the brachial artery at highest risk. Conversely, if the distal fragment displaces posteromedially, the proximal fragment goes anterolaterally, risking the radial nerve.

Question 567

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains a Gartland type III supracondylar humerus fracture. Following closed reduction and percutaneous pinning in the operating room, the child's hand is warm and pink, but the radial pulse remains absent. What is the most appropriate next step in management?
. Immediate vascular exploration by a vascular surgeon
. Close observation for 24 to 48 hours
. Removal of pins and extension of the elbow
. Stat CT angiography of the upper extremity
. Immediate forearm fasciotomy

Correct Answer & Explanation

. Close observation for 24 to 48 hours

Explanation

A 'pink, pulseless' hand following stable reduction and pinning of a supracondylar fracture indicates adequate collateral perfusion. Close clinical observation is the standard of care, as the pulse often returns within a few days as vasospasm resolves.

Question 568

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with a Gartland type III extension-type supracondylar humerus fracture. Examination reveals a pulseless but well-perfused, pink hand. After closed reduction and percutaneous pinning, the hand remains pink but the radial pulse remains absent. What is the most appropriate next step in management?
. Immediate open vascular exploration
. Observation and admission for close monitoring
. Perform an emergency MR angiogram
. Administer intravenous heparin
. Remove the pins and perform open reduction

Correct Answer & Explanation

. Observation and admission for close monitoring

Explanation

In a pulseless but well-perfused (pink) hand after adequate reduction and pinning of a pediatric supracondylar humerus fracture, observation is recommended. Collateral circulation is sufficient, and the pulse typically returns within 24-48 hours.

Question 569

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with an extension-type, Gartland type III supracondylar humerus fracture with posteromedial displacement of the distal fragment. Which nerve is tethered over the proximal fragment and at the highest risk of injury in this specific displacement pattern?
. Median nerve
. Anterior interosseous nerve
. Radial nerve
. Ulnar nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Radial nerve

Explanation

In extension-type supracondylar humerus fractures, posteromedial displacement of the distal fragment pushes the sharp proximal fragment anterolaterally. This classically stretches or tethers the radial nerve. Conversely, posterolateral displacement endangers the median nerve (specifically the AIN branch) and brachial artery as the proximal fragment is pushed anteromedially.

Question 570

Topic: Pediatric Upper Extremity & Spine

During a closed reduction and percutaneous pinning of a supracondylar humerus fracture, a 6-year-old patient develops an unexplained rise in end-tidal CO2, tachycardia, and masseter muscle rigidity. Administration of which medication is the definitive treatment?

. Epinephrine
. Atropine
. Succinylcholine
. Dantrolene
. Propofol

Correct Answer & Explanation

. Epinephrine

Explanation

The patient is exhibiting signs of malignant hyperthermia, an autosomally dominant condition typically triggered by volatile anesthetics and succinylcholine. Dantrolene, a ryanodine receptor antagonist, is the specific antidote.

Question 571

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls from monkey bars and sustains a Gartland Type III extension-type supracondylar humerus fracture. On arrival, his hand is pale, cool, and pulseless. After closed reduction and percutaneous pinning, the hand becomes pink and capillary refill is less than 2 seconds, but the radial pulse remains absent. What is the next most appropriate step in management?
. Immediate vascular surgery consultation for brachial artery exploration and repair
. Perform an intra-operative angiogram
. Observation and hospital admission for close monitoring
. Remove the pins, perform open reduction, and explore the artery
. Administer intravenous heparin

Correct Answer & Explanation

. Observation and hospital admission for close monitoring

Explanation

In the setting of a poorly perfused hand ('pulseless, pinkless') prior to reduction of a pediatric supracondylar humerus fracture, reduction and pinning should be performed urgently. If the hand becomes well-perfused (pink, warm, good capillary refill) after reduction, even if the radial pulse remains absent (a 'pulseless, pink' hand), the standard of care is close clinical observation. Immediate exploration is only indicated if the hand remains ischemic after anatomic reduction.

Question 572

Topic: Pediatric Upper Extremity & Spine

A 12-year-old Little League baseball pitcher presents with acute medial elbow pain and swelling. Radiographs reveal widening and partial avulsion of the medial epicondyle apophysis. Which phase of the throwing motion generates the highest valgus stress on the elbow, directly contributing to this pathophysiology?

. Wind-up
. Early cocking
. Late cocking and early acceleration
. Deceleration
. Follow-through

Correct Answer & Explanation

. Wind-up

Explanation

The late cocking and early acceleration phases of throwing generate the maximum valgus torque across the medial elbow. In skeletally immature athletes, the medial epicondyle apophysis is the weak link, and repetitive valgus stress leads to apophysitis or avulsion ('Little League Elbow'). In adults, this force typically injures the ulnar collateral ligament.

Question 573

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains a Gartland type III supracondylar humerus fracture with posteromedial displacement of the distal fragment. Which nerve is most at risk of injury in this specific displacement pattern?
. Median nerve
. Ulnar nerve
. Radial nerve
. Anterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Radial nerve

Explanation

In posteromedially displaced supracondylar humerus fractures, the proximal fragment goes anterolaterally, putting the radial nerve at the greatest risk of tethering or injury. Posterolateral displacement puts the median nerve (specifically AIN) at greatest risk.

Question 574

Topic: Pediatric Upper Extremity & Spine
A newborn is noted to have severe radial deviation of the wrist with an absent thumb and shortened forearm. A screening echocardiogram reveals an atrial septal defect. Which of the following genetic conditions is most likely responsible?
. Fanconi anemia
. TAR (Thrombocytopenia-Absent Radius) syndrome
. Holt-Oram syndrome
. VACTERL association
. Apert syndrome

Correct Answer & Explanation

. Holt-Oram syndrome

Explanation

Holt-Oram syndrome is an autosomal dominant condition characterized by upper limb abnormalities (typically radial ray deficiencies, including an absent thumb) and congenital heart defects, most commonly an ASD or VSD. In TAR syndrome, the thumb is characteristically present despite an absent radius. Fanconi anemia is associated with aplastic anemia. VACTERL involves multiple organ systems but is less specific for this exact pairing without other findings.

Question 575

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl is evaluated for Adolescent Idiopathic Scoliosis (AIS). Her main thoracic curve measures 55 degrees, and her thoracolumbar curve measures 20 degrees but bends out to 5 degrees on side-bending films. The center sacral vertical line (CSVL) falls between the pedicles of the apical lumbar vertebra. What is her Lenke classification?

. Type 1A
. Type 2B
. Type 3C
. Type 4A
. Type 5C

Correct Answer & Explanation

. Type 1A

Explanation

A main thoracic curve >40 degrees with a flexible thoracolumbar curve that bends out to <25 degrees defines a Lenke Type 1 (Main Thoracic) pattern. Because the CSVL bisects the apical lumbar vertebra, she is assigned a lumbar modifier A.

Question 576

Topic: Pediatric Upper Extremity & Spine
A 6-year-old girl undergoes closed reduction and percutaneous pinning for a Gartland type III supracondylar humerus fracture. Postoperatively, her hand is warm, pink, and has brisk capillary refill, but the radial pulse remains unpalpable. What is the most appropriate next step in management?
. Immediate exploration of the brachial artery
. Perform a CT angiogram of the upper extremity
. Remove the pins and extend the elbow to 20 degrees
. Observation with close clinical monitoring
. Administer intravenous heparin

Correct Answer & Explanation

. Observation with close clinical monitoring

Explanation

A pink, pulseless hand following reduction and pinning of a supracondylar fracture indicates adequate collateral perfusion. The standard of care is close clinical observation rather than immediate surgical exploration, as the pulse often returns over time.

Question 577

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls on an outstretched hand and sustains a Gartland type III extension-type supracondylar humerus fracture. Upon examination, he is unable to make an 'OK' sign with his thumb and index finger. Which nerve is most likely injured?
. Ulnar nerve
. Posterior interosseous nerve
. Anterior interosseous nerve
. Musculocutaneous nerve
. Superficial radial 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, both of which are required to form the 'OK' sign.

Question 578

Topic: Pediatric Upper Extremity & Spine

When evaluating a patient with Adolescent Idiopathic Scoliosis (AIS), which of the following parameters is the strongest clinical predictor for the risk of curve progression?

. Apical vertebral rotation
. Thoracic kyphosis > 40 degrees
. Peak height velocity
. Lumbar curve location
. Positive family history

Correct Answer & Explanation

. Apical vertebral rotation

Explanation

The risk of curve progression in AIS is highly dependent on the remaining growth potential. The period of highest risk for progression corresponds to the adolescent growth spurt, known as peak height velocity. Markers of skeletal immaturity (e.g., Risser 0, open triradiate cartilage) indicate that the child is entering or currently in this high-risk phase.

Question 579

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, his hand remains pink but pulseless. What is the next best step in management?

. Immediate open vascular exploration
. Observation with close clinical monitoring
. Emergent arteriography
. Remove pins and attempt open reduction
. Administer intravenous thrombolytics

Correct Answer & Explanation

. Immediate open vascular exploration

Explanation

A well-perfused (pink) but pulseless hand after adequate reduction and pinning of a supracondylar fracture indicates collateral circulation is intact. Close clinical observation is the standard of care, as the palpable pulse typically returns within a few days.

Question 580

Topic: Pediatric Upper Extremity & Spine

A 13-year-old girl is diagnosed with adolescent idiopathic scoliosis (AIS). She is pre-menarchal, Risser 0, with a right thoracic curve of 35 degrees. What is the most appropriate management?

. Observation with follow-up radiographs in 1 year
. Physical therapy and core strengthening
. Full-time Thoracolumbosacral orthosis (TLSO) bracing
. Posterior spinal fusion
. Anterior tethering procedure

Correct Answer & Explanation

. Observation with follow-up radiographs in 1 year

Explanation

TLSO bracing is indicated for growing children (Risser 0-2, pre-menarchal) with an AIS curve between 25 and 45 degrees. Her high risk of progression makes immediate full-time bracing the standard of care.

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