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Pediatric Upper Extremity & Spine MCQs

Practice Set 3 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 41

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarchal female (Risser 0) presents with adolescent idiopathic scoliosis. Standing PA radiographs reveal a right thoracic curve of 35 degrees. What is the most appropriate management?

. Observation and follow-up in 6 months
. Physical therapy and core strengthening
. TLSO bracing for 16-23 hours per day
. Posterior spinal fusion
. Anterior tethering

Correct Answer & Explanation

. TLSO bracing for 16-23 hours per day

Explanation

In a skeletally immature patient (Risser 0-2) with a curve between 25 and 45 degrees, full-time bracing (TLSO) is indicated to halt progression. Observation is primarily reserved for curves less than 25 degrees.

Question 42

Topic: Pediatric Upper Extremity & Spine
A 6-year-old falls from monkey bars and sustains a widely displaced Gartland type III extension-type supracondylar humerus fracture. The hand is pink, but the radial pulse is absent. What is the immediate next step in management?
. Emergent open exploration of the brachial artery
. Urgent closed reduction and percutaneous pinning
. CT angiography of the upper extremity
. Fasciotomy of the forearm
. Application of a warm compress and elevation

Correct Answer & Explanation

. Urgent closed reduction and percutaneous pinning

Explanation

In a 'pink, pulseless' hand associated with a displaced supracondylar humerus fracture, the initial step is urgent closed reduction and percutaneous pinning. The pulse often returns after fracture reduction.

Question 43

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl with adolescent idiopathic scoliosis (AIS) has a right thoracic curve of 48 degrees. She is premenarchal and Risser stage 0. What is the most appropriate management?

. Observation with clinical exams every 6 months
. Boston brace therapy for 23 hours a day
. Nighttime bending brace
. Posterior spinal fusion
. Anterior tethering surgery

Correct Answer & Explanation

. Posterior spinal fusion

Explanation

In a highly skeletally immature patient (Risser 0, premenarchal) with an AIS curve approaching or exceeding 45-50 degrees, the risk of progression is nearly 100%. Surgical intervention, typically posterior spinal fusion, is indicated to prevent severe deformity.

Question 44

Topic: Pediatric Upper Extremity & Spine

A 12-year-old girl is diagnosed with adolescent idiopathic scoliosis. Her physical examination reveals a right thoracic prominence. Which of the following parameters represents a widely accepted indication for initiating Boston brace treatment?

. Risser stage 4, Cobb angle 35 degrees
. Risser stage 0, Cobb angle 15 degrees
. Risser stage 1, Cobb angle 30 degrees
. Risser stage 5, Cobb angle 45 degrees
. Premenarchal girl, Cobb angle 10 degrees

Correct Answer & Explanation

. Risser stage 1, Cobb angle 30 degrees

Explanation

Bracing is indicated in growing children (Risser 0-2, premenarchal) with curves between 25 and 45 degrees. A curve of 30 degrees in a Risser 1 patient falls perfectly within these bracing parameters.

Question 45

Topic: Pediatric Upper Extremity & Spine

The Sorensen criteria are commonly used to diagnose typical Scheuermann's disease. Which of the following radiographic findings must be present to satisfy these criteria?

. Anterior wedging of >5 degrees in at least three adjacent sequential vertebrae
. Anterior wedging of >10 degrees in two adjacent sequential vertebrae
. Anterior wedging of >5 degrees in at least two adjacent sequential vertebrae
. Presence of Schmorl's nodes in at least three sequential vertebrae
. Kyphotic curve >45 degrees with an Risser sign of 4

Correct Answer & Explanation

. Anterior wedging of >5 degrees in at least three adjacent sequential vertebrae

Explanation

The classic Sorensen criteria define Scheuermann's kyphosis by the presence of anterior wedging of greater than 5 degrees in at least three consecutive vertebral bodies.

Question 46

Topic: Pediatric Upper Extremity & Spine

Following an all-posterior pedicle screw instrumented fusion for Scheuermann's kyphosis, what is the standard postoperative immobilization protocol in a compliant patient?

. Thoracolumbosacral orthosis (TLSO) for 6 months
. Risser cast application for 3 months
. No brace or cast is typically required
. Milwaukee brace for 12 months
. Halo-vest immobilization for 6 weeks

Correct Answer & Explanation

. No brace or cast is typically required

Explanation

Modern pedicle screw instrumentation provides highly rigid internal fixation, typically eliminating the need for any postoperative bracing or casting.

Question 47

Topic: Pediatric Upper Extremity & Spine

A 14-year-old boy presents with a progressive thoracic kyphosis of 65 degrees. The apex of the curve is at T8, and his Risser sign is 1. He complains of mild aching back pain after sports. What is the most appropriate management?

. Observation with radiographs every 12 months
. Physical therapy focusing on core and hamstring stretching alone
. Extension bracing with a Thoracolumbosacral Orthosis (TLSO)
. Cervicothoracolumbosacral Orthosis (Milwaukee brace)
. Posterior spinal fusion with Ponte osteotomies

Correct Answer & Explanation

. Extension bracing with a Thoracolumbosacral Orthosis (TLSO)

Explanation

For a skeletally immature patient (Risser 0-2) with a flexible curve between 50 and 75 degrees, bracing is indicated. Because the apex is at T8 (T7 or below), a TLSO is effective; an apex above T7 would require a Milwaukee brace.

Question 48

Topic: Pediatric Upper Extremity & Spine
Which of the following Risser signs most accurately describes the patient presented?
. Risser 1
. Risser 2
. Risser 3
. Risser 4
. Risser 5

Correct Answer & Explanation

. Risser 5

Explanation

Despite its biologic variability, the Risser sign is one of the most useful indicators of maturity used in the management of pediatric spine disorders. The Risser sign is a depiction of the progressive ossification and fusion of the iliac apophysis, which begins anterolaterally and finishes posteromedially. The initial ossification (Risser 1) begins just after the peak height velocity, after triradiate cartilage closure, and approximately at the time of menarche. The completion of ossification and fusion usually takes 1.5 to 2 years in girls and 2 to 3 years in boys. As the iliac apophysis matures and Risser 4 is reached, the Risser sign becomes a sclerotic line that is whiter than the adjacent ilium. Risser 0 and Risser 5 may be difficult to distinguish except that the cranial border of the ilium in Risser 0 is wavy or ruffled, while it is smooth and sclerotic in Risser 5.

Question 49

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal female presents with right thoracic idiopathic scoliosis. Radiographs demonstrate a Cobb angle of 30 degrees and a Risser stage of 0. What is the most appropriate management?

. Observation with follow-up in 6 months
. Thoracolumbosacral orthosis (TLSO) bracing for 18 hours per day
. Nighttime bending brace
. Posterior spinal fusion
. Physical therapy and core strengthening

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing for 18 hours per day

Explanation

Bracing is indicated for skeletally immature patients (Risser 0-2) with idiopathic scoliosis curves between 25 and 45 degrees. A TLSO worn for at least 18 hours daily has been shown to significantly decrease the risk of curve progression to the surgical threshold.

Question 50

Topic: Pediatric Upper Extremity & Spine

According to the Lenke classification for adolescent idiopathic scoliosis, what criteria define a structural proximal thoracic curve?

. Cobb angle > 25 degrees on side-bending radiographs or kyphosis > 20 degrees between T2 and T5
. Cobb angle > 10 degrees on side-bending radiographs
. Apical vertebral rotation > Grade II
. Cobb angle > 25 degrees on AP standing radiograph
. Cobb angle > 20 degrees on side-bending radiographs or lordosis > 10 degrees

Correct Answer & Explanation

. Cobb angle > 25 degrees on side-bending radiographs or kyphosis > 20 degrees between T2 and T5

Explanation

In the Lenke classification, minor curves are considered structural if they do not bend out to less than 25 degrees on side-bending films, or if there is regional kyphosis of at least +20 degrees. For the proximal thoracic curve, the kyphosis is measured between T2 and T5.

Question 51

Topic: Pediatric Upper Extremity & Spine

To prevent the 'crankshaft phenomenon' in a skeletally immature patient with adolescent idiopathic scoliosis (Risser 0, open triradiate cartilages) undergoing posterior spinal fusion, what surgical strategy has historically been indicated?

. Combined anterior and posterior spinal fusion
. Use of pedicle screw only constructs without osteotomies
. Extension of fusion to the sacrum
. Sublaminar wiring techniques
. Postoperative halo-gravity traction

Correct Answer & Explanation

. Combined anterior and posterior spinal fusion

Explanation

The crankshaft phenomenon occurs due to continued anterior vertebral growth after a solid posterior fusion in very immature patients. Historically, a combined anterior (to arrest growth) and posterior fusion was required to prevent this progressive deformity.

Question 52

Topic: Pediatric Upper Extremity & Spine

A 14-year-old pre-menarchal female (Risser 0) presents with a 35-degree right thoracic idiopathic scoliosis curve. What is the most appropriate initial management?

. Observation with serial radiographs every 6 months
. Thoracolumbosacral orthosis (TLSO) bracing
. Posterior spinal fusion with pedicle screw instrumentation
. Anterior vertebral body tethering
. Physiotherapy and core strengthening alone

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing

Explanation

In a skeletally immature patient (e.g., Risser 0, pre-menarchal) with a progressing idiopathic curve between 25 and 45 degrees, bracing is the standard of care. A TLSO has been shown to be highly effective in preventing curve progression to surgical thresholds.

Question 53

Topic: Pediatric Upper Extremity & Spine

A 12-year-old girl with adolescent idiopathic scoliosis presents with a right thoracic curve of 32 degrees. She is premenarcheal and has a Risser stage of 0. What is the most appropriate management?

. Observation with repeat radiographs in 6 months
. Thoracolumbosacral orthosis (TLSO) bracing for 16-23 hours daily
. Nighttime bending brace only
. Posterior spinal fusion
. Physical therapy and core strengthening

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing for 16-23 hours daily

Explanation

Bracing is indicated for growing children (Risser 0-2, premenarcheal) with curves between 25 and 45 degrees. A TLSO worn 16-23 hours a day significantly decreases the risk of curve progression to the surgical threshold.

Question 54

Topic: Pediatric Upper Extremity & Spine

According to the Lonstein and Carlson formula, which combination of factors carries the highest risk for curve progression in a patient with idiopathic scoliosis?

. Low Risser sign, chronological age greater than 15, small curve magnitude
. High Risser sign, large curve magnitude, postmenarcheal status
. Low Risser sign, large curve magnitude, chronologically young age
. High Risser sign, small curve magnitude, chronologically young age
. High Risser sign, double major curve, chronologically older age

Correct Answer & Explanation

. Low Risser sign, large curve magnitude, chronologically young age

Explanation

Risk of curve progression in idiopathic scoliosis is highest in young, skeletally immature patients (low Risser sign, premenarcheal) with larger curve magnitudes at the time of presentation.

Question 55

Topic: Pediatric Upper Extremity & Spine
A 5-year-old girl sustains an extension-type Gartland III supracondylar humerus fracture with posteromedial displacement. Which nerve is most commonly injured in this specific displacement pattern?
. Radial nerve
. Median nerve
. Ulnar nerve
. Anterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Radial nerve

Explanation

In posteromedial displacement of extension-type supracondylar humerus fractures, the distal fragment goes medially, leaving the proximal fragment protruding laterally. This lateral spike puts the radial nerve at the highest risk of injury.

Question 56

Topic: Pediatric Upper Extremity & Spine
A 13-year-old girl with adolescent idiopathic scoliosis presents with a 25-degree right thoracic curve. Her Risser stage is 0, and she is premenarcheal. What is the most appropriate initial management?
. Observation with radiographs in 1 year
. Thoracolumbosacral orthosis (TLSO) bracing for 18 hours per day
. Nighttime only rigid bending brace
. Posterior spinal fusion
. Anterior vertebral body tethering

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing for 18 hours per day

Explanation

For a growing child (Risser 0-2) with an idiopathic curve between 25 and 45 degrees, TLSO bracing for a minimum of 18 hours per day is the standard of care to prevent curve progression. The BRAIST trial demonstrated a dose-dependent success rate with brace wear.

Question 57

Topic: Pediatric Upper Extremity & Spine

In the Lenke classification for adolescent idiopathic scoliosis, a lumbar curve modifier of 'C' indicates that the center sacral vertical line (CSVL) falls in which relation to the apical lumbar vertebra?

. Between the pedicles
. Touches the medial aspect of the apical pedicle
. Falls completely medial to the medial edge of the apical pedicle
. Falls completely lateral to the lateral edge of the apical vertebra
. Intersects the spinous process exactly

Correct Answer & Explanation

. Falls completely medial to the medial edge of the apical pedicle

Explanation

A Lenke 'C' modifier indicates a substantial lumbar curve where the CSVL falls completely medial to the medial border of the apical lumbar pedicle. A 'B' modifier touches the pedicle, and an 'A' modifier falls between the pedicles.

Question 58

Topic: Pediatric Upper Extremity & Spine

The anterior interosseous nerve enables:

. Sensation and flexion of the thumb and index fingers
. Flexion of the thumb and index fingers
. Flexion of the lateral (ulnar) two fingers
. Flexion and sensation of the ulnar two fingers
. Abduction of the thumb

Correct Answer & Explanation

. Flexion of the thumb and index fingers

Explanation

The anterior interosseous nerve does not carry any sensory fibers. The anterior interosseous nerve enables flexion of the thumb (flexor digitorum pollicis) and index fingers (flexor digitorum profundus). This is the most commonly injured nerve in a supracondylar fracture, and it nearly always spontaneously recovers.

Question 59

Topic: Pediatric Upper Extremity & Spine

Closed reduction without internal fixation is most likely to produce a satisfactory result in which of the following types of supracondylar fracture:

. An intact posterior hinge and 20° of hyperextension
. An intact lateral hinge and 15° of varus
. Posterior and medial translation with no intact hinge
. Posterior and lateral translation with no intact hinge
. Anterior translation with 10° of varus

Correct Answer & Explanation

. An intact posterior hinge and 20° of hyperextension

Explanation

There are many options when treating a supracondylar fracture, but a surgeon should always choose the method with the highest percentage of good results for a given fracture. Answer A describes a type II supracondylar fracture with hyperextension and no varus-valgus displacement. The posterior hinge is intact, and it is relatively simple to reduce the fracture with flexion, immobilizing it at 120°. For the other fractures listed as possible answer choices, the reduction as well as the assessment of reduction is more complex. Therefore, most experts would prefer percutaneous fixation of these fractures once reduced.

Question 60

Topic: Pediatric Upper Extremity & Spine
A 6-year-old child sustains a Gartland type III extension-type supracondylar humerus fracture. On physical examination, the child is unable to 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
. 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. Injury presents with an inability to form the "OK" sign due to weakness of the flexor pollicis longus and the flexor digitorum profundus to the index finger.

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