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Pediatric Upper Extremity & Spine MCQs

Practice Set 30 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 581

Topic: Pediatric Upper Extremity & Spine
A 5-year-old boy presents with an extension-type Gartland III supracondylar humerus fracture. Examination reveals a "pink, pulseless" hand. Following closed reduction and percutaneous pinning, the hand remains pink and pulseless. What is the most appropriate next step in management?
. Immediate open exploration of the brachial artery
. Observation and admission for 24-48 hours
. Administration of intravenous heparin
. Performing a fasciotomy of the forearm
. Performing an arterial duplex ultrasound

Correct Answer & Explanation

. Observation and admission for 24-48 hours

Explanation

A well-perfused (pink) but pulseless hand after adequate reduction of a supracondylar fracture typically has adequate collateral circulation and can be observed closely. Open exploration is indicated if the hand is persistently white, cold, and pulseless after reduction.

Question 582

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarchal female with Risser stage 0 presents with adolescent idiopathic scoliosis. Her right thoracic curve measures 32 degrees on standing PA radiographs. What is the most appropriate management?

. Observation with radiographs in 6 months
. Full-time use of a Thoracolumbosacral Orthosis (TLSO)
. Posterior spinal fusion
. Anterior tethering procedure
. Physical therapy and core strengthening

Correct Answer & Explanation

. Observation with radiographs in 6 months

Explanation

Bracing is indicated in skeletally immature patients (Risser 0-2, premenarchal) with curves between 25 and 40 degrees. A TLSO worn >18 hours/day significantly decreases the risk of curve progression to surgical thresholds.

Question 583

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl with Adolescent Idiopathic Scoliosis is evaluated for surgery. Her standing radiographs show a main thoracic curve of 55 degrees and a lumbar curve of 35 degrees. On side-bending radiographs, her lumbar curve reduces to 15 degrees, and her proximal thoracic curve reduces to 10 degrees. How is her curve pattern classified according to the Lenke system?

. Lenke Type 1
. Lenke Type 2
. Lenke Type 3
. Lenke Type 5
. Lenke Type 6

Correct Answer & Explanation

. Lenke Type 1

Explanation

A Lenke Type 1 curve involves a structural main thoracic curve with non-structural proximal thoracic and lumbar curves. Because the lumbar curve bends out to less than 25 degrees, it is considered non-structural.

Question 584

Topic: Pediatric Upper Extremity & Spine

A 12-year-old pre-menarchal female presents for a routine scoliosis screening. Full-length standing radiographs demonstrate a right thoracic Cobb angle of 32 degrees. Her Risser stage is 0. According to current guidelines, what is the most appropriate primary management strategy?

. Observation with repeat radiographs in 6 months
. Full-time Thoracolumbosacral orthosis (TLSO) bracing
. Nighttime only bending brace
. Posterior spinal fusion with pedicle screws
. Anterior vertebral body tethering

Correct Answer & Explanation

. Full-time Thoracolumbosacral orthosis (TLSO) bracing

Explanation

Full-time TLSO bracing (at least 16-18 hours/day) is indicated for Adolescent Idiopathic Scoliosis in skeletally immature patients (Risser 0-2, pre-menarchal) with a Cobb angle between 25 and 44 degrees to prevent further curve progression.

Question 585

Topic: Pediatric Upper Extremity & Spine

A 14-year-old female presents for evaluation of adolescent idiopathic scoliosis (AIS). She has a right thoracic curve of 55 degrees. Her neurologic exam reveals normal strength and sensation, but you note that her superficial abdominal reflexes are briskly present on the left and entirely absent on the right. What is the most appropriate next step?

. Proceed with TLSO bracing
. Schedule for immediate posterior spinal fusion
. Order a total spine MRI
. Reassure the patient, as this is a normal variant in structural curves
. Perform an electromyography (EMG) of the abdominal wall

Correct Answer & Explanation

. Order a total spine MRI

Explanation

Asymmetric superficial abdominal reflexes in a patient with presumed AIS are a 'red flag' for an underlying intraspinal anomaly, such as syringomyelia, Chiari malformation, or a tethered cord. This reflex is elicited by stroking the skin of the abdomen, causing umbilicus deviation. Atypical curve patterns (left thoracic), rapid progression, pain, or asymmetric abdominal reflexes mandate an MRI of the entire neuraxis prior to any surgical intervention.

Question 586

Topic: Pediatric Upper Extremity & Spine

In the Lenke Classification system for Adolescent Idiopathic Scoliosis, the lumbar spine modifier is determined by the relationship of the Center Sacral Vertical Line (CSVL) to the apical lumbar vertebra. Which of the following defines a Lenke Lumbar Modifier B?

. The CSVL passes directly between the pedicles of the apical lumbar vertebra
. The CSVL falls completely lateral to the lateral margin of the apical vertebral body
. The CSVL falls between the medial border of the pedicle and the lateral margin of the apical vertebral body
. The CSVL intersects the apical intervertebral disc instead of the vertebral body
. The CSVL passes outside the thoracic cage boundaries

Correct Answer & Explanation

. The CSVL falls between the medial border of the pedicle and the lateral margin of the apical vertebral body

Explanation

The Lenke Lumbar Modifiers are: A) CSVL passes between the pedicles of the apical lumbar vertebra. B) CSVL falls between the medial border of the pedicle and the lateral margin of the apical vertebral body. C) CSVL falls completely lateral to the lateral margin of the apical vertebral body. Modifier B indicates a structural but mild lumbar curve.

Question 587

Topic: Pediatric Upper Extremity & Spine

A 14-year-old female with Adolescent Idiopathic Scoliosis has a main thoracic curve of 55 degrees and a lumbar curve of 35 degrees. On lateral bending radiographs, the lumbar curve bends out 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, a minor curve that corrects to less than 25 degrees on side-bending radiographs is considered non-structural. Since the lumbar curve bends out to 15 degrees, it is non-structural, making this a Lenke 1 (Main Thoracic) curve pattern.

Question 588

Topic: Pediatric Upper Extremity & Spine

A 10-year-old Little League baseball pitcher presents with medial elbow pain. Radiographs reveal widening of the medial epicondyle apophysis. Which of the following is the primary static restraint to valgus stress of the elbow during the late cocking phase of throwing?

. Posterior bundle of the MCL
. Anterior bundle of the MCL
. Transverse bundle of the MCL
. Radiocapitellar joint
. Flexor-pronator mass

Correct Answer & Explanation

. Anterior bundle of the MCL

Explanation

The anterior bundle of the medial collateral ligament (MCL) is the primary static restraint to valgus stress at the elbow between 30 and 90 degrees of flexion. In children with open physes, the weak link is the apophysis, leading to 'Little League Elbow' (medial epicondyle apophysitis) rather than a ligamentous tear.

Question 589

Topic: Pediatric Upper Extremity & Spine

Which of the following is the most sensitive and widely used scoring system to quantify injury severity in polytrauma patients, primarily based on anatomical injuries?

. Glasgow Coma Scale (GCS).
. Injury Severity Score (ISS).
. Revised Trauma Score (RTS).
. Abbreviated Injury Scale (AIS).
. Trauma and Injury Severity Score (TRISS).

Correct Answer & Explanation

. Injury Severity Score (ISS).

Explanation

The Injury Severity Score (ISS) is the most widely used scoring system for quantifying overall injury severity in polytrauma patients. It is calculated from the Abbreviated Injury Scale (AIS), which assigns a score from 1 (minor) to 6 (unsurvivable) for injuries to different body regions. The ISS is the sum of the squares of the highest AIS scores in the three most severely injured body regions. GCS assesses neurological status. RTS is a physiological score. TRISS combines ISS, RTS, and age to predict survival. AIS is a component of ISS, not an overall severity score itself.

Question 590

Topic: Pediatric Upper Extremity & Spine

A 16-year-old male sustains a supracondylar femur fracture after a direct blow to the distal thigh. On presentation, he has a weak dorsalis pedis pulse compared to the contralateral side. What is the most appropriate initial diagnostic study to evaluate vascular status?

. Duplex ultrasound.
. Computed tomography angiography (CTA).
. Ankle-brachial index (ABI).
. Magnetic resonance angiography (MRA).
. Immediate surgical exploration of the popliteal artery.

Correct Answer & Explanation

. Ankle-brachial index (ABI).

Explanation

Supracondylar femur fractures are notorious for their association with popliteal artery injury due to the proximity of the fracture fragments to the vessel. In any patient with suspected vascular compromise after a lower limb injury (diminished or absent pulse, pain, pallor, paresthesia, poikilothermia - the '5 Ps'), the initial screening tool is the Ankle-Brachial Index (ABI). An ABI less than 0.9 is highly suspicious for arterial injury. If the ABI is abnormal, or if there are clear hard signs of vascular injury, then a CTA or formal arteriogram is indicated. Immediate surgical exploration is reserved for definitive hard signs of vascular injury (e.g., expanding hematoma, pulsatile bleeding, absent pulse) without time for imaging, or after imaging confirms a repairable injury. Duplex ultrasound can be operator-dependent and MRA is not typically used acutely.

Question 591

Topic: Pediatric Upper Extremity & Spine

A 22-year-old collegiate baseball pitcher undergoes Ulnar Collateral Ligament (UCL) reconstruction. The surgeon opts for the 'docking technique' rather than the classic modified Jobe figure-of-eight technique. What is the primary biomechanical and anatomical advantage of the docking technique?

. It completely avoids the need to manage or mobilize the ulnar nerve
. It uses an interference screw in the ulna, eliminating the need for bone tunnels
. It decreases the number of holes drilled in the medial epicondyle, reducing the risk of epicondylar fracture
. It requires a shorter graft length, allowing for isolated use of the plantaris tendon
. It avoids detachment of the flexor-pronator mass origin

Correct Answer & Explanation

. It decreases the number of holes drilled in the medial epicondyle, reducing the risk of epicondylar fracture

Explanation

The docking technique utilizes a single socket in the medial epicondyle into which the two ends of the graft are 'docked' and tied over a bone bridge via smaller exit punctures. This significantly decreases the number of large converging tunnels in the medial epicondyle compared to the traditional Jobe figure-of-eight technique, thereby reducing the risk of iatrogenic medial epicondyle fracture.

Question 592

Topic: Pediatric Upper Extremity & Spine

A newborn is diagnosed with a bilateral radial longitudinal deficiency (radial club hand). Which of the following clinical or genetic findings reliably differentiates Thrombocytopenia Absent Radius (TAR) syndrome from Fanconi anemia in this presentation?

. The radius is completely absent in Fanconi anemia but hypoplastic in TAR syndrome.
. The thumb is present in TAR syndrome but typically absent or hypoplastic in Fanconi anemia.
. TAR syndrome is associated with an autosomal dominant inheritance pattern.
. Cardiac septal defects are pathognomonic for TAR syndrome.
. Fanconi anemia presents with normal bone marrow function at birth.

Correct Answer & Explanation

. The thumb is present in TAR syndrome but typically absent or hypoplastic in Fanconi anemia.

Explanation

A key distinguishing feature between these syndromes is that in TAR syndrome, the thumb is always present (though the radius is absent), whereas in Fanconi anemia and Holt-Oram syndrome, the thumb is typically absent or severely hypoplastic.

Question 593

Topic: Pediatric Upper Extremity & Spine
A newborn is evaluated for bilateral radial club hands. Which of the following associated syndromes is characterized by thrombocytopenia and absent radii, but classically features anatomically present thumbs?
. Holt-Oram syndrome
. Fanconi anemia
. VACTERL association
. TAR syndrome
. Cornelia de Lange syndrome

Correct Answer & Explanation

. TAR syndrome

Explanation

Thrombocytopenia Absent Radius (TAR) syndrome typically features bilaterally absent radii but present thumbs. In contrast, syndromes like Holt-Oram and Fanconi anemia generally present with hypoplastic or absent thumbs along with their radial deficiency.

Question 594

Topic: Pediatric Upper Extremity & Spine
A 7-year-old child falls from a tree and sustains a supracondylar humerus fracture (Gartland type III). Distal pulses are palpable but weak. There is no sensory deficit. What is the immediate management priority after initial assessment?
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation
. Observation for compartment syndrome
. Vascular exploration
. Traction

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

In a Gartland Type III supracondylar humerus fracture, particularly with signs of impending vascular compromise (weak pulse), urgent closed reduction and percutaneous pinning is the immediate management priority. Reduction of the fracture often relieves kinking or compression of the brachial artery, restoring normal blood flow. If the pulse does not improve after successful reduction and pinning, or if there are clear signs of ongoing ischemia, then further investigation such as Doppler ultrasound or formal vascular exploration would be considered. Observation is insufficient given the vascular concerns.

Question 595

Topic: Pediatric Upper Extremity & Spine

A 15-year-old female presents with progressive thoracic scoliosis, measuring 55 degrees Cobb angle with significant trunk rotation and rib hump. She is Risser 4. What is the most appropriate treatment recommendation?

. Observation with regular follow-up
. Bracing
. Physical therapy
. Spinal fusion surgery
. Chiropractic manipulation

Correct Answer & Explanation

. Spinal fusion surgery

Explanation

For adolescent idiopathic scoliosis, a Cobb angle exceeding 45-50 degrees is an indication for surgical spinal fusion, regardless of the Risser sign (skeletal maturity). While a Risser 4 indicates near-skeletal maturity, curves of this magnitude have a high likelihood of continued progression into adulthood and can lead to significant functional limitations and cosmetic deformity. Bracing is typically used for curves between 25-45 degrees in skeletally immature patients. Observation is for smaller curves.

Question 596

Topic: Pediatric Upper Extremity & Spine

A 16-year-old female is diagnosed with idiopathic scoliosis with a 42-degree thoracic curve (King Moe Type II) and a negative Risser sign (Grade 0). She is still growing. What is the most appropriate management plan?

. Observation with serial radiographs every 6 months
. Initiation of a bracing program (e.g., TLSO)
. Surgical correction with spinal fusion
. Physical therapy focusing on stretching and strengthening
. Referral for chiropractic manipulation

Correct Answer & Explanation

. Initiation of a bracing program (e.g., TLSO)

Explanation

For adolescent idiopathic scoliosis, the management depends on curve magnitude and skeletal maturity. For a growing patient with a curve between 25-45 degrees, bracing (e.g., TLSO) is indicated to prevent curve progression. A 42-degree curve in a skeletally immature patient (Risser 0) falls within this range. Observation is for curves less than 25 degrees or skeletally mature patients with curves less than 45 degrees. Surgical correction is typically indicated for curves >45-50 degrees in growing patients or >50-60 degrees in skeletally mature patients. Physical therapy and chiropractic manipulation are not proven to halt curve progression.

Question 597

Topic: Pediatric Upper Extremity & Spine

An examiner asks about the management of adolescent idiopathic scoliosis. They then ask, 'What is the primary indication for surgical correction in adolescent idiopathic scoliosis?'

. Any curve greater than 20 degrees in a skeletally immature patient.
. Progression of a curve to greater than 40-45 degrees, particularly in skeletally immature patients, or curves progressing despite bracing, along with consideration of spinal balance and cosmetic deformity.
. Cosmetic concerns alone, regardless of curve magnitude or progression.
. Presence of back pain, even if the curve is small and non-progressive.
. Failure to achieve a perfect posture through physical therapy.

Correct Answer & Explanation

. Progression of a curve to greater than 40-45 degrees, particularly in skeletally immature patients, or curves progressing despite bracing, along with consideration of spinal balance and cosmetic deformity.

Explanation

The primary indication for surgical correction of adolescent idiopathic scoliosis is typically curve progression to greater than 40-45 degrees (depending on the specific curve type and surgeon preference), especially in skeletally immature patients. Surgical consideration also involves the potential for future progression, spinal balance, and the degree of cosmetic deformity affecting the patient's quality of life. Curves >20 degrees (A) might warrant bracing, but not necessarily surgery. Cosmetic concerns (C) alone are generally not an indication without significant curve magnitude. Back pain (D) is not typically an indication for surgery in AIS unless associated with significant neurological deficit or instability. Failure of physical therapy (E) does not apply to structural scoliosis.

Question 598

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains a Gartland type III supracondylar humerus fracture. Examination in the emergency department reveals a 'pink, pulseless' hand. He is immediately taken to the operating room for closed reduction and percutaneous pinning. Following stable fixation, the hand remains well-perfused and pink, with brisk capillary refill, but the radial pulse remains non-palpable by Doppler. What is the most appropriate next step in management?
. Immediate open exploration of the brachial artery
. Removal of the percutaneous pins and open reduction
. Administration of intravenous heparin
. Observation and admission for 24-48 hours
. Prophylactic forearm fasciotomy

Correct Answer & Explanation

. Observation and admission for 24-48 hours

Explanation

The management of a 'pink, pulseless' hand after reduction of a supracondylar fracture relies on tissue perfusion rather than pulse status. If the hand remains well-perfused (warm, pink, brisk capillary refill) following closed reduction and pinning, the standard of care is close observation and admission for 24-48 hours. Collateral circulation is typically sufficient to maintain hand viability, and the pulse often returns over days to weeks. Vascular exploration is indicated for a 'white, pulseless' hand or if perfusion is lost after reduction.

Question 599

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal girl presents with an adolescent idiopathic scoliosis. Her standing posteroanterior radiograph shows a right thoracic curve measuring 35 degrees. Her Risser stage is 0. What is the most appropriate evidence-based management for this patient?

. Observation with clinical and radiographic follow-up in 6 months
. Prescription of a TLSO brace for 18 to 23 hours per day
. Prescription of a nighttime-only bending brace
. Posterior spinal fusion with pedicle screw instrumentation
. Anterior vertebral body tethering

Correct Answer & Explanation

. Prescription of a TLSO brace for 18 to 23 hours per day

Explanation

Based on the Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST), bracing significantly decreases the progression of high-risk curves to the surgical threshold. The indication for bracing is a curve between 25 and 45 degrees in a skeletally immature patient (Risser 0-2, premenarchal or <1 year postmenarchal). A TLSO brace worn for a minimum of 18 hours per day demonstrates a dose-dependent success rate.

Question 600

Topic: Pediatric Upper Extremity & Spine

A 5-year-old boy sustains a minimally displaced lateral condyle fracture of the humerus (Milch Type II) that is treated with long-arm cast immobilization. The patient is lost to follow-up and returns 12 years later as a teenager. He has developed a progressive, prominent deformity of the elbow. Which of the following is the most likely long-term neurologic complication associated with nonunion of this specific fracture?

. Anterior interosseous nerve syndrome
. Tardy ulnar nerve palsy
. High radial nerve palsy
. Posterior interosseous nerve syndrome
. Pronator syndrome

Correct Answer & Explanation

. Tardy ulnar nerve palsy

Explanation

Nonunion of a lateral condyle fracture typically results in progressive cubitus valgus due to continued growth of the medial side while the lateral side fails to grow or shifts proximally. Over time, the increasing valgus deformity stretches the ulnar nerve behind the medial epicondyle, classically leading to a tardy ulnar nerve palsy.

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