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Pediatric Upper Extremity & Spine MCQs

Practice Set 32 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 621

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with a Gartland type III supracondylar humerus fracture. The hand is pink but pulseless. After closed reduction and percutaneous pinning, the hand remains pink and pulseless. What is the most appropriate next step?
. Immediate vascular exploration
. Observation and hospital admission
. Perform an intra-operative angiogram
. Remove the pins and open the fracture
. Administer intra-arterial vasodilators

Correct Answer & Explanation

. Observation and hospital admission

Explanation

A "pink, pulseless" hand after successful reduction and pinning of a supracondylar fracture usually signifies adequate collateral circulation. Observation is indicated, as the palpable radial pulse often returns within 24-48 hours.

Question 622

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy has a Gartland type III supracondylar humerus fracture. After closed reduction and percutaneous pinning, the fracture is anatomically aligned, but the radial pulse remains absent while the hand remains pink and warm. What is the next best step?
. Immediate vascular exploration
. Perform a duplex ultrasound
. Observation and admission for close neurovascular checks
. Remove the pins and open the fracture
. Perform an intra-operative angiogram

Correct Answer & Explanation

. Observation and admission for close neurovascular checks

Explanation

In a "pink, pulseless" hand following anatomical reduction and pinning of a pediatric supracondylar humerus fracture, the standard of care is close observation. Vascular exploration is strictly indicated for a "white, pulseless" (ischemic) hand.

Question 623

Topic: Pediatric Upper Extremity & Spine
A 5-year-old boy presents with a displaced Gartland type III supracondylar humerus fracture. His hand is pink and well-perfused, but the radial pulse is absent by palpation and Doppler. Following closed reduction and percutaneous pinning, the fracture is perfectly aligned; however, the radial pulse remains absent while the hand stays pink. What is the most appropriate next step in management?
. Immediate exploration and repair of the brachial artery
. Performance of a brachial arterioventricular bypass graft
. Admission for 24 to 48 hours of observation with serial neurovascular checks
. Urgent CT angiogram of the upper extremity to map the vascular injury
. Immediate administration of weight-based intravenous heparin

Correct Answer & Explanation

. Admission for 24 to 48 hours of observation with serial neurovascular checks

Explanation

A "pulseless, pink hand" following anatomical reduction of a supracondylar humerus fracture indicates robust collateral circulation maintaining adequate distal perfusion. The standard of care is close inpatient observation with serial neurovascular exams, avoiding the morbidity of unnecessary vascular exploration.

Question 624

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with a displaced Gartland type III supracondylar humerus fracture. The hand is pink but pulseless. After closed reduction and percutaneous pinning, the hand remains pink and pulseless. What is the most appropriate next step in management?
. Immediate vascular exploration
. Observation and admission for close neurovascular monitoring
. Angiography to localize the arterial injury
. Fasciotomy of the forearm
. Removal of pins and open reduction

Correct Answer & Explanation

. Observation and admission for close neurovascular monitoring

Explanation

A pink, pulseless hand after adequate reduction and pinning indicates sufficient collateral circulation. The standard of care is close observation and admission, as the radial pulse often returns within 48 hours without the need for vascular exploration.

Question 625

Topic: Pediatric Upper Extremity & Spine
A 6-year-old girl sustains a Gartland type III extension-type supracondylar humerus fracture. Which of the following peripheral nerves is most commonly injured in this specific fracture pattern?
. Anterior interosseous nerve
. Ulnar nerve
. Posterior interosseous nerve
. Superficial radial nerve
. Musculocutaneous 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. Clinically, this presents as an inability to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger (the 'A-OK' sign).

Question 626

Topic: Pediatric Upper Extremity & Spine
A 6-year-old girl sustains a severely displaced (Gartland Type III) supracondylar humerus fracture. On presentation, her radial pulse is absent, but the hand is warm, pink, and has capillary refill less than 2 seconds. What is the most appropriate initial management?
. Immediate open exploration of the brachial artery
. Urgent CT angiography of the upper extremity
. Urgent closed reduction and percutaneous pinning
. Observation with splinting in 90 degrees of flexion
. Thrombolytic therapy

Correct Answer & Explanation

. Urgent closed reduction and percutaneous pinning

Explanation

A pulseless but well-perfused (pink, warm) hand following a displaced supracondylar humerus fracture should undergo urgent closed reduction and percutaneous pinning in the operating room. Anatomical reduction often relieves arterial kinking or spasm, restoring the pulse without needing vascular exploration.

Question 627

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls from monkey bars and sustains a Gartland type III extension supracondylar humerus fracture. On examination, the hand is pink but the radial pulse is absent. The child has strong capillary refill and normal motor function. What is the most appropriate next step in management?
. Emergent brachial artery exploration
. Immediate closed reduction and percutaneous pinning
. Angiography of the upper extremity
. Application of a long arm cast in 120 degrees of flexion
. Observe with hourly neurovascular checks

Correct Answer & Explanation

. Immediate closed reduction and percutaneous pinning

Explanation

For a "pulseless pink hand" following a severe supracondylar humerus fracture, the initial step is prompt closed reduction and percutaneous pinning to restore alignment. If the hand remains well-perfused despite an absent pulse post-reduction, observation is generally acceptable, avoiding immediate vascular exploration.

Question 628

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains a severe Gartland Type III supracondylar humerus fracture. Radiographs show the distal fragment is displaced posteromedially. Based on this displacement pattern, which neurovascular structure is at the greatest risk of injury?
. Median nerve
. Radial nerve
. Ulnar nerve
. Musculocutaneous nerve
. Axillary nerve

Correct Answer & Explanation

. Radial nerve

Explanation

In a posteromedial displacement of a supracondylar humerus fracture, the proximal fragment is pushed anterolaterally, impaling the radial nerve. Conversely, posterolateral displacement puts the median nerve and brachial artery at greatest risk.

Question 629

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a completely displaced supracondylar humerus fracture. After closed reduction and percutaneous pinning, the radial pulse remains unpalpable, but the hand is warm, pink, and has a capillary refill of less than 2 seconds. What is the most appropriate next step in management?

. Immediate exploration of the brachial artery
. Administration of intra-arterial vasodilators
. Observation and admission for close neurovascular monitoring
. Removal of pins and open reduction
. Compartment fasciotomies of the forearm

Correct Answer & Explanation

. Observation and admission for close neurovascular monitoring

Explanation

A 'pulseless but pink' and well-perfused hand following a properly reduced supracondylar humerus fracture typically indicates adequate collateral circulation. The standard of care is close inpatient observation rather than immediate vascular exploration.

Question 630

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy sustains a completely displaced (Gartland type III) extension-type supracondylar humerus fracture. Upon initial evaluation, the hand is pink and well-perfused, but the radial pulse is entirely absent. What is the most appropriate next step in management?
. Immediate open exploration of the brachial artery
. Stat CT angiogram of the upper extremity
. Urgent closed reduction and percutaneous pinning, followed by vascular reassessment
. Application of a long arm cast in hyperflexion to restore the pulse
. Immediate fasciotomy of the forearm

Correct Answer & Explanation

. Urgent closed reduction and percutaneous pinning, followed by vascular reassessment

Explanation

For a 'pulseless, pink' hand following a supracondylar humerus fracture, collateral circulation is providing adequate perfusion. The most appropriate next step is urgent closed reduction and pinning, which unkinks the brachial artery and often restores the palpable pulse.

Question 631

Topic: Pediatric Upper Extremity & Spine
A 5-year-old boy falls from monkey bars and sustains a Gartland type III supracondylar humerus fracture. On presentation to the emergency department, his hand is pale and pulseless, but he has brisk capillary refill and normal motor function of the hand. What is the most appropriate next step in management?
. Immediate open exploration of the brachial artery
. Closed reduction and percutaneous pinning, followed by reassessment of the pulse
. CT angiography of the upper extremity
. Application of a long arm cast in 120 degrees of flexion
. Observation and elevation for 24 hours

Correct Answer & Explanation

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

Explanation

In a pulseless but well-perfused (pink, brisk capillary refill) hand following a displaced supracondylar humerus fracture, the initial step is urgent closed reduction and percutaneous pinning. Often, the brachial artery is kinked, tethered over the proximal fracture fragment, or in spasm, and anatomic reduction restores the pulse. If the hand remains pulseless and becomes poorly perfused (white/ischemic) after reduction, open exploration of the brachial artery is indicated. CT angiography delays definitive treatment and is not indicated in the acute setting of a pulseless, pink hand.

Question 632

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl with adolescent idiopathic scoliosis has a progressive right thoracic curve that now measures 52 degrees. Her Risser stage is 4, and she has had menarche 2 years ago. What is the most appropriate management?

. Observation with radiographs every 6 months
. Full-time thoracolumbosacral orthosis (TLSO)
. Nighttime bending brace
. Posterior spinal fusion
. Anterior vertebral body tethering

Correct Answer & Explanation

. Posterior spinal fusion

Explanation

For adolescents with idiopathic scoliosis, a curve exceeding 50 degrees is highly likely to progress even after skeletal maturity. Posterior spinal fusion is the gold standard treatment for a 52-degree curve in a near-skeletally mature patient.

Question 633

Topic: Pediatric Upper Extremity & Spine

In the Lenke classification system for adolescent idiopathic scoliosis, a lumbar modifier of "C" indicates the relationship between the center sacral vertical line (CSVL) and the apical lumbar vertebra. Which of the following defines a "C" modifier?

. The CSVL passes between the pedicles of the apical lumbar vertebra
. The CSVL touches the medial border of the apical pedicle
. The CSVL does not touch any part of the apical lumbar vertebral body
. The CSVL bisects the apical vertebral body exactly
. The CSVL passes lateral to the convex border of the apical vertebra

Correct Answer & Explanation

. The CSVL does not touch any part of the apical lumbar vertebral body

Explanation

In the Lenke classification, a lumbar C modifier means the center sacral vertical line (CSVL) falls completely outside the apical lumbar vertebra (i.e., it does not touch any part of the vertebral body). This implies a significant structural lumbar curve.

Question 634

Topic: Pediatric Upper Extremity & Spine

In the Lenke classification for adolescent idiopathic scoliosis, a curve characterized by a structural proximal thoracic curve, a structural main thoracic curve, and a non-structural thoracolumbar/lumbar curve is classified as which type?

. Type 1
. Type 2
. Type 3
. Type 4
. Type 5

Correct Answer & Explanation

. Type 2

Explanation

Lenke Type 2 is a 'Double Thoracic' curve. This means both the proximal thoracic and main thoracic curves are structural, while the thoracolumbar/lumbar curve remains non-structural.

Question 635

Topic: Pediatric Upper Extremity & Spine

A 13-year-old girl with adolescent idiopathic scoliosis has a 35-degree right thoracic curve. Pelvic radiographs show ossification over the lateral 50% of the iliac apophysis, with no fusion to the ilium. What is her Risser stage?

. Risser 1
. Risser 2
. Risser 3
. Risser 4
. Risser 5

Correct Answer & Explanation

. Risser 2

Explanation

Risser 2 indicates ossification of the lateral 25% to 50% of the iliac apophysis without fusion. This implies significant spinal growth still remains, placing her at high risk for curve progression and making her an ideal candidate for bracing.

Question 636

Topic: Pediatric Upper Extremity & Spine

When evaluating a 14-year-old female with adolescent idiopathic scoliosis, the Center Sacral Vertical Line (CSVL) falls between the medial aspect of the pedicle and the lateral margin of the apical lumbar vertebra. According to the Lenke Classification system, what is the correct lumbar modifier?

. Modifier A
. Modifier B
. Modifier C
. Modifier D
. Modifier E

Correct Answer & Explanation

. Modifier B

Explanation

In the Lenke classification, a lumbar modifier B is assigned when the CSVL falls between the medial border of the pedicle and the lateral margin of the apical lumbar vertebra. Modifier A is when it passes between the pedicles, and C is when it falls completely medial to the lateral margin.

Question 637

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarchal female with a Risser 0 score presents with a 24-degree right thoracic idiopathic scoliosis. What is the primary indication for initiating brace treatment in this patient?

. Curve greater than 45 degrees
. Curve 25-40 degrees in a growing child (Risser 0-2)
. Curve less than 20 degrees with a family history of scoliosis
. Skeletally mature patient with a 30-degree curve
. Presence of a structural compensatory lumbar curve

Correct Answer & Explanation

. Curve 25-40 degrees in a growing child (Risser 0-2)

Explanation

Bracing in adolescent idiopathic scoliosis is indicated for curves between 25 and 40 degrees in skeletally immature patients (Risser 0-2) to prevent curve progression. Curves greater than 45-50 degrees often require surgical intervention.

Question 638

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal female presents with a right thoracic adolescent idiopathic scoliosis (AIS) measuring 25 degrees. Her Risser stage is 0. Based on standard progression risk charts, what is her approximate risk of curve progression?

. 10%
. 22%
. 68%
. 90%
. 100%

Correct Answer & Explanation

. 68%

Explanation

Risk of progression in AIS depends heavily on remaining growth and current curve magnitude. A 20-29 degree curve in a Risser 0 or 1 patient has an approximately 68% risk of progression.

Question 639

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal female presents for evaluation of adolescent idiopathic scoliosis. Radiographs demonstrate a 28-degree right thoracic curve. Her Risser stage is 0. What is the most appropriate next step in management?

. Observation with repeat radiographs in 6 months
. Initiation of a thoracolumbosacral orthosis (TLSO)
. Nighttime-only bending brace
. Posterior spinal fusion
. Physical therapy and Schroth exercises

Correct Answer & Explanation

. Initiation of a thoracolumbosacral orthosis (TLSO)

Explanation

Bracing is indicated for immature patients (Risser 0-2, premenarchal) with curves between 25 and 45 degrees. A TLSO worn for at least 18 hours a day has been shown to significantly decrease the risk of curve progression to surgical magnitude.

Question 640

Topic: Pediatric Upper Extremity & Spine
A 12-year-old premenarchal female (Risser 0) presents with a right thoracic adolescent idiopathic scoliosis curve measuring 35 degrees. According to the Bracing in Adolescent Idiopathic Scoliosis Trial (BRAIST), which of the following is the most appropriate recommendation to prevent curve progression to surgical magnitude?
. Observation with 6-month radiographs
. Physical therapy focusing on core strengthening
. Night-time only bending brace
. Rigid thoracolumbosacral orthosis (TLSO) wear for at least 18 hours per day
. Posterior spinal fusion

Correct Answer & Explanation

. Rigid thoracolumbosacral orthosis (TLSO) wear for at least 18 hours per day

Explanation

The BRAIST trial demonstrated that rigid bracing (TLSO) significantly decreases the progression of high-risk adolescent idiopathic scoliosis curves to the surgical threshold (≥50 degrees). A dose-response relationship was found, with maximum benefit observed in patients wearing the brace for at least 18 hours per day.

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