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Pediatric Upper Extremity & Spine MCQs

Practice Set 4 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 61

Topic: Pediatric Upper Extremity & Spine

A 12-year-old girl is evaluated for Adolescent Idiopathic Scoliosis (AIS). She has not yet reached menarche. Radiographs show a right thoracic curve of 35 degrees. Her Risser stage is 1. What is the most appropriate recommendation regarding treatment?

. Observation with repeated radiographs in 6 months
. Initiation of full-time TLSO bracing
. Immediate posterior spinal fusion
. Nighttime bending brace only
. Physical therapy for curve correction

Correct Answer & Explanation

. Initiation of full-time TLSO bracing

Explanation

Indications for bracing in AIS include a curve between 25 and 45 degrees in a patient with significant remaining growth (typically Risser 0-2 and pre-menarchal). A full-time TLSO brace is recommended to prevent further progression in this high-risk scenario.

Question 62

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a supracondylar humerus fracture that is displaced posterolaterally. Which nerve is at the highest risk of injury in this specific displacement pattern?

. Radial nerve
. Anterior interosseous nerve (AIN)
. Ulnar nerve
. Posterior interosseous nerve (PIN)
. Musculocutaneous nerve

Correct Answer & Explanation

. Anterior interosseous nerve (AIN)

Explanation

Posterolaterally displaced supracondylar humerus fractures stretch the medial structures, putting the anterior interosseous nerve (AIN) and brachial artery at highest risk.

Question 63

Topic: Pediatric Upper Extremity & Spine

A 5-year-old girl falls from monkey bars and sustains an extension-type supracondylar humerus fracture. On examination, which finding is most indicative of the most commonly injured nerve in this specific fracture pattern?

. Inability to extend the wrist
. Inability to flex the distal interphalangeal joint of the index finger
. Numbness over the dorsal first web space
. Inability to cross the index and middle fingers
. Weakness of shoulder abduction

Correct Answer & Explanation

. Inability to flex 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. Injury is assessed by the inability to flex the IP joint of the thumb and the DIP joint of the index finger (the 'OK' sign).

Question 64

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy presents with a completely displaced posterolateral supracondylar humerus fracture. Which of the following neurologic deficits is most likely to be observed?

. Inability to extend the wrist
. Inability to cross the fingers
. Inability to flex the interphalangeal joint of the thumb
. Loss of sensation over the dorsal first web space
. Loss of sensation over the small finger

Correct Answer & Explanation

. Inability to flex the interphalangeal joint of the thumb

Explanation

Posterolateral displacement of a supracondylar humerus fracture stretches anterior structures, predominantly putting the anterior interosseous nerve (AIN) at risk. AIN palsy presents with weakness in the flexor pollicis longus and flexor digitorum profundus to the index finger, resulting in an inability to make the 'A-OK' sign.

Question 65

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy presents with a completely displaced, extension-type supracondylar fracture of the humerus. Which of the following neurologic deficits is most commonly associated with this specific injury pattern?

. Inability to abduct the fingers
. Inability to flex the interphalangeal joint of the thumb
. Inability to extend the metacarpophalangeal joints
. Decreased sensation over the volar aspect of the small finger
. Decreased sensation over the lateral aspect of the shoulder

Correct Answer & Explanation

. Inability to flex the interphalangeal joint of the thumb

Explanation

The anterior interosseous nerve (AIN) is the most commonly injured nerve in extension-type supracondylar humerus fractures. AIN palsy presents with an inability to flex the IP joint of the thumb and the distal IP joint of the index finger, resulting in an abnormal "OK" sign.

Question 66

Topic: Pediatric Upper Extremity & Spine
A 6-year-old girl presents with an extension-type, Gartland III supracondylar fracture of the humerus with posteromedial displacement of the distal fragment. Which nerve is most commonly injured in this specific displacement pattern?
. Median nerve
. Ulnar nerve
. Radial nerve
. Musculocutaneous nerve
. Axillary nerve

Correct Answer & Explanation

. Radial nerve

Explanation

In posteromedially displaced extension-type supracondylar fractures, the proximal humerus fragment is displaced anterolaterally. This makes the radial nerve the most commonly injured structure.

Question 67

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with a completely displaced posteromedial supracondylar fracture of the humerus (Gartland Type III). Which nerve is most commonly injured in this specific fracture pattern?
. Ulnar nerve
. Median nerve
. Anterior interosseous nerve
. Radial nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Radial nerve

Explanation

Posteromedial displacement of the distal fragment puts the radial nerve at greatest risk as it gets tethered over the proximal fragment. In contrast, posterolateral displacement places the anterior interosseous nerve (AIN) and median nerve at higher risk.

Question 68

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy presents with a completely displaced, extension-type supracondylar humerus fracture. He has an absent radial pulse but the hand is warm and pink. What is the most appropriate next step in management?

. Immediate open vascular exploration
. Closed reduction and percutaneous pinning
. CT angiography of the upper extremity
. Application of a long arm cast in hyperflexion
. Observation and elevation only

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

A "pink, pulseless" hand in the setting of a supracondylar humerus fracture is generally managed with urgent closed reduction and percutaneous pinning. Vascular exploration is indicated if the hand remains dysvascular (white and pulseless) after anatomical reduction is achieved.

Question 69

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy diagnosed with Duchenne Muscular Dystrophy requires an urgent closed reduction and percutaneous pinning of a displaced supracondylar humerus fracture. Which of the following anesthetic agents is absolutely contraindicated in this patient?

. Propofol
. Ketamine
. Succinylcholine
. Fentanyl
. Rocuronium

Correct Answer & Explanation

. Succinylcholine

Explanation

Succinylcholine, a depolarizing neuromuscular blocker, is absolutely contraindicated in patients with Duchenne Muscular Dystrophy. Its use can cause massive potassium efflux from fragile, unstable muscle cells, leading to life-threatening hyperkalemia and cardiac arrest.

Question 70

Topic: Pediatric Upper Extremity & Spine
A 6-year-old girl falls onto her outstretched hand and sustains a Gartland type III supracondylar humerus fracture. On evaluation, the hand is well-perfused and warm with brisk capillary refill, but the radial pulse is absent. What is the most appropriate initial management?
. Immediate open vascular exploration by a vascular surgeon
. Closed reduction and percutaneous pinning of the fracture
. CT angiogram of the upper extremity
. Emergent volar fasciotomy
. Observation and casting in 90 degrees of flexion

Correct Answer & Explanation

. Closed reduction and percutaneous pinning of the fracture

Explanation

For a 'pink, pulseless' hand associated with a severely displaced supracondylar fracture, the standard initial step is urgent closed reduction and percutaneous pinning. The radial pulse frequently returns once the brachial artery is unkinked by the reduction.

Question 71

Topic: Pediatric Upper Extremity & Spine

During closed reduction and percutaneous pinning of a supracondylar humerus fracture, a healthy 6-year-old boy suddenly develops tachycardia, masseter muscle rigidity, and a rapidly rising end-tidal CO2. The anesthesiologist administers the definitive antidote. What is the mechanism of action of this life-saving drug?

. Inhibits calcium release from the sarcoplasmic reticulum via the ryanodine receptor
. Competitively blocks acetylcholine at the postsynaptic neuromuscular junction
. Stimulates central alpha-2 adrenergic receptors to reduce sympathetic outflow
. Directly vasodilates peripheral arterioles to rapidly dissipate core body heat
. Inhibits acetylcholinesterase to increase synaptic acetylcholine

Correct Answer & Explanation

. Inhibits calcium release from the sarcoplasmic reticulum via the ryanodine receptor

Explanation

The patient is experiencing malignant hyperthermia. The definitive treatment is Dantrolene, which works by inhibiting the ryanodine receptor (RyR1), thereby preventing the release of calcium from the sarcoplasmic reticulum and halting muscle hypermetabolism.

Question 72

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls from monkey bars and sustains a Gartland type III supracondylar humerus fracture. Examination reveals weakness in flexing the interphalangeal joint of the thumb. Which nerve is most likely injured?
. Ulnar nerve
. Anterior interosseous 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 pediatric supracondylar humerus fractures. AIN injury results in the inability to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger (OK sign).

Question 73

Topic: Pediatric Upper Extremity & Spine

A 5-year-old girl sustains a widely displaced extension-type supracondylar humerus fracture. On presentation, her hand is pink, but the radial pulse is absent. After closed reduction and percutaneous pinning, her hand remains pink and well-perfused, but the radial pulse remains unpalpable. What is the most appropriate next step?

. Immediate open exploration of the brachial artery
. Angiography of the upper extremity
. Observation and admission for neurovascular monitoring
. Application of a warm compress and immediate discharge
. Removal of pins and transition to a cast

Correct Answer & Explanation

. Observation and admission for neurovascular monitoring

Explanation

The 'pink, pulseless hand' following reduction and pinning of a supracondylar humerus fracture indicates adequate collateral circulation. Current guidelines recommend close observation and monitoring rather than immediate vascular exploration.

Question 74

Topic: Pediatric Upper Extremity & Spine
A 6-year-old falls from monkey bars and sustains a widely displaced Gartland Type III supracondylar humerus fracture. The hand is pink and warm, but the radial pulse is completely absent. What is the most appropriate next step in management?
. Immediate vascular surgery consult for arterial bypass
. Urgent closed reduction and percutaneous pinning
. Emergent upper extremity arteriogram
. Observation and elevation for 24 hours
. Open reduction with immediate brachial artery exploration

Correct Answer & Explanation

. Urgent closed reduction and percutaneous pinning

Explanation

A "pulseless but pink" hand after a displaced supracondylar fracture usually indicates arterial kinking or spasm rather than complete transection. Urgent closed reduction and percutaneous pinning typically restores the pulse.

Question 75

Topic: Pediatric Upper Extremity & Spine
A 5-year-old boy presents with a completely displaced posteromedial Gartland type III supracondylar humerus fracture. Which of the following neurologic structures is most at risk with this specific displacement pattern?
. Median nerve
. Anterior interosseous nerve
. Ulnar nerve
. Radial nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Radial nerve

Explanation

In a posteromedially displaced supracondylar fracture, the proximal fragment is displaced anterolaterally, putting the radial nerve at greatest risk. Posterolateral displacement places the median nerve and anterior interosseous nerve at highest risk.

Question 76

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy presents with a completely displaced extension-type supracondylar humerus fracture. On arrival, his hand is pink, but the radial pulse is absent. After a satisfactory closed reduction and percutaneous pinning, the hand remains pink and warm with a capillary refill of less than 2 seconds, but the pulse remains absent on Doppler ultrasound. What is the most appropriate next step in management?

. Perform immediate brachial artery exploration
. Remove the pins and attempt an open reduction
. Admit for close clinical observation and serial neurovascular checks
. Perform an immediate CT angiogram of the upper extremity
. Administer intravenous heparin and consult vascular surgery

Correct Answer & Explanation

. Admit for close clinical observation and serial neurovascular checks

Explanation

A pink, pulseless hand after adequate reduction and stabilization of a supracondylar humerus fracture is generally managed with close clinical observation. Emergent exploration is indicated only if the hand is poorly perfused (white and pulseless) after reduction.

Question 77

Topic: Pediatric Upper Extremity & Spine

A 13-year-old girl with adolescent idiopathic scoliosis (AIS) has a right thoracic curve of 35 degrees. She is Risser stage 1 and premenarchal. What is the most appropriate management?

. Observation with repeat radiographs in 6 months
. Physical therapy for core strengthening
. Full-time bracing (TLSO)
. Posterior spinal fusion
. Anterior spinal tethering

Correct Answer & Explanation

. Full-time bracing (TLSO)

Explanation

In a skeletally immature patient (Risser 0-2, premenarchal) with an AIS curve between 25 and 40 degrees, full-time bracing (e.g., Thoracolumbosacral orthosis) is the gold standard to prevent curve progression to surgical magnitude.

Question 78

Topic: Pediatric Upper Extremity & Spine

A 6-year-old girl sustains a severely displaced, extension-type supracondylar fracture of the humerus. On examination, the hand is pink but the radial pulse is non-palpable. Capillary refill is less than 2 seconds. What is the most appropriate initial management?

. Immediate open anterior exploration of the brachial artery
. CT angiography of the upper extremity
. Closed reduction and percutaneous pinning
. Application of a long arm cast in 90 degrees of flexion
. Administration of a thrombolytic agent

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

In a "pink, pulseless" hand following a displaced supracondylar humerus fracture, the first step is urgent closed reduction and percutaneous pinning to restore alignment, which often relieves kinking of the brachial artery. Vascular exploration is generally reserved for hands that remain persistently ischemic (white) after fracture reduction.

Question 79

Topic: Pediatric Upper Extremity & Spine

The timing of maximal progression of idiopathic scoliosis is most closely correlated with:

. C hronological age
. Skeletal age
. Peak height velocity
. Risser sign
. Tanner stage

Correct Answer & Explanation

. Peak height velocity

Explanation

The cause of scoliosis or its progression is still not known. However, the timing of the progression is most closely correlated with the peak velocity of growth. The other factors are more weakly correlated: a chronological or skeletal age of 10 to 12 years, Risser sign of 0, or Tanner sign of 0 to 1.

Question 80

Topic: Pediatric Upper Extremity & Spine

Which of the following events typically occurs first in adolescent girls:

. Risser sign turning to 1
. Peak height velocity
. Menarche
. Skeletal maturity
. Tanner sign of 3

Correct Answer & Explanation

. Peak height velocity

Explanation

Typically, the peak height velocity is the first of these events to occur in adolescent girls. Skeletal maturity is the last event to occur.

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