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Pediatric Upper Extremity & Spine MCQs

Practice Set 5 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 81

Topic: Pediatric Upper Extremity & Spine
According to the modified Gartland classification for pediatric supracondylar humerus fractures, which of the following best describes a Type III injury?
. Completely displaced fracture with no cortical contact
. Undisplaced fracture with a positive posterior fat pad sign
. Displaced fracture with an intact posterior cortical hinge
. Fracture with metaphyseal comminution but intact medial hinge
. Flexion-type injury with an intact anterior hinge

Correct Answer & Explanation

. Completely displaced fracture with no cortical contact

Explanation

In the Gartland classification, a Type I fracture is nondisplaced, and a Type II fracture is displaced but has an intact posterior hinge. A Type III fracture is completely displaced with no cortical contact, presenting a higher risk for neurovascular compromise.

Question 82

Topic: Pediatric Upper Extremity & Spine

Which of the following statements is true of the King classification of idiopathic scoliosis:

. It takes into account sagittal alignment of curves.
. It defines structural and nonstructural curves.
. It classifies all possible curve patterns.
. It has a lower interobserver reliability than the Lenke system.
. It has more curve types than the Lenke system.

Correct Answer & Explanation

. It takes into account sagittal alignment of curves.

Explanation

The Lenke system is more comprehensive than the King system, for the latter considers the entire range or thoracolumbar and lumbar curve possibilities, as well as the sagittal plane. The Lenke system also appears to have a higher interobserver reliability.

Question 83

Topic: Pediatric Upper Extremity & Spine

A 9-year-old boy injures his elbow in a fall from a 12-foot height. Radiographs reveal a posterior dislocation of the elbow with a fracture of the medial epicondyle which is displaced. The ossification center is 5 mm in diameter. You recommend:

. Open reduction internal fixation with a smooth pin
. Open reduction internal fixation with a small screw
. Open reduction and fixation with a suture
. Open reduction with excision of the fragment and suture of the medial collateral ligament
. C losed reduction of the dislocation and application of a splint

Correct Answer & Explanation

. C losed reduction of the dislocation and application of a splint

Explanation

A recent long-term study has shown that open reduction of displaced medial epicondyle fractures does not yield superior results to closed treatment. This applies even when the elbow is initially dislocated. Excision of the epicondyle with suture of the ligament yields the highest incidence of late problems, such as flexion contractures and degenerative changes.

Question 84

Topic: Pediatric Upper Extremity & Spine

A 2-year-old boy fell 4 feet from a countertop and landed on his outstretched hand. There is circumferential swelling and tenderness. Radiographs show no fracture, but the posterior fat pad elbow is elevated and the radius and ulna are translated slightly laterally on the anteroposterior view, and posteriorly on the lateral view. The most likely diagnosis is:

. Undisplaced supracondylar fracture
. Transphyseal fracture of the distal humerus
. Lateral condyle fracture
. Traumatic elbow dislocation
. C ongenital elbow dislocation

Correct Answer & Explanation

. Transphyseal fracture of the distal humerus

Explanation

The separation occurs through cartilage, so it is not visible as a fracture on plain films. However, the translation indicates a problem and elbow dislocation does not occur with any frequency at this age. An undisplaced supracondylar fracture would not produce translation of the radius and ulna. A lateral condyle fracture would not produce translation of the ulna. Traumatic dislocation is extremely uncommon in this age group. C ongenital elbow subluxation would not account for the swelling and tenderness. This is an extremely rare condition.

Question 85

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls on an outstretched hand, sustaining a Gartland Type III extension-type supracondylar humerus fracture. Which nerve is most commonly injured in this specific fracture pattern?
. Ulnar nerve
. Radial nerve
. Anterior interosseous nerve (AIN)
. Posterior interosseous nerve (PIN)
. Musculocutaneous nerve

Correct Answer & Explanation

. Anterior interosseous nerve (AIN)

Explanation

The anterior interosseous nerve (AIN), a branch of the median nerve, is the most frequently injured nerve in extension-type supracondylar humerus fractures. Clinically, this presents as an inability to make the "OK" sign.

Question 86

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy falls off monkey bars and sustains a significantly displaced supracondylar humerus fracture (Gartland Type III). He has an absent radial pulse but a well-perfused, "pink, and warm" hand. What is the most appropriate initial management in the operating room?
. Emergent brachial artery exploration
. Closed reduction and percutaneous pinning followed by reassessment of the pulse
. Open reduction via an anterior approach
. Angiography to localize the arterial injury
. Application of a splint and observation for 24 hours

Correct Answer & Explanation

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

Explanation

For a "pink, pulseless" hand in the setting of a displaced supracondylar humerus fracture, the initial step is urgent closed reduction and percutaneous pinning. The pulse frequently returns after fracture realignment; vascular exploration is reserved for cases where the hand remains dysvascular (white and pulseless) after reduction.

Question 87

Topic: Pediatric Upper Extremity & Spine

Which of the following is not usually associated with radial deficiency:

. Thrombocytopenia absent radii
. Fanconi anemia
. Holt-Oram syndrome
. Larsen syndrome
. C ardiac anomalies

Correct Answer & Explanation

. Larsen syndrome

Explanation

Patients with thrombocytopenia absent radii, Fanconi anemia, Holt-Oram syndrome, and cardiac anomolies all are associated with radial deficiency. Larsen syndrome is associated with multiple, larger joint dislocation.

Question 88

Topic: Pediatric Upper Extremity & Spine

A radial club hand is the result of an insult during which phase of the gestation period:

. Weeks 1 to 4
. Weeks 4 to 7
. Weeks 8 to 12
. Weeks 12 to 16
. Anytime during gestation

Correct Answer & Explanation

. Weeks 4 to 7

Explanation

A radial club hand is the result of an insult during weeks 4 to 7 of gestation.

Question 89

Topic: Pediatric Upper Extremity & Spine
A 15-day-old boy presents with deformity of the right hand. The boy was delivered prematurely and underwent an urgent arterial switch for transposition of great vessels. The patient is in stable condition. He has a radial club hand, and because the radial head cannot be palpated, total absence of radius is suspected. The thumb is absent and the index finger has camptodactyly. The forearm is short compared to the left side, and the patient flexes his elbow upon stimulation. Spontaneous finger motion is also present. A thorough physical examination is performed and a set of investigations is ordered. The results are as follows: complete blood count 10,000/ยตL; platelet 254ร—10^3/ยตL; neutrophils 50%; Hb 14.2 g/dL; lymphocytes 40%; Hct 45%; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal. Diagnosis is:
. Vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, and radial and renal anomalies (VATER)
. Abnormalities of vertebrae, anus, cardiovascular tree, trachea, esophagus, renal system, and limb buds (VACTERL)
. Thrombocytopenia absent radii (TAR) syndrome
. Holt-Oram syndrome
. Fanconi's anemia

Correct Answer & Explanation

. Holt-Oram syndrome

Explanation

The patient has a radial club hand with a cardiac defect. Because the spine radiograph is normal, the diagnosis cannot be VATER or VACTERL anomaly as both involve vertebrae. Blood work up is normal, making this diagnosis Holt-Oram syndrome.

Question 90

Topic: Pediatric Upper Extremity & Spine

The principal abnormality associated with Holt-Oram syndrome is:

. Platelet deficiency
. Cardiac defects
. Pancytopenia
. Malignancy
. Vertebral defects

Correct Answer & Explanation

. Cardiac defects

Explanation

Holt-Oram syndrome is associated with cardiac defects. The most common defect is aldosterone secretion.

Question 91

Topic: Pediatric Upper Extremity & Spine

The hereditary pattern for Holt-Oram syndrome is:

. Autosomal recessive
. Autosomal dominant
. Sex-linked recessive
. Sex-linked dominant
. Sporadic

Correct Answer & Explanation

. Autosomal dominant

Explanation

Holt-Oram syndrome is inherited in an autosomal dominant manner.

Question 92

Topic: Pediatric Upper Extremity & Spine
A 15-day-old boy presents with deformity of the right hand. The boy was delivered prematurely and underwent an urgent arterial switch for transposition of great vessels. The patient is in stable condition. He has a radial club hand, and because the radial head cannot be palpated, total absence of radius is suspected. The thumb is absent and the index finger has camptodactyly. The forearm is short compared to the left side, and the patient flexes his elbow upon stimulation. Spontaneous finger motion is also present. A thorough physical examination is performed and a set of investigations is ordered. The results are as follows: complete blood count 10,000/ยตL; platelet 254ร—10^3/ยตL; neutrophils 50%; Hb 14.2 g/dL; lymphocytes 40%; Hct 45%; and monocytes 10%. No renal abnormalities were noted on ultrasonogram of the abdomen. A radiograph of the spine is normal. The next step in the management of the radial club hand is:
. Stretching
. Soft-tissue distraction
. Radialization
. Centralization
. Pollicization

Correct Answer & Explanation

. Stretching

Explanation

For the first 6 to 9 months, parents and therapists perform passive stretching. Serial casting and splinting may also be used. Sometimes, preoperative soft-tissue distraction is performed, usually before a wrist stabilization procedure.

Question 93

Topic: Pediatric Upper Extremity & Spine

Which of the following conditions is present in patients with radial club hand but not in patients with ulnar club hand:

. Thumb hypoplasia
. Thumb aplasia
. Short forearm
. Renal malformations
. Bowing of the forearm

Correct Answer & Explanation

. Renal malformations

Explanation

Ulnar club hand differs from radial club hand in that cardiopulmonary, hematopoeitic, gastrointestinal, and genitourinary anomalies are uncommon.

Question 94

Topic: Pediatric Upper Extremity & Spine

All of the following developmental anomalies are associated with ulnar club hand except:

. Atrial septal defects
. Proximal focal femoral deficiencies
. Fibular agenesis
. Mental retardation
. Radial ray defects

Correct Answer & Explanation

. Atrial septal defects

Explanation

Atrial septal defects are developmental abnormalities present in patients with radial club hand or Holt-Oram syndrome.

Question 95

Topic: Pediatric Upper Extremity & Spine

Which of the following syndromes is associated with ulnar club hand:

. Vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, and radial and renal anomalies (VATER)
. Abnormalities of vertebrae, anus, cardiovascular tree, trachea, esophagus, renal system, and limb buds (VAC TERL)
. Holt-Oram syndrome
. Thrombocytopenia absent radii (TAR) syndrome
. Femur-fibular-ulnar syndrome

Correct Answer & Explanation

. Femur-fibular-ulnar syndrome

Explanation

VATER, VAC TERL, Holt-Oram syndrome, and TAR syndrome are associated with radial club hand. Femur-fibular-ulnar syndrome is characterized by proximal femoral focal deficiency, fibular agenesis, and ulnar ray defects.

Question 96

Topic: Pediatric Upper Extremity & Spine
Syndromes that may be associated with macrodactyly include:
. Proteus syndrome
. Freeman-Sheldon syndrome
. Madelung's deformity
. Holt-Oram syndrome
. Poland syndrome

Correct Answer & Explanation

. Proteus syndrome

Explanation

Some surgeons believe that macrodactyly is a variant of neurofibromatosis. Although macrodactyly is not an inherited anomaly, there are syndromes that may be associated with enlarged digits such as Proteus syndrome. Theoretical causes for macrodactyly include a neural cause, a vascular cause, as well as a humoral mechanism. The most accepted theory is that abnormal nerves exert some influence on the local tissues to stimulate growth.

Question 97

Topic: Pediatric Upper Extremity & Spine

A newborn presents with an absent radius and an absent thumb. Which of the following tests is most appropriate to rule out a life-threatening associated condition?

. Chromosomal breakage test
. Complete blood count
. Echocardiogram
. Renal ultrasound
. Spine radiograph

Correct Answer & Explanation

. Chromosomal breakage test

Explanation

A newborn with an absent radius and absent thumb is highly suspicious for Fanconi anemia, which is fatal if missed due to aplastic anemia. A chromosomal breakage test using diepoxybutane is mandatory for diagnosis.

Question 98

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a displaced, extension-type supracondylar humerus fracture presenting with a pale, pulseless hand. After closed reduction and percutaneous pinning, the hand becomes well-perfused (pink) with brisk capillary refill, but the radial pulse remains absent. What is the most appropriate next step?

. Immediate vascular exploration and bypass
. Observation and close clinical monitoring
. Administration of intra-arterial vasodilators
. Removal of pins and transition to open reduction
. Perform an emergent forearm fasciotomy

Correct Answer & Explanation

. Observation and close clinical monitoring

Explanation

A "pink, pulseless" hand following the successful reduction of a supracondylar fracture indicates adequate collateral perfusion. The standard of care is close observation, as the radial pulse typically returns within several days to weeks without necessitating vascular surgery.

Question 99

Topic: Pediatric Upper Extremity & Spine

A 12-year-old female presents with a 42-degree right thoracic scoliosis. She is premenarchal and has a Risser sign of 0. Her parents report a recent growth spurt. Based on the provided information, which of the following factors is the strongest indicator of a high likelihood of curve progression in this patient?

. A. The curve's location in the thoracic spine.
. B. The patient's female gender.
. C. The current Cobb angle of 42 degrees.
. D. Her premenarchal status and Risser 0.
. E. The presence of a right-sided curve.

Correct Answer & Explanation

. D. Her premenarchal status and Risser 0.

Explanation

Correct Answer: DExplanation:The provided text explicitly lists features that indicate an increased likelihood of curve progression in adolescent idiopathic scoliosis. These include: young age at onset, premenarchal status, physical immaturity (like Risser 0), large curves, and female gender. Among these, premenarchal status and a low Risser sign (indicating significant remaining growth potential) are critical indicators of ongoing skeletal immaturity and thus a high risk for rapid progression during the adolescent growth spurt.A. The curve's location in the thoracic spine.While thoracic curves are common in AIS, the location itself is not listed as the strongest predictor of progression compared to skeletal maturity.B. The patient's female gender.Female gender is indeed a risk factor for progression, especially for curves over 20 degrees (F:M 5.4:1). However, in the context of a 12-year-old premenarchal girl with Risser 0, the immaturity indicators (premenarchal status, Risser 0) are more direct and stronger predictors offutureprogression than gender alone, as they signify the peak growth period.C. The current Cobb angle of 42 degrees.A large curve (over 40 degrees) is a risk factor for progression. However, thepotentialfor further rapid progression is most strongly linked to the remaining growth. A 42-degree curve in a skeletally mature individual would progress much less than a 42-degree curve in a skeletally immature individual.E. The presence of a right-sided curve.A right thoracic curve is the most common pattern in AIS and is not considered an atypical feature indicating higher progression risk compared to, for example, a left-sided curve which might suggest underlying pathology.

Question 100

Topic: Pediatric Upper Extremity & Spine

A 15-year-old patient presents with a 48-degree left-sided lumbar scoliosis, as depicted in the AP radiograph. The patient reports no pain but is concerned about the cosmetic appearance. She is skeletally mature with a Risser sign of 4. Given the curve characteristics and patient's maturity, what is the most likely natural history of this curve going forward?

. A. Rapid progression is expected due to the left-sided curve and lumbar location.
. B. The curve will likely stabilize with no further progression.
. C. Slow progression of approximately 1 degree per year is expected.
. D. Spontaneous resolution of the curve is highly probable.
. E. The curve will likely accelerate in progression during the next growth spurt.

Correct Answer & Explanation

. C. Slow progression of approximately 1 degree per year is expected.

Explanation

Correct Answer: CExplanation:The text states: 'Once skeletal maturity is reached the scoliosis tends to stabilize and progress less rapidly (1 per year).' This patient is 15 years old and has a Risser sign of 4, indicating significant skeletal maturity. While a 48-degree curve is substantial, the key factor here is the patient's maturity. Therefore, slow progression at approximately 1 degree per year is the most likely natural history.A. Rapid progression is expected due to the left-sided curve and lumbar location.While left-sided curves can be atypical and warrant further investigation for underlying pathology, the primary driver of rapid progression in idiopathic scoliosis is skeletal immaturity. With a Risser 4, rapid progression is unlikely.B. The curve will likely stabilize with no further progression.While progression slows, it doesn't typically cease entirely. A small degree of progression (around 1 degree per year) is still expected even after skeletal maturity for larger curves.D. Spontaneous resolution of the curve is highly probable.Spontaneous resolution is primarily seen in a significant number of infantile idiopathic scoliosis cases (80-90% of curves before age 2), not in adolescent or mature patients with a 48-degree curve.E. The curve will likely accelerate in progression during the next growth spurt.With a Risser 4, the patient is past the peak of their adolescent growth spurt, so an acceleration in progression due to growth is highly unlikely.

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