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4. Pediatrics MCQs

Practice Set 101 of 334

This practice set contains high-yield board review questions covering key concepts in 4. Pediatrics. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 2001

Topic: 4. Pediatrics

A 3-year-old boy is brought to the clinic for progressive bowing of his left leg. Radiographs demonstrate a sharp varus deformity localized to the proximal tibial metaphysis with medial beaking. The metaphyseal-diaphyseal angle (MDA) of Drennan is measured at 18 degrees. What is the most appropriate initial management for this patient?

. Knee-ankle-foot orthosis (KAFO) bracing
. Observation with repeat radiographs in 6 months
. Guided growth via medial proximal tibial hemiepiphysiodesis
. High tibial osteotomy with rigid internal fixation
. Administration of bisphosphonates

Correct Answer & Explanation

. Knee-ankle-foot orthosis (KAFO) bracing

Explanation

This child has infantile Blount's disease (tibia vara). While physiologic bowing is common in toddlers, a metaphyseal-diaphyseal angle (MDA) > 16 degrees strongly suggests true infantile Blount's disease rather than physiologic bowing (which typically has an MDA < 10 degrees). For a child under the age of 4 with a high MDA, the initial recommended treatment is KAFO bracing to unweight the medial compartment. Surgery is reserved for older children or failure of conservative management.

Question 2002

Topic: Pediatric Hip
A 12-year-old obese male undergoes in-situ percutaneous screw fixation for a unilateral Slipped Capital Femoral Epiphysis (SCFE). Prophylactic pinning of the contralateral, asymptomatic hip is considered. Which of the following patient profiles is the strongest indication for prophylactic contralateral pinning?
. Male sex and a body mass index (BMI) > 95th percentile
. Age of 14 years at initial presentation
. A known underlying diagnosis of hypothyroidism
. A severe (Grade III) slip on the affected side
. Closed triradiate cartilages bilaterally

Correct Answer & Explanation

. A known underlying diagnosis of hypothyroidism

Explanation

The risk of developing a contralateral SCFE is significant (around 20-30%, higher in certain populations). Strong indications for prophylactic pinning of the contralateral hip include patients with underlying endocrinopathies (e.g., hypothyroidism, renal osteodystrophy, growth hormone deficiency), patients presenting at an unusually young age (males < 10, females < 9), and patients who are unreliable for follow-up. Obesity alone, while a risk factor for the primary slip, is not an absolute indication for prophylactic pinning.

Question 2003

Topic: 4. Pediatrics

A 12-year-old obese male presents with a 3-week history of groin pain and an obligatory external rotation of the hip during flexion.

What is the primary pathoanatomic mechanical failure occurring in the proximal femur?

. Failure through the zone of resting cartilage
. Failure through the zone of proliferation
. Failure through the zone of hypertrophy
. Failure through the zone of provisional calcification
. Failure of the labral suction seal

Correct Answer & Explanation

. Failure through the zone of hypertrophy

Explanation

Slipped Capital Femoral Epiphysis (SCFE) occurs due to shear failure through the physis. Histologically, this failure specifically occurs through the zone of hypertrophy, which is the weakest zone of the growth plate due to an increased matrix-to-cell ratio and decreased structural integrity.

Question 2004

Topic: Pediatric Hip

A 4-month-old female with Developmental Dysplasia of the Hip (DDH) is being treated with a Pavlik harness. Two weeks into treatment, examination reveals absent active knee extension on the affected side. What is the most likely iatrogenic cause?

. Obturator nerve palsy from excessive abduction
. Femoral nerve palsy from excessive hyperflexion
. Sciatic nerve palsy from excessive extension
. Development of a septic hip joint
. Avascular necrosis of the femoral head

Correct Answer & Explanation

. Femoral nerve palsy from excessive hyperflexion

Explanation

Femoral nerve palsy is a known complication of the Pavlik harness, typically caused by excessive hip hyperflexion which compresses the femoral nerve against the inguinal ligament. It manifests as decreased spontaneous leg movement and absent active knee extension. The harness should be adjusted to reduce flexion or temporarily removed.

Question 2005

Topic: Pediatric Lower Extremity

When applying the Ponseti method for the serial casting of idiopathic clubfoot (talipes equinovarus), the deformity must be corrected in a specific sequence to unlock the subtalar joint. What is the correct order of deformity correction?

. Cavus, Adductus, Varus, Equinus
. Varus, Adductus, Cavus, Equinus
. Equinus, Cavus, Adductus, Varus
. Adductus, Varus, Cavus, Equinus
. Cavus, Varus, Adductus, Equinus

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The Ponseti method dictates sequential correction following the CAVE acronym: Cavus (by elevating the first ray), Adductus, Varus, and finally Equinus (often requiring a percutaneous Achilles tenotomy). Correcting the cavus first aligns the forefoot with the hindfoot, allowing the talonavicular joint to be reduced.

Question 2006

Topic: Pediatric Hip

A 12-year-old obese boy presents with left hip pain and an obligate external rotation of the hip during flexion. A radiograph is shown below. What is the most appropriate initial management for the condition demonstrated?

. Non-weight bearing and urgent in-situ percutaneous pinning
. Closed reduction and hip spica casting
. Open reduction and surgical dislocation (Dunn procedure)
. Protected weight-bearing and serial observation
. Proximal femoral intertrochanteric osteotomy

Correct Answer & Explanation

. Non-weight bearing and urgent in-situ percutaneous pinning

Explanation

The clinical presentation and radiograph represent a stable Slipped Capital Femoral Epiphysis (SCFE). The gold standard for initial management of a stable SCFE is in-situ pinning, typically utilizing a single partially threaded cannulated screw placed in the center-center position of the epiphysis to prevent further slip and promote physeal closure.

Question 2007

Topic: Pediatric Lower Extremity

In the Ponseti method for the conservative management of idiopathic clubfoot, the sequence of deformity correction is strictly ordered to avoid creating a midfoot break. What is the correct sequence of correction?

. Cavus, Adductus, Varus, Equinus
. Equinus, Varus, Adductus, Cavus
. Cavus, Varus, Adductus, Equinus
. Adductus, Varus, Cavus, Equinus
. Equinus, Adductus, Varus, Cavus

Correct Answer & Explanation

. Cavus, Varus, Adductus, Equinus

Explanation

The Ponseti method systematically corrects clubfoot deformities following the acronym CAVE: Cavus (corrected first by supinating the forefoot to align it with the hindfoot), followed simultaneously by Adductus and Varus (by abducting the foot around the head of the talus), and finally Equinus (often requiring a percutaneous Achilles tenotomy).

Question 2008

Topic: Pediatric Hip

A 12-year-old boy presents with a left-sided stable slipped capital femoral epiphysis (SCFE). Which of the following is the strongest indication for prophylactic in situ pinning of the contralateral asymptomatic right hip?

. Patient age greater than 14 years
. Presence of an underlying endocrine disorder
. Male gender
. Body mass index greater than 35
. Slipped angle greater than 50 degrees on the affected side

Correct Answer & Explanation

. Presence of an underlying endocrine disorder

Explanation

The risk of developing a contralateral SCFE is significantly elevated in patients with underlying endocrinopathies (such as hypothyroidism, panhypopituitarism, or renal osteodystrophy). In idiopathic cases, contralateral slip occurs in about 20-40% of patients. However, in patients with endocrine or metabolic disorders, the risk of a bilateral slip approaches 100%. Therefore, an underlying endocrine disorder is an absolute indication for prophylactic pinning of the contralateral hip.

Question 2009

Topic: Pediatric Hip

A 12-year-old obese boy presents with acute on chronic Slipped Capital Femoral Epiphysis (SCFE) of the left hip.

In considering treatment options for the asymptomatic contralateral right hip, which of the following is considered the strongest indication for prophylactic in situ pinning?

. Age > 14 years
. Female gender
. Presence of an underlying endocrine disorder
. Severe initial slip > 50 degrees on the affected side
. Body Mass Index in the 90th percentile

Correct Answer & Explanation

. Presence of an underlying endocrine disorder

Explanation

Prophylactic pinning of the contralateral asymptomatic hip in SCFE is highly recommended in patients with an underlying endocrine disorder (e.g., hypothyroidism, growth hormone deficiency, renal osteodystrophy) due to an exceedingly high rate of bilateral involvement (up to 100% in some series). Other relative indications include age < 10 years and inability to ensure reliable follow-up.

Question 2010

Topic: 4. Pediatrics
A 3-year-old child presents with progressive bowing of the legs and is diagnosed with infantile Blount's disease (Langenskiöld stage II). Which of the following best describes the primary histological defect in this condition?
. Abnormal endochondral ossification of the medial proximal tibial physis
. Defective intramembranous ossification of the tibial diaphysis
. Avascular necrosis of the medial tibial epiphysis
. Premature fusion of the lateral distal femoral physis
. Hypertrophy of the zone of provisional calcification secondary to rickets

Correct Answer & Explanation

. Abnormal endochondral ossification of the medial proximal tibial physis

Explanation

Blount's disease is an osteochondrosis that involves abnormal endochondral ossification at the medial aspect of the proximal tibial physis. Increased compressive forces across the medial knee lead to suppression of physeal growth (Heuter-Volkmann principle). Histologically, there is a disordered, hypercellular zone of hypertrophy and delayed ossification in the medial physis.

Question 2011

Topic: 4. Pediatrics

An 8-year-old boy reports ankle pain after striking the ground with the medial aspect of his foot while attempting to kick a soccer ball. Radiographs reveal slight distal tibial physeal widening but no other abnormalities. In treating this injury, which of the following associated conditions is most likely present but may be missed without careful evaluation?

Orthopedic Surgery Board Review 2026 | High-Yield MCQs - Set 7 - Figure 97

. Malrotation of the foot
. Neurologic injury
. Vascular injury
. Knee meniscal injury
. Hip fracture

Correct Answer & Explanation

. Malrotation of the foot

Explanation

Malrotation of the foot is frequently overlooked in this clinical setting. This can be judged by evaluating and comparing the transmalleolar axes of the affected and unaffected legs. The rotation occurs through the physis and frequently is not recognized until the patient has been walking for a few months. The other conditions are not expected to occur in the clinical setting described. Phan VC, Wroten E, Yngve DA: Foot progression angle after distal tibial physeal fractures. J Pediatr Orthop 2002;22:31-35.

Question 2012

Topic: 4. Pediatrics

The husband of a 22-year-old woman has hypophosphatemic rickets. The woman has no orthopaedic abnormalities, but she is concerned about her chances of having a child with the same disease. What should they be told regarding this disorder?

. Their sons will have a 50% chance of having this X-linked dominant disorder.
. All of their daughters will be carriers or will have this disorder.
. They should be advised to not have any children as the risk of having boys with the disorder and girls who will be carriers is too hard for any parent.
. As long as the woman does not carry the trait, the children will not be affected because the husband has the disease and this is an X-linked dominant disorder.
. Their sons or daughters may be born with this disorder, but males are more severely affected.

Correct Answer & Explanation

. All of their daughters will be carriers or will have this disorder.

Explanation

Hypophosphatemia is a rare genetic disease usually inherited as an X-linked dominant trait. The fact that the woman has no skeletal manifestations would indicate that the husband has the X-linked mutation. The disease is more severe in boys than it is in girls. The husband will not transmit the disease to his sons. However, all of their daughters will be affected either with the disease or as carriers. If the woman has the disease or the trait, there is a 50% chance that her sons will inherit the disease and a 50% chance that her daughters will be carriers or have a milder form of the disease. Parents should be advised to have genetic counseling so they can be informed when deciding whether to have children. Herring JA: Metabolic and endocrine bone diseases, in Tachdjian's Pediatric Orthopaedics, ed 3. New York, NY, WB Saunders, 2002, pp 1685-1743. Sillence DO: Disorders of bone density, volume, and mineralization, in Rimoin DL, Conner JM, Pyerite RE, et al (eds): Principles and Practice of Medical Genetics, ed 4. New York, NY, Churchill Livingstone, 2002.

Question 2013

Topic: 4. Pediatrics

A child born with myelomeningocele is expected to be an ambulator with bracing. Examination by the consulting orthopaedic surgeon reveals rigid clubfeet in addition to the neurologic issues. Management should consist of

Foot & Ankle Board Review 2000: High-Yield MCQs (Set 2) - Figure 8

. immediate casting with the expectation of a satisfactory correction.
. immediate casting with the expectation that surgical correction will be needed.
. immediate surgery to correct the deformity.
. delayed casting and corrective bracing.
. therapeutic and frequent physical therapy to stretch the soft tissues and observe the skin.

Correct Answer & Explanation

. immediate casting with the expectation that surgical correction will be needed.

Explanation

In a child with myelomeningocele, the guiding principle of treatment is to achieve a plantigrade foot by the time the child is ready to stand. The standard clubfoot protocol should be followed, but these children will require an aggressive surgical release to obtain a sufficient correction. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 65-78.

Question 2014

Topic: 4. Pediatrics

A 2-year-old child has marked hypotonia and depressed reflexes. History reveals that the child was normal at birth and developed normally for the first year. The child also began to ambulate, but lost this ability during the next 6 months. Laboratory studies show a creatine phosphokinase level that is within the normal range. DNA testing confirms a deletion in the survival motor neuron (SMN) gene. What is the most likely diagnosis?

. Rett syndrome
. Spinal muscular atrophy, type 2
. Congenital muscular dystrophy
. Duchenne muscular dystrophy
. Congenital myotonic dystrophy

Correct Answer & Explanation

. Spinal muscular atrophy, type 2

Explanation

The patient has spinal muscular atrophy, type 2. This type is intermediate in severity between the Werdnig-Hoffmann type (type 1) and the Kugelberg-Welander type (type 3). It normally manifests itself between the ages of 3 and 15 months. Survival until adolescence is common. All three types of spinal muscular atrophy have been linked to the SMN gene at the 5q12.2-13.3 locus. DNA testing is available and is preferred to muscle biopsy because it is less invasive and more definitive. Biros I, Forrest S: Spinal muscular atrophy: Untangling the knot? J Med Genet 1999;36:1-8.

Question 2015

Topic: Pediatric Hip

Figure 46 shows the radiograph of an obese 12-year-old boy who has had left hip pain for the past 3 months. What is the best course of action?

Pediatrics Board Review 2004: High-Yield MCQs (Set 4) - Figure 8

. Decreased activities and physical therapy
. Left hip reduction and internal fixation
. Left hip pinning in situ
. Bilateral hip pinning in situ
. Spica cast immobilization

Correct Answer & Explanation

. Left hip pinning in situ

Explanation

The patient has an obvious slipped capital femoral epiphysis of the left hip for which the recommended treatment is percutaneus pinning in situ. Development of a contralateral slip is less likely at this age; therefore, observation of the right hip is indicated because there is no general agreement regarding prophylactic fixation. Typically, there is no role for spica casting. Physical therapy is not indicated as a primary treatment, and reduction is contraindicated, as it has been associated with osteonecrosis. Loder RT, Aronsson DD, Greenfield ML: The epidemiology of bilateral slipped capital femoral epiphysis: A study of children in Michigan. J Bone Joint Surg Am 1993;75:1141-1147. Aronsson DD, Karol LA: Stable slipped capital femoral epiphysis: Evaluation and management. J Am Acad Orthop Surg 1996;4:173-181. Hurley JM, Betz RR, Loder RT, Davidson RS, Alburger PD, Steel HH: Slipped capital femoral epiphysis: The prevalence of late contralateral slip. J Bone Joint Surg Am 1996;78:226-230.

Question 2016

Topic: Pediatric Hip

A 2-year-old girl is diagnosed with unilateral developmental dysplasia of the hip (DDH). Radiographs, seen here, show a dislocated left hip with an acetabular index of 45 degrees and evidence of femoral head flattening. Attempts at closed reduction under general anesthesia are unsuccessful.

What is the most appropriate next step in management?

. Repeat closed reduction with higher force.
. Observation with serial radiographs.
. Open reduction with capsulorrhaphy and possibly femoral shortening osteotomy.
. Pavlik harness application.
. Triple innominate osteotomy.

Correct Answer & Explanation

. Open reduction with capsulorrhaphy and possibly femoral shortening osteotomy.

Explanation

This 2-year-old girl has a late-presenting, irreducible developmental dysplasia of the hip (DDH). The inability to achieve a closed reduction under general anesthesia, coupled with a dislocated hip and significant acetabular dysplasia (acetabular index of 45 degrees, normal < 30 degrees for age), indicates the need for surgical intervention. By 18-24 months of age, closed reduction becomes less successful due to soft tissue contractures (e.g., iliopsoas, adductors), an inverted labrum, and a hypertrophied ligamentum teres, and a dysplastic acetabulum.Option A (repeat closed reduction with higher force) is contraindicated. Forceful reduction attempts in late-presenting DDH significantly increase the risk of avascular necrosis (AVN) of the femoral head.Option B (observation) is incorrect; an unreduced dislocated hip will lead to severe long-term disability and degenerative arthritis.Option C (open reduction with capsulorrhaphy and possibly femoral shortening osteotomy) is the most appropriate next step. Open reduction addresses the soft tissue impediments to reduction and allows for direct visualization of the femoral head and acetabulum. Capsulorrhaphy stabilizes the hip after reduction. Femoral shortening osteotomy is often required in older children (typically >18-24 months) to reduce tension on the femoral head after reduction, thereby reducing the risk of AVN and facilitating a stable reduction. Addressing the acetabular dysplasia (e.g., with a Dega or Salter osteotomy) may also be necessary at the time of open reduction or as a staged procedure, depending on the residual dysplasia after reduction.Option D (Pavlik harness) is effective for reducible DDH in infants younger than 6 months and is ineffective and contraindicated for irreducible or late-presenting DDH in a 2-year-old.Option E (Triple innominate osteotomy) is an acetabular redirection osteotomy typically performed for residual acetabular dysplasia in older children (usually 6-12 years) after successful hip reduction, not as a primary treatment for an irreducible dislocation in a 2-year-old.

Question 2017

Topic: Pediatric Hip

A 13-year-old obese male presents with a 3-month history of right hip and knee pain, worsening with activity. Physical examination reveals a painful gait, decreased internal rotation, and external rotation with hip flexion (Drehmann sign). Radiographs show a right slipped capital femoral epiphysis (SCFE) with a moderate slip angle.

What is the MOST appropriate acute management for this patient?

. Non-weight bearing immediately, followed by in situ pinning of the affected hip.
. Surgical osteotomy to correct the slip angle immediately.
. Bed rest and traction for 2 weeks, then consideration of pinning.
. Observation with activity modification and close follow-up.
. In situ pinning of both hips to prevent contralateral slip.

Correct Answer & Explanation

. Non-weight bearing immediately, followed by in situ pinning of the affected hip.

Explanation

The patient's presentation is classic for a stable slipped capital femoral epiphysis (SCFE). The Drehmann sign is pathognomonic. The MOST appropriate acute management for a stable SCFE is immediate non-weight bearing to prevent further slippage, followed by in situ pinning of the affected hip. In situ pinning stabilizes the physis and prevents progression of the slip. Surgical osteotomy is reserved for severe slips or malunion after initial pinning. Bed rest and traction are not standard acute management. Observation is contraindicated due to the risk of progression and avascular necrosis. Prophylactic pinning of the contralateral hip is often considered, especially in high-risk patients (e.g., endocrine disorders, severe obesity), but the immediate priority is the symptomatic hip.

Question 2018

Topic: Pediatric Hip

An 11-year-old obese male presents with a 3-month history of left knee pain, which he attributes to 'growing pains.' He denies any specific trauma. On examination, he has an antalgic gait, and active range of motion of the left hip reveals significantly limited internal rotation and abduction. Radiographs of the hips (AP and frog-leg lateral views, as shown) are ordered.

The images show a stable Slipped Capital Femoral Epiphysis (SCFE) on the left. What is the MOST appropriate definitive treatment for this condition?

. Spica cast immobilization for 6-8 weeks.
. Closed reduction and single screw fixation in situ.
. Open reduction with osteotomy and internal fixation.
. Percutaneous single screw fixation in situ without attempted reduction.
. Non-weight-bearing with crutches until symptoms resolve.

Correct Answer & Explanation

. Percutaneous single screw fixation in situ without attempted reduction.

Explanation

For a stable Slipped Capital Femoral Epiphysis (SCFE), the standard of care is percutaneous single screw fixation in situ without attempting any reduction maneuver. Attempted closed reduction of a stable SCFE significantly increases the risk of avascular necrosis (AVN) of the femoral head. Fixation in situ aims to stabilize the physis and prevent further slip. Non-weight-bearing is important prior to fixation but is not definitive treatment. Spica cast immobilization is ineffective in preventing further slip and is not a definitive treatment. Open reduction and osteotomy are reserved for severe, unstable, or chronic SCFE with significant deformity after initial fixation, or for salvage procedures.

Question 2019

Topic: Pediatric Hip

A 9-month-old female is diagnosed with a unilateral left developmental dysplasia of the hip (DDH) that failed Pavlik harness treatment despite good compliance. Clinical examination reveals a reducible but unstable hip. An anteroposterior pelvic radiograph confirms a dislocated hip with a severely dysplastic acetabulum and a high riding femoral head.

Given the age and failed conservative management, what is the MOST appropriate next step in management?

. Continue Pavlik harness treatment with increased abduction.
. Refer for a triple innominate osteotomy.
. Proceed with a closed reduction under general anesthesia with subsequent hip spica casting.
. Perform an open reduction and femoral shortening osteotomy.
. Initiate traction followed by repeat Pavlik harness application.

Correct Answer & Explanation

. Proceed with a closed reduction under general anesthesia with subsequent hip spica casting.

Explanation

The image provided is a hip X-ray likely showing DDH. For a 9-month-old infant with DDH that has failed Pavlik harness treatment, the typical next step is a closed reduction under general anesthesia. The Pavlik harness is most effective in infants up to 6 months of age. Beyond this age, particularly if conservative measures fail or the hip remains irreducible/unstable, more invasive methods are considered.At 9 months, the hip is typically still reducible, and soft tissue contractures are not as severe as in older children. A closed reduction aims to relocate the femoral head into the acetabulum, followed by immobilization in a hip spica cast, usually in the 'human' position (hip flexion 90-100°, abduction 45-60°, slight internal rotation). Arthrography is often performed during the procedure to confirm concentric reduction and identify any impediments to reduction.Rationale for options:A. Pavlik harness is typically ineffective and contraindicated after 6-9 months of age or after failure, due to increased stiffness and potential for avascular necrosis (AVN) with excessive force.B. Closed reduction under general anesthesia with subsequent hip spica casting is the standard next step for failed Pavlik harness in an infant of this age with a reducible hip. This is the correct answer.C. A triple innominate osteotomy is an acetabular redirection osteotomy performed in older children (typically > 18-24 months) or adolescents for residual dysplasia after successful reduction, not as the primary reduction method in an infant.D. Open reduction and femoral shortening osteotomy is indicated for irreducible hips, severe dislocations, or older children (typically >12-18 months) where significant soft tissue contractures or bony deformities prevent closed reduction. At 9 months, closed reduction is usually attempted first unless there's clear evidence of irreducibility.E. Traction may be used as a preparatory step for open or closed reduction in older infants (e.g., >12 months) to stretch soft tissues, but it is not followed by another Pavlik harness application after failed initial treatment.

Question 2020

Topic: Pediatric Lower Extremity

A 15-year-old male presents with persistent anterior knee pain and a palpable tender mass just distal to the patella. He is active in basketball and gymnastics. Radiographs show fragmentation and irregularity of the patellar tendon insertion onto the tibial tuberosity, consistent with Osgood-Schlatter disease. Despite 6 months of conservative treatment including rest, NSAIDs, and physical therapy, his pain persists, significantly limiting his athletic activities. What is the MOST appropriate next step in management?

. Continued conservative management with activity modification until skeletal maturity.
. Surgical excision of ossicles and debridement of the patellar tendon insertion.
. Corticosteroid injection into the patellar tendon.
. Patellar tendon realignment surgery.
. High tibial osteotomy to alter mechanical axis.

Correct Answer & Explanation

. Continued conservative management with activity modification until skeletal maturity.

Explanation

The patient presents with Osgood-Schlatter disease, an apophysitis of the tibial tuberosity. It is a self-limiting condition that typically resolves with skeletal maturity. While conservative management has failed to provide complete relief, the first line of treatment remains non-surgical. Surgical intervention is rarely indicated and only considered after skeletal maturity for persistent, debilitating pain due to ununited ossicles that act as a mechanical irritant.Given the patient is 15 years old and still skeletally immature (implied by the active apophysis), the MOST appropriate next step is typically continued, often more intensive, conservative management. This could include further activity modification, specific bracing, eccentric quadriceps strengthening, or temporary immobilization. Corticosteroid injections are contraindicated due to the risk of tendon rupture.Rationale for options:A. Continued conservative management, with specific focus on activity modification, pain management, and physical therapy, remains the cornerstone until skeletal maturity. The condition is self-limiting and surgical intervention is typically reserved for those who have failed all conservative measuresafterskeletal maturity. This is the correct answer.B. Surgical excision of ossicles and debridement of the patellar tendon insertion is a rare indication, reserved for patients who have persistent, debilitating pain from ununited ossiclesafterskeletal maturity and failed extensive conservative management.C. Corticosteroid injection into the patellar tendon or tibial tuberosity is contraindicated due to the risk of tendon weakening, rupture, and skin atrophy.D. Patellar tendon realignment surgery is typically for patellar instability, not for Osgood-Schlatter disease.E. High tibial osteotomy is performed for unicompartmental knee osteoarthritis with varus deformity, not Osgood-Schlatter disease.

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