Menu

4. Pediatrics MCQs

Practice Set 120 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 2381

Topic: 4. Pediatrics

A 5-year-old child presents to the emergency department after a minor fall. A lateral cervical radiograph shows 3 mm of anterior translation of C2 on C3. Swischuk's line is evaluated. Which of the following findings confirms physiologic pseudosubluxation rather than true injury?

. The anterior aspect of the posterior arch of C2 lies within 1 mm of the line connecting the posterior arches of C1 and C3
. The line passes 3 mm anterior to the posterior arch of C2
. The predental space measures 4 mm
. The retropharyngeal space is 10 mm wide
. The spinolaminar line of C2 is displaced 3 mm posterior

Correct Answer & Explanation

. The anterior aspect of the posterior arch of C2 lies within 1 mm of the line connecting the posterior arches of C1 and C3

Explanation

Swischuk's line connects the anterior aspects of the posterior arches of C1 and C3. In normal pseudosubluxation, the anterior aspect of the C2 posterior arch should deviate less than 1.5 to 2 mm from this line.

Question 2382

Topic: Pediatric Upper Extremity & Spine

In the Lenke classification for adolescent idiopathic scoliosis, a curve with a structural proximal thoracic curve, a structural main thoracic curve, and a nonstructural thoracolumbar curve is classified as which type?

. Type 1 (Main Thoracic)
. Type 2 (Double Thoracic)
. Type 3 (Double Major)
. Type 4 (Triple Major)
. Type 5 (Thoracolumbar/Lumbar)

Correct Answer & Explanation

. Type 2 (Double Thoracic)

Explanation

Lenke Type 2 is a Double Thoracic curve pattern, characterized by structural proximal and main thoracic curves, while the thoracolumbar/lumbar curve remains nonstructural.

Question 2383

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarchal girl presents for evaluation of a spinal deformity. Examination reveals a right thoracic prominence. Radiographs show a right-sided structural main thoracic curve of 36 degrees. Her Risser stage is 1. What is the most appropriate next step in management?

. Observation with repeat radiographs in 6 months
. Nighttime-only bending brace
. Thoracolumbosacral orthosis (TLSO) for 16-23 hours per day
. Posterior spinal fusion with instrumentation
. Anterior vertebral body tethering

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) for 16-23 hours per day

Explanation

This patient has Adolescent Idiopathic Scoliosis (AIS) with a curve between 25-45 degrees, significant remaining growth (premenarchal, Risser 1), and is at high risk for progression. Full-time bracing (TLSO) with a dose-response goal of >18 hours daily has been shown to effectively decrease the progression of curves to the surgical threshold.

Question 2384

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl is diagnosed with Adolescent Idiopathic Scoliosis. Her standing posteroanterior radiograph shows a 50-degree right thoracic curve and a 35-degree left lumbar curve. On dynamic side-bending radiographs, the thoracic curve corrects to 30 degrees and the lumbar curve corrects to 15 degrees. According to the Lenke Classification system, how is the lumbar curve defined?

. Major structural
. Minor structural
. Non-structural
. Compensatory structural
. Fractional curve

Correct Answer & Explanation

. Non-structural

Explanation

In the Lenke Classification system, a minor curve is considered non-structural if it bends out to less than 25 degrees on side-bending radiographs. Since her lumbar curve corrects to 15 degrees, it is non-structural, classifying this as a Lenke Type 1 (Main Thoracic) curve.

Question 2385

Topic: Pediatric Upper Extremity & Spine

A 12-year-old girl is evaluated for a spinal deformity. She is premenarchal, has open triradiate cartilages, and is Risser 0. Radiographs reveal a right thoracic adolescent idiopathic scoliosis (AIS) curve of 35 degrees. What is the most appropriate management?

. Observation with follow-up radiographs in 6 months
. Part-time bracing (8-10 hours/day)
. Full-time bracing (16-23 hours/day)
. Posterior spinal fusion
. Physical therapy and core strengthening

Correct Answer & Explanation

. Full-time bracing (16-23 hours/day)

Explanation

In a highly immature patient (Risser 0, open triradiate cartilage, premenarchal) with an AIS curve between 25 and 44 degrees, full-time bracing (16-23 hours/day) is indicated to prevent curve progression. Observation is inappropriate given her extremely high risk of progression.

Question 2386

Topic: 4. Pediatrics

A 13-year-old premenarchal girl presents with a right thoracic curve of 32 degrees. Her Risser stage is 1. What is the most appropriate management?

. Observation with radiographs in 6 months
. Thoracolumbosacral orthosis (TLSO) bracing for 18 hours daily
. Nighttime bending brace
. Posterior spinal fusion
. Physical therapy and core strengthening

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing for 18 hours daily

Explanation

In a growing child (Risser 0-2, premenarchal) with an idiopathic curve between 25 and 45 degrees, bracing is indicated. A rigid TLSO worn for at least 18 hours a day has been shown to significantly decrease the risk of curve progression to surgical magnitude.

Question 2387

Topic: Pediatric Upper Extremity & Spine

A 14-year-old Risser 0 female presents with adolescent idiopathic scoliosis. A standing posteroanterior radiograph demonstrates a right thoracic curve measuring 52 degrees and a left lumbar curve measuring 35 degrees. On supine lateral bending films, the thoracic curve reduces to 28 degrees and the lumbar curve reduces to 15 degrees. Sagittal alignment is normal. What is the most appropriate surgical strategy?

. Selective thoracic fusion
. Anterior lumbar interbody fusion
. Posterior spinal fusion from T4 to L4
. Vertical Expandable Prosthetic Titanium Rib (VEPTR) insertion
. Thoracolumbosacral orthosis (TLSO) bracing

Correct Answer & Explanation

. Selective thoracic fusion

Explanation

This patient has a Lenke Type 1 curve, defined by a structural main thoracic curve (residual bend >25 degrees) and a non-structural lumbar curve (bends to <25 degrees). The gold standard surgical treatment is a selective thoracic fusion, which corrects the primary deformity while preserving lumbar motion segments.

Question 2388

Topic: Pediatric Upper Extremity & Spine

According to the Lenke Classification system for adolescent idiopathic scoliosis, a proximal thoracic curve is considered structural if a supine side-bending radiograph shows a residual Cobb angle of at least what magnitude?

. 10 degrees
. 15 degrees
. 20 degrees
. 25 degrees
. 35 degrees

Correct Answer & Explanation

. 25 degrees

Explanation

In the Lenke classification, minor curves are considered structural if they fail to bend out to less than 25 degrees on side-bending radiographs, or if there is a regional kyphosis of >20 degrees.

Question 2389

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal girl (Risser 0) presents with Adolescent Idiopathic Scoliosis. Standing radiographs demonstrate a right thoracic curve of 32 degrees. What is the most appropriate management?

. Observation with radiographs in 6 months
. Nighttime bending brace
. Thoracolumbosacral orthosis (TLSO) bracing
. Posterior spinal fusion with instrumentation
. Anterior vertebral body tethering

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing

Explanation

A patient with significant growth remaining (premenarchal, Risser 0) and a curve between 25 and 45 degrees meets the classic indications for bracing. A TLSO worn for 16-23 hours a day is standard of care to halt progression.

Question 2390

Topic: Pediatric Upper Extremity & Spine

According to the Lenke classification for adolescent idiopathic scoliosis, a minor curve is considered 'structural' and should generally be included in the fusion construct if it demonstrates which characteristic on side-bending radiographs?

. Fails to correct to less than 25 degrees
. Fails to correct to 0 degrees
. Shows greater than Grade II Nash-Moe rotation
. Maintains a Cobb angle of >10 degrees
. Shows translation greater than 1 cm

Correct Answer & Explanation

. Fails to correct to less than 25 degrees

Explanation

In the Lenke classification, a secondary or minor curve is defined as structural if it remains greater than or equal to 25 degrees on maximum voluntary side-bending radiographs.

Question 2391

Topic: Pediatric Upper Extremity & Spine

According to the Lenke Classification for Adolescent Idiopathic Scoliosis, what specific radiographic criterion defines a "structural" proximal thoracic curve?

. Cobb angle > 25 degrees on side-bending radiographs
. Cobb angle > 10 degrees on side-bending radiographs
. Kyphosis (T2-T5) of at least +20 degrees
. Apical vertebral translation > 2 cm
. Nash-Moe rotation of Grade 3

Correct Answer & Explanation

. Cobb angle > 25 degrees on side-bending radiographs

Explanation

In the Lenke classification, a minor curve is considered structural if it does not correct to less than 25 degrees on supine side-bending radiographs, or if there is a regional kyphosis of >20 degrees.

Question 2392

Topic: Pediatric Upper Extremity & Spine

At what Risser stage and Cobb angle is rigid brace treatment typically indicated for Adolescent Idiopathic Scoliosis (AIS)?

. Risser 0-2 with a curve of 15-20 degrees
. Risser 0-2 with a curve of 25-40 degrees
. Risser 4-5 with a curve of 25-40 degrees
. Risser 0-2 with a curve > 50 degrees
. Risser 4-5 with a curve of 15-20 degrees

Correct Answer & Explanation

. Risser 0-2 with a curve of 25-40 degrees

Explanation

Bracing for AIS is indicated in skeletally immature patients (Risser 0-2, pre-menarchal) with a Cobb angle between 25 and 40 degrees, or documented curve progression of 5 degrees in curves between 20 and 25 degrees.

Question 2393

Topic: Pediatric Upper Extremity & Spine

A 14-year-old female with adolescent idiopathic scoliosis (AIS) has a right main thoracic curve of 52 degrees and a left lumbar curve of 34 degrees. On side-bending radiographs, the thoracic curve corrects to 30 degrees and the lumbar curve corrects to 15 degrees. Thoracic kyphosis (T5-T12) is +15 degrees. According to the Lenke classification, what is the appropriate curve type and recommended fusion approach?

. Lenke 1 (Main Thoracic), selective thoracic fusion
. Lenke 2 (Double Thoracic), fusion extending to the upper thoracic spine
. Lenke 3 (Double Major), combined thoracic and lumbar fusion
. Lenke 5 (Thoracolumbar/Lumbar), selective lumbar fusion
. Lenke 6 (Thoracolumbar/Lumbar-Main Thoracic), combined fusion

Correct Answer & Explanation

. Lenke 1 (Main Thoracic), selective thoracic fusion

Explanation

This is a Lenke 1 curve because the main thoracic curve is structural (>25 degrees on bending) while the lumbar curve is nonstructural (<25 degrees on bending). The standard surgical treatment for a Lenke 1 curve is a selective thoracic fusion, sparing the lumbar spine.

Question 2394

Topic: 4. Pediatrics
A 14-year-old boy sustains a Salter-Harris type III fracture of the anterolateral distal tibia. Which of the following accurately describes the mechanism of this injury and the anatomic structure responsible for the fracture pattern?
. Inversion mechanism; pull of the anterior talofibular ligament
. External rotation mechanism; pull of the anterior inferior tibiofibular ligament
. Axial loading; impact of the talar dome
. Plantarflexion mechanism; pull of the posterior talofibular ligament
. Eversion mechanism; pull of the deltoid ligament

Correct Answer & Explanation

. External rotation mechanism; pull of the anterior inferior tibiofibular ligament

Explanation

This describes a juvenile Tillaux fracture, which is an avulsion of the anterolateral distal tibial epiphysis. It is caused by an external rotation force with avulsion mediated by the anterior inferior tibiofibular ligament (AITFL) before the lateral physis closes.

Question 2395

Topic: 4. Pediatrics

A 14-year-old boy sustains an external rotation ankle injury. Radiographs reveal a fracture of the anterolateral aspect of the distal tibial epiphysis (Tillaux fracture). What is the underlying anatomical reason for this specific fracture pattern?

. The deltoid ligament is stronger than the medial malleolus
. The syndesmosis completely tears prior to bone failure
. The anterolateral physis is the last portion of the distal tibial physis to close
. The AITFL avulses the posterolateral tibia
. The medial physis remains open the longest

Correct Answer & Explanation

. The anterolateral physis is the last portion of the distal tibial physis to close

Explanation

The distal tibial physis closes from central, to medial, to anterolateral. The open anterolateral physis is the point of least resistance, leading to avulsion by the AITFL.

Question 2396

Topic: 4. Pediatrics
A 14-year-old boy injures his ankle while skateboarding. Radiographs demonstrate a Salter-Harris III fracture of the anterolateral distal tibia. Avulsion of which of the following ligaments is responsible for this specific fracture pattern?
. Posterior inferior tibiofibular ligament (PITFL)
. Deltoid ligament
. Calcaneofibular ligament (CFL)
. Anterior inferior tibiofibular ligament (AITFL)
. Interosseous membrane

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

This is a juvenile Tillaux fracture, caused by external rotation of the foot. The anterior inferior tibiofibular ligament (AITFL) avulses the anterolateral distal tibial epiphysis because the medial portion of the physis closes before the lateral portion.

Question 2397

Topic: Pediatric Lower Extremity

A 48-year-old female presents with chronic, progressive midfoot pain and a newly developing planovarus deformity. Radiographs demonstrate comminution, sclerosis, and a 'comma-shaped' deformity of the tarsal navicular. What is the most likely diagnosis?

. Muller-Weiss syndrome
. Kohler disease
. Freiberg's infraction
. Charcot neuroarthropathy
. Sever's disease

Correct Answer & Explanation

. Muller-Weiss syndrome

Explanation

Muller-Weiss syndrome is spontaneous adult-onset osteonecrosis of the tarsal navicular, characterized by a comma-shaped navicular and progressive midfoot collapse. Kohler disease is also navicular osteonecrosis but occurs in young children.

Question 2398

Topic: 4. Pediatrics
A 13-year-old boy presents with ankle pain after a fall while skateboarding. Radiographs reveal a Salter-Harris type III fracture of the anterolateral aspect of the distal tibia. Which of the following ligaments is primarily responsible for the avulsion of this fracture fragment?
. Anterior talofibular ligament (ATFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Calcaneofibular ligament (CFL)
. Anterior inferior tibiofibular ligament (AITFL)
. Deltoid ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

A juvenile Tillaux fracture is a Salter-Harris III fracture of the anterolateral distal tibia. It occurs due to avulsion by the anterior inferior tibiofibular ligament (AITFL) during an external rotation mechanism, as the medial physis closes before the lateral physis.

Question 2399

Topic: Pediatric Lower Extremity

A 28-year-old woman presents with bilateral progressive cavovarus foot deformities. A Coleman block test is performed, which neutralizes the hindfoot varus to neutral. Which of the following muscle imbalances is the primary driver of this patient's forefoot-driven hindfoot varus?

. Overpull of the tibialis anterior relative to the peroneus longus
. Overpull of the peroneus longus relative to the tibialis anterior
. Overpull of the peroneus brevis relative to the tibialis posterior
. Weakness of the gastrocnemius-soleus complex
. Spasticity of the extensor digitorum longus

Correct Answer & Explanation

. Overpull of the peroneus longus relative to the tibialis anterior

Explanation

In Charcot-Marie-Tooth disease, a forefoot-driven cavovarus deformity is typically initiated by an overpull of the peroneus longus relative to a weak tibialis anterior, leading to a rigidly plantarflexed first ray. The Coleman block test confirms the hindfoot varus is flexible and driven by the forefoot.

Question 2400

Topic: 4. Pediatrics

A 2-year-old child is brought in by his parents for evaluation of intoeing. The child has a normal neuromuscular examination, but the heel bisector line is in the fourth web space, indicating a severe flexible metatarsus adductus deformity. The remainder of the lower extremity examination is unremarkable. What is the most appropriate treatment?

. Observation as the deformity should resolve in time
. Wearing of straight last shoes
. Serial stretching and casting for the next 6 to 12 weeks
. Heyman, Herndon, and Strong capsular release at the tarsometatarsal and intermetatarsal joints
. Berman and Gartland dome-shaped osteotomies of the metatarsal bases

Correct Answer & Explanation

. Serial stretching and casting for the next 6 to 12 weeks

Explanation

Weinstein reported on 31 patients (45 feet) with congenital metatarsus adductus followed for an average of 33 years. Twenty-nine feet had moderate to severe deformities treated with manipulation and casting with a 90% success rate. In a young child, surgery is not indicated until nonsurgical management has failed. In patients 2 to 4 years of age, tarsometatarsal capsulotomies are indicated, whereas multiple metatarsal osteotomies are reserved for recalcitrant deformities in children older than 4 years of age. Mild or moderate metatarsus adductus that is passively correctable will resolve without treatment. Beaty J: Congenital anomalies of the lower extremity, in Canale ST (ed): Campbell's Operative Orthopaedics, ed 10. Philadelphia PA, Mosby, 2003, pp 983-988. Katz K, David R, Soudry M: Below-knee plaster cast for the treatment of metatarsus adductus. J Pediatr Orthop 1999;19:49-50.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page