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4. Pediatrics MCQs

Practice Set 169 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 3361

Topic: 4. Pediatrics

A 2-year-old girl is noted to have anterolateral bowing of her left tibia. Radiographs reveal sclerosis and a narrowed medullary canal at the apex of the bow. Her history is significant for multiple cafe-au-lait spots. What is the most likely diagnosis?

. Posteromedial bowing of the tibia
. Blount disease
. Osteogenesis imperfecta
. Congenital pseudarthrosis of the tibia
. Fibrous dysplasia

Correct Answer & Explanation

. Congenital pseudarthrosis of the tibia

Explanation

Anterolateral bowing of the tibia with a narrowed medullary canal is the classic presentation of congenital pseudarthrosis of the tibia (CPT). It is strongly associated with Neurofibromatosis type 1 (NF1).

Question 3362

Topic: Pediatric Hip
A 7-year-old boy presents with a painless limp. Radiographs demonstrate sclerosis and fragmentation of the left femoral head. According to the Herring lateral pillar classification for Legg-Calvé-Perthes disease, a patient with >50% but <100% maintenance of lateral pillar height is classified as:
. Group A
. Group B
. Group B/C
. Group C
. Group D

Correct Answer & Explanation

. Group B

Explanation

In the Herring lateral pillar classification, Group B indicates >50% but <100% maintenance of the lateral pillar height. Group C is defined as <50% of the lateral pillar height maintained.

Question 3363

Topic: 4. Pediatrics

A 6-year-old girl with spastic quadriplegic cerebral palsy (GMFCS Level V) is evaluated for hip surveillance. An AP pelvis radiograph demonstrates a migration percentage (Reimer's index) of 45% bilaterally. What is the most appropriate management?

. Continued observation with annual radiographs
. Botulinum toxin injections to the adductors
. Adductor and iliopsoas releases
. Varus derotational osteotomy (VDRO) and pelvic osteotomy
. Total hip arthroplasty

Correct Answer & Explanation

. Varus derotational osteotomy (VDRO) and pelvic osteotomy

Explanation

In non-ambulatory children with CP and a hip migration percentage >40%, reconstructive surgery including VDRO and often a pelvic osteotomy is indicated to prevent painful dislocation. Soft tissue releases alone are insufficient at this stage.

Question 3364

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarchal female with Adolescent Idiopathic Scoliosis presents with a right thoracic curve of 32 degrees. Her Risser stage is 0, and her Sanders maturity scale is 2. What is the most appropriate treatment recommendation?

. Observation with radiographs in 6 months
. Physical therapy alone
. Full-time TLSO bracing
. Posterior spinal fusion
. Anterior vertebral body tethering

Correct Answer & Explanation

. Full-time TLSO bracing

Explanation

Bracing is indicated for skeletally immature patients (Risser 0-2, premenarchal) with an AIS curve between 25 and 45 degrees. A TLSO brace worn 16-23 hours a day decreases the risk of curve progression to a surgical threshold.

Question 3365

Topic: 4. Pediatrics
A 5-year-old child with severe osteogenesis imperfecta (Type III) has suffered multiple femur and tibia fractures resulting in progressive bowing deformities. Which surgical intervention is the gold standard for correcting the deformity and preventing further fractures in this patient?
. Multi-level closing wedge osteotomies with plate fixation
. External fixator application
. Sofield-Millar procedure with extensible intramedullary nailing
. Rigid unreamed intramedullary nailing
. Administration of intravenous pamidronate alone

Correct Answer & Explanation

. Sofield-Millar procedure with extensible intramedullary nailing

Explanation

The Sofield-Millar procedure (multiple osteotomies) combined with extensible (telescoping) intramedullary rods, such as Fassier-Duval nails, is the surgical gold standard. This corrects long bone deformities and prevents fractures in growing children with severe OI.

Question 3366

Topic: Pediatric Hip

An 11-year-old boy with obesity presents with 2 weeks of worsening left groin pain and an inability to bear weight that started acutely yesterday. Radiographs confirm an acute-on-chronic slipped capital femoral epiphysis. Which of the following is the most significant risk factor for developing avascular necrosis in this patient?

. Duration of prodromal symptoms
. Severity of the slip angle
. Inability to bear weight at presentation
. Open triradiate cartilage
. Use of a single screw for fixation

Correct Answer & Explanation

. Inability to bear weight at presentation

Explanation

According to the Loder classification, an unstable SCFE is defined by the inability to bear weight, even with crutches. Unstable slips carry a much higher risk of avascular necrosis (up to 47%) compared to stable slips.

Question 3367

Topic: Pediatric Upper Extremity & Spine

A 5-year-old girl sustains a severely displaced extension-type supracondylar humerus fracture. On presentation, her hand is warm and pink, but the radial pulse is not palpable. After closed reduction and percutaneous pinning, the hand remains pink and warm, but the pulse is still absent. What is the most appropriate next step in management?

. Immediate vascular exploration
. Observe and admit for 24-48 hours
. Perform a CT angiogram
. Remove the pins and perform an open reduction
. Administer intravenous heparin

Correct Answer & Explanation

. Observe and admit for 24-48 hours

Explanation

In a pulseless but pink and well-perfused hand following reduction and pinning of a supracondylar fracture, observation is recommended. The collateral circulation is adequate, and the radial pulse often returns within a few days due to the resolution of vasospasm.

Question 3368

Topic: Pediatric Lower Extremity

A 4-year-old boy who was successfully treated for idiopathic clubfoot with the Ponseti method presents with a relapse. Examination reveals dynamic supination during the swing phase of gait and fixed equinus. He has been compliant with bracing. What is the most appropriate surgical intervention?

. Posteromedial release
. Split anterior tibial tendon transfer and Achilles tendon lengthening
. Cuboid decancellation
. Lateral column shortening
. Talonavicular arthrodesis

Correct Answer & Explanation

. Split anterior tibial tendon transfer and Achilles tendon lengthening

Explanation

Relapse in a young child treated with the Ponseti method often presents with dynamic supination. The treatment of choice is a split anterior tibial tendon transfer (to the lateral cuneiform) combined with Achilles tendon lengthening for the equinus contracture.

Question 3369

Topic: Pediatric Hip

A 6-week-old female is being treated with a Pavlik harness for developmental dysplasia of the hip. During a follow-up visit, the parents note she has stopped kicking her left leg. On exam, there is an absent patellar reflex and lack of active knee extension on the left. What is the most appropriate management?

. Adjust the anterior strap to increase flexion
. Adjust the posterior strap to increase abduction
. Remove the harness and transition to a rigid abduction orthosis
. Remove the harness and observe until neurologic function returns
. Proceed to immediate closed reduction and spica casting

Correct Answer & Explanation

. Remove the harness and observe until neurologic function returns

Explanation

The patient has developed a femoral nerve palsy, a known complication of hyperflexion in a Pavlik harness. The harness must be removed immediately to allow for neurologic recovery, which usually occurs within a few weeks, before resuming DDH treatment.

Question 3370

Topic: Pediatric Hip
An 8-year-old boy is diagnosed with Legg-Calvé-Perthes disease. Radiographs reveal fragmentation with maintenance of more than 50% of the lateral pillar height. According to the Herring classification, which group does this represent, and what is the typical recommendation?
. Group A; conservative management
. Group B; surgical containment
. Group B; conservative management
. Group C; surgical containment
. Group C; salvage procedure

Correct Answer & Explanation

. Group B; surgical containment

Explanation

This is a Herring Group B classification (lateral pillar height >50% but <100%). In children over the age of 8, surgical containment (e.g., femoral or pelvic osteotomy) for Group B hips yields better long-term outcomes than conservative management.

Question 3371

Topic: 4. Pediatrics

A 6-year-old child with spastic quadriplegic cerebral palsy is unable to walk and sits in a wheelchair (GMFCS level V). Routine hip surveillance radiographs show a Reimers migration percentage of 45% bilaterally. What is the recommended management?

. Observation with repeat radiographs in 1 year
. Botulinum toxin injections to the adductors
. Bilateral adductor tenotomies
. Bilateral varus derotational osteotomies (VDRO)
. Bilateral proximal femoral resections

Correct Answer & Explanation

. Bilateral varus derotational osteotomies (VDRO)

Explanation

A migration percentage greater than 40% in a child with spastic cerebral palsy typically necessitates bony reconstructive surgery (VDRO) to prevent painful dislocation. Soft tissue releases alone are insufficient at this degree of subluxation.

Question 3372

Topic: 4. Pediatrics
A 13-year-old girl presents after an external rotation ankle injury. Radiographs and CT show a fracture line extending through the distal tibial epiphysis on the sagittal view and through the metaphysis on the coronal view. How is this fracture classified overall according to the Salter-Harris system?
. Salter-Harris I
. Salter-Harris II
. Salter-Harris III
. Salter-Harris IV
. Salter-Harris V

Correct Answer & Explanation

. Salter-Harris IV

Explanation

A triplane fracture is considered an overall Salter-Harris IV equivalent because the fracture lines cross the epiphysis, physis, and metaphysis. It typically occurs in early adolescence as the distal tibial physis closes asymmetrically.

Question 3373

Topic: Pediatric Hip

An 11-year-old boy with obesity presents with acute left groin pain and inability to bear weight after a minor fall. He has a 3-week history of mild limp. Radiographs confirm an unstable slipped capital femoral epiphysis (SCFE). In addition to urgent in situ pinning of the left hip, what is the most appropriate management regarding the contralateral hip?

. Observation with clinical follow-up only
. Routine prophylactic pinning of the right hip
. Prophylactic pinning of the right hip only if the modified Oxford bone age score is low
. Immediate open reduction of the left hip and prophylactic pinning of the right hip
. Bilateral spica casting

Correct Answer & Explanation

. Prophylactic pinning of the right hip only if the modified Oxford bone age score is low

Explanation

Prophylactic pinning of the contralateral hip is indicated in patients with a high risk of a second slip, such as those with endocrine disorders or significant remaining growth (e.g., modified Oxford bone age score <= 16). Routine prophylactic pinning without risk stratification is not universally recommended.

Question 3374

Topic: Pediatric Upper Extremity & Spine

A 6-year-old girl sustains a severely displaced extension-type supracondylar humerus fracture. After closed reduction and percutaneous pinning, the hand is pink but lacks a palpable radial pulse. Capillary refill is less than 2 seconds. What is the most appropriate next step in management?

. Immediate exploration of the brachial artery
. Intravenous heparin infusion
. Removal of pins and open reduction
. Observation with close neurovascular monitoring
. Compartment fasciotomies

Correct Answer & Explanation

. Observation with close neurovascular monitoring

Explanation

A "pink, pulseless" hand after reduction and pinning of a supracondylar humerus fracture with adequate perfusion (capillary refill < 2 seconds) should be observed closely. Vascular exploration is indicated if the hand becomes pale and dysvascular after an anatomic reduction.

Question 3375

Topic: 4. Pediatrics

A 5-year-old boy with Gross Motor Function Classification System (GMFCS) level V cerebral palsy is undergoing routine surveillance. An anteroposterior pelvic radiograph shows a Reimers migration percentage of 45% bilaterally. He is pain-free. What is the most appropriate treatment?

. Observation with repeat radiographs in 1 year
. Botulinum toxin A injections to the hip adductors
. Bilateral adductor tenotomies
. Bilateral varus derotational osteotomies (VDRO) with or without pelvic osteotomies
. Bilateral proximal femoral resection interposition arthroplasties

Correct Answer & Explanation

. Bilateral varus derotational osteotomies (VDRO) with or without pelvic osteotomies

Explanation

In a child with cerebral palsy, a migration percentage >40-50% indicates significant hip subluxation with a high risk of progression to dislocation. Reconstructive surgery, typically involving a varus derotational osteotomy (VDRO) and often a pelvic osteotomy, is the treatment of choice to prevent painful dislocation.

Question 3376

Topic: Pediatric Lower Extremity
A 3-year-old child with a history of idiopathic clubfoot treated successfully with the Ponseti method presents with a dynamic supination deformity during the swing phase of gait. Passive range of motion is full, and the foot is plantigrade. What is the most appropriate surgical intervention?
. Achilles tendon lengthening
. Split anterior tibial tendon transfer (SPLATT)
. Complete anterior tibial tendon transfer to the lateral cuneiform
. Posteromedial soft tissue release
. Calcaneal sliding osteotomy

Correct Answer & Explanation

. Complete anterior tibial tendon transfer to the lateral cuneiform

Explanation

Dynamic supination of the foot in a toddler with a treated clubfoot represents a relapse often driven by an overactive anterior tibial tendon. Transfer of the entire anterior tibial tendon to the lateral cuneiform balances the foot and corrects the dynamic deformity.

Question 3377

Topic: Pediatric Hip

An 18-month-old girl is brought in for a waddling gait. Radiographs reveal a completely dislocated left hip with a false acetabulum and an acetabular index of 42 degrees. What is the most appropriate management?

. Pavlik harness application
. Closed reduction and spica casting
. Open reduction, femoral shortening, and pelvic osteotomy
. Arthroscopic debridement and reduction
. Observation until age 3

Correct Answer & Explanation

. Open reduction, femoral shortening, and pelvic osteotomy

Explanation

Children presenting with DDH between 18 and 24 months of age typically require open reduction due to soft tissue contractures and acetabular dysplasia. Concomitant femoral shortening minimizes avascular necrosis risk, and a pelvic osteotomy corrects the severe acetabular dysplasia.

Question 3378

Topic: 4. Pediatrics
A 4-year-old girl with obesity presents with progressive bowing of her left leg. Radiographs show varus deformity of the proximal tibia with a metaphyseal-diaphyseal angle of 18 degrees and profound depression of the medial tibial plateau (Langenskiöld stage IV). What is the recommended treatment?
. Knee-ankle-foot orthosis (KAFO)
. Proximal tibial valgus osteotomy alone
. Proximal tibial valgus osteotomy with elevation of the medial plateau
. Guided growth with a lateral tension band plate
. Observation

Correct Answer & Explanation

. Proximal tibial valgus osteotomy with elevation of the medial plateau

Explanation

Infantile Blount's disease with severe medial plateau depression (Langenskiöld stage IV or higher) in a child older than 3-4 years requires surgical intervention. Proximal tibial osteotomy combined with elevation of the depressed medial tibial plateau is necessary to restore joint congruity and correct the mechanical axis.

Question 3379

Topic: Pediatric Hip
An 8-year-old boy presents with a 6-month history of right hip pain and a painless limp. AP and frog-leg lateral radiographs show sclerosis and fragmentation of the lateral pillar of the femoral head. Dynamic arthrogram demonstrates hinge abduction. What is the most appropriate management?
. Observation and non-weight bearing
. A-frame bracing
. Adductor tenotomy and petrie cast application
. Proximal femoral varus osteotomy or pelvic osteotomy
. Core decompression

Correct Answer & Explanation

. Proximal femoral varus osteotomy or pelvic osteotomy

Explanation

In Legg-Calvé-Perthes disease, hinge abduction is a sign of severe impingement between the extruded, deformed femoral head and the lateral acetabular margin. Surgical containment via proximal femoral or pelvic osteotomy is required to redirect the head into the acetabulum and restore congruity.

Question 3380

Topic: 4. Pediatrics
A 14-year-old boy sustains an ankle injury while playing soccer. Radiographs and CT scan reveal a displaced Salter-Harris III fracture of the anterolateral aspect of the distal tibial epiphysis. Which ligament is primarily responsible for the avulsion of this fracture fragment?
. Anterior talofibular ligament (ATFL)
. Calcaneofibular ligament (CFL)
. Deltoid ligament
. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

A juvenile Tillaux fracture is a Salter-Harris III fracture of the anterolateral distal tibial epiphysis. It occurs because the anterior inferior tibiofibular ligament (AITFL) avulses the fragment during an external rotation force, due to the asymmetric closure pattern of the distal tibial physis.

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