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4. Pediatrics MCQs

Practice Set 178 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 3541

Topic: 4. Pediatrics
A 14-year-old boy presents with an ankle injury after falling off a skateboard. Radiographs reveal a Salter-Harris III fracture of the anterolateral distal tibia. Avulsion of which ligament is responsible for this fracture pattern?
. Anterior talofibular ligament
. Calcaneofibular ligament
. Deltoid ligament
. Anterior inferior tibiofibular ligament
. Posterior inferior tibiofibular ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament

Explanation

A juvenile Tillaux fracture is a Salter-Harris III fracture of the anterolateral distal tibia. It is caused by an avulsion of the anterior inferior tibiofibular ligament (AITFL) occurring because the medial aspect of the distal tibial physis closes before the lateral aspect.

Question 3542

Topic: Pediatric Hip

A 13-year-old boy presents to the emergency department with acute right hip pain after a minor fall. He is unable to bear weight. Radiographs demonstrate a slipped capital femoral epiphysis (SCFE) with 40 degrees of slip. What is the most significant risk associated with this specific presentation compared to a patient who is able to bear weight?

. Chondrolysis
. Avascular necrosis (AVN)
. Slip progression
. Cam impingement
. Leg length discrepancy

Correct Answer & Explanation

. Avascular necrosis (AVN)

Explanation

This patient has an unstable SCFE, defined by the inability to bear weight even with crutches. Unstable SCFE carries a significantly higher risk of avascular necrosis (AVN), up to 50%, compared to nearly 0% in stable SCFE.

Question 3543

Topic: Pediatric Hip

A 6-week-old female infant is referred for an ultrasound of the hips due to a breech presentation. The ultrasound report notes an alpha angle of 50 degrees and a beta angle of 65 degrees. According to the Graf classification, what is the most appropriate management for this patient?

. Observation with a repeat ultrasound in 4 weeks
. Application of a Pavlik harness
. Closed reduction and spica casting
. Open reduction and capsulorrhaphy
. Varus derotational osteotomy

Correct Answer & Explanation

. Application of a Pavlik harness

Explanation

An alpha angle less than 60 degrees indicates developmental dysplasia of the hip (Graf Type IIb or worse depending on age and specific angle). Treatment with a Pavlik harness is indicated for dysplastic hips in infants younger than 6 months.

Question 3544

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains a completely displaced, extension-type supracondylar humerus fracture. On presentation, the hand is pink but lacks a palpable radial pulse. Following closed reduction and percutaneous pinning, the fracture is anatomically aligned, but the radial pulse remains absent while the hand remains warm and pink. What is the most appropriate next step in management?

. Immediate exploration of the brachial artery
. Arteriography of the upper extremity
. Observation and admission for close neurovascular monitoring
. Application of a warm compress to the antecubital fossa
. Removal of pins and open reduction

Correct Answer & Explanation

. Observation and admission for close neurovascular monitoring

Explanation

For a pink, pulseless hand following anatomic reduction and pinning of a supracondylar humerus fracture, close clinical observation is the standard of care. Arterial exploration is indicated if the hand becomes pale and poorly perfused.

Question 3545

Topic: Pediatric Lower Extremity
A 4-year-old boy with a history of right idiopathic clubfoot treated successfully with the Ponseti method presents with a new gait abnormality. His parents note that he walks on the outside of his right foot. Examination reveals dynamic supination during the swing phase of gait, but the foot is passively correctable. What is the most appropriate surgical intervention?
. Achilles tendon lengthening
. Posteromedial release
. Split anterior tibial tendon transfer (SPLATT)
. Whole tibialis anterior tendon transfer to the lateral cuneiform
. Calcaneocuboid wedge osteotomy

Correct Answer & Explanation

. Whole tibialis anterior tendon transfer to the lateral cuneiform

Explanation

Dynamic supination in a previously corrected clubfoot is typically caused by an overactive tibialis anterior muscle. The treatment of choice for a flexible deformity in this age group is transfer of the entire tibialis anterior tendon to the lateral cuneiform.

Question 3546

Topic: 4. Pediatrics

An 8-month-old infant with achondroplasia is noted by her parents to have episodes of apnea during sleep. She also exhibits brisk lower extremity reflexes and sustained clonus. Which of the following diagnostic studies is most urgent?

. Polysomnography
. Echocardiogram
. MRI of the craniocervical junction
. CT scan of the temporal bone
. Radiographs of the thoracolumbar spine

Correct Answer & Explanation

. MRI of the craniocervical junction

Explanation

Infants with achondroplasia are at high risk for foramen magnum stenosis, which can lead to cervicomedullary compression, central sleep apnea, hyperreflexia, and sudden death. Urgent MRI of the craniocervical junction is required to assess the need for foramen magnum decompression.

Question 3547

Topic: 4. Pediatrics
A 4-year-old girl is evaluated for worsening bilateral genu varum. Radiographs demonstrate an abrupt medial angulation of the proximal tibial metaphysis with depression of the medial aspect of the physis, consistent with Langenskiold stage III infantile Blount disease. Conservative management with bracing has failed. What is the most appropriate next step in management?
. Continued observation until skeletal maturity
. Guided growth with medial tension band plates
. Proximal tibial and fibular valgus-producing osteotomy
. Epiphysiodesis of the lateral proximal tibia
. Medial plateau elevation osteotomy

Correct Answer & Explanation

. Proximal tibial and fibular valgus-producing osteotomy

Explanation

For Langenskiold stage III infantile Blount disease in a 4-year-old child where bracing has failed, a proximal tibial valgus-producing osteotomy (with fibular osteotomy) is the gold standard. Guided growth alone is less reliable in advanced stages with significant physeal depression.

Question 3548

Topic: Pediatric Hip

A 12-year-old obese boy presents with sudden inability to bear weight on his left leg after a minor fall. Radiographs show a severe left slipped capital femoral epiphysis (SCFE). He has a known medical history of panhypopituitarism. What is the most appropriate management for the contralateral, asymptomatic right hip?

. Observation with routine radiographic follow-up
. Prophylactic in situ pinning
. Spica casting
. Dunn procedure
. Valgus intertrochanteric osteotomy

Correct Answer & Explanation

. Prophylactic in situ pinning

Explanation

Prophylactic pinning of the contralateral hip is highly recommended in patients with endocrine disorders, such as panhypopituitarism, due to the high risk of bilateral involvement. Bilateral slips can occur in up to 100% of patients with certain endocrinopathies.

Question 3549

Topic: 4. Pediatrics
A 3-year-old boy treated successfully for idiopathic clubfoot as an infant using the Ponseti method presents with a relapsed deformity. His parents report compliance with bracing until age 2. On examination, he has dynamic supination during the swing phase of gait. Which of the following is the most appropriate surgical management?
. Repeat serial casting and Achilles tenotomy
. Split anterior tibial tendon transfer (SPLATT)
. Full anterior tibial tendon transfer to the lateral cuneiform
. Posteromedial release
. Calcaneal sliding osteotomy

Correct Answer & Explanation

. Full anterior tibial tendon transfer to the lateral cuneiform

Explanation

Dynamic supination in a relapsed clubfoot treated via the Ponseti method is best managed with a transfer of the entire tibialis anterior tendon to the lateral cuneiform. A SPLATT is typically reserved for spastic conditions like cerebral palsy.

Question 3550

Topic: Pediatric Upper Extremity & Spine

A 6-year-old girl sustains a severely displaced extension-type supracondylar humerus fracture. On initial presentation, her hand is pink and warm, but the radial pulse is absent. After closed reduction and percutaneous pinning, the hand remains pink with brisk capillary refill, but the radial pulse is still absent on Doppler ultrasound. What is the most appropriate next step in management?

. Immediate vascular exploration
. Fasciotomy of the forearm
. Observation and admission for close monitoring
. Angiography
. Open reduction and internal fixation

Correct Answer & Explanation

. Observation and admission for close monitoring

Explanation

A "pulseless, pink hand" following anatomical reduction and pinning of a supracondylar humerus fracture can be safely observed if perfusion is clinically adequate (capillary refill <2 seconds). Vascular exploration is indicated only if the hand becomes dysvascular (cool, pale) after reduction.

Question 3551

Topic: Pediatric Hip

An 18-month-old girl presents with a limp. Pelvic radiographs reveal a dislocated left hip with a false acetabulum and an acetabular index of 42 degrees. Which of the following is the most appropriate primary surgical management?

. Closed reduction and spica casting
. Pavlik harness application
. Open reduction with pelvic osteotomy
. Proximal femoral varus osteotomy alone
. Shelf osteotomy

Correct Answer & Explanation

. Open reduction with pelvic osteotomy

Explanation

In children older than 18 months with untreated Developmental Dysplasia of the Hip (DDH), closed reduction has a high failure rate and elevated risk of osteonecrosis. The standard of care is open reduction, often combined with a pelvic osteotomy (e.g., Salter) to address significant residual acetabular dysplasia.

Question 3552

Topic: Pediatric Hip
A 7-year-old boy is diagnosed with Legg-Calvé-Perthes disease. Radiographs reveal fragmentation of the capital femoral epiphysis with >50% maintenance of the lateral pillar height. According to the Herring lateral pillar classification, what is his group and expected outcome without surgical intervention?
. Group A; excellent outcome
. Group B; good outcome
. Group B; poor outcome
. Group C; good outcome
. Group C; poor outcome

Correct Answer & Explanation

. Group B; good outcome

Explanation

According to the Herring classification, maintenance of >50% of the lateral pillar height defines Group B. Children diagnosed before age 8 with Group B LCPD generally have good outcomes with conservative management and rarely require surgical containment.

Question 3553

Topic: 4. Pediatrics
A 13-year-old girl sustains a twisting ankle injury. Radiographs show an isolated Salter-Harris III fracture of the anterolateral distal tibial epiphysis with 3 mm of displacement. What is the pathomechanics of this specific injury pattern?
. Avulsion by the anterior inferior tibiofibular ligament (AITFL)
. Impaction by the talus in extreme external rotation
. Avulsion by the calcaneofibular ligament
. Hyper-plantarflexion with an axial load
. Avulsion by the posterior inferior tibiofibular ligament (PITFL)

Correct Answer & Explanation

. Avulsion by the 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) as the distal tibial physis closes in an asymmetric, predictable pattern (central, medial, then lateral).

Question 3554

Topic: Pediatric Lower Extremity
A 4-year-old boy presents with a relapsed right clubfoot. He was initially treated with the Ponseti method as an infant. Examination reveals dynamic supination during the swing phase of gait. Passive range of motion is normal. What is the most appropriate next step in management?
. Repeat serial casting alone
. Anterior tibial tendon transfer to the third cuneiform
. Split posterior tibial tendon transfer
. Cuboid decancellation
. Talonavicular arthrodesis

Correct Answer & Explanation

. Anterior tibial tendon transfer to the third cuneiform

Explanation

Dynamic supination in a relapsed clubfoot previously treated with the Ponseti method is best managed with an anterior tibial tendon transfer (ATTT) to the lateral cuneiform, provided passive correction is achievable. This rebalances the foot to prevent further relapse.

Question 3555

Topic: Pediatric Hip

A 13-year-old obese boy presents with acute on chronic left hip pain. He is unable to bear weight. Radiographs confirm an unstable slipped capital femoral epiphysis. During surgical fixation, an anterior capsulotomy is performed. What is the primary theoretical purpose of the capsulotomy in this setting?

. To facilitate reduction of the epiphysis
. To reduce intracapsular pressure and potentially decrease the risk of avascular necrosis
. To allow direct visualization of the screw entering the epiphysis
. To repair an associated labral tear
. To prevent chondrolysis

Correct Answer & Explanation

. To reduce intracapsular pressure and potentially decrease the risk of avascular necrosis

Explanation

Unstable SCFE is associated with a high rate of avascular necrosis. Capsulotomy is often performed to decompress the hematoma, lower intracapsular pressure, and potentially decrease the risk of AVN, although its ultimate efficacy remains debated.

Question 3556

Topic: Pediatric Hip
In a 7-year-old boy diagnosed with Legg-Calvé-Perthes disease, radiographs demonstrate that 60% of the lateral pillar height is maintained. According to the Herring lateral pillar classification, what group does this patient fall into, and what is the general prognosis?
. Group A, excellent prognosis
. Group B, moderate prognosis
. Group B/C, poor prognosis
. Group C, poor prognosis
. Group C, excellent prognosis

Correct Answer & Explanation

. Group B, moderate prognosis

Explanation

According to the Herring lateral pillar classification, Group B indicates that greater than 50% of the lateral pillar height is maintained. It carries a moderate prognosis, and these patients often benefit from containment surgery if they are over 8 years old.

Question 3557

Topic: Pediatric Hip

A 5-month-old female with developmental dysplasia of the hip has failed a 4-week trial of Pavlik harness treatment. Ultrasound shows the hip remains persistently dislocated. What is the most appropriate next step in management?

. Continue Pavlik harness for 4 more weeks
. Transition to a rigid abduction orthosis
. Closed reduction and spica casting
. Open reduction and spica casting
. Varus derotational osteotomy

Correct Answer & Explanation

. Closed reduction and spica casting

Explanation

If Pavlik harness treatment fails (persistent dislocation after 3-4 weeks), it should be discontinued to prevent "Pavlik harness disease" (posterior lip erosion). Closed reduction with spica casting or transition to a rigid orthosis is the next recommended step.

Question 3558

Topic: 4. Pediatrics

In a 6-year-old non-ambulatory child with spastic quadriplegic cerebral palsy, routine radiographic hip surveillance reveals a Reimers migration percentage of 45%. The child is asymptomatic. What is the most appropriate management?

. Continued observation with annual radiographs
. Botulinum toxin injection to the adductors
. Adductor and iliopsoas tenotomies
. Varus derotational osteotomy of the proximal femur and pelvic osteotomy
. Proximal femoral resection (Castle procedure)

Correct Answer & Explanation

. Varus derotational osteotomy of the proximal femur and pelvic osteotomy

Explanation

A Reimers migration percentage >40% in a child with spastic CP represents significant hip subluxation with a high risk of progression to dislocation. Bony reconstructive surgery (VDRO and often a pelvic osteotomy) is indicated to restore hip stability.

Question 3559

Topic: 4. Pediatrics
A 3-year-old obese boy presents with progressive bilateral genu varum. Radiographs demonstrate a Langenskiöld stage III deformity of the medial proximal tibia. Bracing has been attempted for 1 year without success. What is the most appropriate surgical treatment?
. Medial hemiepiphysiodesis
. Proximal tibial corrective osteotomy
. Lateral hemiepiphysiodesis
. Observation, as this is physiologic bowing
. Epiphyseal distraction

Correct Answer & Explanation

. Proximal tibial corrective osteotomy

Explanation

Langenskiöld stage III infantile Blount's disease with failed bracing in a 3-year-old requires surgical correction. A proximal tibial osteotomy (often with fibular osteotomy) is indicated to realign the mechanical axis and relieve stress on the medial physis.

Question 3560

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal girl presents with a right thoracic curve measuring 32 degrees. Her Risser stage is 0. What is the most appropriate management?

. Observation with radiographs in 6 months
. Thoracolumbosacral orthosis (TLSO) bracing for 16-23 hours/day
. Posterior spinal fusion
. Night-time only bending brace
. Schroth physical therapy exercises alone

Correct Answer & Explanation

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

Explanation

In a skeletally immature patient (premenarchal, Risser 0-2) with an AIS curve between 25 and 45 degrees, TLSO bracing for a minimum of 16-18 hours per day is indicated to prevent curve progression.

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