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4. Pediatrics MCQs

Practice Set 19 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 361

Topic: Pediatric Lower Extremity
A 3-year-old obese female presents with progressive bowing of her right leg. Radiographs reveal a metaphyseal-diaphyseal angle (Drennan angle) of 18 degrees. What is the most appropriate initial management?
. Observation and reassurance
. Knee-ankle-foot orthosis (KAFO)
. Proximal tibial osteotomy
. Epiphysiodesis of the lateral proximal tibia
. Hemiepiphysiodesis of the medial proximal tibia

Correct Answer & Explanation

. Knee-ankle-foot orthosis (KAFO)

Explanation

A metaphyseal-diaphyseal angle >16 degrees in a 3-year-old with characteristic bowing strongly indicates infantile Blount's disease. Initial management for children under age 4 with Langenskiöld stage I-II disease is full-time bracing with a KAFO.

Question 362

Topic: Pediatric Hip
A 6-year-old boy presents with a painless limp. Radiographs demonstrate sclerosis and fragmentation of the capital femoral epiphysis. Which of the following is the most important prognostic factor in Legg-Calvé-Perthes disease?
. Age at clinical onset
. Gender of the patient
. Presence of a subchondral fracture line (crescent sign)
. Family history of the disease
. Initial range of motion

Correct Answer & Explanation

. Age at clinical onset

Explanation

Age at clinical onset is the single most important prognostic factor in Legg-Calvé-Perthes disease. Children who develop the disease before age 6 generally have a more favorable prognosis and greater potential for spherical remodeling.

Question 363

Topic: 4. Pediatrics

A 5-year-old child with spastic quadriplegic cerebral palsy is found to have a migration percentage of 45% in the right hip. The child is a GMFCS level V. What is the most appropriate management?

. Botulinum toxin injection to the adductors
. Adductor tenotomy alone
. Varus derotational osteotomy (VDRO) with or without pelvic osteotomy
. Total hip arthroplasty
. Observation with yearly radiographs

Correct Answer & Explanation

. Varus derotational osteotomy (VDRO) with or without pelvic osteotomy

Explanation

A migration percentage >40% in a spastic CP patient (especially GMFCS V) indicates significant hip subluxation unresponsive to soft tissue release alone. Bony reconstructive surgery, typically a VDRO of the femur (often with a pelvic osteotomy), is required to prevent painful dislocation.

Question 364

Topic: 4. Pediatrics

A 4-year-old child with blue sclerae, dentinogenesis imperfecta, and multiple prior fractures is diagnosed with Osteogenesis Imperfecta (OI). Which genetic mutation is most commonly associated with this condition?

. FGFR3
. COMP
. COL1A1 or COL1A2
. FBN1
. RUNX2

Correct Answer & Explanation

. COL1A1 or COL1A2

Explanation

Osteogenesis imperfecta is most commonly caused by an autosomal dominant mutation in the COL1A1 or COL1A2 genes. This defect leads to qualitative or quantitative abnormalities in type I collagen synthesis.

Question 365

Topic: 4. Pediatrics

A 2-year-old child presents with anterolateral bowing of the left tibia and a newly diagnosed fracture through the apex of the curve. The condition is most closely associated with which of the following systemic disorders?

. Neurofibromatosis type 1
. Marfan syndrome
. Ehlers-Danlos syndrome
. Osteogenesis imperfecta
. Cleidocranial dysplasia

Correct Answer & Explanation

. Neurofibromatosis type 1

Explanation

Congenital pseudarthrosis of the tibia (CPT) typically presents with anterolateral bowing and is highly associated with Neurofibromatosis type 1 (NF1). Approximately 50% of patients with CPT have an underlying diagnosis of NF1.

Question 366

Topic: Pediatric Upper Extremity & Spine

A 14-year-old girl with adolescent idiopathic scoliosis (AIS) has a right thoracic curve of 48 degrees. She is premenarchal and Risser stage 0. What is the most appropriate management?

. Observation with clinical exams every 6 months
. Boston brace therapy for 23 hours a day
. Nighttime bending brace
. Posterior spinal fusion
. Anterior tethering surgery

Correct Answer & Explanation

. Posterior spinal fusion

Explanation

In a highly skeletally immature patient (Risser 0, premenarchal) with an AIS curve approaching or exceeding 45-50 degrees, the risk of progression is nearly 100%. Surgical intervention, typically posterior spinal fusion, is indicated to prevent severe deformity.

Question 367

Topic: Pediatric Hip
Which of the following conditions is represented by this radiograph?
. Developmental dysplasia of the hip
. Juvenile rheumatoid arthritis
. Hemophilic arthropathy
. Legg-Calvé-Perthes disease
. Rickets

Correct Answer & Explanation

. Legg-Calvé-Perthes disease

Explanation

This patient has early fragmentation, epiphyseal flattening, metaphyseal lucency and widening, and sclerosis typical of patients with Legg-Calvé-Perthes disease in the early stages. In patients with juvenile rheumatoid arthritis, osteopenia and joint space narrowing are present, whereas in patients with developmental dysplasia, the acetabulum is shallow.

Question 368

Topic: Pediatric Hip

In which stage of Legg-Calva-Perthes disease is this patient:

. Initial
. Fragmentation
. Reossification
. Healed
. Degenerative

Correct Answer & Explanation

. Fragmentation

Explanation

This patient is in the end of the fragmentation phase of Legg-Calv-Perthes disease. Note the extreme flattening of the head and the lateral fragmentation.

Question 369

Topic: Pediatric Hip
All of the following conditions are indicated by this radiograph of a patient with Legg-Calvé-Perthes disease except:
. Coxa magna
. Coxa brevis
. Trochanteric overgrowth
. Coxa vara
. Coxa plana

Correct Answer & Explanation

. Coxa magna

Explanation

The hip of this patient with Legg-Calvé-Perthes disease has undergone epiphyseal flattening and premature (primarily lateral) physeal arrest. The femoral head has regrown with an enlarged width. The radiograph shows elements of coxa magna, coxa brevis, trochanteric overgrowth, and coxa plana. Coxa vara is not present.

Question 370

Topic: Pediatric Hip

A 5-year-old girl is evaluated for Legg-Calva-Perthes disease. She is in the fragmentation phase, and rotation is 10° internal and 15° external. Her epiphyseal extrusion index is 15%. Recommended treatment includes:

. Femoral osteotomy
. Iliac osteotomy
. Traction
. Shelf procedure
. Observation

Correct Answer & Explanation

. Observation

Explanation

The patients restricted range of motion is normal for a patient in the fragmentation phase of Legg-Calva-Perthe disease. The patiens degree of epiphyseal extrusion is not extreme. Observation is the most appropriate course of treatment.

Question 371

Topic: Pediatric Hip

What is the risk of hip arthroplasty for 50-year-old patients with Legg-C alva-Perthes disease:

. 10%
. 25%
. 33%
. 50%
. 75%

Correct Answer & Explanation

. 50%

Explanation

Long-term study has shown that 50% of 50-year-old patients with Legg-C alva-Perthes disease will have degenerative changes in their hips significant enough to make them candidates for hip arthroplasty.

Question 372

Topic: 4. Pediatrics
In which of the following conditions is a Trendelenburg's gait unlikely to occur:
. L4 myelomeningocele
. Legg-Calvé-Perthes disease
. Untreated developmental dysplasia of the hip
. Polio (L5)
. Osgood-Schlatter disease

Correct Answer & Explanation

. Osgood-Schlatter disease

Explanation

Patients with complications that cause pain around their hips or that decrease the abductor strength of their hips may develop a Trendelenburg's gait. Osgood-Schlatter disease affects the tibial tubercle and does not typically affect hip abductor strength or cause a Trendelenburg's gait.

Question 373

Topic: 4. Pediatrics
Which of the following conditions has the highest rate of bilaterality:
. Slipped capital femoral epiphysis
. Legg-Calvé-Perthes disease
. Developmental dysplasia of the hip
. Discoid lateral meniscus
. Fibular hemimelia

Correct Answer & Explanation

. Slipped capital femoral epiphysis

Explanation

Slipped capital femoral epiphysis has a bilaterality rate of 25% to 40%. Legg-Calvé-Perthes disease, developmental dysplasia of the hip, discoid lateral meniscus, and fibular hemimelia have bilateral rates of less than 20%.

Question 374

Topic: 4. Pediatrics

When evaluating a lateral cervical radiograph of a 5-year-old child following minor trauma, anterior displacement of C2 on C3 of 3 mm is noted. Which of the following radiographic lines is most helpful to differentiate physiologic pseudosubluxation from true injury?

. Chamberlain line
. McGregor line
. Wackenheim clivus line
. Swischuk line
. Ranawat line

Correct Answer & Explanation

. Swischuk line

Explanation

Swischuk's line (spinolaminar line of C1 to C3) helps differentiate physiologic pseudosubluxation of C2 on C3 from a true injury. If the line passes within 2 mm of the posterior arch of C2, it is considered physiologic.

Question 375

Topic: 4. Pediatrics

A 2-year-old child presents with refusal to walk, low-grade fever, and irritability. Laboratory tests show an ESR of 65 mm/hr and normal WBC count. MRI reveals abnormal signal in the L4-L5 disc space and adjacent endplates. What is the most common causative organism?

. Streptococcus pneumoniae
. Staphylococcus aureus
. Kingella kingae
. Mycobacterium tuberculosis
. Pseudomonas aeruginosa

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Pediatric discitis most commonly affects children under 5. Staphylococcus aureus is the most frequent organism isolated when a pathogen is identified, although blood cultures are often negative.

Question 376

Topic: Pediatric Upper Extremity & Spine

A 12-year-old girl is diagnosed with adolescent idiopathic scoliosis. Her physical examination reveals a right thoracic prominence. Which of the following parameters represents a widely accepted indication for initiating Boston brace treatment?

. Risser stage 4, Cobb angle 35 degrees
. Risser stage 0, Cobb angle 15 degrees
. Risser stage 1, Cobb angle 30 degrees
. Risser stage 5, Cobb angle 45 degrees
. Premenarchal girl, Cobb angle 10 degrees

Correct Answer & Explanation

. Risser stage 1, Cobb angle 30 degrees

Explanation

Bracing is indicated in growing children (Risser 0-2, premenarchal) with curves between 25 and 45 degrees. A curve of 30 degrees in a Risser 1 patient falls perfectly within these bracing parameters.

Question 377

Topic: 4. Pediatrics
All of the disorders listed below are examples of osteochondrosis except:
. Legg-Calvé-Perthes disease
. Scheuermann's disease
. Osgood-Schlatter disorder
. Gorham's disease
. Blount disease

Correct Answer & Explanation

. Gorham's disease

Explanation

The term osteochondrosis refers to symptomatic disorders involving cartilage growth. Cartilage affected by osteochondrosis may be epiphyseal, physeal, or apophyseal. Gorham's disease is not an example of osteochondrosis. Gorham's disease is a lymphatic disorder known as disappearing bone disease.

Question 378

Topic: 4. Pediatrics

A 1-year-old patient presents with a pseudarthrosis of the left clavicle. Which of the following conditions is most likely to coexist with pseudarthrosis of the left clavicle:

. Neurofibromatosis
. Proteus syndrome
. Osteogenesis imperfecta
. Fibrous dysplasia
. Dextrocardia

Correct Answer & Explanation

. Dextrocardia

Explanation

Almost all cases of congenital pseudarthrosis involve the right clavicle. C ases of congenital pseudarthrosis involving the left clavicle often coexist with dextrocardia. Patients with pseudarthrosis of the clavicle respond well to standard orthopedic treatment, unlike patients with congenital pseudarthrosis of the tibia.C orrect Answer: Dextrocardia

Question 379

Topic: Pediatric Upper Extremity & Spine

The Sorensen criteria are commonly used to diagnose typical Scheuermann's disease. Which of the following radiographic findings must be present to satisfy these criteria?

. Anterior wedging of >5 degrees in at least three adjacent sequential vertebrae
. Anterior wedging of >10 degrees in two adjacent sequential vertebrae
. Anterior wedging of >5 degrees in at least two adjacent sequential vertebrae
. Presence of Schmorl's nodes in at least three sequential vertebrae
. Kyphotic curve >45 degrees with an Risser sign of 4

Correct Answer & Explanation

. Anterior wedging of >5 degrees in at least three adjacent sequential vertebrae

Explanation

The classic Sorensen criteria define Scheuermann's kyphosis by the presence of anterior wedging of greater than 5 degrees in at least three consecutive vertebral bodies.

Question 380

Topic: Pediatric Upper Extremity & Spine

Following an all-posterior pedicle screw instrumented fusion for Scheuermann's kyphosis, what is the standard postoperative immobilization protocol in a compliant patient?

. Thoracolumbosacral orthosis (TLSO) for 6 months
. Risser cast application for 3 months
. No brace or cast is typically required
. Milwaukee brace for 12 months
. Halo-vest immobilization for 6 weeks

Correct Answer & Explanation

. No brace or cast is typically required

Explanation

Modern pedicle screw instrumentation provides highly rigid internal fixation, typically eliminating the need for any postoperative bracing or casting.

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