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4. Pediatrics MCQs

Practice Set 2 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 21

Topic: Pediatric Lower Extremity

When treating an infant with a severe rigid clubfoot (talipes equinovarus) using the Ponseti method, the very first step in the serial casting process targets which component of the deformity?

. Equinus of the ankle
. Varus of the hindfoot
. Cavus by elevating the first ray
. Adductus of the forefoot
. Internal tibial torsion

Correct Answer & Explanation

. Cavus by elevating the first ray

Explanation

The Ponseti method systematically addresses the CAVE deformities (Cavus, Adductus, Varus, Equinus). The critical first step is to correct the cavus by elevating the first metatarsal, which aligns the forefoot properly with the hindfoot.

Question 22

Topic: 4. Pediatrics

A 14-year-old male baseball pitcher complains of right shoulder pain while throwing. Radiographs demonstrate widening and irregularity of the proximal humeral physis compared to the contralateral side. What is the most appropriate initial management?

. Corticosteroid injection into the subacromial space
. Arthroscopic superior labrum anterior to posterior (SLAP) repair
. Complete rest from throwing for 3 months followed by a progressive throwing program
. Physical therapy focusing on rotator cuff strengthening while continuing to throw
. Prophylactic proximal humerus epiphysiodesis

Correct Answer & Explanation

. Complete rest from throwing for 3 months followed by a progressive throwing program

Explanation

Little League Shoulder is a stress fracture or epiphysiolysis of the proximal humeral physis caused by repetitive rotational stresses. The standard treatment is complete cessation of throwing for 3 months, followed by physical therapy and a graduated throwing program.

Question 23

Topic: Pediatric Lower Extremity

In the Ponseti method for the treatment of idiopathic clubfoot, the sequence of correction is paramount to achieve a successful plantigrade foot. Which of the following represents the correct sequential order for correcting the deformities?

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The Ponseti method sequentially corrects the components of clubfoot deformity using the mnemonic CAVE: Cavus, Adductus, Varus, and Equinus. The cavus is corrected first by elevating the first ray to align the forefoot with the hindfoot.

Question 24

Topic: Pediatric Hip

A 12-year-old obese male presents with left knee pain and an obligate external rotation of the hip during passive hip flexion. Radiographs confirm a slipped capital femoral epiphysis (SCFE). Which of the following is a recognized specific indication for prophylactic pinning of the contralateral, asymptomatic hip?

. Body Mass Index greater than 30
. Age of 12 years at initial presentation
. Presence of an endocrine or metabolic disorder
. Symptom duration less than 4 weeks prior to diagnosis
. Slip angle greater than 50 degrees on the primarily affected side

Correct Answer & Explanation

. Presence of an endocrine or metabolic disorder

Explanation

Prophylactic pinning of the contralateral hip in SCFE is strongly recommended in patients with endocrine or metabolic disorders (e.g., hypothyroidism, renal osteodystrophy). These patients have a significantly higher risk of developing bilateral slip compared to the idiopathic population.

Question 25

Topic: Pediatric Hip

A 13-year-old obese boy is diagnosed with a mild stable slipped capital femoral epiphysis (SCFE). Which of the following is an accepted absolute indication for prophylactic pinning of the contralateral asymptomatic hip?

. Age greater than 14 years
. Female gender
. Presence of an underlying endocrine disorder
. Body mass index in the 85th percentile
. Closed triradiate cartilage

Correct Answer & Explanation

. Presence of an underlying endocrine disorder

Explanation

Prophylactic pinning of the contralateral hip in SCFE is strongly indicated in patients with underlying endocrinopathies (e.g., hypothyroidism) or metabolic disorders due to a nearly 100% risk of bilateral involvement. Young age is also considered a relative indication.

Question 26

Topic: Pediatric Hip

A 6-week-old female is being treated for developmental dysplasia of the hip with a Pavlik harness. She develops an absent knee jerk and lack of active knee extension on the treated side. What is the most appropriate next step in management?

. Immediate transition to a rigid spica cast
. Loosen the posterior straps to reduce hip abduction
. Loosen the anterior straps to reduce hip flexion
. Order a stat MRI of the lumbar spine
. Continue current treatment as this is a transient normal finding

Correct Answer & Explanation

. Loosen the anterior straps to reduce hip flexion

Explanation

The patient has developed a femoral nerve palsy, a known complication of extreme hip flexion in a Pavlik harness. Immediate management requires loosening the anterior flexion straps or temporarily discontinuing the harness until nerve function recovers.

Question 27

Topic: Pediatric Upper Extremity & Spine
A 6-year-old boy presents with an extension-type displaced supracondylar humerus fracture (Gartland Type III). He is unable to flex the interphalangeal joint of his thumb or the distal interphalangeal joint of his index finger. Which nerve is most likely injured?
. Posterior interosseous nerve
. Ulnar nerve
. Anterior interosseous nerve
. Musculocutaneous nerve
. Superficial radial nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

The anterior interosseous nerve (AIN), a branch of the median nerve, is the most commonly injured nerve in extension-type supracondylar humerus fractures. It provides motor innervation to the flexor pollicis longus and the flexor digitorum profundus of the index and middle fingers.

Question 28

Topic: Pediatric Hip

A 12-year-old obese male presents with a slipped capital femoral epiphysis (SCFE) of the left hip. Prophylactic pinning of the asymptomatic right hip is most strongly indicated if the patient has a history of:

. Asthma treated with occasional bronchodilators
. Type 1 diabetes mellitus
. Hypothyroidism
. Attention deficit hyperactivity disorder
. Previous ipsilateral tibial shaft fracture

Correct Answer & Explanation

. Hypothyroidism

Explanation

Prophylactic pinning of the contralateral hip in SCFE is indicated in patients with underlying endocrine or metabolic disorders, such as hypothyroidism or renal osteodystrophy, due to the high risk of bilateral involvement.

Question 29

Topic: Pediatric Upper Extremity & Spine

A 6-year-old boy sustains an extension-type supracondylar humerus fracture. Upon presentation, he is unable to flex the interphalangeal joint of his thumb or the distal interphalangeal joint of his index finger. Which nerve is most likely injured?

. Ulnar nerve
. Radial nerve
. Anterior interosseous nerve
. Posterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

The anterior interosseous nerve (AIN) is the most commonly injured nerve in extension-type supracondylar humerus fractures. Injury presents with the inability to form an "OK" sign due to weakness of the FPL and FDP to the index finger.

Question 30

Topic: Pediatric Hip

A 6-year-old boy is diagnosed with Legg-Calve-Perthes disease. Which of the following is considered the most significant prognostic factor for the long-term development of osteoarthritis?

. Gender of the patient
. Body mass index
. Age at the onset of symptoms
. Presence of a limp at presentation
. Symmetric bilateral involvement

Correct Answer & Explanation

. Age at the onset of symptoms

Explanation

Age at the onset of symptoms is the most important prognostic factor in Legg-Calve-Perthes disease. Children who develop the disease before age 6 generally have a better prognosis due to greater remodeling potential of the femoral head.

Question 31

Topic: Pediatric Hip

A 4-month-old infant is being treated with a Pavlik harness for developmental dysplasia of the hip (DDH). At a follow-up visit, the infant exhibits decreased spontaneous active extension of the knee. Which of the following adjustments or actions is most appropriate?

. Increase flexion of the anterior straps
. Increase abduction of the posterior straps
. Loosen the anterior straps to reduce hip flexion
. Perform an immediate closed reduction in the operating room
. Apply a spica cast

Correct Answer & Explanation

. Loosen the anterior straps to reduce hip flexion

Explanation

Decreased active knee extension in a Pavlik harness indicates a femoral nerve palsy, typically caused by excessive hip flexion. The appropriate management is to loosen the anterior straps to decrease the degree of hip flexion.

Question 32

Topic: 4. Pediatrics

A 13-year-old baseball pitcher presents with vague proximal arm pain during throwing. Radiographs reveal widening and lateral fragmentation of the proximal humeral physis. What is the most appropriate initial management?

. Arthroscopic SLAP repair
. Open reduction and internal fixation of the physis
. Corticosteroid injection into the subacromial space
. Rest from throwing for 3 to 6 months followed by a structured rehabilitation program
. Immediate physical therapy focusing on aggressive stretching

Correct Answer & Explanation

. Arthroscopic SLAP repair

Explanation

Little League Shoulder is a proximal humeral epiphysiolysis caused by repetitive rotational stress. The standard treatment is immediate cessation of throwing (rest) for several months, followed by a gradual return-to-throwing program.

Question 33

Topic: 4. Pediatrics

A 13-year-old baseball pitcher presents with progressive shoulder pain during throwing. Radiographs show widening and sclerosis of the proximal humeral physis compared to the contralateral side. What is the most appropriate initial treatment?

. Immediate operative epiphysiodesis
. Corticosteroid injection into the subacromial space
. Complete rest from throwing for 3 months followed by a progressive return
. Continuation of throwing with a strict pitch count limit
. Physical therapy focusing solely on internal rotation stretching

Correct Answer & Explanation

. Complete rest from throwing for 3 months followed by a progressive return

Explanation

'Little Leaguer's shoulder' is a proximal humeral epiphysiolysis caused by repetitive rotational stress. The cornerstone of treatment is absolute rest from throwing for typically 3 months until clinically and radiographically healed.

Question 34

Topic: 4. Pediatrics

A 14-year-old elite baseball pitcher presents with generalized shoulder pain and declining throwing velocity. Radiographs reveal widening and irregularity of the proximal humeral physis. What is the most appropriate initial management?

. Corticosteroid injection into the subacromial space
. Arthroscopic labral repair
. Immediate cessation of throwing and rest for 2 to 3 months
. Physical therapy focusing on aggressive stretching
. Open reduction and internal fixation of the physis

Correct Answer & Explanation

. Immediate cessation of throwing and rest for 2 to 3 months

Explanation

This presentation is classic for 'Little Leaguer's Shoulder' (proximal humeral epiphysiolysis). It is a stress injury to the physis, and the mainstay of treatment is absolute rest from throwing until symptoms resolve and radiographs normalize.

Question 35

Topic: 4. Pediatrics

A 10-year-old Tanner stage 1 female sustains a complete ACL tear. Due to recurrent instability, surgical reconstruction is planned. To minimize the risk of growth arrest, which technique is most appropriate?

. Transphyseal bone-patellar tendon-bone autograft
. Iliotibial band extra-articular tenodesis (MacIntosh) only
. Epiphyseal-sparing, all-epiphyseal reconstruction
. Transphyseal hamstring autograft with interference screw fixation at the physis
. Non-operative management until skeletal maturity

Correct Answer & Explanation

. Epiphyseal-sparing, all-epiphyseal reconstruction

Explanation

In prepubescent children with significant remaining growth, physeal-sparing techniques such as an all-epiphyseal reconstruction are recommended. Bone blocks or implants traversing an open physis carry a high risk of growth arrest and angular deformity.

Question 36

Topic: Pediatric Lower Extremity

A 55-year-old male with end-stage renal disease presents with acute knee pain and an inability to actively extend his knee after a fall. Lateral radiographs demonstrate significant patella baja. Which of the following is the most likely diagnosis?

. Patellar tendon rupture
. Quadriceps tendon rupture
. Osgood-Schlatter disease
. Sinding-Larsen-Johansson syndrome
. Tibial tubercle avulsion

Correct Answer & Explanation

. Quadriceps tendon rupture

Explanation

A quadriceps tendon rupture leaves the patellar tendon intact, allowing the patella to migrate inferiorly (patella baja). Conversely, a patellar tendon rupture results in patella alta.

Question 37

Topic: 4. Pediatrics

All of the following are possible treatments for congenital or acquired torticollis except:

. No treatment because spontaneous resolution is possible in cases of congenital torticollis
. Active and passive stretching therapies in patients with congenital torticollis until puberty
. Holding infants so that chin is rotated toward the affected side
. Physical therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) and use of a soft collar
. Use botulinum toxin, hard collars, or braces in severe cases

Correct Answer & Explanation

. Active and passive stretching therapies in patients with congenital torticollis until puberty

Explanation

Several treatment options exist for congenital and acquired torticollis. In very mild cases of congenital torticollis, the deformity may be self-limited and no therapy needs to be administered. Sometimes active and passive stretching of the neck can work well if performed before 1 year of life. Parents may hold the babys head so that the chin is rotated toward the affected side. Acquired torticollis can also be managed by physical therapy using NSAIDs and a soft collar. The use of botulinum toxin or braces can be a form of therapy in recalcitrant cases.

Question 38

Topic: 4. Pediatrics

What is the incidence of congenital torticollis in the general population:

. 0.1% to 0.3%
. 0.5% to 0.8%
. 0.3 to 1.0%
. 0.3% to 1.9%
. 2% to 5%

Correct Answer & Explanation

. 0.3% to 1.9%

Explanation

Epidemiological studies have shown that the incidence of congenital torticollis is approximately 0.3% to 1.9% in the general population.

Question 39

Topic: Pediatric Hip

A patient with slipped capital femoral epiphysis (SC FE) should have an endocrine workup if presenting with which of the following features:

. Bilateral involvement
. Body mass index greater than the 95th percentile for age
. Age <10 or >15 years
. Negative family history
. Female gender

Correct Answer & Explanation

. Age <10 or >15 years

Explanation

Endocrine workup is only indicated for age ,10 or .15 years, or stature less than the 10th percentile. Bilaterality, obesity, and negative family history are common findings in idiopathic SC FE. Although SC FE is more common in males, it is not uncommon in females.

Question 40

Topic: 4. Pediatrics

A 5-year-old girl is diagnosed with Klippel-Feil syndrome. Which of the following associated conditions must be screened for routinely due to its high incidence and potential severity?

. Congenital heart defects
. Renal anomalies
. Sprengel deformity
. Hearing loss
. All of the above

Correct Answer & Explanation

. All of the above

Explanation

Klippel-Feil syndrome involves congenital fusion of cervical vertebrae and is highly associated with multiple systemic anomalies. Screening should include renal ultrasound, echocardiogram, and audiometry due to the high incidence of renal, cardiac, and otic abnormalities.

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