Menu

4. Pediatrics MCQs

Practice Set 202 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 4021

Topic: 4. Pediatrics

Which type of screw is typically preferred for metaphyseal fractures in pediatric patients where growth plate sparing is critical?

. Large diameter cancellous screws.
. Fully threaded cortical screws.
. Partially threaded small diameter cannulated screws.
. Locking screws in fixed-angle plates.
. Bioabsorbable interference screws.

Correct Answer & Explanation

. Partially threaded small diameter cannulated screws.

Explanation

In pediatric metaphyseal fractures requiring screw fixation near the physis, partially threaded, small-diameter cannulated screws (often K-wires or similar small pins if minimal fixation is needed) are preferred. The small diameter minimizes damage to the growth plate. The partially threaded design allows for compression across the fracture without violating the physis if the threads are placed distal to it, and cannulation aids precise placement to avoid critical structures. Larger diameter screws or fully threaded screws crossing the physis are generally avoided due to the higher risk of growth arrest or deformity.

Question 4022

Topic: Pediatric Hip

A 13-year-old boy with a BMI of 32 presents with acute-on-chronic left hip pain and an inability to bear weight. Radiographs confirm a severe Slipped Capital Femoral Epiphysis (SCFE). Which of the following is a recognized indication for prophylactic in situ pinning of the contralateral asymptomatic hip?

. Patient age > 14 years
. Endocrine disorder such as hypothyroidism
. Male sex
. Acute presentation < 3 weeks
. Unilateral slip angle > 50 degrees

Correct Answer & Explanation

. Endocrine disorder such as hypothyroidism

Explanation

Prophylactic pinning of the contralateral hip in SCFE is generally recommended for patients with underlying metabolic or endocrine disorders (e.g., hypothyroidism, renal osteodystrophy), prior radiation therapy, or an age outside the typical range (e.g., < 10 years).

Question 4023

Topic: Pediatric Lower Extremity

When applying the Ponseti method for the treatment of idiopathic clubfoot, what is the first deformity that must be corrected?

. Equinus
. Varus
. Adductus
. Cavus
. Internal tibial torsion

Correct Answer & Explanation

. Cavus

Explanation

The sequence of correction in the Ponseti method follows the acronym CAVE: Cavus, Adductus, Varus, Equinus. The cavus deformity is corrected first by elevating the first ray to align the forefoot with the hindfoot.

Question 4024

Topic: Pediatric Hip

A 13-year-old obese male presents with right hip pain, an antalgic gait, and an obligate external rotation of the hip upon flexion. Radiographs demonstrate a slipped capital femoral epiphysis (SCFE). Relative to the femoral neck, in which anatomical direction does the epiphysis translate in a typical SCFE?

. Anterior and superior
. Anterior and inferior
. Posterior and superior
. Posterior and inferior
. Directly posterior

Correct Answer & Explanation

. Posterior and inferior

Explanation

In a slipped capital femoral epiphysis (SCFE), the epiphysis typically remains within the acetabulum while the femoral neck displaces anteriorly and superiorly. Therefore, relative to the femoral neck, the epiphysis displaces posteriorly and inferiorly. This creates the classic 'ice cream slipping off the cone' radiographic appearance on the lateral view.

Question 4025

Topic: Pediatric Lower Extremity

In the Ponseti method for the non-operative treatment of congenital talipes equinovarus (clubfoot), what is the correct anatomical sequence of deformity correction during serial casting?

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

Correct Answer & Explanation

. Cavus, Varus, Adductus, Equinus

Explanation

The Ponseti method corrects the clubfoot deformities in a specific, sequential order remembered by the mnemonic CAVE: Cavus (corrected first by supinating the forefoot to align with the hindfoot), Adductus, Varus, and finally Equinus (which often requires a percutaneous Achilles tenotomy as the final step).

Question 4026

Topic: 4. Pediatrics

Which of the following is generally considered the strongest indication for routine elective removal of orthopedic screws?

. Patient age less than 18 years.
. Implant material is stainless steel.
. Screws cross a major joint or growth plate.
. Pain or tenderness directly over the implant.
. Fracture healing has occurred and 12 months have passed.

Correct Answer & Explanation

. Screws cross a major joint or growth plate.

Explanation

While implant removal is often driven by patient symptoms (D), a strong orthopedic rationale forroutine electiveremoval exists when screws cross a major joint or a physis (growth plate). In growing children, screws crossing a physismustbe removed to prevent growth disturbance. In adults, screws crossing joints (e.g., syndesmotic screws) are often removed to restore normal joint motion and prevent impingement or wear. Patient age (A) isn't an absolute indication on its own. Stainless steel (B) vs. titanium generally doesn't dictate removal unless there's an allergic reaction. Simple time passage (E) is insufficient without symptoms or specific anatomical reasons.

Question 4027

Topic: 4. Pediatrics

In the context of pediatric epiphyseal fractures, what is a key advantage of bioabsorbable screws over metallic screws?

. Superior biomechanical strength for load-bearing.
. Complete avoidance of any growth disturbance risk.
. Eliminates the need for a second surgery for implant removal.
. Reduced risk of infection compared to metallic implants.
. Faster osseointegration into the bone.

Correct Answer & Explanation

. Eliminates the need for a second surgery for implant removal.

Explanation

The primary advantage of bioabsorbable screws in children, particularly in epiphyseal fractures or those near growth plates, is that they eventually resorb, eliminating the need for a second surgery to remove the implant. This avoids the trauma and risks associated with a second procedure. While they generally cause less growth disturbance than metallic screwsifthey cross a physis (B is a strong but not absolute claim, as even bioabsorbables can transiently affect growth), the key advantage is surgical avoidance. Metallic screws are generally stronger (A). Infection risk (D) is similar. Faster osseointegration (E) is not a proven advantage.

Question 4028

Topic: 4. Pediatrics

What is the primary concern when performing bicortical screw fixation in the metadiaphyseal region of a pediatric long bone?

. Risk of thermal necrosis during drilling.
. Compromising the nutrient artery supply.
. Damage to the physis (growth plate).
. Insufficient bone density for adequate purchase.
. Premature degradation of the implant material.

Correct Answer & Explanation

. Damage to the physis (growth plate).

Explanation

In pediatric long bones, the physis (growth plate) is extremely vulnerable. Crossing or damaging the physis with a bicortical screw can lead to growth arrest, angular deformities, or limb length discrepancies. Therefore, fixation techniques in children often involve avoiding the physis or using epiphyseal-sparing techniques, or bioabsorbable implants if crossing is unavoidable. Thermal necrosis (A) is a general risk but not specific to the pediatric metadiaphyseal region's unique concern. Nutrient artery (B) is less of a concern than the physis. Insufficient bone density (D) is less common in healthy children than adults. Premature degradation (E) is a material property concern, not a surgical risk specific to the region.

Question 4029

Topic: 4. Pediatrics

A 3-year-old child successfully treated with the Ponseti method for congenital talipes equinovarus (CTEV) presents with recurrent equinus and varus deformity despite good initial correction and compliance with bracing. Physical examination confirms mild residual hindfoot varus and equinus, but the foot remains flexible. What is the most appropriate next step in management?

. Repeat serial casting with the Ponseti method.
. Posteromedial release surgery.
. Tibialis anterior tendon transfer.
. Calcaneal osteotomy.
. Orthotic shoe inserts and observation.

Correct Answer & Explanation

. Tibialis anterior tendon transfer.

Explanation

For a recurrent, flexible clubfoot deformity in a child previously treated with Ponseti, a tibialis anterior tendon transfer (usually to the cuboid or third cuneiform) is a common and effective procedure. This addresses the dynamic imbalance (overpull of tibialis anterior in supination) that contributes to the recurrence, without the morbidity of a full posteromedial release. Repeat casting (A) might be considered for very mild, flexible recurrence, but if bracing compliance was good and recurrence still occurred, it's less likely to be definitive. Posteromedial release (B) is reserved for rigid, severe recurrences or initial failed casting. Calcaneal osteotomy (D) is typically used for more severe fixed valgus or varus deformities, often in older children. Orthotic inserts (E) alone are insufficient for a recurrent deformity.

Question 4030

Topic: Pediatric Hip
A 14-year-old obese male presents to the emergency department with a 2-day history of severe left hip pain and inability to bear weight after twisting his leg. He reports a 3-month history of intermittent mild hip discomfort. On exam, the left lower extremity is held in external rotation and he has severe pain with any attempt at passive motion. Radiographs demonstrate an unstable Slipped Capital Femoral Epiphysis (SCFE) with significant posterior and inferior displacement (Grade III). What is the most appropriate immediate management to minimize the risk of avascular necrosis (AVN)?
. Emergent open reduction and internal fixation.
. In situ pinning with a single screw, without any manipulation or reduction attempt.
. Gentle closed reduction under anesthesia, followed by in situ pinning.
. Traction for 24-48 hours followed by in situ pinning.
. Modified Dunn procedure (subcapital osteotomy) and internal fixation.

Correct Answer & Explanation

. In situ pinning with a single screw, without any manipulation or reduction attempt.

Explanation

For unstable SCFE, the most critical complication is avascular necrosis (AVN) of the femoral head. Any attempts at reduction, even gentle ones, significantly increase the risk of AVN due to disruption of the retinacular vessels. Therefore, in situ pinning without manipulation is generally considered the safest immediate management to minimize AVN and stabilize the epiphysis. While some surgeons might consider a very gentle reduction for extreme displacements, the highest priority is typically placed on avoiding AVN, making no manipulation the safest initial approach. Open reduction carries a very high risk of AVN. Gentle closed reduction also has a significant risk of AVN and is controversial. Traction is not a definitive treatment. The Modified Dunn procedure is an osteotomy used for severe chronic deformities or failed pinning, not for acute unstable SCFE.

Question 4031

Topic: 4. Pediatrics
A 6-year-old obese boy presents with progressive genu varum of the right lower extremity. Radiographs show beaking of the medial proximal tibial metaphysis, depression of the medial tibial plateau, and a metaphyseal-diaphyseal angle of 18 degrees. According to the Langenskiöld classification, this is most likely Stage IV Blount's disease. What is the most appropriate surgical management?
. Observation with close follow-up as he is still growing.
. Night splinting and physical therapy.
. Valgus producing osteotomy of the proximal tibia.
. Medial proximal tibial hemiepiphysiodesis (guided growth with an 8-plate).
. High tibial osteotomy with external fixator.

Correct Answer & Explanation

. Valgus producing osteotomy of the proximal tibia.

Explanation

For Blount's disease (Tibia Vara) in a 6-year-old child with Langenskiöld Stage IV, a valgus-producing osteotomy of the proximal tibia is the most appropriate and definitive treatment. At this age and stage, the deformity is typically severe and established, requiring surgical correction to realign the limb. Guided growth (hemiepiphysiodesis with an 8-plate) is generally more effective and preferred for younger children (typically <4-5 years) with less severe deformities (Langenskiöld Stages I-III) where there is significant growth remaining to allow for gradual correction. Observation is only for very early, mild cases (<2 years) where spontaneous resolution may occur. Night splinting and physical therapy are ineffective for established Blount's disease. While a high tibial osteotomy can be performed with an external fixator, the core procedure for correction of the deformity is the valgus-producing osteotomy, which can also be done with internal fixation.

Question 4032

Topic: 4. Pediatrics

A 2-year-old child presents with anterior bowing and a nonunion of the mid-diaphyseal tibia, first noticed at 6 months of age, consistent with congenital pseudoarthrosis of the tibia (CPT). Radiographs show a sclerotic nonunion site and narrow medullary canal. Which associated condition is often found in these patients, and what is a common complication of surgical treatment?

. Neurofibromatosis Type 1; high risk of refracture and recurrence.
. Achondroplasia; delayed union and malunion.
. Osteogenesis Imperfecta; severe limb length discrepancy.
. Fibrous Dysplasia; malignant transformation.
. Marfan Syndrome; joint instability.

Correct Answer & Explanation

. Neurofibromatosis Type 1; high risk of refracture and recurrence.

Explanation

Congenital pseudoarthrosis of the tibia (CPT) is strongly associated with Neurofibromatosis Type 1 (NF1), occurring in 50-90% of CPT cases. It is a notoriously challenging condition to treat surgically, characterized by a very high rate of refracture, persistent nonunion, and recurrence, often requiring multiple complex procedures throughout childhood. Achondroplasia (Option B), Osteogenesis Imperfecta (Option C), Fibrous Dysplasia (Option D), and Marfan Syndrome (Option E) are not typically associated with CPT in this manner, and their common complications differ.

Question 4033

Topic: Pediatric Hip

A 7-year-old boy is diagnosed with Legg-Calve-Perthes disease (LCPD) of the left hip. Radiographs show significant femoral head collapse and fragmentation (Herring Lateral Pillar B/C border). He has limited abduction and internal rotation. What is the primary goal of treatment for LCPD, particularly in this age group and severity?

. Pain control and activity modification.
. Maintaining containment of the femoral head within the acetabulum.
. Promoting revascularization of the femoral head.
. Accelerating ossification of the femoral head.
. Preventing slipped capital femoral epiphysis.

Correct Answer & Explanation

. Maintaining containment of the femoral head within the acetabulum.

Explanation

For Legg-Calve-Perthes disease (LCPD), especially in older children (typically 6-8+ years) and more severe cases (such as Herring Lateral Pillar B/C border), the primary goal of treatment is 'containment' of the femoral head within the acetabulum. The acetabulum acts as a natural mold, helping to maintain the spherical shape of the femoral head as it undergoes revascularization and reossification. This minimizes deformity, prevents incongruity, and reduces the risk of early degenerative arthritis. Containment can be achieved through non-surgical methods (e.g., abduction orthoses) or surgically (e.g., varus osteotomy of the femur or Salter innominate osteotomy). While pain control (Option A) is important, it's a symptomatic treatment, not the primary goal for long-term hip health. Promoting revascularization (Option C) is the body's natural process during LCPD, and treatment aims to protect the femoral head during this phase. Accelerating ossification (Option D) is not a treatment goal. Preventing slipped capital femoral epiphysis (Option E) is incorrect, as SCFE is a distinct hip condition.

Question 4034

Topic: 4. Pediatrics

A 12-year-old boy sustains a Salter-Harris Type V injury of the distal tibia. Radiographs show a crush injury to the epiphyseal plate without displacement. What is the most important long-term complication to monitor for, and what is the typical management strategy?

. Acute compartment syndrome; emergent fasciotomy
. Avascular necrosis of the epiphysis; non-weight-bearing
. Premature physeal arrest and angular deformity/shortening; close observation and guided growth/epiphysiodesis as needed
. Nonunion; surgical fixation with bone grafting
. Osteomyelitis; intravenous antibiotics

Correct Answer & Explanation

. Premature physeal arrest and angular deformity/shortening; close observation and guided growth/epiphysiodesis as needed

Explanation

A Salter-Harris Type V injury involves a crush of the growth plate and carries a very high risk (nearly 100%) of premature partial or complete physeal arrest. This can lead to significant limb length discrepancy and/or angular deformity as the child grows. Management typically involves initial non-weight-bearing immobilization, followed by meticulous long-term follow-up with serial radiographs to detect growth disturbances early. Guided growth (hemiepiphysiodesis) or complete epiphysiodesis may be required to correct or prevent angular deformities and manage limb length discrepancies. Compartment syndrome is a general trauma risk, AVN is not typical for distal tibia SH V, and nonunion is unlikely as there is no fracture gap in SH V.

Question 4035

Topic: 4. Pediatrics
An 8-year-old with Osteogenesis Imperfecta Type III presents with severe lower extremity bowing and a history of multiple recurrent long bone fractures despite bisphosphonate therapy. Which of the following surgical techniques is most effective for managing recurrent long bone fractures and progressive deformity in this patient?
. Serial casting and bracing.
. External fixation for gradual correction.
. Intramedullary rodding with Fassier-Duval telescopic rods.
. Open reduction and internal fixation with plates and screws.
. Osteotomy and allograft reconstruction.

Correct Answer & Explanation

. Intramedullary rodding with Fassier-Duval telescopic rods.

Explanation

For children with Osteogenesis Imperfecta (OI) and recurrent long bone fractures or severe progressive deformity, intramedullary rodding using telescopic rods (e.g., Fassier-Duval, Bailey-Dubow) is the gold standard surgical treatment. These rods are designed to grow with the child, providing internal splinting and stability to the osteopenic bones, which significantly reduces fracture rates and prevents progression of deformity, while also allowing for bone remodeling and growth. Other methods are generally less effective or carry higher risks in OI patients.

Question 4036

Topic: 4. Pediatrics

A 6-month-old infant is diagnosed with congenital muscular torticollis. After 3 months of conservative treatment, including physical therapy focusing on stretching and positional maneuvers, the infant still exhibits a 20-degree head tilt and a palpable sternocleidomastoid mass. What is the most appropriate next step in management?

. Discontinue physical therapy, as it is no longer effective.
. Refer for CT scan of the cervical spine to rule out underlying bony abnormalities.
. Continue physical therapy and consider botulinum toxin injections into the sternocleidomastoid muscle.
. Surgical release of the sternocleidomastoid muscle.
. Apply a cervical collar to maintain the head in a neutral position.

Correct Answer & Explanation

. Continue physical therapy and consider botulinum toxin injections into the sternocleidomastoid muscle.

Explanation

For congenital muscular torticollis, physical therapy is the mainstay of treatment, with success rates over 90% if initiated early. However, if significant torticollis (e.g., >15-20 degrees) persists after 6-12 months of consistent therapy, or if a significant mass persists, other options are considered. Before 12 months of age, continuing physical therapy combined with adjunctive treatments like botulinum toxin injections into the sternocleidomastoid muscle can be effective in relaxing the muscle and improving the response to stretching. Surgical release (Option D) is typically reserved for children over 12 months who fail conservative therapy, or those with severe, fixed deformity. A CT scan (Option B) might be considered if atypical features suggest bony abnormalities, but it's not the primary next step for persistent muscular torticollis. Discontinuing therapy (Option A) is incorrect as therapy should continue. A cervical collar (Option E) is not an effective primary treatment for muscular torticollis.

Question 4037

Topic: 4. Pediatrics
A 5-year-old child presents with a limp and pain in the left hip for 3 weeks. Radiographs show flattening and fragmentation of the femoral head epiphysis, with widening of the medial joint space. There is no evidence of infection. Which of the following statements regarding the natural history and management of this condition is most accurate?
. Surgical intervention is always required to prevent long-term deformity.
. The prognosis is generally good, and complete revascularization and remodeling of the femoral head occur within 1 year.
. Early diagnosis and containment (e.g., with bracing or osteotomy) are crucial to prevent femoral head deformation, especially in older children.
. Antibiotics are indicated to treat the suspected underlying infectious etiology.
. The primary treatment involves systemic anti-inflammatory medications to reduce pain and inflammation.

Correct Answer & Explanation

. Early diagnosis and containment (e.g., with bracing or osteotomy) are crucial to prevent femoral head deformation, especially in older children.

Explanation

This presentation is classic for Legg-Calvé-Perthes disease (LCPD), an idiopathic avascular necrosis of the femoral head in children. The natural history and management are highly dependent on the child's age at onset and the extent of femoral head involvement. Early diagnosis and containment strategies (e.g., abduction bracing, varus derotation osteotomy, or Salter innominate osteotomy) are crucial to prevent femoral head deformation and improve long-term outcomes, especially in older children (over 6-8 years old) with significant involvement, as they have a poorer prognosis for spontaneous remodeling. Option A is incorrect; many cases, especially in younger children, can be managed conservatively. Option B is incorrect; revascularization and remodeling can take 2-4 years, and residual deformity is common. Option D is incorrect; LCPD is not an infectious process. Option E is incorrect; while pain management is important, it's not the primary treatment for preventing deformity.

Question 4038

Topic: 4. Pediatrics
A 7-year-old girl is diagnosed with a Type III Salter-Harris fracture of the distal tibia following a playground injury. The fracture involves the epiphysis and extends into the joint, but the physis itself is only partially involved and not crushed. Given the nature of this fracture in a pediatric patient, what is the most significant long-term complication to monitor for?
. Nonunion of the fracture.
. Acute compartment syndrome.
. Leg length discrepancy and angular deformity due to physeal arrest.
. Osteomyelitis.
. Avascular necrosis of the distal tibia.

Correct Answer & Explanation

. Leg length discrepancy and angular deformity due to physeal arrest.

Explanation

A Salter-Harris Type III fracture involves the epiphysis and extends into the joint, but the physis is not completely separated. The main concern with any physeal injury (Salter-Harris fractures) in a growing child is damage to the growth plate (physis). While Type III fractures technically involve the epiphysis, the fracture line also crosses the physis, making physeal arrest a significant risk. This can lead to leg length discrepancy and/or angular deformity as the child continues to grow. Nonunion (Option A) is rare in pediatric fractures, especially Type III. Acute compartment syndrome (Option B) is a general trauma complication but not the most significant long-term risk unique to this fracture type. Osteomyelitis (Option D) is a risk if the fracture is open, but not an inherent complication of a closed Type III fracture. Avascular necrosis (Option E) is a concern in certain fractures (e.g., femoral head, talus) but less common for the distal tibia Type III fracture, especially if blood supply to the epiphysis is preserved.

Question 4039

Topic: 4. Pediatrics

Which type of intramedullary nail is generally contraindicated in pediatric patients with open growth plates?

. A. Elastic stable intramedullary nails (ESIN).
. B. Flexible intramedullary nails.
. C. Solid, unreamed nails that cross growth plates.
. D. Rigid, reamed nails that cross growth plates.
. E. Titanium nails.

Correct Answer & Explanation

. D. Rigid, reamed nails that cross growth plates.

Explanation

Rigid, reamed intramedullary nails that cross open growth plates (D) are generally contraindicated in pediatric patients. These nails can cause physeal arrest and subsequent limb length discrepancy or angular deformity. Flexible intramedullary nails (ESIN or TENS nails) (A, B) are specifically designed for pediatric long bone fractures, bypassing the physis or causing minimal damage. Solid, unreamed nails (C) may be used if they spare the physis. Titanium (E) is a material, not a specific nail type, and is used for flexible nails.

Question 4040

Topic: 4. Pediatrics
A 12-year-old girl with cerebral palsy (GMFCS Level III) presents with a rapidly progressing 75-degree thoracolumbar scoliosis, causing significant trunk imbalance and seating difficulties. She has a high risk of developing respiratory compromise. Her Risser score is 0. What is the most appropriate surgical intervention to address her spinal deformity and functional needs?
. Observation with bracing.
. Growing rod implantation.
. Anterior vertebral body tethering (AVBT).
. Posterior spinal fusion with instrumentation from T2 to L5/S1.
. Hemivertebra resection and fusion.

Correct Answer & Explanation

. Posterior spinal fusion with instrumentation from T2 to L5/S1.

Explanation

The patient has a severe, rapidly progressing scoliosis (75 degrees) with significant functional impact (trunk imbalance, seating difficulties, respiratory compromise risk) in the setting of cerebral palsy. Her Risser 0 indicates significant remaining growth potential, but the severity of the curve and the underlying neurological condition make non-operative management or growth-friendly strategies like growing rods less ideal as definitive solutions. Growing rods are typically used for younger patients with significant growth remaining and less severe curves to delay definitive fusion, and a 75-degree curve at 12 with GMFCS III requires more immediate, robust correction. Anterior vertebral body tethering is a growth modulation technique reserved for skeletally immature patients with idiopathic scoliosis, generally curves between 35-50 degrees, and is not suitable for severe neuromuscular scoliosis due to its limitations in correcting large, stiff curves and its dependency on continued growth. Hemivertebra resection is for congenital scoliosis due to a hemivertebra, which is not described here. For a severe, progressive neuromuscular scoliosis in an adolescent with cerebral palsy, posterior spinal fusion with instrumentation, typically extending from the upper thoracic spine to the pelvis (T2 to L5/S1), is the most appropriate definitive surgical intervention. This provides robust correction of the deformity, achieves permanent stability, improves seating balance, and prevents further progression and respiratory compromise. Fusion to the pelvis (L5/S1) is often necessary in neuromuscular scoliosis to prevent pelvic obliquity and ensure stable seating.

Test Yourself

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

On this Page