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4. Pediatrics MCQs

Practice Set 223 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 4441

Topic: 4. Pediatrics
Which of the following growth plate fractures, classified by Salter-Harris, carries the highest risk of growth arrest and angular deformity?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type V

Explanation

Salter-Harris Type V fractures involve a crush injury to the epiphyseal growth plate. Due to the complete destruction of the growth plate cartilage, they carry the highest risk of premature growth arrest and subsequent angular deformity, often with an unpredictable outcome. Type IV fractures (epiphysis and metaphysis) also have a high risk if not anatomically reduced, but Type V is considered the most severe in terms of growth plate damage.

Question 4442

Topic: 4. Pediatrics

A 5-year-old child presents with a high-riding scapula and limited abduction of the shoulder. Radiographs reveal an omovertebral bone connecting the scapula to the cervical spine. What is the MOST likely diagnosis?

. Congenital pseudoarthrosis of the clavicle
. Sprengel's deformity
. Klippel-Feil syndrome
. Congenital scoliosis
. Cleidocranial dysostosis

Correct Answer & Explanation

. Sprengel's deformity

Explanation

This is a classic description of Sprengel's deformity, which is congenital elevation of the scapula, often associated with an omovertebral bone connecting the scapula to the cervical spine, leading to a cosmetically high-riding scapula and limited shoulder motion. Klippel-Feil syndrome involves congenital fusion of cervical vertebrae and is often associated with Sprengel's but is not the primary diagnosis here. Congenital pseudoarthrosis of the clavicle and cleidocranial dysostosis affect the clavicle primarily.

Question 4443

Topic: 4. Pediatrics
Which of the following describes a Salter-Harris Type III fracture?
. Fracture through the physis only
. Fracture through the metaphysis and physis
. Fracture through the epiphysis and physis
. Fracture through the metaphysis, physis, and epiphysis
. Crush injury to the physis

Correct Answer & Explanation

. Fracture through the epiphysis and physis

Explanation

A Salter-Harris Type III fracture is an intra-articular fracture that extends from the joint surface through the epiphysis and then turns to exit through the physis (growth plate). This type of fracture can lead to growth arrest due to involvement of the germinal cells in the physis and often requires anatomical reduction to prevent articular incongruity. Type I is physis only, Type II is metaphysis and physis, Type IV is metaphysis, physis, and epiphysis, and Type V is a crush injury to the physis.

Question 4444

Topic: Pediatric Hip

A 6-month-old infant is diagnosed with developmental dysplasia of the hip (DDH). Physical examination reveals a positive Barlow test and Galeazzi sign. Radiographs show a dislocated left hip. What is the most appropriate initial treatment?

. Immediate open reduction and spica cast
. Pavlik harness
. Closed reduction under anesthesia and spica cast
. Observation with serial ultrasounds
. Referral for triple osteotomy

Correct Answer & Explanation

. Pavlik harness

Explanation

For an infant diagnosed with DDH at 6 months of age, a Pavlik harness is the gold standard initial treatment for reducible hips. The Barlow test indicates reducibility. The Pavlik harness holds the hips in flexion and abduction, promoting femoral head seating and acetabular development. Open reduction or closed reduction with spica cast is typically reserved for older infants, failed harness treatment, or irreducible hips. Observation is inappropriate for a dislocated hip. Triple osteotomy is for older children with persistent dysplasia.

Question 4445

Topic: Pediatric Upper Extremity & Spine

A 12-year-old female presents with progressive thoracic spinal deformity. Radiographs show a right thoracic curve measuring 45 degrees, with significant vertebral rotation. She is Risser 0. What is the most appropriate management?

. Observation and serial radiographs every 6 months
. Bracing with a thoracolumbosacral orthosis (TLSO)
. Posterior spinal fusion
. Anterior vertebral body tethering (VBT)
. Physical therapy and stretching exercises

Correct Answer & Explanation

. Posterior spinal fusion

Explanation

For adolescent idiopathic scoliosis, a curve magnitude of 45 degrees in a skeletally immature patient (Risser 0 indicates significant growth remaining) is typically an indication for surgical intervention, most commonly posterior spinal fusion. Bracing is generally recommended for curves between 25-45 degrees in growing patients to prevent progression, but a 45-degree curve at Risser 0 has a high likelihood of progression beyond 50 degrees, warranting surgery. Observation is for curves <25 degrees. VBT is a growth modulation technique, but a 45-degree curve may be pushing its limits, and posterior fusion is more definitive for this magnitude. Physical therapy does not typically prevent progression of structural scoliosis.

Question 4446

Topic: Pediatric Upper Extremity & Spine

A 3-year-old child presents with a painful, swollen elbow after being pulled up by the hand by an adult. The child holds the arm pronated and slightly flexed, refusing to use it. Radiographs are normal. What is the most likely diagnosis?

. Supracondylar humerus fracture
. Lateral condyle fracture
. Radial head subluxation (nursemaid's elbow)
. Olecranon fracture
. Septic elbow arthritis

Correct Answer & Explanation

. Radial head subluxation (nursemaid's elbow)

Explanation

The classic presentation of a child (typically 1-4 years old) with a painful arm held in pronation and flexion after a sudden pull on the hand, with normal radiographs, is highly suggestive of a radial head subluxation, commonly known as 'nursemaid's elbow.' This occurs when the annular ligament slips over the radial head and becomes trapped in the radiohumeral joint. Fractures would typically be visible on X-ray, and septic arthritis would present with fever and more systemic signs.

Question 4447

Topic: 4. Pediatrics

A 6-month-old infant presents with a torticollis and a firm, non-tender mass in the sternocleidomastoid muscle. The child's head is tilted to one side and rotated to the opposite. What is the most likely diagnosis?

. Congenital muscular torticollis
. Klippel-Feil syndrome
. Congenital scoliosis
. Cervical dystonia
. Infectious torticollis

Correct Answer & Explanation

. Congenital muscular torticollis

Explanation

Congenital muscular torticollis (CMT) is the most likely diagnosis. It typically presents in infants aged 2-4 weeks with a progressively palpable, firm, non-tender mass (pseudotumor) in the sternocleidomastoid muscle, along with a characteristic head tilt to the ipsilateral side and rotation to the contralateral side. It is thought to be due to fibrosis within the SCM. Klippel-Feil syndrome and congenital scoliosis are bony abnormalities of the spine. Cervical dystonia usually presents later in life. Infectious torticollis would typically involve pain, fever, and signs of inflammation.

Question 4448

Topic: 4. Pediatrics

Which zone of the physis (growth plate) is most susceptible to shear forces and is primarily responsible for longitudinal bone growth?

. Resting zone
. Proliferative zone
. Hypertrophic zone
. Calcification zone
. Resorption zone

Correct Answer & Explanation

. Hypertrophic zone

Explanation

The hypertrophic zone of the physis is where chondrocytes rapidly enlarge, forming columns, and become calcified. This zone is mechanically the weakest part of the physis, making it most susceptible to shear forces and fractures (e.g., Salter-Harris fractures typically occur through this zone). The proliferative zone is where chondrocytes multiply, contributing to longitudinal growth by producing new cells. The resting zone serves as a reserve of cells. The calcification zone is where the cartilage matrix calcifies, and the resorption zone is where chondroclasts and osteoblasts invade, leading to ossification.

Question 4449

Topic: 4. Pediatrics

A 4-month-old infant is brought to the clinic for routine check-up. The mother notes the baby keeps the head tilted to the left. On examination, the left sternocleidomastoid muscle is palpably tight. Passive range of motion reveals limited rotation to the right and left lateral flexion. What is the most appropriate initial treatment?

. MRI of the cervical spine
. Referral for surgical release of the sternocleidomastoid
. Physical therapy focusing on stretching and strengthening exercises
. Botulinum toxin injection into the SCM
. Orthosis (collar) to correct head position

Correct Answer & Explanation

. Physical therapy focusing on stretching and strengthening exercises

Explanation

This is a classic presentation of congenital muscular torticollis. The most appropriate initial treatment, especially in infants under one year of age, is conservative management with physical therapy. This involves gentle stretching exercises (passive stretching of the SCM and active range of motion) to elongate the tight muscle, along with positioning and strengthening exercises to encourage symmetrical head posture and neck muscle development. Surgery is reserved for cases that fail extensive conservative therapy (e.g., after 12-18 months of treatment). MRI might be considered if there are atypical features or persistent concerns, but not as the first step. Botulinum toxin and orthoses are less common initial treatments.

Question 4450

Topic: Pediatric Hip

A 3-month-old infant presents for a routine check-up. The pediatrician notes asymmetric thigh folds and a positive Ortolani test on the left hip. What is the most appropriate next step in management?

. Reassure the parents and observe for 3 months.
. Order a plain radiograph of the pelvis.
. Refer for immediate orthopedic consultation and likely Pavlik harness application.
. Start physical therapy exercises for hip strengthening.
. Obtain an MRI of the hip.

Correct Answer & Explanation

. Refer for immediate orthopedic consultation and likely Pavlik harness application.

Explanation

A positive Ortolani test in a 3-month-old infant indicates a reducible dislocated hip, which is a definitive sign of developmental dysplasia of the hip (DDH). Given the age and positive clinical finding, immediate orthopedic consultation and Pavlik harness application are the most appropriate steps. The Pavlik harness is highly effective for DDH when initiated early, especially before 6 months of age. Reassurance and observation are inappropriate for a dislocated hip. Plain radiographs are less reliable for cartilaginous hips in infants younger than 4-6 months, where ultrasound is preferred, but the clinical exam is diagnostic here. Physical therapy is not the primary treatment for a dislocated hip. MRI is usually reserved for complex cases or failed harness treatment.

Question 4451

Topic: 4. Pediatrics
A 10-year-old girl sustains a Salter-Harris Type II fracture of the distal tibia. What is the most important concern regarding long-term complications?
. Avascular necrosis of the epiphysis.
. Recurrent dislocation of the ankle.
. Growth arrest leading to limb length discrepancy or angular deformity.
. Osteoarthritis of the ankle joint.
. Non-union of the metaphysis.

Correct Answer & Explanation

. Growth arrest leading to limb length discrepancy or angular deformity.

Explanation

Salter-Harris fractures involve the growth plate (physis). Type II fractures involve the physis and the metaphysis. The most important long-term complication concern for any Salter-Harris fracture, especially in a growing child, is growth arrest. This can lead to limb length discrepancy (shortening) or angular deformity, particularly if the fracture is displaced, involves a significant portion of the physis, or if repeated attempts at reduction cause further physeal damage. Avascular necrosis is a risk in some physeal fractures (e.g., Type IV, or specific locations like femoral neck), but less common in Type II distal tibia. Ankle dislocation is not a typical long-term complication. Osteoarthritis is a long-term risk of intra-articular fractures (Type III, IV). Non-union is rare for physeal fractures.

Question 4452

Topic: Pediatric Upper Extremity & Spine

What is the primary goal of surgical treatment for adolescent idiopathic scoliosis (AIS) with curves greater than 45-50 degrees?

. Elimination of all back pain.
. Correction of cosmetic deformity and prevention of curve progression.
. Complete normalization of spinal alignment.
. Improvement of pulmonary function only.
. Prevention of neurological deficits.

Correct Answer & Explanation

. Correction of cosmetic deformity and prevention of curve progression.

Explanation

The primary goal of surgical treatment for adolescent idiopathic scoliosis (AIS) with significant curves (typically >45-50 degrees in skeletally immature or >50 degrees in mature patients) is to correct the cosmetic deformity and, most importantly, prevent further curve progression. Curves exceeding 50 degrees in adults tend to progress throughout life and can eventually lead to significant back pain and pulmonary compromise. While pain improvement can occur, it is not the primary indication for surgery. Complete normalization of spinal alignment is generally not achievable or necessary. Pulmonary function improvement is a secondary benefit, especially in very severe curves. Prevention of neurological deficits is a concern during surgery, but not the primary indication for elective correction of AIS.

Question 4453

Topic: Pediatric Lower Extremity

Which of the following statements about clubfoot (congenital talipes equinovarus) is FALSE?

. It is characterized by hindfoot equinus, hindfoot varus, forefoot adduction, and forefoot supination.
. The Ponseti method is the gold standard for initial non-operative treatment.
. Correction involves serial casting with gentle manipulation, primarily addressing hindfoot equinus first.
. Percutaneous Achilles tenotomy is often performed as part of the Ponseti method.
. Surgical release is typically reserved for failed Ponseti treatment or recurrence.

Correct Answer & Explanation

. Correction involves serial casting with gentle manipulation, primarily addressing hindfoot equinus first.

Explanation

The statement that 'Correction involves serial casting with gentle manipulation, primarily addressing hindfoot equinus first' is FALSE. The Ponseti method, the gold standard for clubfoot correction, addresses the components of the deformity in a specific sequence: first correcting the cavus and adduction, then the varus, and finally the equinus. The hindfoot equinus is usually the last deformity addressed, often requiring a percutaneous Achilles tenotomy. If equinus is corrected first, it can lead to a 'rocker-bottom' foot. The other statements are true: clubfoot has characteristic deformities, Ponseti is the gold standard, Achilles tenotomy is common, and surgery is reserved for failures.

Question 4454

Topic: 4. Pediatrics

A 6-month-old infant is diagnosed with congenital muscular torticollis. What is the most appropriate initial management?

. Immediate surgical release of the sternocleidomastoid muscle.
. Referral for botulinum toxin injection.
. Passive stretching exercises and physical therapy.
. Cervical collar immobilization.
. Wait until the child is older to assess for spontaneous resolution.

Correct Answer & Explanation

. Passive stretching exercises and physical therapy.

Explanation

Congenital muscular torticollis (CMT) is a common musculoskeletal condition in infants characterized by sternocleidomastoid muscle shortening and head tilt. The most appropriate initial management is non-operative, primarily consisting of passive stretching exercises and physical therapy to lengthen the affected sternocleidomastoid muscle and encourage symmetrical head posture. This is highly effective, especially when started early (before 6 months of age). Surgical release is reserved for cases that fail extensive non-operative treatment (e.g., after 12-18 months of therapy, or with significant facial asymmetry). Botulinum toxin injections are rarely used and not first-line. Cervical collar immobilization is contraindicated. Waiting for spontaneous resolution is not recommended as it can lead to permanent facial and skull asymmetry.

Question 4455

Topic: Pediatric Hip

A 12-year-old boy, overweight, presents with a 3-week history of right hip and knee pain, particularly when walking. Examination shows a painful limp, limited internal rotation, and abduction of the hip. What is the most appropriate initial diagnostic imaging?

. MRI of the hip to rule out avascular necrosis.
. AP and frog-leg lateral radiographs of both hips.
. Ultrasound of the hip to check for effusion.
. CT scan of the pelvis.
. Plain radiographs of the knee.

Correct Answer & Explanation

. AP and frog-leg lateral radiographs of both hips.

Explanation

This clinical scenario (overweight adolescent with hip and knee pain, painful limp, limited internal rotation) is highly suspicious for Slipped Capital Femoral Epiphysis (SCFE). SCFE requires urgent diagnosis and treatment to prevent further slip and complications. The most appropriate initial diagnostic imaging is AP and frog-leg lateral radiographs of BOTH hips. This is crucial because SCFE can be bilateral (even if asymptomatic on the other side) and a frog-leg lateral view is essential to visualize the slip, which may not be obvious on the AP view. MRI is more sensitive but often not needed initially for diagnosis. Ultrasound and CT are typically not first-line for SCFE diagnosis. Plain radiographs of the knee would likely be normal given the hip pathology, but hip pain often refers to the knee.

Question 4456

Topic: Pediatric Upper Extremity & Spine
A 5-year-old child sustains a supracondylar humerus fracture (Gartland Type III) after a fall. Examination reveals a pale, pulseless hand. What is the most appropriate emergent management?
. Immediate closed reduction and percutaneous pinning.
. Observation and repeat vascular assessment in 1 hour.
. Open reduction and internal fixation with vascular exploration.
. Angiography to localize the vascular injury.
. Administer IV fluids and heparin.

Correct Answer & Explanation

. Immediate closed reduction and percutaneous pinning.

Explanation

A supracondylar humerus fracture with signs of vascular compromise (pale, pulseless hand) is an orthopedic emergency. The most appropriate emergent management is immediate closed reduction of the fracture and percutaneous pinning. Often, reduction of the fracture itself can restore arterial flow by relieving mechanical compression of the brachial artery. If the pulse does not return after successful reduction and pinning, then further investigation (e.g., Doppler ultrasound, formal angiography) and vascular exploration would be necessary. Observation is contraindicated in an ischemic limb. Open reduction and vascular exploration are secondary steps if closed reduction fails to restore perfusion. Administering fluids and heparin is supportive but not definitive.

Question 4457

Topic: 4. Pediatrics

A 10-year-old child presents with a severe kyphoscoliosis (70-degree Cobb angle in both planes) due to congenital vertebral anomalies. What is the primary long-term concern related to their respiratory system if this deformity remains uncorrected?

. Obstructive sleep apnea.
. Increased susceptibility to viral pneumonia.
. Chronic restrictive lung disease and respiratory failure.
. Recurrent aspirations.
. Pulmonary hypertension and right ventricular hypertrophy.

Correct Answer & Explanation

. Chronic restrictive lung disease and respiratory failure.

Explanation

Severe kyphoscoliosis significantly compromises the volume and compliance of the thoracic cage, leading to chronic restrictive lung disease. This reduces lung volumes and can progress to chronic respiratory failure, requiring ventilatory support. Ultimately, the sustained increased pulmonary vascular resistance can lead to pulmonary hypertension and right ventricular hypertrophy (cor pulmonale), which is a serious long-term complication of the restrictive lung disease. So, while pulmonary hypertension is a grave outcome, the primary and preceding respiratory concern is the restrictive lung disease and eventual respiratory failure. Obstructive sleep apnea can occur but is not the primary long-term pulmonary issue from severe kyphoscoliosis itself. Increased susceptibility to pneumonia or aspirations are complications that can arise from the chronic respiratory impairment, but the underlying problem is restrictive lung disease.

Question 4458

Topic: 4. Pediatrics

A 2-year-old child with spina bifida (myelomeningocele at L3-L4 level) is being evaluated. What is the most likely orthopedic problem this child will develop that requires intervention related to their neurological deficit?

. Scoliosis.
. Clubfoot (talipes equinovarus).
. Hip dislocation.
. Progressive ankle valgus.
. All of the above.

Correct Answer & Explanation

. All of the above.

Explanation

Children with myelomeningocele at the L3-L4 level have significant neurological deficits affecting motor and sensory function below that level. This leads to a multitude of orthopedic problems due to muscle imbalance, paralysis, and lack of sensation. These commonly include scoliosis (due to truncal muscle imbalance), clubfoot (often rigid and severe), and hip dislocation (due to unopposed hip flexor and adductor activity). Progressive ankle valgus can also develop. Therefore, 'All of the above' is the most appropriate answer as these children often present with multiple complex deformities requiring comprehensive orthopedic management, including consideration of bladder and bowel neurogenic dysfunction.

Question 4459

Topic: Pediatric Upper Extremity & Spine

What is the most accurate statement regarding the assessment of respiratory function in a patient with severe adolescent idiopathic scoliosis (AIS) undergoing surgical correction?

. Pulmonary function tests (PFTs) are rarely needed as respiratory complications are uncommon.
. Forced vital capacity (FVC) is the most sensitive predictor of postoperative respiratory complications.
. Surgical correction always leads to immediate and significant improvement in lung function.
. Patients with preoperative FVC < 40% are at highest risk for significant postoperative respiratory morbidity.
. Routine arterial blood gas (ABG) analysis is sufficient to assess respiratory reserve.

Correct Answer & Explanation

. Patients with preoperative FVC < 40% are at highest risk for significant postoperative respiratory morbidity.

Explanation

In severe AIS, preoperative pulmonary function tests are crucial. Patients with a forced vital capacity (FVC) less than 40% of predicted are considered to be at highest risk for significant postoperative respiratory morbidity and potential respiratory failure. While FVC is an important parameter, it's not themostsensitive predictor as others like forced expiratory volume in 1 second (FEV1) and FEV1/FVC ratio are also important. Surgical correction can improve lung function, but not always immediately or significantly, and it carries its own risks. PFTs are definitely needed for assessment, and ABG provides snapshot information, not a comprehensive assessment of reserve.

Question 4460

Topic: Pediatric Hip
A 10-year-old boy presents with a 3-week history of right hip pain and a limp, without antecedent trauma. Physical examination reveals limited internal rotation and abduction of the right hip. Radiographs show sclerosis and flattening of the right femoral epiphysis. What is the most likely diagnosis?
. Slipped Capital Femoral Epiphysis (SCFE)
. Developmental Dysplasia of the Hip (DDH)
. Transient synovitis
. Legg-Calvé-Perthes disease (LCPD)
. Septic arthritis

Correct Answer & Explanation

. Legg-Calvé-Perthes disease (LCPD)

Explanation

The age (peak incidence 4-10 years), presentation (atraumatic hip pain, limp), and radiographic findings (sclerosis, flattening of the femoral epiphysis) are classic for Legg-Calvé-Perthes disease (LCPD), which is idiopathic avascular necrosis of the femoral head. SCFE typically occurs in older, obese adolescents. DDH is usually diagnosed in infancy. Transient synovitis is acute and self-limiting. Septic arthritis would present with more acute, severe pain, fever, and systemic signs.

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