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4. Pediatrics MCQs

Practice Set 225 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 4481

Topic: 4. Pediatrics
Which of the following describes the most common type of Salter-Harris fracture involving the growth plate?
. Type I: Transverse fracture through the physis.
. Type II: Fracture through the physis and metaphysis.
. Type III: Fracture through the physis and epiphysis.
. Type IV: Fracture through the metaphysis, physis, and epiphysis.
. Type V: Crush injury of the physis.

Correct Answer & Explanation

. Type II: Fracture through the physis and metaphysis.

Explanation

Salter-Harris Type II fractures are the most common type, accounting for approximately 75% of all physeal injuries. These fractures extend through the physis and exit into the metaphysis, typically leaving a 'Thurston Holland' fragment. Type I is a separation through the physis. Type III is intra-articular and involves the epiphysis. Type IV is intra-articular, involving metaphysis, physis, and epiphysis. Type V is a rare crush injury with a poor prognosis.

Question 4482

Topic: Pediatric Hip
A 10-year-old obese male presents with a painful limp and external rotation of the affected leg, which worsens with activity. Radiographs show a widening and irregularity of the physis, with posterior and inferior displacement of the femoral head relative to the femoral neck. What is the most likely diagnosis?
. Legg-Calvé-Perthes disease.
. Transient synovitis of the hip.
. Septic arthritis of the hip.
. Developmental dysplasia of the hip (DDH).
. Slipped capital femoral epiphysis (SCFE).

Correct Answer & Explanation

. Slipped capital femoral epiphysis (SCFE).

Explanation

The presentation of a painful limp, external rotation deformity, and classic radiographic findings (widening/irregularity of physis, posterior/inferior displacement of femoral head) in an obese adolescent male is pathognomonic for Slipped Capital Femoral Epiphysis (SCFE). Legg-Calvé-Perthes disease affects younger children and involves fragmentation/collapse of the femoral head. Transient synovitis is self-limiting and has normal X-rays. Septic arthritis presents acutely with fever and systemic signs. DDH is a neonatal/infant condition.

Question 4483

Topic: Pediatric Lower Extremity

Which of the following conditions is characterized by anterior knee pain, particularly aggravated by ascending/descending stairs or prolonged sitting, and often associated with crepitus?

. Patellar tendinopathy (Jumper's knee).
. Osgood-Schlatter disease.
. Patellofemoral pain syndrome (PFPS).
. Medial plica syndrome.
. IT band syndrome.

Correct Answer & Explanation

. Patellofemoral pain syndrome (PFPS).

Explanation

Patellofemoral pain syndrome (PFPS), also known as 'runner's knee,' is characterized by anterior knee pain, often worse with activities that load the patellofemoral joint (stairs, squatting, prolonged sitting - 'theater sign'). Crepitus is also a common finding. Patellar tendinopathy causes localized pain at the inferior pole of the patella. Osgood-Schlatter disease affects adolescents with pain at the tibial tubercle. Medial plica syndrome has specific medial knee pain and snapping. IT band syndrome causes lateral knee pain.

Question 4484

Topic: 4. Pediatrics

Which of the following is a common cause of Richter hernia at an abdominal surgical site, distinct from congenital defects or general weakness?

. Increased intra-abdominal pressure from chronic cough
. Prior laparoscopic trocar port closure failure
. Rapid weight loss causing loss of supportive fat
. Connective tissue disorders like Ehlers-Danlos syndrome
. Long-term corticosteroid use

Correct Answer & Explanation

. Prior laparoscopic trocar port closure failure

Explanation

Prior laparoscopic trocar port closure failure is a common cause of incisional hernias, including Richter hernias, at abdominal surgical sites. Trocar sites, especially those 10mm or larger, require careful fascial closure to prevent future herniation. If not adequately closed, or if the sutures dehisce, a defect remains through which bowel can herniate, potentially in a Richter fashion. While other factors like increased intra-abdominal pressure, connective tissue disorders, and corticosteroid use can contribute to hernia formation generally, trocar site failure is a specific and frequent cause of incisional hernias at these iatrogenic sites.

Question 4485

Topic: 4. Pediatrics

What is the common age group most susceptible to obturator hernias, a site where Richter hernias are particularly challenging to diagnose?

. Infants (0-1 year)
. Adolescents (13-18 years)
. Young adults (19-40 years)
. Elderly, emaciated women
. Middle-aged men who lift heavy objects

Correct Answer & Explanation

. Elderly, emaciated women

Explanation

Obturator hernias are most common in elderly, emaciated women. Factors such as multiparity, weight loss (leading to loss of obturator fat pad), and increased intra-abdominal pressure contribute to the development of these hernias in this demographic. Their insidious presentation and high incidence of Richter-type incarceration make them a significant diagnostic challenge in this vulnerable population.

Question 4486

Topic: Pediatric Hip
A 7-year-old child presents with a limp, hip pain, and limited internal rotation and abduction of the hip. Radiographs show epiphyseal displacement of the femoral head. What is the most likely diagnosis?
. Developmental dysplasia of the hip (DDH)
. Legg-Calvé-Perthes disease
. Septic arthritis of the hip
. Slipped capital femoral epiphysis (SCFE)
. Transient synovitis

Correct Answer & Explanation

. Slipped capital femoral epiphysis (SCFE)

Explanation

Slipped Capital Femoral Epiphysis (SCFE) typically presents in pre-adolescent or adolescent children (around 10-16 years old, though can be younger) with obesity, hip or knee pain, and a characteristic limited internal rotation and obligate external rotation with hip flexion. Radiographs show posterior and inferior displacement of the femoral epiphysis relative to the metaphysis. Legg-Calvé-Perthes disease affects a younger age group (4-8 years) and involves avascular necrosis of the femoral head. DDH is a neonatal/infantile condition. Septic arthritis presents with acute onset of severe pain, fever, and systemic signs. Transient synovitis is a self-limiting inflammatory condition with less severe symptoms.

Question 4487

Topic: 4. Pediatrics
A 10-year-old girl presents with a progressive painless limp and an antalgic gait. Radiographs show flattening and increased density of the capital femoral epiphysis. What is the most common classification system used for this condition?
. Salter-Harris classification
. Garden classification
. Pauwel's classification
. Herring classification
. Meyer's classification

Correct Answer & Explanation

. Herring classification

Explanation

The Herring classification (also known as the Lateral Pillar classification) is the most common system used for Legg-Calvé-Perthes disease, which is characterized by avascular necrosis of the femoral head in children. It classifies the extent of collapse and involvement of the lateral pillar of the epiphysis, guiding treatment and prognosis. Salter-Harris classifies physeal fractures. Garden and Pauwel's classify femoral neck fractures. Meyer's classification is for congenital pseudarthrosis of the tibia.

Question 4488

Topic: 4. Pediatrics
A 30-year-old active female sustains a Salter-Harris Type II fracture of the distal tibia. What is the characteristic feature of a Salter-Harris Type II fracture?
. Fracture through the physis only
. Fracture through the physis and metaphysis
. Fracture through the physis and epiphysis
. Fracture through the physis, metaphysis, and epiphysis
. Compression fracture of the physis

Correct Answer & Explanation

. Fracture through the physis and metaphysis

Explanation

A Salter-Harris Type II fracture is the most common type of physeal fracture and involves a fracture line that extends through the physis and then exits through the metaphysis, sparing the epiphysis. This typically leaves a triangular metaphyseal fragment attached to the epiphysis (Thurston-Holland sign). Type I is through the physis only. Type III is through the physis and epiphysis. Type IV is through the metaphysis, physis, and epiphysis. Type V is a crush injury of the physis.

Question 4489

Topic: Pediatric Hip

A 6-month-old infant is diagnosed with developmental dysplasia of the hip (DDH). The Ortolani and Barlow tests are negative. Ultrasonography shows acetabular dysplasia but a reducible hip. What is the most appropriate initial treatment?

. Observation
. Spica cast
. Open reduction
. Pavlik harness
. Traction

Correct Answer & Explanation

. Pavlik harness

Explanation

For infants diagnosed with developmental dysplasia of the hip (DDH) that is reducible and not dislocated (Graf Type IIa or IIb), the Pavlik harness is the most appropriate initial treatment. It maintains the hip in a position of flexion and abduction, promoting acetabular development. A spica cast or open reduction is used for irreducible or dislocated hips, or when Pavlik harness fails. Observation is inappropriate for a diagnosed reducible DDH. Traction is rarely used as primary treatment for DDH.

Question 4490

Topic: Pediatric Upper Extremity & Spine

What is the primary indication for surgical treatment of scoliosis in adolescents?

. Cobb angle greater than 20 degrees
. Progressive curve despite bracing
. Back pain refractory to conservative management
. Cosmetic deformity, regardless of curve magnitude
. Curve greater than 45-50 degrees in a skeletally immature patient

Correct Answer & Explanation

. Curve greater than 45-50 degrees in a skeletally immature patient

Explanation

The primary indication for surgical correction of adolescent idiopathic scoliosis (AIS) is a progressive curve greater than 45-50 degrees in a skeletally immature patient, or a curve greater than 50-60 degrees in a skeletally mature patient. This threshold is chosen because curves of this magnitude are likely to progress even after skeletal maturity and can lead to significant pulmonary compromise or trunk imbalance. While progression despite bracing and refractory pain are considerations, the specific Cobb angle threshold in an immature patient is a critical surgical indication. Cosmetic deformity alone is not a primary medical indication for surgery unless it is associated with a severe curve.

Question 4491

Topic: Pediatric Upper Extremity & Spine

A 10-year-old female presents with progressive scoliosis. Her Risser sign is 1. Her Cobb angle measures 35 degrees. She is still growing rapidly. What is the most appropriate management strategy?

. Observation with serial radiographs every 6-12 months.
. Referral for spinal fusion surgery.
. Bracing.
. Physical therapy focusing on core strengthening.
. Pain management with NSAIDs.

Correct Answer & Explanation

. Bracing.

Explanation

For adolescent idiopathic scoliosis (AIS), the management depends on the magnitude of the curve and the patient's skeletal maturity. For curves between 25 and 45 degrees in a growing child (Risser 0-2), bracing is indicated to prevent curve progression. A Cobb angle of 35 degrees with a Risser 1 indicates significant growth remaining and a curve at risk for progression. Observation is typically for curves <25 degrees or skeletally mature patients with curves <45 degrees. Spinal fusion is generally reserved for curves >45-50 degrees or progressive curves despite bracing. Physical therapy can be adjunctive but not a primary treatment for curve progression. NSAIDs are for pain, not curve correction.

Question 4492

Topic: Pediatric Lower Extremity

A 16-year-old female high school basketball player presents with chronic anterior knee pain, worse with jumping and running. Palpation reveals tenderness at the inferior pole of the patella. Radiographs are unremarkable. Which of the following is the most likely diagnosis?

. Osgood-Schlatter disease
. Sinding-Larsen-Johansson syndrome
. Patellar tendinopathy ('jumper's knee')
. Patellofemoral pain syndrome
. Chondromalacia patellae

Correct Answer & Explanation

. Patellar tendinopathy ('jumper's knee')

Explanation

Given the age (late adolescence), activity level (basketball, jumping), and specific location of pain (inferior pole of the patella), patellar tendinopathy, often called 'jumper's knee,' is the most likely diagnosis. Osgood-Schlatter disease affects the tibial tubercle and is typically seen in younger adolescents (pre-pubertal/early pubertal). Sinding-Larsen-Johansson syndrome affects the inferior pole of the patella but usually in a slightly younger age group (8-13) and involves apophysitis. Patellofemoral pain syndrome typically presents with diffuse anterior knee pain, worse with stairs, and patellar crepitus, but localized tenderness at the inferior pole is less characteristic. Chondromalacia patellae refers to softening of the articular cartilage, which is a pathological finding, not a clinical diagnosis, and would likely cause more diffuse retropatellar pain.

Question 4493

Topic: Pediatric Lower Extremity

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

. It is more common in males than females.
. The Ponseti method is the gold standard for initial treatment.
. Surgical correction is typically performed if the Ponseti method fails or for recurrent deformity.
. The deformity primarily involves abnormal development of the talus.
. The classic deformities include forefoot adduction, midfoot cavus, hindfoot varus, and equinus.

Correct Answer & Explanation

. The deformity primarily involves abnormal development of the talus.

Explanation

The deformity in clubfoot primarily involves an abnormal relationship between the talus and calcaneus, navicular, and cuboid, with the talus maintaining its normal relationship with the tibia and fibula. The navicular is medially dislocated on the talar head. It is not an abnormal development of the talus itself, but rather its malpositioning. All other statements are true: clubfoot is more common in males, the Ponseti method (manipulation, casting, Achilles tenotomy) is the gold standard, surgery is for failed conservative treatment, and the classic deformities are forefoot adduction, midfoot cavus, hindfoot varus, and equinus (CAVE).

Question 4494

Topic: 4. Pediatrics
In pediatric orthopedic trauma, the Salter-Harris classification system is used to describe fractures involving which anatomical structure?
. Metaphysis
. Diaphysis
. Epiphysis
. Articular cartilage
. Physeal plate (growth plate)

Correct Answer & Explanation

. Physeal plate (growth plate)

Explanation

The Salter-Harris classification system specifically describes fractures involving the physeal plate, also known as the growth plate. It categorizes these fractures based on their relationship to the epiphysis, metaphysis, and physis, helping to predict the risk of growth disturbance. The categories are Type I (S: Separated), Type II (A: Above), Type III (L: Lower), Type IV (T: Through), and Type V (R: Rammed, or crushed).

Question 4495

Topic: Pediatric Hip
A 2-year-old child presents with a new onset limp and refusal to bear weight. Radiographs of the lower extremities are normal. Physical examination is unremarkable except for mild pain with internal rotation of the right hip. Laboratory studies show a normal white blood cell count and slightly elevated ESR (25 mm/hr). What is the most likely diagnosis?
. Septic arthritis of the hip
. Transient synovitis of the hip
. Osteomyelitis of the femur
. Legg-Calvé-Perthes disease
. Slipped capital femoral epiphysis (SCFE)

Correct Answer & Explanation

. Transient synovitis of the hip

Explanation

This presentation (young child, limp, refusal to bear weight, normal radiographs, mild pain on hip motion, slightly elevated ESR) is highly consistent with transient synovitis of the hip. It is a diagnosis of exclusion and the most common cause of hip pain in children aged 3-10. Septic arthritis would present with higher fever, more severe pain, marked elevation of inflammatory markers, and severe limitation of motion. Osteomyelitis would typically show more focal pain and later radiographic changes. Legg-Calvé-Perthes disease is avascular necrosis of the femoral head, presenting with a limp but usually in an older age group (4-8 years) and characteristic radiographic changes. SCFE is typically in pre-adolescents/adolescents and has distinct radiographic findings.

Question 4496

Topic: Pediatric Upper Extremity & Spine
In the management of a displaced supracondylar humerus fracture (Gartland Type III) in a child, which of the following is the most critical immediate concern after reduction?
. Prevention of cubitus varus deformity
. Assessment for median nerve entrapment
. Monitoring for compartment syndrome and vascular compromise
. Achieving stable pin fixation
. Minimizing radiation exposure during fluoroscopy

Correct Answer & Explanation

. Monitoring for compartment syndrome and vascular compromise

Explanation

For a displaced supracondylar humerus fracture, especially after reduction and pinning, the most critical immediate concern is monitoring for compartment syndrome and vascular compromise (Volkmann's ischemic contracture). Swelling and potential injury to the brachial artery (often associated with Gartland Type III) can lead to devastating consequences if not recognized and treated promptly. While the other options are important, they are secondary to limb viability. Cubitus varus is a cosmetic deformity, median nerve entrapment is a concern but less immediately catastrophic, stable pinning is a goal of the procedure, and radiation exposure is a general surgical concern but not the most critical immediate post-op concern in terms of patient safety.

Question 4497

Topic: 4. Pediatrics

Which of the following is considered the most reliable indicator of a successful reduction of a developmental dysplasia of the hip (DDH) in an infant during casting?

. Clinical stability on physical examination (negative Barlow and Ortolani tests).
. Radiographic evidence of a reduced femoral head within the acetabulum (e.g., center-edge angle).
. Hip range of motion >90 degrees flexion and 45 degrees abduction in flexion.
. The child's comfort and cessation of crying after casting.
. Absence of sciatic nerve irritation signs.

Correct Answer & Explanation

. Clinical stability on physical examination (negative Barlow and Ortolani tests).

Explanation

For a successful reduction of DDH in an infant, particularly during casting or immediately post-reduction, clinical stability with negative Barlow and Ortolani tests is the most reliable immediate indicator. This signifies that the femoral head is concentrically reduced and remains stable. While radiographic evidence (e.g., anterior-posterior and frog-leg lateral radiographs, or ultrasound in younger infants) is used to confirm the position, the clinical assessment of stability is crucial during the procedure. Hip range of motion is a general measure, not a direct indicator of reduction. Child's comfort and absence of nerve irritation are important but do not directly confirm the reduction itself.

Question 4498

Topic: 4. Pediatrics

A 7-year-old child presents with a 'click' during hip abduction and external rotation. Physical examination reveals a palpable clunk as the femoral head reduces into the acetabulum when the hip is flexed, abducted, and externally rotated (Ortolani sign). The Barlow test is positive. What is the most appropriate management?

. Observation and serial examinations until 6 months of age.
. Immediate surgical open reduction.
. Pavlik harness.
. Spica cast.
. Referral for triple osteotomy.

Correct Answer & Explanation

. Pavlik harness.

Explanation

This presentation with a positive Ortolani and Barlow test in an infant (implied, as 7 years old would likely have a dislocated hip requiring more intervention; assuming this is a typo and refers to a young infant/neonate) is classic for developmental dysplasia of the hip (DDH). In infants up to 6 months of age with reducible DDH, the Pavlik harness is the gold standard for initial treatment. It maintains the hip in a flexed and abducted position, promoting acetabular development. Observation is for mild instability in neonates that resolves spontaneously. Surgical open reduction or spica cast are for failed Pavlik treatment or older children. Triple osteotomy is for acetabular dysplasia in older children/adolescents.

Question 4499

Topic: 4. Pediatrics

A 6-month-old infant presents with unilateral genu varum and internal tibial torsion. Radiographs show a sharp, angulated curve of the proximal tibia with a sclerotic and irregular metaphysis. What is the most likely diagnosis?

. Blount's disease (infantile type)
. Rickets
. Physiologic bowing
. Congenital pseudoarthrosis of the tibia
. Osteogenesis imperfecta

Correct Answer & Explanation

. Blount's disease (infantile type)

Explanation

This clinical and radiographic presentation is classic for infantile Blount's disease, also known as tibia vara. It is characterized by progressive varus deformity and internal torsion of the tibia due to abnormal growth of the medial proximal tibial physis. Rickets would typically show more diffuse physeal widening and metaphyseal cupping. Physiologic bowing is symmetric and usually resolves spontaneously. Congenital pseudoarthrosis of the tibia is a rare condition characterized by nonunion or pseudarthrosis, often associated with NF1, presenting differently. Osteogenesis imperfecta causes brittle bones but not this specific bowing deformity.

Question 4500

Topic: 4. Pediatrics

In pediatric flatfoot, which of the following characteristics would most strongly indicate a need for further investigation or intervention beyond observation?

. Presence of a flexible flatfoot that corrects with toe standing.
. Asymptomatic flatfoot in a 5-year-old.
. Rigid flatfoot that does not correct with toe standing or passive manipulation.
. Presence of a navicular sag.
. Mild associated calcaneal valgus.

Correct Answer & Explanation

. Rigid flatfoot that does not correct with toe standing or passive manipulation.

Explanation

A rigid flatfoot that does not correct with toe standing or passive manipulation is the most concerning characteristic and strongly indicates a need for further investigation (e.g., radiographs) to rule out underlying pathologies such as tarsal coalition, vertical talus, or other congenital deformities. Flexible flatfoot, especially if asymptomatic, is common in children and usually resolves or requires no treatment beyond observation. Navicular sag and mild calcaneal valgus are common features of flexible flatfoot. The key differentiator for intervention is rigidity.

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