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4. Pediatrics MCQs

Practice Set 263 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 5241

Topic: Pediatric Upper Extremity & Spine

A 22-year-old collegiate baseball pitcher undergoes Ulnar Collateral Ligament (UCL) reconstruction. The surgeon opts for the 'docking technique' rather than the classic modified Jobe figure-of-eight technique. What is the primary biomechanical and anatomical advantage of the docking technique?

. It completely avoids the need to manage or mobilize the ulnar nerve
. It uses an interference screw in the ulna, eliminating the need for bone tunnels
. It decreases the number of holes drilled in the medial epicondyle, reducing the risk of epicondylar fracture
. It requires a shorter graft length, allowing for isolated use of the plantaris tendon
. It avoids detachment of the flexor-pronator mass origin

Correct Answer & Explanation

. It decreases the number of holes drilled in the medial epicondyle, reducing the risk of epicondylar fracture

Explanation

The docking technique utilizes a single socket in the medial epicondyle into which the two ends of the graft are 'docked' and tied over a bone bridge via smaller exit punctures. This significantly decreases the number of large converging tunnels in the medial epicondyle compared to the traditional Jobe figure-of-eight technique, thereby reducing the risk of iatrogenic medial epicondyle fracture.

Question 5242

Topic: 4. Pediatrics

A 13-year-old male baseball pitcher complains of gradually worsening shoulder pain in his throwing arm over the last two months. Examination reveals pain with resisted internal rotation and tenderness over the proximal humerus. Radiographs show widening and sclerosis of the proximal humeral physis. What is the most appropriate initial management?

. Corticosteroid injection into the subacromial space
. Diagnostic shoulder arthroscopy
. Immediate cessation of throwing for 3 months followed by physical therapy
. Surgical pinning of the physis
. Sleeper stretch program while continuing to throw through the pain

Correct Answer & Explanation

. Immediate cessation of throwing for 3 months followed by physical therapy

Explanation

The presentation is classic for 'Little Leaguer's shoulder,' which is a proximal humeral epiphysiolysis caused by repetitive rotational stress across the open physis. The gold standard of treatment is complete rest from throwing (usually a minimum of 3 months) until symptoms resolve and radiographic healing is noted, followed by physical therapy and a structured return-to-throw program.

Question 5243

Topic: 4. Pediatrics
A newborn is evaluated for congenital bilateral radial longitudinal deficiency (radial clubhand). On physical examination, the child has well-developed, functioning thumbs bilaterally. Echocardiogram is normal. Blood work reveals profound thrombocytopenia. What is the most likely diagnosis?
. Holt-Oram syndrome
. Fanconi anemia
. VACTERL association
. Thrombocytopenia-Absent Radius (TAR) syndrome
. Amniotic band sequence

Correct Answer & Explanation

. Thrombocytopenia-Absent Radius (TAR) syndrome

Explanation

Thrombocytopenia-Absent Radius (TAR) syndrome is unique among the syndromes associated with radial longitudinal deficiency because the thumbs are classically present and functional, despite the total absence of the radius. In Holt-Oram and Fanconi anemia, the thumbs are typically hypoplastic or absent. VACTERL association involves varying degrees of radial dysplasia but is characterized by vertebral, anorectal, cardiac, tracheoesophageal, renal, and limb anomalies.

Question 5244

Topic: Pediatric Upper Extremity & Spine

A newborn is diagnosed with a bilateral radial longitudinal deficiency (radial club hand). Which of the following clinical or genetic findings reliably differentiates Thrombocytopenia Absent Radius (TAR) syndrome from Fanconi anemia in this presentation?

. The radius is completely absent in Fanconi anemia but hypoplastic in TAR syndrome.
. The thumb is present in TAR syndrome but typically absent or hypoplastic in Fanconi anemia.
. TAR syndrome is associated with an autosomal dominant inheritance pattern.
. Cardiac septal defects are pathognomonic for TAR syndrome.
. Fanconi anemia presents with normal bone marrow function at birth.

Correct Answer & Explanation

. The thumb is present in TAR syndrome but typically absent or hypoplastic in Fanconi anemia.

Explanation

A key distinguishing feature between these syndromes is that in TAR syndrome, the thumb is always present (though the radius is absent), whereas in Fanconi anemia and Holt-Oram syndrome, the thumb is typically absent or severely hypoplastic.

Question 5245

Topic: 4. Pediatrics
Madelung deformity is a developmental abnormality of the wrist caused by premature closure of the volar-ulnar aspect of the distal radial physis. It is strongly associated with Léri-Weill dyschondrosteosis, which is linked to a mutation in which of the following genes?
. FGFR3
. SHOX
. COL1A1
. FBN1
. EXT1

Correct Answer & Explanation

. SHOX

Explanation

Léri-Weill dyschondrosteosis is a pseudoautosomal dominant condition caused by mutations or deletions of the SHOX (Short Stature Homeobox) gene. It is characterized by short stature and mesomelic limb shortening, with Madelung deformity being a classic feature.

Question 5246

Topic: 4. Pediatrics

Replantation surgery of amputated digits involves complex microsurgery and careful patient selection. Which of the following is considered a universally accepted absolute contraindication to replantation?

. Amputation of the thumb in a young adult
. Multiple digit amputations in a child
. Single digit amputation distal to the FDS insertion (Zone I)
. Severe crush injury with multilevel segmental vascular damage
. Amputation with a cold ischemia time of 10 hours

Correct Answer & Explanation

. Severe crush injury with multilevel segmental vascular damage

Explanation

Severe crush injuries with multilevel segmental damage are absolute contraindications for replantation because the extensive vascular intimal damage precludes reliable anastomosis and leads to an unacceptably high failure rate. Thumb amputations, multiple digits, and amputations in children are prime indications for replantation. Cold ischemia up to 24 hours can be tolerated in digits because they contain no muscle tissue.

Question 5247

Topic: Pediatric Upper Extremity & Spine
A newborn is evaluated for bilateral radial club hands. Which of the following associated syndromes is characterized by thrombocytopenia and absent radii, but classically features anatomically present thumbs?
. Holt-Oram syndrome
. Fanconi anemia
. VACTERL association
. TAR syndrome
. Cornelia de Lange syndrome

Correct Answer & Explanation

. TAR syndrome

Explanation

Thrombocytopenia Absent Radius (TAR) syndrome typically features bilaterally absent radii but present thumbs. In contrast, syndromes like Holt-Oram and Fanconi anemia generally present with hypoplastic or absent thumbs along with their radial deficiency.

Question 5248

Topic: 4. Pediatrics

A 10-year-old child with an open growth plate presents with recurrent patellar dislocations. The family is concerned about the effects of surgery on growth. Which MPFL reconstruction technique is generally preferred in this population?

. Transphyseal femoral tunnel with a single anterior screw.
. All-epiphyseal femoral and patellar tunnels, avoiding the physis.
. Extraphyseal femoral fixation with an independent patellar tunnel.
. Femoral physeal arrest using a permanent screw.
. Combined tibial tubercle osteotomy and MPFL reconstruction.

Correct Answer & Explanation

. All-epiphyseal femoral and patellar tunnels, avoiding the physis.

Explanation

For skeletally immature patients, all-epiphyseal (or physeal-sparing) techniques for MPFL reconstruction are generally preferred. These techniques aim to place tunnels or fixation points entirely within the epiphysis or metaphysis, or use techniques like soft tissue fixation on the femur and patella, to avoid violating the growth plates and prevent growth disturbance. Transphyseal tunnels are generally avoided unless carefully planned to minimize physeal damage (e.g., small diameter tunnels, specific locations, or using a drill guide perpendicular to the physis). Tibial tubercle osteotomies are usually contraindicated. The key is to avoid permanent physeal damage.

Question 5249

Topic: 4. Pediatrics

In terms of meniscal development, the menisci are fully vascularized during fetal development, and this vascularity recedes to the periphery during childhood. What is the approximate age by which the adult pattern of peripheral vascularity (red-red zone) is typically established?

. Birth.
. 1-2 years of age.
. 5-7 years of age.
. 10-12 years of age.
. 18-20 years of age.

Correct Answer & Explanation

. 10-12 years of age.

Explanation

During fetal development and early childhood, the menisci are largely vascularized. However, this extensive vascularity gradually recedes from the central part of the meniscus towards the periphery as the child grows and ambulates. By approximately 10-12 years of age, the adult pattern of peripheral vascularity (the 'red-red zone' covering the outer 10-30%) and avascularity (the 'white-white zone') is generally established.

Question 5250

Topic: 4. Pediatrics

A 5-year-old child sustains a displaced phalangeal neck fracture of the proximal phalanx. Which complication is most uniquely associated with failing to anatomically reduce the extension deformity in this specific pediatric fracture?

. Premature physeal closure
. Loss of proximal interphalangeal joint flexion due to subcondylar fossa obliteration
. Extensor tendon central slip rupture
. Avascular necrosis of the phalangeal base
. Nonunion

Correct Answer & Explanation

. Loss of proximal interphalangeal joint flexion due to subcondylar fossa obliteration

Explanation

Pediatric phalangeal neck fractures typically displace with the distal fragment in extension. If left unreduced, the distal prominent aspect of the proximal fragment fills the subcondylar fossa. Because the PIP joint requires the subcondylar fossa to accommodate the dorsal lip of the middle phalanx during flexion, obliteration of this space leads to a mechanical block to PIP flexion.

Question 5251

Topic: 4. Pediatrics
A 14-year-old girl presents with progressive bilateral wrist pain and deformity. Radiographs reveal increased volar and ulnar tilt of the distal radial articular surface, a V-shaped configuration of the carpus with proximal subsidence of the lunate, and dorsal subluxation of the distal ulna. This condition is most strongly associated with a mutation in which of the following genes?
. FGFR3
. SHOX
. COL1A1
. RUNX2
. COMP

Correct Answer & Explanation

. SHOX

Explanation

The patient has Madelung deformity, characterized by a premature growth arrest of the volar and ulnar aspects of the distal radius physis. It is highly associated with Léri-Weill dyschondrosteosis, a condition caused by a mutation or deletion in the SHOX (Short Stature Homeobox) gene located on the pseudoautosomal region of the sex chromosomes.

Question 5252

Topic: 4. Pediatrics
An infant is born with bilateral radial longitudinal deficiency (radial club hands). Which of the following systemic conditions must be urgently evaluated with an echocardiogram to rule out associated, potentially fatal, congenital heart defects?
. TAR syndrome
. Holt-Oram syndrome
. VACTERL association
. Fanconi anemia
. Apert syndrome

Correct Answer & Explanation

. Holt-Oram syndrome

Explanation

Holt-Oram syndrome is an autosomal dominant condition characterized by upper extremity anomalies, particularly preaxial (radial) deficiencies, and congenital heart defects. An urgent cardiac evaluation is required to rule out atrial or ventricular septal defects.

Question 5253

Topic: Pediatric Upper Extremity & Spine
A 7-year-old child falls from a tree and sustains a supracondylar humerus fracture (Gartland type III). Distal pulses are palpable but weak. There is no sensory deficit. What is the immediate management priority after initial assessment?
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation
. Observation for compartment syndrome
. Vascular exploration
. Traction

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

In a Gartland Type III supracondylar humerus fracture, particularly with signs of impending vascular compromise (weak pulse), urgent closed reduction and percutaneous pinning is the immediate management priority. Reduction of the fracture often relieves kinking or compression of the brachial artery, restoring normal blood flow. If the pulse does not improve after successful reduction and pinning, or if there are clear signs of ongoing ischemia, then further investigation such as Doppler ultrasound or formal vascular exploration would be considered. Observation is insufficient given the vascular concerns.

Question 5254

Topic: Pediatric Upper Extremity & Spine

A 15-year-old female presents with progressive thoracic scoliosis, measuring 55 degrees Cobb angle with significant trunk rotation and rib hump. She is Risser 4. What is the most appropriate treatment recommendation?

. Observation with regular follow-up
. Bracing
. Physical therapy
. Spinal fusion surgery
. Chiropractic manipulation

Correct Answer & Explanation

. Spinal fusion surgery

Explanation

For adolescent idiopathic scoliosis, a Cobb angle exceeding 45-50 degrees is an indication for surgical spinal fusion, regardless of the Risser sign (skeletal maturity). While a Risser 4 indicates near-skeletal maturity, curves of this magnitude have a high likelihood of continued progression into adulthood and can lead to significant functional limitations and cosmetic deformity. Bracing is typically used for curves between 25-45 degrees in skeletally immature patients. Observation is for smaller curves.

Question 5255

Topic: Pediatric Hip
A 4-year-old child presents with a painless limp. Radiographs of the hip show flattening and fragmentation of the femoral epiphysis. ESR and CRP are normal. What is the most likely diagnosis?
. Septic arthritis
. Transient synovitis
. Legg-Calvé-Perthes disease
. Slipped Capital Femoral Epiphysis (SCFE)
. Juvenile Idiopathic Arthritis

Correct Answer & Explanation

. Legg-Calvé-Perthes disease

Explanation

This clinical presentation is classic for Legg-Calvé-Perthes disease, which is idiopathic avascular necrosis of the femoral head in children, typically affecting those between 4 and 8 years of age. A painless limp is a common symptom, and radiographs showing flattening and fragmentation of the femoral epiphysis are diagnostic. Normal inflammatory markers (ESR, CRP) help differentiate it from infectious or inflammatory conditions like septic arthritis or juvenile idiopathic arthritis. SCFE typically affects older, often obese, adolescents.

Question 5256

Topic: Pediatric Lower Extremity

A newborn is noted to have a clubfoot (talipes equinovarus) deformity. What is the preferred initial treatment for idiopathic clubfoot in a neonate?

. Kite method of serial casting
. Surgical release
. Ponseti method of serial casting
. Physiotherapy and stretching
. Custom orthotics

Correct Answer & Explanation

. Ponseti method of serial casting

Explanation

The Ponseti method of serial casting is the universally accepted gold standard and preferred initial treatment for idiopathic clubfoot in neonates and young infants. It involves a specific sequence of gentle manipulations and weekly cast changes to gradually correct the deformity, often followed by a percutaneous Achilles tenotomy and then bracing. This method has largely superseded older casting techniques (like the Kite method) and initial surgical releases due to its high success rates and avoidance of extensive surgery.

Question 5257

Topic: 4. Pediatrics
A 12-year-old female sustains a Salter-Harris Type II fracture of the distal tibia. What is the primary concern with Salter-Harris fractures, particularly Type II and above?
. Malunion
. Non-union
. Compartment syndrome
. Premature physeal arrest
. Infection

Correct Answer & Explanation

. Premature physeal arrest

Explanation

The primary and most significant concern with Salter-Harris growth plate fractures, particularly Types II, III, IV, and V, is the potential for damage to the physis (growth plate). This damage can lead to premature physeal arrest (growth arrest), resulting in limb length discrepancy or angular deformity as the child grows. While malunion can occur, growth arrest is a unique and critical complication specific to physeal injuries that can have long-term functional consequences.

Question 5258

Topic: 4. Pediatrics

A 13-year-old obese male presents with a painful limp and external rotation of the affected leg. Radiographs of the hip show a posterior and inferior displacement of the capital femoral epiphysis relative to the femoral neck. What is the most appropriate initial management?

. Immediate non-weight bearing
. Application of a spica cast
. Closed reduction and percutaneous screw fixation
. Open reduction and internal fixation
. Physiotherapy to improve range of motion

Correct Answer & Explanation

. Immediate non-weight bearing

Explanation

This clinical picture is classic for Slipped Capital Femoral Epiphysis (SCFE). The immediate priority in managing SCFE, especially in a potentially unstable or acute on chronic slip, is to make the child immediately non-weight bearing on the affected limb. This prevents further slippage of the femoral head, which can worsen the deformity and significantly increase the risk of devastating complications such as avascular necrosis. Once non-weight bearing, the definitive treatment typically involves in situ percutaneous screw fixation to stabilize the physis.

Question 5259

Topic: 4. Pediatrics

A 3-month-old female is diagnosed with a dislocated left hip during a routine well-child check. The Ortolani sign is positive, and the Barlow sign is positive. There are no other abnormalities. What is the most appropriate initial treatment?

. Immediate surgical open reduction
. Application of a hip spica cast
. Pavlik harness application
. Triple osteotomy of the pelvis
. Observation with serial ultrasounds

Correct Answer & Explanation

. Pavlik harness application

Explanation

For infants diagnosed with developmental dysplasia of the hip (DDH) under 6 months of age, especially with positive Ortolani and Barlow signs indicating a reducible, dislocatable hip, the Pavlik harness is the gold standard of treatment. It maintains the hips in a position of flexion and abduction, promoting concentric reduction and acetabular development. Surgical open reduction or osteotomies are reserved for failed harness treatment or later presentations. A hip spica cast may be used after a successful closed reduction for older infants, but the Pavlik harness is preferred initially for reducible hips in this age group. Observation is inappropriate for a dislocated hip.

Question 5260

Topic: Pediatric Upper Extremity & Spine

A 16-year-old female is diagnosed with idiopathic scoliosis with a 42-degree thoracic curve (King Moe Type II) and a negative Risser sign (Grade 0). She is still growing. What is the most appropriate management plan?

. Observation with serial radiographs every 6 months
. Initiation of a bracing program (e.g., TLSO)
. Surgical correction with spinal fusion
. Physical therapy focusing on stretching and strengthening
. Referral for chiropractic manipulation

Correct Answer & Explanation

. Initiation of a bracing program (e.g., TLSO)

Explanation

For adolescent idiopathic scoliosis, the management depends on curve magnitude and skeletal maturity. For a growing patient with a curve between 25-45 degrees, bracing (e.g., TLSO) is indicated to prevent curve progression. A 42-degree curve in a skeletally immature patient (Risser 0) falls within this range. Observation is for curves less than 25 degrees or skeletally mature patients with curves less than 45 degrees. Surgical correction is typically indicated for curves >45-50 degrees in growing patients or >50-60 degrees in skeletally mature patients. Physical therapy and chiropractic manipulation are not proven to halt curve progression.

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