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4. Pediatrics MCQs

Practice Set 264 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 5261

Topic: 4. Pediatrics

A 6-year-old child falls from a tree, sustaining a supracondylar humerus fracture. The arm is markedly swollen, and the radial pulse is absent. The hand is cool and pale, but the child can still move his fingers. What is the most appropriate immediate management?

. Observation and repeat assessment in 30 minutes
. Closed reduction and percutaneous pinning
. Emergent surgical exploration of the brachial artery
. Application of a long arm cast in full elbow extension
. Traction in an overhead position

Correct Answer & Explanation

. Emergent surgical exploration of the brachial artery

Explanation

An absent radial pulse with a pale and cool hand, despite some finger movement (which indicates viable median nerve function at that moment), in the context of a supracondylar humerus fracture is a medical emergency. This suggests compromise of the brachial artery. While some surgeons might attempt a gentle closed reduction first, the safest and most definitive immediate management for a pulseless but still viable hand is emergent surgical exploration of the brachial artery to restore perfusion. Delaying this can lead to Volkmann's ischemic contracture. Closed reduction and pinning would ideally precede this but not with an absent pulse and ischemia. Applying a cast in full extension is incorrect. Traction is not the most immediate or definitive solution for arterial compromise.

Question 5262

Topic: 4. Pediatrics
A 10-year-old male sustains a fall, resulting in a fracture through the growth plate and a small metaphyseal fragment attached to the epiphysis of the distal tibia. Radiographs demonstrate an oblique fracture line extending from the physis into the metaphysis. Which Salter-Harris classification type best describes this fracture?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

The Salter-Harris classification describes physeal fractures. A Type II fracture is the most common and involves a fracture line through the physis and extending into the metaphysis, leaving a triangular metaphyseal fragment attached to the epiphysis (Thurston-Holland sign). Type I is a fracture through the physis only. Type III is a fracture through the physis and epiphysis. Type IV is a fracture through the metaphysis, physis, and epiphysis. Type V is a crush injury to the physis. The description clearly matches Type II.

Question 5263

Topic: 4. Pediatrics

A 3-month-old male is diagnosed with congenital clubfoot (talipes equinovarus) of his right foot. Physical examination reveals a rigid deformity with hindfoot varus and equinus, midfoot adduction, and forefoot supination that cannot be passively corrected. What is the gold standard initial treatment method?

. Immediate surgical correction with soft tissue release
. Serial manipulation and casting using the Ponseti method
. Bracing with a fixed ankle-foot orthosis (AFO)
. Observation with gentle stretching exercises at home
. Application of dynamic splints with electrical stimulation

Correct Answer & Explanation

. Serial manipulation and casting using the Ponseti method

Explanation

For congenital clubfoot, the Ponseti method of serial manipulation and casting is the universally accepted gold standard initial treatment. This non-surgical approach involves gentle stretching and casting over several weeks to gradually correct the deformity, often followed by a percutaneous Achilles tenotomy and then bracing (foot abduction orthosis). Surgical correction is typically reserved for severe, rigid, or recurrent deformities after failure of the Ponseti method. Observation, simple stretching, or fixed AFOs alone are inadequate for the correction of true clubfoot.

Question 5264

Topic: 4. Pediatrics
A 6-year-old child presents with a limp, mild hip pain, and limited hip abduction and internal rotation. Radiographs are normal. The child has no fever, and inflammatory markers (ESR, CRP) are normal. What is the most likely diagnosis?
. Septic arthritis of the hip
. Transient synovitis of the hip
. Legg-Calvé-Perthes disease
. Slipped capital femoral epiphysis (SCFE)
. Proximal femoral focal deficiency

Correct Answer & Explanation

. Transient synovitis of the hip

Explanation

The presentation of a limp, mild hip pain, limited motion, normal radiographs, absence of fever, and normal inflammatory markers in a 6-year-old child is highly characteristic of transient synovitis of the hip. This is a self-limiting inflammatory condition. Septic arthritis would typically present with high fever, marked pain, severe limitation of motion, and elevated inflammatory markers. Legg-Calvé-Perthes disease would show characteristic changes on radiographs (e.g., flattening of the femoral head) or MRI. SCFE typically affects older, often obese adolescents. Proximal femoral focal deficiency is a congenital malformation.

Question 5265

Topic: Pediatric Hip
A 5-year-old child presents with a 2-month history of a painless limp. Examination reveals limited hip abduction and internal rotation, and a positive Trendelenburg sign. Radiographs show increased density (sclerosis) and flattening of the femoral epiphysis. What is the most appropriate initial management?
. Immediate surgical epiphysiodesis
. Observation with activity restriction and protected weight-bearing
. Casting in abduction and internal rotation
. Non-steroidal anti-inflammatory drugs (NSAIDs) only
. Urgent MRI of the hip

Correct Answer & Explanation

. Observation with activity restriction and protected weight-bearing

Explanation

The clinical picture (painless limp, limited abduction/internal rotation, Trendelenburg sign) and radiographic findings (sclerosis and flattening of the femoral epiphysis) are classic for Legg-Calvé-Perthes disease (LCPD), which is osteonecrosis of the femoral head in children. The primary goal of management is to maintain the femoral head containment within the acetabulum while it revascularizes and remodels. Initial management usually involves observation with activity modification (avoiding high-impact activities), protected weight-bearing, and possibly bracing or casts to maintain abduction and internal rotation, especially for younger children or those with less severe involvement. Urgent MRI confirms the diagnosis and extent but is not the initial management. Epiphysiodesis or other surgeries are reserved for specific stages or to contain the femoral head when conservative measures fail. NSAIDs alone only address symptoms.

Question 5266

Topic: Pediatric Hip

Which of the following interventions has been shown to be most effective in reducing the risk of subsequent contralateral Slipped Capital Femoral Epiphysis (SCFE) in a patient diagnosed with a unilateral stable SCFE?

. Prophylactic pinning of the contralateral asymptomatic hip
. Intensive physical therapy and weight loss program
. Long-term oral bisphosphonate therapy
. Regular MRI surveillance of the contralateral hip
. Activity restriction for 12 months

Correct Answer & Explanation

. Prophylactic pinning of the contralateral asymptomatic hip

Explanation

For patients diagnosed with unilateral stable Slipped Capital Femoral Epiphysis (SCFE), the risk of developing SCFE in the contralateral hip is significant (reported between 20-60%), especially in younger patients and those with endocrine disorders. Prophylactic pinning of the contralateral asymptomatic hip is often recommended, particularly in skeletally immature patients, to prevent the contralateral slip. While weight loss and activity modification are important for overall health, they are not proven to prevent contralateral slips as effectively as prophylactic pinning. Bisphosphonates are not indicated. Regular MRI surveillance would detect a slip, but not prevent it.

Question 5267

Topic: 4. Pediatrics

A 4-year-old child presents with a progressive antalgic gait and external rotation deformity of the right leg. Physical examination reveals limited hip abduction and internal rotation, and a positive Galeazzi sign (unequal knee height when hips and knees are flexed to 90 degrees with feet flat on table). Radiographs confirm Developmental Dysplasia of the Hip (DDH) with a dislocated right hip. What is the most appropriate initial treatment in this older child?

. Pavlik harness application
. Abduction brace
. Closed reduction with hip spica cast immobilization
. Open reduction with possible pelvic or femoral osteotomy
. Observation and physical therapy

Correct Answer & Explanation

. Open reduction with possible pelvic or femoral osteotomy

Explanation

For a 4-year-old child with a confirmed dislocated hip due to DDH, a Pavlik harness is ineffective due to the child's age and rigidity of the tissues. An abduction brace would also be insufficient. At this age, the hip dislocation is often irreducible by closed means, and there are likely significant adaptive changes in the acetabulum and proximal femur. Therefore, open reduction with possible concomitant pelvic osteotomy (to improve acetabular coverage) or femoral osteotomy (to correct femoral anteversion or valgus) is typically required to achieve and maintain concentric reduction. Observation or physical therapy alone would lead to progressive deformity and functional limitations.

Question 5268

Topic: Pediatric Lower Extremity

A 4-year-old child presents with a limp, knee pain, and difficulty bearing weight. Radiographs show a small, irregular appearance of the medial femoral condyle. The child has no history of trauma, fever, or inflammatory markers. What is the most likely diagnosis?

. Osteochondritis dissecans (OCD)
. Juvenile idiopathic arthritis
. Septic arthritis
. Blount's disease
. Osgood-Schlatter disease

Correct Answer & Explanation

. Osteochondritis dissecans (OCD)

Explanation

Osteochondritis dissecans (OCD) commonly presents in children and adolescents with knee pain, limp, and mechanical symptoms. Radiographic findings of an irregular appearance or fragmentation of the medial femoral condyle are characteristic. While the exact etiology is unknown, it involves avascular changes in the subchondral bone. Juvenile idiopathic arthritis would present with more diffuse joint swelling and inflammatory markers. Septic arthritis would involve acute pain, fever, and markedly elevated inflammatory markers. Blount's disease affects the proximal tibia, causing bowing. Osgood-Schlatter disease causes pain at the tibial tubercle, typically in older adolescents.

Question 5269

Topic: Pediatric Hip

Which of the following is the most accurate radiographic sign for diagnosing an unstable slipped capital femoral epiphysis (SCFE)?

. Widening of the physis on AP view
. Positive Klein's line on AP view
. Posterior and inferior displacement of the epiphysis on frog-leg lateral view
. Absence of a palpable pulse in the affected extremity
. Inability to bear weight on the affected extremity

Correct Answer & Explanation

. Inability to bear weight on the affected extremity

Explanation

While all options except 'absence of palpable pulse' are relevant to SCFE, the definition of an unstable SCFE is the inability to bear weight on the affected extremity, even with crutches. This clinical finding distinguishes unstable from stable SCFE and carries a significantly higher risk of complications, particularly avascular necrosis. Radiographic signs like physeal widening, positive Klein's line (metaphysis not intersecting the epiphysis), and posterior/inferior displacement are characteristic of SCFE but do not differentiate between stable and unstable slips. A palpable pulse is generally present, as vascular compromise is a complication, not a defining characteristic of instability.

Question 5270

Topic: Pediatric Lower Extremity

A 16-year-old male presents with chronic anterior knee pain, worse with activity and stair climbing. Examination reveals generalized knee laxity, a positive apprehension test, and J-sign. Radiographs are normal. What is the most likely diagnosis?

. Patellar tendinopathy
. Osgood-Schlatter disease
. Recurrent patellar instability (patellar subluxation/dislocation)
. Chondromalacia patellae
. Plica syndrome

Correct Answer & Explanation

. Recurrent patellar instability (patellar subluxation/dislocation)

Explanation

The patient's age, chronic anterior knee pain, pain with activity, generalized knee laxity, a positive apprehension test (indicating fear of patellar dislocation), and J-sign (lateral patellar tracking during knee extension) are all characteristic of recurrent patellar instability (subluxation or dislocation). Patellar tendinopathy causes pain at the inferior pole of the patella. Osgood-Schlatter disease causes pain at the tibial tubercle. Chondromalacia patellae is a descriptive term for cartilage softening and is often a symptom, not a diagnosis. Plica syndrome presents with medial knee pain and snapping.

Question 5271

Topic: 4. Pediatrics

When asked about the management of pediatric fractures, what is the most important consideration to highlight that differentiates it from adult fracture management and demonstrates a nuanced understanding?

. The use of smaller implants.
. The lower incidence of complications in children.
. The unique physiological properties of pediatric bone, including growth plate injury (Salter-Harris classification), remodeling potential, and specialized indications for reduction/fixation based on age and remaining growth.
. Immediate surgical intervention for all pediatric fractures.
. Ignoring pain management as children are resilient.

Correct Answer & Explanation

. The unique physiological properties of pediatric bone, including growth plate injury (Salter-Harris classification), remodeling potential, and specialized indications for reduction/fixation based on age and remaining growth.

Explanation

The defining feature of pediatric fracture management is the presence of open physes (growth plates) and the remarkable remodeling potential of immature bone. A high-scoring answer will focus on the implications of growth plate injuries (Salter-Harris classification), age-dependent remodeling capacity, and the specific thresholds for acceptable alignment and angulation based on skeletal maturity. This demonstrates a specialized understanding of pediatric orthopedics.

Question 5272

Topic: Pediatric Hip

In a viva, you are asked to discuss the management of developmental dysplasia of the hip (DDH) in an infant. What is the most crucial aspect to convey for optimal scoring?

. That it always requires surgery.
. Ignoring family history.
. Early diagnosis through screening (Ortolani/Barlow maneuvers, ultrasound in high-risk infants), prompt initiation of treatment (e.g., Pavlik harness for reducible hips), and close monitoring for concentric reduction and acetabular development.
. Assuming it will resolve spontaneously.
. Only focusing on X-ray findings.

Correct Answer & Explanation

. Early diagnosis through screening (Ortolani/Barlow maneuvers, ultrasound in high-risk infants), prompt initiation of treatment (e.g., Pavlik harness for reducible hips), and close monitoring for concentric reduction and acetabular development.

Explanation

For DDH, early diagnosis and prompt, appropriate management are critical for optimal outcomes. A high-scoring answer will emphasize systematic screening methods (clinical exams, targeted ultrasound), the role of early intervention (e.g., Pavlik harness), and the importance of monitoring for concentric reduction and proper acetabular development. This demonstrates an understanding of growth, development, and preventative orthopedics.

Question 5273

Topic: Pediatric Lower Extremity

In a discussion about the management of clubfoot (talipes equinovarus) in an infant, what is the most important principle to articulate regarding initial treatment?

. Immediate surgical correction is always necessary.
. Ignoring the foot's flexibility.
. The Ponseti method of serial casting, initiated shortly after birth, to achieve gradual, non-operative correction, followed by bracing to maintain correction, with surgery reserved for failed non-operative treatment.
. Parents should stretch the foot themselves.
. Only observing the foot for spontaneous correction.

Correct Answer & Explanation

. The Ponseti method of serial casting, initiated shortly after birth, to achieve gradual, non-operative correction, followed by bracing to maintain correction, with surgery reserved for failed non-operative treatment.

Explanation

The Ponseti method is the universally accepted gold standard for initial treatment of clubfoot. A high-scoring answer will detail this method: serial manipulation and casting, initiated soon after birth, followed by tenotomy of the Achilles tendon (if needed) and bracing to maintain correction. Emphasizing the non-operative, gentle, and sequential nature of Ponseti, with surgery reserved for failures, demonstrates current best practice.

Question 5274

Topic: Pediatric Upper Extremity & Spine

An examiner asks about the management of adolescent idiopathic scoliosis. They then ask, 'What is the primary indication for surgical correction in adolescent idiopathic scoliosis?'

. Any curve greater than 20 degrees in a skeletally immature patient.
. Progression of a curve to greater than 40-45 degrees, particularly in skeletally immature patients, or curves progressing despite bracing, along with consideration of spinal balance and cosmetic deformity.
. Cosmetic concerns alone, regardless of curve magnitude or progression.
. Presence of back pain, even if the curve is small and non-progressive.
. Failure to achieve a perfect posture through physical therapy.

Correct Answer & Explanation

. Progression of a curve to greater than 40-45 degrees, particularly in skeletally immature patients, or curves progressing despite bracing, along with consideration of spinal balance and cosmetic deformity.

Explanation

The primary indication for surgical correction of adolescent idiopathic scoliosis is typically curve progression to greater than 40-45 degrees (depending on the specific curve type and surgeon preference), especially in skeletally immature patients. Surgical consideration also involves the potential for future progression, spinal balance, and the degree of cosmetic deformity affecting the patient's quality of life. Curves >20 degrees (A) might warrant bracing, but not necessarily surgery. Cosmetic concerns (C) alone are generally not an indication without significant curve magnitude. Back pain (D) is not typically an indication for surgery in AIS unless associated with significant neurological deficit or instability. Failure of physical therapy (E) does not apply to structural scoliosis.

Question 5275

Topic: 4. Pediatrics

During your orthopedic viva, the examiner presents an X-ray of a child with a Salter-Harris Type II physeal fracture of the distal tibia. They ask, 'What are the two MOST important considerations in the management of any physeal fracture in a child?'

. Achieving absolute anatomical reduction and immediate full weight-bearing.
. Preventing deep vein thrombosis (DVT) and minimizing post-operative pain.
. Preserving the physis (growth plate) to prevent growth arrest or angular deformity, and ensuring adequate reduction to prevent malunion.
. Immediate operative fixation with a large plate and screws to provide rigid stability.
. Strict bed rest to promote rapid healing and prevent displacement.

Correct Answer & Explanation

. Preserving the physis (growth plate) to prevent growth arrest or angular deformity, and ensuring adequate reduction to prevent malunion.

Explanation

For any physeal fracture in a child, the two most important considerations are: 1) Preserving the integrity and function of the physis (growth plate) to prevent growth arrest (shortening) or angular deformity, and 2) Achieving an adequate, typically anatomical or near-anatomical reduction to prevent malunion which can also lead to growth disturbances. Overly aggressive fixation (D) can damage the physis. Absolute anatomical reduction (A) is important but less critical than preserving the physis, and immediate weight-bearing is inappropriate. DVT prevention (B) and pain management are general post-op considerations, not specific to physeal fractures. Strict bed rest (E) is often detrimental.

Question 5276

Topic: 4. Pediatrics

In a discussion about pediatric fractures, the examiner shows you an X-ray of a displaced supracondylar humerus fracture in a 7-year-old. They ask, 'What is the most important clinical assessment to perform immediately in the emergency department, prior to any reduction or immobilization?'

. Assessment of the range of motion of the elbow joint.
. Detailed neurovascular assessment (radial pulse, capillary refill, median/radial/ulnar nerve function) and documentation.
. Pain assessment using a visual analog scale.
. Review of the child's vaccination history.
. Obtaining a detailed history of the mechanism of injury from the parents.

Correct Answer & Explanation

. Detailed neurovascular assessment (radial pulse, capillary refill, median/radial/ulnar nerve function) and documentation.

Explanation

For a displaced supracondylar humerus fracture, neurovascular compromise is a significant and potentially devastating complication. Therefore, the MOST important clinical assessment to perform immediately is a detailed neurovascular examination (checking for radial pulse presence/quality, capillary refill, and function of the median, radial, and ulnar nerves) and thorough documentation. This guides immediate management decisions (e.g., urgent reduction for pulseless limb) and serves as a baseline for future comparison. Range of motion (A) is contraindicated initially. Pain assessment (C) is important but secondary. Vaccination history (D) and mechanism of injury (E) are important but not the immediate priority over limb viability.

Question 5277

Topic: 4. Pediatrics

You are asked to describe the surgical management of a common pediatric condition, such as developmental dysplasia of the hip (DDH). The examiner interjects, 'How do you ensure you are communicating effectively and building rapport with the child's parents, who are clearly anxious about surgery?'

. Presenting a vast amount of scientific literature to demonstrate your expertise.
. Using medical jargon to establish authority and quickly move on to the next topic.
. Listening actively to their concerns, using clear and empathetic language, explaining the condition and proposed treatment simply, drawing diagrams, involving them in shared decision-making, and answering all questions patiently.
. Asking the nurse to answer all their questions as you are busy with other patients.
. Solely focusing on the surgical technique, assuming they understand the risks and benefits from prior discussions.

Correct Answer & Explanation

. Listening actively to their concerns, using clear and empathetic language, explaining the condition and proposed treatment simply, drawing diagrams, involving them in shared decision-making, and answering all questions patiently.

Explanation

Effective communication and rapport-building with anxious parents are crucial in pediatric orthopedics. This involves active listening to their specific concerns, using clear, jargon-free and empathetic language, providing simple explanations with visual aids, involving them in shared decision-making, and patiently addressing all their questions. This approach builds trust and ensures informed consent. Overloading with literature (A) or jargon (B) can overwhelm and confuse. Delegating (D) or assuming understanding (E) are poor communication practices.

Question 5278

Topic: Pediatric Hip
In a viva, you are discussing the management of a child with Legg-Calvé-Perthes disease. The examiner asks, 'What is the primary goal of treatment for Legg-Calvé-Perthes disease, regardless of whether surgical or non-surgical methods are employed?'
. To eliminate all pain immediately and completely.
. To restore normal blood supply to the femoral head to prevent avascular necrosis.
. To maintain containment of the femoral head within the acetabulum to preserve its spherical shape and prevent deformity, thereby minimizing the risk of developing early osteoarthritis.
. To accelerate the revascularization process of the femoral head.
. To prolong the disease process to allow for maximal growth before healing.

Correct Answer & Explanation

. To maintain containment of the femoral head within the acetabulum to preserve its spherical shape and prevent deformity, thereby minimizing the risk of developing early osteoarthritis.

Explanation

The primary goal of treatment for Legg-Calvé-Perthes disease, regardless of the method, is to maintain containment of the femoral head within the acetabulum. This helps to preserve the spherical shape of the femoral head as it undergoes revascularization and healing, preventing the development of a 'mushroom-shaped' deformity, which is highly predictive of early-onset osteoarthritis. While pain relief (A) and revascularization (B, D) are important, they are secondary to the goal of containment and preserving femoral head morphology. Prolonging the disease (E) is incorrect.

Question 5279

Topic: 4. Pediatrics

When preparing for topics involving pediatric orthopedics, what should be emphasized beyond adult principles?

. Only focusing on genetic syndromes.
. Treating children as 'small adults.'
. Understanding unique aspects like growth plate physiology, potential for remodeling, age-specific pathologies (e.g., SCFE, DDH, Perthes), differences in fracture patterns and healing, and distinct anesthetic/rehabilitation considerations.
. Memorizing only treatment algorithms for common conditions.
. Avoiding discussion of congenital conditions.

Correct Answer & Explanation

. Understanding unique aspects like growth plate physiology, potential for remodeling, age-specific pathologies (e.g., SCFE, DDH, Perthes), differences in fracture patterns and healing, and distinct anesthetic/rehabilitation considerations.

Explanation

Pediatric orthopedics has unique considerations that fundamentally differ from adult care. Emphasizing growth plate biology, remodeling potential, age-specific pathologies, distinct fracture characteristics, and tailored anesthetic/rehabilitation approaches demonstrates a specialized understanding critical for safely managing pediatric patients. Treating children as 'small adults' is a common and dangerous misconception.

Question 5280

Topic: 4. Pediatrics

When evaluating an AC joint injury in an adolescent, what unique anatomical consideration should be kept in mind?

. Increased elasticity of ligaments making dislocations less common.
. Higher risk of concomitant rotator cuff tears.
. The presence of an open physis (growth plate) at the distal clavicle.
. Greater incidence of frozen shoulder.
. The AC joint capsule is typically stronger than in adults.

Correct Answer & Explanation

. The presence of an open physis (growth plate) at the distal clavicle.

Explanation

In adolescents, the presence of an open physis (growth plate) at the distal clavicle is a crucial consideration. Injuries that appear as AC joint dislocations in adults may actually be Salter-Harris fractures of the distal clavicular physis in adolescents. This requires careful radiographic interpretation and specific management considerations for physeal injuries.

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