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4. Pediatrics MCQs

Practice Set 310 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 6181

Topic: Pediatric Hip

A 13-year-old boy with a BMI of 32 presents with 4 months of left groin and thigh pain. On physical examination, as his left hip is passively flexed, it obligatorily externally rotates. Which of the following is the most appropriate initial management?

. Closed reduction and spica casting
. In situ single screw fixation
. Open reduction and internal fixation
. Proximal femoral osteotomy
. Observation and crutch use

Correct Answer & Explanation

. In situ single screw fixation

Explanation

The patient has a stable SCFE, indicated by the Drehmann sign. The gold standard treatment for stable SCFE is in situ pinning with a single cannulated screw.

Question 6182

Topic: Pediatric Hip

A 10-year-old girl with previously undiagnosed hypothyroidism presents to the emergency department unable to bear weight on her right leg after a minor fall. Radiographs confirm an acute, unstable slipped capital femoral epiphysis (SCFE). What is the most devastating common complication associated with her diagnosis?

. Chondrolysis
. Avascular necrosis (AVN)
. Femoral neck fracture
. Osteoarthritis
. Nonunion

Correct Answer & Explanation

. Avascular necrosis (AVN)

Explanation

Avascular necrosis is the most severe and relatively common complication of an unstable SCFE, occurring in up to 47% of cases. Urgent decompression and stabilization are debated, but AVN risk remains high.

Question 6183

Topic: Pediatric Hip

Routine prophylactic pinning of the contralateral hip in a patient with a unilateral slipped capital femoral epiphysis (SCFE) is most strongly indicated in which of the following scenarios?

. A 14-year-old boy with a BMI of 25
. A 10-year-old girl with renal osteodystrophy
. A 12-year-old boy with a stable slip
. A 15-year-old girl with an acute unstable slip
. A 13-year-old boy with no medical comorbidities

Correct Answer & Explanation

. A 10-year-old girl with renal osteodystrophy

Explanation

Prophylactic pinning of the asymptomatic contralateral hip is indicated in patients with endocrine disorders (e.g., renal osteodystrophy, hypothyroidism) due to the high risk of bilateral involvement.

Question 6184

Topic: Pediatric Hip

A 12-year-old boy undergoes in situ pinning for a stable slipped capital femoral epiphysis. During the procedure, the surgeon decides on screw placement. Which of the following describes the ideal position of the screw within the epiphysis?

. Anterior and superior
. Anterior and inferior
. Center of the epiphysis
. Posterior and superior
. Posterior and inferior

Correct Answer & Explanation

. Center of the epiphysis

Explanation

The ideal position for a single screw in SCFE fixation is in the center-center of the epiphysis. This provides maximal stability and reduces the risk of joint penetration.

Question 6185

Topic: Pediatric Hip

Which of the following radiographic lines is most useful for diagnosing a subtle slipped capital femoral epiphysis (SCFE) on an AP radiograph of the pelvis?

. Shenton's line
. Hilgenreiner's line
. Perkins' line
. Klein's line
. Ilioischial line

Correct Answer & Explanation

. Klein's line

Explanation

Klein's line is drawn along the superior margin of the femoral neck on an AP view. In a normal hip, it should intersect a portion of the lateral epiphysis; in SCFE, the line passes superior to the epiphysis.

Question 6186

Topic: 4. Pediatrics

Which of the following syndromes is most frequently associated with Sprengel's deformity?

. Marfan syndrome
. Klippel-Feil syndrome
. Achondroplasia
. Osteogenesis imperfecta
. Down syndrome

Correct Answer & Explanation

. Klippel-Feil syndrome

Explanation

Klippel-Feil syndrome, characterized by congenital fusion of cervical vertebrae, is seen in up to one-third of patients with Sprengel's deformity.

Question 6187

Topic: 4. Pediatrics

A 4-year-old child with severe Sprengel's deformity is planned for a Woodward procedure. What does this surgical intervention primarily involve?

. Osteotomy of the clavicle
. Resection of the coracoid process
. Detachment and inferior advancement of the paraspinal muscular origins of the scapula
. Fusion of the scapula to the rib cage
. Complete scapulectomy

Correct Answer & Explanation

. Detachment and inferior advancement of the paraspinal muscular origins of the scapula

Explanation

The Woodward procedure involves releasing the origins of the trapezius, rhomboids, and levator scapulae from the spinous processes, excising any omovertebral connection, and advancing the muscle origins inferiorly to lower the scapula.

Question 6188

Topic: Pediatric Hip

A 7-year-old boy, whose weight is in the 25th percentile, presents with right knee pain and a limp. Radiographs demonstrate a mild posterior and inferior displacement of the proximal femoral epiphysis. After surgical stabilization, what is the most appropriate next step in management?

. Endocrine workup
. Immediate prophylactic pinning of the contralateral side
. Serial casting
. Non-weight bearing for 6 months
. MRI of the knee

Correct Answer & Explanation

. Endocrine workup

Explanation

SCFE in patients younger than 10 years or older than 16 years, or those with weight below the 50th percentile, warrants an endocrine workup to rule out underlying conditions like hypothyroidism or growth hormone deficiency.

Question 6189

Topic: 4. Pediatrics

Which of the following is an established indication for prophylactic in situ fixation of the contralateral hip in a patient presenting with unilateral Slipped Capital Femoral Epiphysis (SCFE)?

. Age 13 years and obese
. Previous history of Osgood-Schlatter disease
. Presence of renal osteodystrophy
. Mild slip angle (<30 degrees)
. African American descent

Correct Answer & Explanation

. Presence of renal osteodystrophy

Explanation

Prophylactic pinning of the contralateral hip is indicated in patients with metabolic or endocrine disorders, such as renal osteodystrophy or hypothyroidism, due to the exceptionally high risk of bilateral involvement.

Question 6190

Topic: 4. Pediatrics

A 6-year-old girl is evaluated for congenital high scapula (Sprengel's deformity). A fibrous/cartilaginous connection is identified between the superomedial border of the scapula and the cervical spine. Which of the following anomalies is most commonly associated with this deformity?

. Cleft palate
. Klippel-Feil syndrome
. Developmental dysplasia of the hip
. Radial clubhand
. Osteogenesis imperfecta

Correct Answer & Explanation

. Klippel-Feil syndrome

Explanation

Sprengel's deformity is highly associated with Klippel-Feil syndrome, congenital scoliosis, and fused ribs. The omovertebral connection is present in about 30% of these cases.

Question 6191

Topic: 4. Pediatrics

In a patient with Slipped Capital Femoral Epiphysis (SCFE), the mechanical failure occurs predominantly through which layer of the physis?

. Resting zone
. Proliferative zone
. Zone of hypertrophy
. Zone of provisional calcification
. Primary spongiosa

Correct Answer & Explanation

. Zone of hypertrophy

Explanation

Slippage in SCFE typically occurs through the hypertrophic zone of the physis. This is often secondary to an imbalance between mechanical shear stresses and the endocrine-mediated structural integrity of the growth plate.

Question 6192

Topic: Pediatric Hip
A 14-year-old boy underwent in situ pinning for a stable SCFE 6 months ago. He now presents with increasing stiffness, pain, and marked limitation of hip motion. Radiographs show uniform joint space narrowing to <3 mm. What is the most likely diagnosis?
. Avascular necrosis
. Chondrolysis
. Pin penetration into the joint
. Septic arthritis
. Femoroacetabular impingement

Correct Answer & Explanation

. Chondrolysis

Explanation

Chondrolysis presents with severe stiffness, pain, and uniform joint space narrowing (<3 mm) after SCFE. Avascular necrosis primarily shows subchondral collapse and sclerosis rather than rapid, global joint space narrowing.

Question 6193

Topic: 4. Pediatrics

A 10-year-old child presents with an insidious onset of symmetric, proximal muscle weakness, fatigue, and a purplish discoloration over the upper eyelids. What autoantibody is most classically associated with an increased risk of severe interstitial lung disease in this condition?

. Anti-CCP
. Anti-dsDNA
. Anti-Jo-1
. Anti-Sm
. Anti-Scl-70

Correct Answer & Explanation

. Anti-Jo-1

Explanation

Anti-Jo-1 is a myositis-specific antibody directed against histidyl-tRNA synthetase. It is strongly associated with interstitial lung disease and a more chronic disease course in inflammatory myopathies.

Question 6194

Topic: Pediatric Hip

According to Loder's classification, which clinical finding differentiates an unstable Slipped Capital Femoral Epiphysis (SCFE) from a stable SCFE?

. Radiographic slip angle greater than 50 degrees
. Inability to ambulate even with crutches
. Presence of a joint effusion on ultrasound
. Displacement >50% of the femoral neck width
. Symptom duration less than 3 weeks

Correct Answer & Explanation

. Inability to ambulate even with crutches

Explanation

Loder classified SCFE based on stability, defining an unstable slip by the patient's inability to walk, even with assistive devices. Unstable SCFE carries a significantly higher rate of avascular necrosis.

Question 6195

Topic: Pediatric Hip

The deformity in Slipped Capital Femoral Epiphysis (SCFE) typically causes the proximal femoral metaphysis to displace in which direction relative to the epiphysis?

. Anterior and superior
. Posterior and inferior
. Posterior and superior
. Anterior and inferior
. Purely lateral

Correct Answer & Explanation

. Anterior and superior

Explanation

In SCFE, the epiphysis stays relatively fixed within the acetabulum while the femoral neck (metaphysis) typically displaces anteriorly and superiorly. This creates the classic clinical presentation of external rotation and shortening.

Question 6196

Topic: 4. Pediatrics

In the treatment of an unstable Slipped Capital Femoral Epiphysis, which surgical maneuver has been advocated by some to reduce the high risk of avascular necrosis?

. Anterior capsulotomy to decompress intracapsular hematoma
. Routine use of three cannulated screws
. Aggressive closed reduction before pinning
. Open reduction and internal fixation through a posterior approach
. Over-drilling the physis

Correct Answer & Explanation

. Anterior capsulotomy to decompress intracapsular hematoma

Explanation

Unstable SCFE carries a high risk of AVN. Performing an anterior capsulotomy decompresses the joint hematoma, which can lower intracapsular pressure and theoretically preserve epiphyseal blood flow.

Question 6197

Topic: 4. Pediatrics
Kรถhler's disease most commonly affects which of the following patient populations?
. Female adolescents aged 12-14
. Male children aged 4-6
. Female children aged 7-9
. Male infants aged 1-2
. Male adults aged 20-30

Correct Answer & Explanation

. Male children aged 4-6

Explanation

Kรถhler's disease typically occurs in young children, predominantly boys, between the ages of 4 and 6 years. It correlates with the normal delayed ossification timing of the navicular.

Question 6198

Topic: Pediatric Hip

An obese 12-year-old boy presents with left hip pain and an inability to bear weight, even with crutches. Radiographs confirm a slipped capital femoral epiphysis. According to the Loder classification, what is the most significant risk associated with his presentation?

. Chondrolysis
. Avascular necrosis of the femoral head
. Femoroacetabular impingement
. Contralateral slip
. Leg length discrepancy

Correct Answer & Explanation

. Avascular necrosis of the femoral head

Explanation

Inability to bear weight characterizes an unstable SCFE according to Loder. Unstable SCFE has a high rate of AVN (up to 47%), whereas stable SCFE has an AVN rate near zero.

Question 6199

Topic: 4. Pediatrics

A 13-year-old girl undergoes in situ pinning for a stable SCFE. Postoperatively, she develops progressive hip stiffness and narrowing of the joint space on radiographs. Which technical error during surgery most strongly predisposes to this complication?

. Pin placement in the anterior-superior quadrant
. Unrecognized anterior capsular penetration
. Unrecognized joint penetration by the screw
. Failure to achieve threads fully across the physis
. Starting the screw distal to the lesser trochanter

Correct Answer & Explanation

. Unrecognized joint penetration by the screw

Explanation

Chondrolysis is a severe complication of SCFE, highly associated with unrecognized articular penetration by hardware. Utilizing the "approach-withdraw" technique under fluoroscopy helps prevent this complication.

Question 6200

Topic: Pediatric Hip
Which of the following patients who underwent unilateral pinning for a SCFE has the strongest indication for prophylactic pinning of the contralateral hip?
. A 14-year-old male with a BMI of 25
. A 12-year-old female with an isolated stable slip
. An 11-year-old male with an unstable slip
. A 10-year-old male with secondary SCFE due to panhypopituitarism
. A 15-year-old female with a severe slipped capital femoral epiphysis

Correct Answer & Explanation

. A 10-year-old male with secondary SCFE due to panhypopituitarism

Explanation

Prophylactic contralateral pinning is highly recommended for patients with endocrine disorders (e.g., panhypopituitarism, hypothyroidism) or renal failure due to the exceptionally high risk of a contralateral slip.

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