Menu

4. Pediatrics MCQs

Practice Set 4 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 61

Topic: 4. Pediatrics

A 4-year-old child presents with refusal to walk, back pain, and low-grade fever. ESR is 45 mm/hr, and WBC is normal. MRI shows fluid in the L4-L5 disc space. Blood cultures are pending. What is the most common causative organism for this condition?

. Streptococcus pneumoniae
. Escherichia coli
. Kingella kingae
. Staphylococcus aureus
. Haemophilus influenzae

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Pediatric discitis is most commonly caused by Staphylococcus aureus. It typically affects children under 5 who present with a refusal to walk or sit up.

Question 62

Topic: 4. Pediatrics

Pediatric thoracic disc calcifications are often discovered incidentally or present with localized back pain. What is the most appropriate management for a neurologically intact child with a symptomatic calcified thoracic disc?

. Urgent surgical decompression
. Epidural steroid injections
. Conservative management with NSAIDs and observation
. Prophylactic rigid bracing
. Microdiscectomy

Correct Answer & Explanation

. Conservative management with NSAIDs and observation

Explanation

Pediatric thoracic disc calcifications are usually self-limiting and tend to resorb over time. Conservative management is the treatment of choice in the absence of neurological deficits.

Question 63

Topic: Pediatric Upper Extremity & Spine

In a 14-year-old patient diagnosed with Scheuermann's kyphosis, which of the following scenarios is the most appropriate indication for initiating treatment with a Milwaukee brace?

. A 30-degree flexible curve
. A 60-degree rigid curve with anterior wedging
. An 85-degree rigid curve with intractable back pain
. A 45-degree curve in a patient with a Risser 5 status
. A 20-degree rigid curve

Correct Answer & Explanation

. A 60-degree rigid curve with anterior wedging

Explanation

Extension bracing is indicated for skeletally immature patients presenting with a kyphotic curve between 50 and 75 degrees. Curves exceeding 75 degrees often require surgical correction, while mature patients or mild curves are managed symptomatically.

Question 64

Topic: Pediatric Upper Extremity & Spine

In evaluating a 12-year-old female with adolescent idiopathic scoliosis (AIS), which of the following combinations of factors represents the highest risk for curve progression?

. Risser 4 stage, post-menarchal, 20-degree curve
. Risser 0 stage, pre-menarchal, 35-degree curve
. Risser 2 stage, post-menarchal, 15-degree curve
. Risser 5 stage, post-menarchal, 45-degree curve
. Male sex, Risser 3 stage, 25-degree curve

Correct Answer & Explanation

. Risser 0 stage, pre-menarchal, 35-degree curve

Explanation

The risk of curve progression in AIS is highest in patients with significant remaining growth (pre-menarchal, Risser 0-1) and larger magnitude curves (>25-30 degrees) at the time of presentation.

Question 65

Topic: Pediatric Upper Extremity & Spine

The Lenke classification system for Adolescent Idiopathic Scoliosis (AIS) utilizes a sagittal modifier. Which specific radiographic measurement determines this modifier?

. T1-T5 kyphosis
. T5-T12 kyphosis
. T10-L2 kyphosis
. L1-S1 lordosis

Correct Answer & Explanation

. T5-T12 kyphosis

Explanation

The Lenke sagittal thoracic modifier is determined by measuring the kyphosis between T5 and T12. It is classified as hypokyphotic (-), normal (N), or hyperkyphotic (+).

Question 66

Topic: Pediatric Upper Extremity & Spine

A 12-year-old premenarchal girl is diagnosed with adolescent idiopathic scoliosis. Her physical examination reveals a right thoracic prominence. Radiographs show a right thoracic curve with a Cobb angle of 34 degrees and a Risser stage of 1. What is the most appropriate management?

. Observation with radiographs every 6 months
. Physical therapy and spinal manipulation
. Prescription of a Thoracolumbosacral orthosis (TLSO)
. Posterior spinal fusion with instrumentation
. Anterior release and fusion

Correct Answer & Explanation

. Prescription of a Thoracolumbosacral orthosis (TLSO)

Explanation

Bracing is indicated for skeletally immature patients (Risser 0-2, premenarchal) with an idiopathic curve between 25 and 45 degrees. A TLSO brace effectively alters the natural history of curve progression in this high-risk population.

Question 67

Topic: Pediatric Upper Extremity & Spine

Which of the following parameters indicates the highest risk for curve progression in a 12-year-old female with adolescent idiopathic scoliosis?

. Risser grade 4
. Closed triradiate cartilage
. Menarche onset 2 years prior
. Risser grade 0 with open triradiate cartilage
. A single thoracic curve of 15 degrees

Correct Answer & Explanation

. Risser grade 4

Explanation

The risk of curve progression in adolescent idiopathic scoliosis is highest during the peak height velocity. A Risser grade of 0 combined with an open triradiate cartilage indicates significant remaining skeletal growth, placing the patient at maximum risk.

Question 68

Topic: 4. Pediatrics

A 3-year-old boy is referred by the pediatrician for neck stiffness. He has a mild hearing loss, but is otherwise healthy. On examination, his neck is rather short, and he has limitation of lateral rotation and bending, but flexion and extension are normal. There are no palpable bands in his neck. The anteroposterior and lateral cervical spine films ordered by the pediatrician show a congenital fusion of cervical vertebrae. The most likely diagnosis is:

. Klippel-Feil syndrome
. Fixed atlantoaxial rotatory subluxation
. Congenital muscular torticollis
. Arnold-C hiari malformation
. Axial neck pain

Correct Answer & Explanation

. Klippel-Feil syndrome

Explanation

The classic findings of Klippel-Feil syndrome include a short neck, low posterior hairline, and decreased neck range of motion, but <50% of patients have all 3 elements of the triad. The neck motion is limited due to congenital fusion of cervical vertebrae, and the severity of cervical spine involvement usually heralds associated manifestations. Facial asymmetry, cranial nerve palsy, deafness, cardiac anomalies, and synkinesia may be detected in the involved child. It is important to differentiate congenital muscular torticollis from Klippel- Feil syndrome, because releasing the sternocleidomastoid muscle will not correct a bony deformity. Static lateral radiographs of the cervical spine may appear normal in young children, as ossification of abnormal levels has not yet occurred. Flexion/extension lateral radiographs are useful to define congenital fusions, and magnetic resonance imaging may further delineate the anatomy. It is also important to test neck motion in all planes, because flexion/extension may be normal if movement occurs through just a few spared levels. Children with Klippel-Feil syndrome rarely develop neurological symptoms as a result of the congenital cervical fusion. Later in life, they may develop neurological impairment as a result of instability or degenerative disk disease.

Question 69

Topic: 4. Pediatrics

A 4-week-old female infant has congenital muscular torticollis. Which of the following is not associated with this condition?

. Plagiocephaly
. C ervical spine anomalies
. Developmental dysplasia of the hips
. Sternocleidomastoid muscle fibrosis
. Difficult delivery

Correct Answer & Explanation

. Plagiocephaly

Explanation

Congenital muscular torticollis is the most common cause of torticollis in the infant and young child. Usually, the children have a history of a breech or difficult delivery or primiparous birth. The exact etiology is unknown, but theories center around a compartment syndrome of the sternocleidomastoid muscle as a result of compression of soft tissues around the neck at the time of delivery. This results in fibrosis of the sternocleidomastoid muscle, tilting of the head to the ipsilateral side, and rotation of the head to the opposite side. Congenital muscular torticollis is associated with developmental dysplasia of the hips in up to 20% of children, so a careful examination of hip stability is mandatory, with dynamic ultrasound, if necessary. Plagiocephaly or facial and skull deformities occur in progressive torticollis within the first year of life. The association of metatarsus adductus with congenital muscular torticollis is variable in the literature. Plain radiographs of the cervical spines of children with congenital muscular torticollis are always normal, with the exception of the head tilt and rotation. Treatment initially includes stretching exercises and physical therapy early in life. Surgery (release of the muscle) is recommended if the torticollis persists after 1 year of age.

Question 70

Topic: 4. Pediatrics

A 14-year-old boy with spastic quadriplegic cerebral palsy (GMFCS Level V) has a progressive 75-degree thoracolumbar scoliosis and a 25-degree pelvic obliquity. He is losing sitting balance and has developed ischial pressure sores. When planning surgical correction (posterior spinal fusion), what is the most appropriate distal extent of the fusion?

. Fusion to the pelvis
. Fusion to L4
. Fusion to L5
. Fusion to the lower end vertebra
. Fusion to the stable vertebra

Correct Answer & Explanation

. Fusion to the pelvis

Explanation

In non-ambulatory patients with severe neuromuscular scoliosis (like GMFCS V CP) and significant pelvic obliquity (>15 degrees), the fusion construct must be extended to the pelvis. This corrects the pelvic obliquity, restores sitting balance, and prevents progressive deformity.

Question 71

Topic: Pediatric Upper Extremity & Spine
A 12-year-old premenarcheal female with adolescent idiopathic scoliosis presents with a right thoracic curve measuring 32 degrees on standing AP radiographs. Her Risser stage is 0. What is the most appropriate evidence-based recommendation for her treatment?
. Observation with radiographs in 6 months
. Physical therapy focusing on core strengthening
. Posterior spinal fusion
. Thoracolumbosacral orthosis (TLSO) brace wear for 18-23 hours a day
. Nighttime-only bending brace

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) brace wear for 18-23 hours a day

Explanation

This patient has significant remaining growth (premenarcheal, Risser 0) and a curve between 25 and 45 degrees. According to the BRAIST trial, rigid bracing (like a TLSO) for at least 18 hours per day is indicated and highly effective at preventing progression to surgery.

Question 72

Topic: Pediatric Upper Extremity & Spine

According to the Lenke Classification system for Adolescent Idiopathic Scoliosis, what specific radiographic criterion officially defines a 'structural' minor curve on side-bending films?

. A residual coronal curve of greater than or equal to 25 degrees
. A residual coronal curve of greater than or equal to 10 degrees
. Apical vertebral rotation of Grade II or higher
. A rigid kyphosis greater than 40 degrees
. Failure of the apical vertebra to cross the midline

Correct Answer & Explanation

. A residual coronal curve of greater than or equal to 25 degrees

Explanation

In the Lenke classification system, a minor curve is considered structural if the residual curve on a maximum supine side-bending radiograph remains greater than or equal to 25 degrees, or if the regional kyphosis is +20 degrees or greater.

Question 73

Topic: 4. Pediatrics

A 5-year-old girl is diagnosed with Klippel-Feil syndrome after presenting with a short neck, low posterior hairline, and restricted cervical motion. Radiographs confirm congenital fusion of C3-C4 and C5-C6. Aside from an echocardiogram and a hearing evaluation, which of the following screening tests is mandatory for this patient?

. Renal ultrasound
. Pulmonary function testing
. Bone mineral density scan
. Ophthalmologic slit-lamp exam
. Whole exome sequencing

Correct Answer & Explanation

. Renal ultrasound

Explanation

Klippel-Feil syndrome is associated with several systemic anomalies. Up to 30% of these patients have structural renal abnormalities, making a screening renal ultrasound mandatory.

Question 74

Topic: Pediatric Upper Extremity & Spine

A 13-year-old pre-menarchal girl presents with a right thoracic adolescent idiopathic scoliosis measuring 32 degrees. Her Risser stage is 0, and her Sanders bone age corresponds to stage 2. What is the most appropriate, evidence-based management strategy?

. Observation with radiographs every 6 months
. Schroth physical therapy alone
. Thoracolumbosacral orthosis (TLSO) for 18-23 hours daily
. Nighttime-only bending brace
. Posterior spinal fusion

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) for 18-23 hours daily

Explanation

For a skeletally immature patient (Risser 0-2) with a progressive idiopathic curve between 25 and 40 degrees, the BRAIS study demonstrated that TLSO bracing for at least 18 hours a day significantly decreases the risk of progression to surgery.

Question 75

Topic: Pediatric Hip

An 8-year-old boy presents for evaluation. He has unusually broad shoulders and is able to bring his shoulders together anteriorly at the midline. Radiographs confirm hypoplastic clavicles and delayed skull suture closure. Which of the following pelvic abnormalities is most highly associated with this patient's syndrome?

. Acetabular dysplasia
. Coxa vara
. Slipped capital femoral epiphysis
. Protrusio acetabuli
. Femoroacetabular impingement

Correct Answer & Explanation

. Coxa vara

Explanation

Cleidocranial dysplasia is a skeletal dysplasia caused by a RUNX2 gene mutation. In the lower extremities, it is classically associated with delayed pubic symphysis ossification and developmental coxa vara.

Question 76

Topic: 4. Pediatrics

A 6-year-old girl is diagnosed with Klippel-Feil syndrome after radiographs reveal multiple congenital cervical fusions. She has no neurological deficits. As part of her comprehensive initial evaluation, which of the following screening tests is mandatory?

. Pulmonary function testing
. Renal ultrasound
. Colonoscopy
. Skeletal survey for non-accidental trauma
. Brain magnetic resonance imaging

Correct Answer & Explanation

. Renal ultrasound

Explanation

Klippel-Feil syndrome is associated with several systemic anomalies, most notably genitourinary defects. A renal ultrasound is mandatory to screen for unilateral renal agenesis or other urologic abnormalities present in up to 30% of patients.

Question 77

Topic: 4. Pediatrics

A 12-month-old infant with achondroplasia is noted to have a 40-degree thoracolumbar kyphosis on sitting lateral radiographs. The child is neurologically intact and has just started pulling to stand. What is the most appropriate management for this spinal deformity at this time?

. Immediate posterior spinal fusion
. Combined anterior and posterior spinal fusion
. Thoracolumbosacral orthosis (TLSO) extension bracing
. Observation and reassurance
. Laminectomy and decompression

Correct Answer & Explanation

. Observation and reassurance

Explanation

Thoracolumbar kyphosis is common in infants with achondroplasia and typically resolves spontaneously once the child begins to walk and develops lumbar lordosis. Observation is the standard of care unless the deformity is rigid, severe, or associated with neurological deficit.

Question 78

Topic: 4. Pediatrics

A 4-week-old infant is brought to the clinic with a right-sided neck mass and a persistent head tilt to the right with the chin rotated to the left. After diagnosing congenital muscular torticollis and initiating physical therapy, what additional screening is highly recommended?

. Echocardiogram
. Ultrasound of the hips
. Renal ultrasound
. Cranial vault CT
. Pyloric ultrasound

Correct Answer & Explanation

. Ultrasound of the hips

Explanation

Congenital muscular torticollis is strongly associated with developmental dysplasia of the hip (DDH), occurring in up to 20% of cases. A screening hip ultrasound is recommended to rule out DDH.

Question 79

Topic: 4. Pediatrics

A 6-month-old child with achondroplasia presents with central sleep apnea, failure to thrive, and lower extremity hyperreflexia. What is the best diagnostic test to identify the source of these symptoms?

. Computed tomography of the temporal bones
. Polysomnography alone
. MRI of the cervicomedullary junction
. Lateral flexion-extension cervical radiographs
. Electroencephalogram

Correct Answer & Explanation

. MRI of the cervicomedullary junction

Explanation

Infants with achondroplasia are at high risk for foramen magnum stenosis, which can compress the cervicomedullary junction leading to central sleep apnea, hyperreflexia, and even sudden death. MRI is the diagnostic modality of choice.

Question 80

Topic: Pediatric Upper Extremity & Spine

A 13-year-old female with Marfan syndrome presents with a progressive 35-degree thoracic scoliosis. Regarding the management of her spinal deformity, which of the following statements is most accurate?

. Bracing is highly effective and rarely fails
. The curve is typically less responsive to bracing compared to adolescent idiopathic scoliosis
. Bracing is contraindicated due to aortic root fragility
. Posterior spinal fusion alone is contraindicated
. Her curve is likely to resolve spontaneously with growth

Correct Answer & Explanation

. The curve is typically less responsive to bracing compared to adolescent idiopathic scoliosis

Explanation

Scoliosis in Marfan syndrome is often more rigid and less responsive to conservative treatment (bracing) than adolescent idiopathic scoliosis (AIS), frequently progressing to require surgical intervention.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page