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4. Pediatrics MCQs

Practice Set 47 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 921

Topic: 4. Pediatrics

Despite meticulous surgical technique for the triplane fracture, the patient is at risk for several postoperative complications. Which of the following complications is considered the most dreaded in pediatric distal tibial physeal fractures, particularly if not anatomically reduced?

. Hardware prominence requiring removal.
. Superficial wound infection.
. Premature physeal closure leading to angular deformity or leg length discrepancy.
. Deep vein thrombosis (DVT).
. Neurological deficit due to nerve injury during surgery.

Correct Answer & Explanation

. Premature physeal closure leading to angular deformity or leg length discrepancy.

Explanation

Correct Answer: CThe case explicitly states: 'The most dreaded complication is premature physeal closure leading to angular deformity or leg length discrepancy.' While the risk is mitigated in older adolescents, precise anatomical reduction of the physis minimizes the formation of a transphyseal bony bar. This complication can have significant long-term functional and cosmetic consequences for a growing child.Option A, hardware prominence, is a frequent complaint (30-40% incidence) often requiring secondary surgery, but it is generally not considered 'dreaded' in the same way as growth arrest. Option B, superficial wound infection, has a low incidence (less than 2%) and is typically manageable. Option D, DVT, is rare in pediatric trauma patients. Option E, neurological deficit, while serious, is also a rare complication with careful surgical technique and is not specifically highlighted as the 'most dreaded' in the context of physeal fractures compared to growth disturbances.

Question 922

Topic: 4. Pediatrics
A 14-year-old boy sustains an ankle injury while sliding into a base. Radiographs reveal a fracture of the anterolateral aspect of the distal tibia epiphysis. Which of the following ligaments is responsible for the avulsion of this bony fragment?
. Anterior talofibular ligament
. Anterior inferior tibiofibular ligament
. Posterior inferior tibiofibular ligament
. Calcaneofibular ligament
. Deltoid ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament

Explanation

A juvenile Tillaux fracture is a Salter-Harris III fracture of the anterolateral distal tibia epiphysis. It is caused by an avulsion force from the anterior inferior tibiofibular ligament (AITFL) during external rotation.

Question 923

Topic: 4. Pediatrics
A 13-year-old girl sustains an ankle fracture. Radiographs show a fracture line in the sagittal plane on the AP view and in the coronal plane on the lateral view. What Salter-Harris classification does this fracture pattern functionally represent?
. Salter-Harris I
. Salter-Harris II
. Salter-Harris III
. Salter-Harris IV
. Salter-Harris V

Correct Answer & Explanation

. Salter-Harris IV

Explanation

A triplane fracture appears as a Salter-Harris III fracture on the AP radiograph and a Salter-Harris II fracture on the lateral radiograph. Overall, it functions as a Salter-Harris IV injury because the fracture components cross the epiphysis, physis, and metaphysis.

Question 924

Topic: 4. Pediatrics
A 9-year-old child sustains a Salter-Harris IV fracture of the medial malleolus. Which of the following is the most significant long-term complication uniquely associated with this specific injury pattern?
. Avascular necrosis of the talus
. Nonunion of the medial malleolus
. Premature asymmetric physeal closure causing a varus deformity
. Compartment syndrome
. Chronic syndesmotic instability

Correct Answer & Explanation

. Premature asymmetric physeal closure causing a varus deformity

Explanation

Salter-Harris III and IV fractures of the medial malleolus cross the physis and have a uniquely high risk of premature physeal closure. This often results in a progressive varus deformity of the ankle due to continued lateral growth.

Question 925

Topic: 4. Pediatrics

A 13-year-old girl presents with ankle pain after a twisting injury. Radiographs reveal a fracture of the anterolateral aspect of the distal tibial epiphysis. What is the normal sequence of closure of the distal tibial physis that predisposes her to this specific injury pattern?

. Lateral, central, medial
. Medial, central, lateral
. Central, medial, lateral
. Medial, lateral, central
. Central, lateral, medial

Correct Answer & Explanation

. Medial, central, lateral

Explanation

The distal tibial physis typically closes in a medial-to-central-to-lateral sequence. A juvenile Tillaux fracture occurs because the lateral physis remains open last, allowing the anterior inferior tibiofibular ligament to avulse the anterolateral epiphysis.

Question 926

Topic: 4. Pediatrics
A 14-year-old boy presents after an ankle injury. Radiographs show a fracture line extending vertically through the epiphysis on the AP view, and extending posteriorly through the metaphysis on the lateral view. Which Salter-Harris classification functionally describes this fracture?
. Salter-Harris I
. Salter-Harris II
. Salter-Harris III
. Salter-Harris IV
. Salter-Harris V

Correct Answer & Explanation

. Salter-Harris IV

Explanation

This describes a triplane fracture, which appears as a Salter-Harris III on the AP radiograph and a Salter-Harris II on the lateral radiograph. Because it crosses the epiphysis, physis, and metaphysis, it is functionally a Salter-Harris IV injury.

Question 927

Topic: 4. Pediatrics

A 9-year-old boy sustains a severe crush injury to his distal femoral physis (Salter-Harris V). Two years later, he is noted to have a significant leg length discrepancy and angular deformity due to a physeal bar. Which of the following is an absolute contraindication to physeal bar resection?

. Physeal bar size comprising 20% of the physis
. Patient age with 3 years of remaining growth
. A peripheral bar location
. Physeal bar size comprising greater than 50% of the total physeal area
. A central bar location

Correct Answer & Explanation

. Physeal bar size comprising greater than 50% of the total physeal area

Explanation

Physeal bar resection is generally contraindicated if the bar comprises more than 50% of the total cross-sectional area of the physis, or if there is less than 2 years (or 2 cm) of growth remaining. In such cases, completion of the epiphysiodesis is preferred.

Question 928

Topic: 4. Pediatrics

A 10-year-old falls on an outstretched hand, sustaining a Salter-Harris II fracture of the distal radius. According to the standard biomechanics of this injury pattern, where does the periosteum typically remain intact?

. On the tension side, opposite the metaphyseal fragment
. On the compression side, attached to the metaphyseal (Thurston-Holland) fragment
. It is circumferentially ruptured
. It is completely stripped from the epiphysis
. On the volar aspect, regardless of fracture displacement direction

Correct Answer & Explanation

. On the compression side, attached to the metaphyseal (Thurston-Holland) fragment

Explanation

In a Salter-Harris II fracture, the periosteum typically ruptures on the tension side but remains intact as a hinge on the compression side, which is attached to the metaphyseal spike (Thurston-Holland fragment).

Question 929

Topic: 4. Pediatrics
A 14-year-old boy presents with ankle pain after an external rotation injury sustained while playing soccer. Radiographs reveal a Salter-Harris III fracture of the anterolateral distal tibia. Which of the following structures is biomechanically responsible for avulsing this fracture fragment?
. Anterior talofibular ligament
. Anterior inferior tibiofibular ligament
. Posterior inferior tibiofibular ligament
. Calcaneofibular ligament
. Deltoid ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament

Explanation

A juvenile Tillaux fracture is a Salter-Harris III fracture of the anterolateral distal tibia. It occurs due to avulsion by the anterior inferior tibiofibular ligament (AITFL) during external rotation when the medial physis has closed but the lateral remains open.

Question 930

Topic: 4. Pediatrics
A 13-year-old boy presents with severe right ankle pain following an external rotation injury while playing soccer. CT imaging reveals an epiphyseal fracture of the distal tibia. The fracture pattern appears as a sagittal fracture line on the AP view and a coronal fracture line on the lateral view. How is this specific fracture pattern categorized according to the Salter-Harris (SH) classification on these distinct imaging planes?
. SH III on the AP view and SH II on the lateral view
. SH II on the AP view and SH III on the lateral view
. SH IV on the AP view and SH I on the lateral view
. SH I on the AP view and SH IV on the lateral view
. SH II on the AP view and SH IV on the lateral view

Correct Answer & Explanation

. SH III on the AP view and SH II on the lateral view

Explanation

A triplane fracture typically presents as a Salter-Harris III fracture on the anteroposterior (AP) view (sagittal fracture line through the epiphysis) and a Salter-Harris II fracture on the lateral view (coronal fracture line through the metaphysis). It occurs during the transitional period of physeal closure.

Question 931

Topic: 4. Pediatrics

A 6-year-old girl sustained a distal femoral Salter-Harris II fracture 18 months ago. Recent scanograms demonstrate a 2.5 cm leg length discrepancy and 15 degrees of progressive valgus deformity. An MRI maps an osseous physeal bar occupying 40% of the cross-sectional area of the central physis. What is the most appropriate definitive management for this patient?

. Physeal bar resection and interposition of autologous fat
. Guided growth (hemiepiphysiodesis) of the lateral distal femur without bar resection
. Completion epiphysiodesis of the injured femur with a corrective osteotomy
. Observation with shoe lifts until skeletal maturity
. Radiofrequency ablation of the remaining physis and immediate limb lengthening

Correct Answer & Explanation

. Completion epiphysiodesis of the injured femur with a corrective osteotomy

Explanation

Physeal bars that occupy greater than 30-50% of the cross-sectional area or present with significant angular deformity and leg length discrepancy are generally not amenable to simple bar resection. The most appropriate treatment is completion epiphysiodesis (to halt further asymmetric growth) combined with a corrective osteotomy, followed by addressing the leg length discrepancy.

Question 932

Topic: Pediatric Hip

A 12-year-old obese boy presents with progressive left groin and knee pain. Radiographs demonstrate a stable slipped capital femoral epiphysis (SCFE). Which of the following is an established indication for prophylactic in situ pinning of the asymptomatic contralateral hip?

. Male sex
. Patient age greater than 14 years
. Presence of an underlying endocrine disorder
. Body mass index > 95th percentile
. Presence of a metaphyseal blanch sign of Steel

Correct Answer & Explanation

. Presence of an underlying endocrine disorder

Explanation

Prophylactic pinning of the contralateral hip in SCFE is recommended for patients with underlying endocrine disorders (e.g., hypothyroidism, renal osteodystrophy) due to an exceptionally high risk of bilateral involvement. Age less than 10 years or open triradiate cartilage are also common indications.

Question 933

Topic: Pediatric Hip

An 11-year-old obese male presents with left groin pain and an obligatory external rotation of the hip during passive flexion. Radiographs confirm a slipped capital femoral epiphysis (SCFE). Prophylactic pinning of the contralateral asymptomatic hip is most strongly indicated in patients with which of the following underlying conditions?

. Asthma
. Hypothyroidism
. Scoliosis
. Attention deficit hyperactivity disorder
. Type 1 Diabetes Mellitus

Correct Answer & Explanation

. Hypothyroidism

Explanation

Prophylactic pinning of the contralateral hip is highly recommended for patients with underlying endocrine disorders, such as hypothyroidism or renal osteodystrophy. These conditions significantly increase the risk of a contralateral slip.

Question 934

Topic: Pediatric Hip

A 3-month-old female is being treated with a Pavlik harness for developmental dysplasia of the hip. At a follow-up visit, the mother notes that the child is no longer actively extending the knee on the treated side. This complication is most likely due to which of the following positioning errors?

. Excessive hip flexion
. Excessive hip extension
. Excessive hip adduction
. Excessive knee flexion
. Inadequate hip abduction

Correct Answer & Explanation

. Excessive hip flexion

Explanation

Femoral nerve palsy is a known complication of the Pavlik harness, typically caused by excessive hip flexion. It presents as an inability to actively extend the knee and usually resolves with adjustment of the harness.

Question 935

Topic: Pediatric Hip

A 13-year-old obese male presents with acute-on-chronic left knee pain and an inability to bear weight. Radiographs confirm a slipped capital femoral epiphysis (SCFE). Which of the following is the most significant risk factor for the development of avascular necrosis (AVN) in this patient?

. Patient obesity
. Instability of the slip
. Severity of the slip angle
. Use of a single screw for fixation
. Patient age at presentation

Correct Answer & Explanation

. Instability of the slip

Explanation

Instability of a SCFE, defined as the inability to bear weight even with crutches, is the most significant predictor for the development of AVN. The rate of AVN in unstable SCFE can be as high as 20-50%.

Question 936

Topic: 4. Pediatrics

A 6-year-old child presents with a painless, palpable, and audible 'clunk' on the lateral side of the knee during terminal extension. An MRI confirms a lateral discoid meniscus. If the Wrisberg variant is present, which of the following anatomic structures is characteristically absent?

. Ligament of Wrisberg
. Ligament of Humphrey
. Posterior meniscofemoral ligament
. Posterior meniscotibial (coronary) ligament
. Anterior meniscofemoral ligament

Correct Answer & Explanation

. Posterior meniscotibial (coronary) ligament

Explanation

The Wrisberg variant of a discoid lateral meniscus is uniquely characterized by the absence of the normal posterior meniscotibial (coronary) ligament attachments. This hypermobility causes the meniscus to subluxate, producing the classic snapping knee.

Question 937

Topic: 4. Pediatrics

A 10-year-old boy presents with a painful popping sensation in his lateral knee. MRI demonstrates a Wrisberg variant discoid lateral meniscus. What specific anatomical deficiency defines this variant?

. Absence of the anterior horn meniscotibial attachment
. Absence of the posterior meniscotibial (coronary) ligaments
. Hypertrophy of the meniscofemoral ligament of Humphry
. Complete absence of the meniscofemoral ligament of Wrisberg
. Congenital fusion of the lateral meniscus to the popliteus tendon

Correct Answer & Explanation

. Absence of the posterior meniscotibial (coronary) ligaments

Explanation

The Wrisberg variant of a discoid meniscus lacks the normal posterior capsular and meniscotibial (coronary) ligament attachments. It is solely anchored posteriorly by the meniscofemoral ligament of Wrisberg, leading to hypermobility and the classic 'snapping knee' syndrome.

Question 938

Topic: Pediatric Upper Extremity & Spine

A 12-year-old female presents with a 42-degree right thoracic scoliosis. She is premenarchal and has a Risser sign of 0. Her parents report a recent growth spurt. Based on the provided information, which of the following factors is the strongest indicator of a high likelihood of curve progression in this patient?

. A. The curve's location in the thoracic spine.
. B. The patient's female gender.
. C. The current Cobb angle of 42 degrees.
. D. Her premenarchal status and Risser 0.
. E. The presence of a right-sided curve.

Correct Answer & Explanation

. D. Her premenarchal status and Risser 0.

Explanation

Correct Answer: DExplanation:The provided text explicitly lists features that indicate an increased likelihood of curve progression in adolescent idiopathic scoliosis. These include: young age at onset, premenarchal status, physical immaturity (like Risser 0), large curves, and female gender. Among these, premenarchal status and a low Risser sign (indicating significant remaining growth potential) are critical indicators of ongoing skeletal immaturity and thus a high risk for rapid progression during the adolescent growth spurt.A. The curve's location in the thoracic spine.While thoracic curves are common in AIS, the location itself is not listed as the strongest predictor of progression compared to skeletal maturity.B. The patient's female gender.Female gender is indeed a risk factor for progression, especially for curves over 20 degrees (F:M 5.4:1). However, in the context of a 12-year-old premenarchal girl with Risser 0, the immaturity indicators (premenarchal status, Risser 0) are more direct and stronger predictors offutureprogression than gender alone, as they signify the peak growth period.C. The current Cobb angle of 42 degrees.A large curve (over 40 degrees) is a risk factor for progression. However, thepotentialfor further rapid progression is most strongly linked to the remaining growth. A 42-degree curve in a skeletally mature individual would progress much less than a 42-degree curve in a skeletally immature individual.E. The presence of a right-sided curve.A right thoracic curve is the most common pattern in AIS and is not considered an atypical feature indicating higher progression risk compared to, for example, a left-sided curve which might suggest underlying pathology.

Question 939

Topic: Pediatric Upper Extremity & Spine

A 15-year-old patient presents with a 48-degree left-sided lumbar scoliosis, as depicted in the AP radiograph. The patient reports no pain but is concerned about the cosmetic appearance. She is skeletally mature with a Risser sign of 4. Given the curve characteristics and patient's maturity, what is the most likely natural history of this curve going forward?

. A. Rapid progression is expected due to the left-sided curve and lumbar location.
. B. The curve will likely stabilize with no further progression.
. C. Slow progression of approximately 1 degree per year is expected.
. D. Spontaneous resolution of the curve is highly probable.
. E. The curve will likely accelerate in progression during the next growth spurt.

Correct Answer & Explanation

. C. Slow progression of approximately 1 degree per year is expected.

Explanation

Correct Answer: CExplanation:The text states: 'Once skeletal maturity is reached the scoliosis tends to stabilize and progress less rapidly (1 per year).' This patient is 15 years old and has a Risser sign of 4, indicating significant skeletal maturity. While a 48-degree curve is substantial, the key factor here is the patient's maturity. Therefore, slow progression at approximately 1 degree per year is the most likely natural history.A. Rapid progression is expected due to the left-sided curve and lumbar location.While left-sided curves can be atypical and warrant further investigation for underlying pathology, the primary driver of rapid progression in idiopathic scoliosis is skeletal immaturity. With a Risser 4, rapid progression is unlikely.B. The curve will likely stabilize with no further progression.While progression slows, it doesn't typically cease entirely. A small degree of progression (around 1 degree per year) is still expected even after skeletal maturity for larger curves.D. Spontaneous resolution of the curve is highly probable.Spontaneous resolution is primarily seen in a significant number of infantile idiopathic scoliosis cases (80-90% of curves before age 2), not in adolescent or mature patients with a 48-degree curve.E. The curve will likely accelerate in progression during the next growth spurt.With a Risser 4, the patient is past the peak of their adolescent growth spurt, so an acceleration in progression due to growth is highly unlikely.

Question 940

Topic: Pediatric Upper Extremity & Spine
A 13-year-old premenarchal female presents with a 35-degree right main thoracic adolescent idiopathic scoliosis. Hand radiographs indicate she is at Sanders Skeletal Maturity Stage 3. What is the most evidence-based management strategy to prevent progression to surgery?
. Observation with radiographs every 6 months
. Thoracolumbosacral orthosis (TLSO) bracing for at least 18 hours per day
. Nighttime-only bending brace
. Anterior vertebral body tethering (VBT)
. Posterior spinal fusion with pedicle screws

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing for at least 18 hours per day

Explanation

The BRAIST trial demonstrated that TLSO bracing significantly decreases the rate of curve progression to the surgical threshold (50 degrees) in immature patients (Sanders 2-3, Risser 0-2) with curves of 20-40 degrees. The effect is highly dose-dependent, with optimal results seen with >18 hours of daily wear.

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