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4. Pediatrics MCQs

Practice Set 48 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 941

Topic: 4. Pediatrics

A 1-year-old infant is evaluated for congenital scoliosis. Radiographs demonstrate a fully unsegmented unilateral bar with a fully segmented contralateral hemivertebra at the apex of the curve. What is the expected natural history of this specific deformity?

. Spontaneous resolution with growth
. Slow progression averaging 1-2 degrees per year
. Rapid progression often exceeding 5-10 degrees per year
. Stability until the adolescent growth spurt
. High rate of spontaneous neurological deficit without intervention

Correct Answer & Explanation

. Rapid progression often exceeding 5-10 degrees per year

Explanation

A unilateral unsegmented bar with a contralateral hemivertebra has the highest progression potential of all congenital spinal deformities, rapidly progressing at 5 to 10 degrees per year. Early surgical intervention is highly indicated to prevent severe, rigid deformity.

Question 942

Topic: Pediatric Upper Extremity & Spine

According to the Lenke classification for adolescent idiopathic scoliosis, a curve pattern consisting of a structural main thoracic curve and a structural proximal thoracic curve, accompanied by a non-structural lumbar curve, is classified as which type?

. Lenke 1
. Lenke 2
. Lenke 3
. Lenke 4
. Lenke 5

Correct Answer & Explanation

. Lenke 2

Explanation

A Lenke 2 curve is a "Double Thoracic" pattern, characterized by structural proximal thoracic and main thoracic curves, with a non-structural lumbar curve. A Lenke 1 is a main thoracic curve only.

Question 943

Topic: Pediatric Upper Extremity & Spine

A 15-year-old female is undergoing a posterior spinal fusion for adolescent idiopathic scoliosis (Lenke 1A). During the derotation maneuver, the neurophysiologist reports a sudden loss of motor evoked potentials (MEPs) in the bilateral lower extremities, while somatosensory evoked potentials (SSEPs) remain stable. What is the most appropriate initial management step?

. Administer a bolus of intravenous methylprednisolone
. Perform a wake-up test immediately
. Increase mean arterial pressure (MAP) to > 90 mmHg and release the deformity correction
. Order an intraoperative MRI to assess for epidural hematoma
. Proceed with the surgery as stable SSEPs indicate an intact posterior column

Correct Answer & Explanation

. Increase mean arterial pressure (MAP) to > 90 mmHg and release the deformity correction

Explanation

Loss of MEPs with intact SSEPs suggests anterior spinal cord ischemia. The immediate algorithm involves increasing the MAP to optimize cord perfusion and releasing the surgical correction or hardware that precipitated the change.

Question 944

Topic: Pediatric Upper Extremity & Spine

In the Lenke classification system for adolescent idiopathic scoliosis, a minor curve is defined as non-structural based on its flexibility on side-bending radiographs. What is the specific Cobb angle threshold on a side-bending radiograph that defines a curve as non-structural?

. Reduces to < 10 degrees
. Reduces to < 15 degrees
. Reduces to < 20 degrees
. Reduces to < 25 degrees
. Reduces to < 30 degrees

Correct Answer & Explanation

. Reduces to < 25 degrees

Explanation

In the Lenke classification, a minor curve is considered non-structural if it reduces to less than 25 degrees on supine maximum voluntary side-bending radiographs. Curves that remain 25 degrees or greater are considered structural.

Question 945

Topic: 4. Pediatrics

A 3-year-old girl is diagnosed with congenital scoliosis secondary to a hemivertebra at T8. Given the known embryologic associations with this condition, which of the following screening tests must be ordered to evaluate for the most common concurrent visceral anomaly?

. Echocardiogram
. Renal ultrasound
. Pulmonary function testing
. Cranial MRI
. Barium swallow

Correct Answer & Explanation

. Renal ultrasound

Explanation

Genitourinary tract anomalies (such as unilateral renal agenesis) occur in up to 20-30% of patients with congenital scoliosis due to simultaneous embryogenesis. A renal ultrasound is mandatory screening for all patients presenting with congenital scoliosis.

Question 946

Topic: Pediatric Upper Extremity & Spine
According to the results of the Bracing in Adolescent Idiopathic Scoliosis Trial (BRAIST), which of the following factors was most significantly correlated with the successful prevention of curve progression to the surgical threshold?
. The type of brace utilized (Boston vs. Charleston)
. The patient's initial Risser stage
. The amount of in-brace curve correction achieved
. The duration of brace wear exceeding 18 hours per day
. The patient's body mass index (BMI)

Correct Answer & Explanation

. The duration of brace wear exceeding 18 hours per day

Explanation

The BRAIST trial demonstrated a significant dose-response relationship between hours of brace wear and success rate. Wearing the brace for more than 18 hours per day was highly correlated with preventing curve progression to the surgical threshold (>50 degrees).

Question 947

Topic: 4. Pediatrics

A 7-year-old boy is diagnosed with Klippel-Feil syndrome. He exhibits a low posterior hairline, short neck, and limited cervical range of motion. During physical examination, an elevation of the left scapula is noted. Which of the following conditions is most commonly associated with this specific physical finding?

. Sprengel deformity
. Cleidocranial dysplasia
. Poland syndrome
. Achondroplasia
. Marfan syndrome

Correct Answer & Explanation

. Sprengel deformity

Explanation

Sprengel deformity, an undescended and elevated scapula, is strongly associated with Klippel-Feil syndrome. Up to 30% of patients with Klippel-Feil syndrome have a concurrent Sprengel deformity, often linked by an omovertebral bone.

Question 948

Topic: Pediatric Upper Extremity & Spine

A 12-year-old girl is diagnosed with adolescent idiopathic scoliosis (AIS). She has not yet reached menarche. Which of the following radiographic findings indicates the highest risk for curve progression?

. Risser stage 4
. Closed triradiate cartilage
. Open triradiate cartilage
. Nash-Moe grade I rotation
. Cobb angle of 15 degrees

Correct Answer & Explanation

. Open triradiate cartilage

Explanation

Open triradiate cartilage indicates the patient is in the peak height velocity phase of growth, which corresponds to the highest risk of curve progression in AIS. The triradiate cartilage typically closes right around or shortly after peak height velocity.

Question 949

Topic: Pediatric Upper Extremity & Spine
In the Lenke classification system for adolescent idiopathic scoliosis (AIS), a minor curve is defined as 'structural' and should be included in the fusion construct if:
. It does not correct to less than 25 degrees on side-bending radiographs.
. It does not correct to less than 10 degrees on side-bending radiographs.
. It has a Nash-Moe rotation of grade III.
. The patient has a Risser stage of 0.
. It is accompanied by a positive sagittal vertical axis (SVA).

Correct Answer & Explanation

. It does not correct to less than 25 degrees on side-bending radiographs.

Explanation

According to the Lenke classification, a minor curve is deemed structural if it remains 25 degrees or greater on supine maximum side-bending radiographs, or if there is regional kyphosis of 20 degrees or more.

Question 950

Topic: Pediatric Upper Extremity & Spine

A 13-year-old girl with adolescent idiopathic scoliosis (AIS) has a right thoracic curve of 34 degrees. She is pre-menarchal and Risser stage 0. What is the most appropriate management?

. Observation with radiographs every 6 months
. Full-time TLSO bracing
. Nighttime-only Providence bracing
. Posterior spinal fusion
. Anterior vertebral body tethering

Correct Answer & Explanation

. Full-time TLSO bracing

Explanation

For an immature patient (Risser 0-2) with a curve between 25 and 40 degrees, TLSO bracing for a minimum of 16-18 hours a day is the gold standard to prevent progression to surgical magnitude.

Question 951

Topic: Pediatric Lower Extremity

Which of the following clinical examination findings is most characteristic of a patient with a tethered spinal cord presenting with a progressive scoliotic deformity?

. Hyporeflexia in the upper extremities
. Asymmetric abdominal reflexes and cavovarus foot deformity
. Unilateral ptosis and miosis
. Saddle anesthesia and loss of bowel control as early signs
. Symmetric, brisk patellar reflexes with flexor plantar responses

Correct Answer & Explanation

. Asymmetric abdominal reflexes and cavovarus foot deformity

Explanation

Tethered cord syndrome often presents subtly in children with asymmetric abdominal reflexes, lower extremity hyperreflexia, asymmetric foot deformities (like cavovarus), or cutaneous stigmata. Bowel/bladder incontinence are typically late findings.

Question 952

Topic: 4. Pediatrics

A 9-year-old boy crushes his finger in a door. Examination reveals a transverse laceration through the nail bed, the nail root is avulsed on top of the eponychial fold, and the distal phalanx is volarly flexed. Radiographs show a displaced Salter-Harris I fracture of the distal phalanx. What is the most appropriate definitive management?

. Splinting in extension with outpatient follow-up
. Closed reduction and percutaneous pinning without nail removal
. Oral antibiotics and buddy taping
. Nail removal, irrigation, nail bed repair, and fracture reduction with or without pinning
. Immediate amputation of the fingertip

Correct Answer & Explanation

. Nail removal, irrigation, nail bed repair, and fracture reduction with or without pinning

Explanation

This is a Seymour fracture, which is an open physeal fracture of the distal phalanx. It requires formal irrigation, debridement, nail bed repair, and reduction of the fracture to prevent deep infection and growth arrest.

Question 953

Topic: 4. Pediatrics
Which of the following Salter-Harris fracture types has the highest risk of growth arrest?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type V

Explanation

Salter-Harris Type V fractures, which involve a crush injury to the growth plate, have the highest risk of growth arrest due to direct damage to the germinal cells. While relatively rare, the prognosis for future growth is poor. Type IV fractures (fracture through metaphysis, physis, and epiphysis) also carry a high risk if not anatomically reduced, as a cartilaginous bridge can form across the physis. Type I (separation of physis) and Type II (physis and metaphysis) generally have good prognoses if reduced. Type III (physis and epiphysis) have a better prognosis than Type IV or V but still require anatomical reduction, especially if intra-articular.

Question 954

Topic: 4. Pediatrics
A 6-year-old child sustains a Gartland type III extension-type supracondylar humerus fracture. On examination, the patient cannot flex the interphalangeal joint of the thumb. Which nerve is most likely injured?
. Median nerve
. Anterior interosseous nerve
. Ulnar nerve
. Radial nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

The anterior interosseous nerve (AIN) is the most commonly injured nerve in extension-type pediatric supracondylar humerus fractures. Injury results in weakness of the flexor pollicis longus, presenting as an inability to form the "OK" sign.

Question 955

Topic: 4. Pediatrics
A 10-year-old male falls from a trampoline, landing on his elbow. Radiographs show a fracture of the distal humerus that extends through the metaphysis and then obliquely through the physis, exiting into the epiphysis and involving the articular surface. Which Salter-Harris classification best describes this injury?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type IV

Explanation

The Salter-Harris classification system categorizes physeal (growth plate) fractures: Type I: Fracture through the physis only. Type II: Fracture through the physis and metaphysis. Type III: Fracture through the physis and epiphysis, involving the articular surface. Type IV: Fracture through the metaphysis, physis, and epiphysis, involving the articular surface. Type V: Crush injury to the physis. The description of a fracture extending through the metaphysis, physis, and epiphysis (involving the articular surface) perfectly matches a Salter-Harris Type IV fracture.

Question 956

Topic: Pediatric Lower Extremity

A newborn is diagnosed with congenital talipes equinovarus (clubfoot) characterized by ankle equinus, hindfoot varus, forefoot adduction, and internal rotation. The foot is rigid and cannot be passively corrected. Which of the following is the most appropriate initial treatment?

. Immediate surgical correction with soft tissue release
. Serial casting using the Ponseti method
. Custom orthotics and bracing for 12 months
. Intensive physical therapy and stretching exercises
. Observation with serial radiographs to monitor progression

Correct Answer & Explanation

. Serial casting using the Ponseti method

Explanation

Correct Answer: BFor congenital talipes equinovarus (clubfoot), the Ponseti method of serial casting is the gold standard and most appropriate initial treatment. This non-surgical technique involves a series of gentle manipulations and plaster casts applied weekly over several weeks, followed by a percutaneous Achilles tenotomy in most cases, and then maintenance with a foot abduction brace. The Ponseti method has a high success rate in achieving correction and avoiding extensive surgery. Immediate surgical correction is typically reserved for cases that fail Ponseti treatment or are diagnosed later in childhood. Custom orthotics and physical therapy alone are insufficient for rigid clubfoot. Observation is inappropriate for a condition that requires active correction.

Question 957

Topic: Pediatric Upper Extremity & Spine

A 25-year-old male sustains a C5 burst fracture with significant retropulsion into the spinal canal after a diving accident. On initial assessment, he has complete paralysis below the C5 level, including absent motor and sensory function in the bilateral upper and lower extremities, and absent sacral sparing. Which ASIA Impairment Scale (AIS) grade best describes his neurological status?

. AIS A
. AIS B
. AIS C
. AIS D
. AIS E

Correct Answer & Explanation

. AIS A

Explanation

Correct Answer: ARationale:The ASIA Impairment Scale (AIS) is used to classify the severity of spinal cord injury. AIS A is defined as a complete spinal cord injury, characterized by no motor or sensory function preserved in the sacral segments S4-S5. The patient's description of 'complete paralysis below the C5 level, including absent motor and sensory function in the bilateral upper and lower extremities, and absent sacral sparing' directly corresponds to the definition of AIS A.Why other options are incorrect:B) AIS B:Incomplete injury with sensory but not motor function preserved below the neurological level and extending through the sacral segments S4-S5.C) AIS C:Incomplete injury with motor function preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3.D) AIS D:Incomplete injury with motor function preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or greater.E) AIS E:Normal motor and sensory function.

Question 958

Topic: Pediatric Hip
A 7-year-old boy presents with a 3-week history of right hip pain and a limp. He denies trauma. On examination, he has decreased internal rotation and abduction of the right hip. Radiographs show increased density of the right femoral epiphysis and a flattened appearance. What is the most likely diagnosis?
. Septic arthritis of the hip
. Transient synovitis of the hip
. Slipped capital femoral epiphysis (SCFE)
. Legg-Calvé-Perthes disease
. Developmental dysplasia of the hip (DDH)

Correct Answer & Explanation

. Legg-Calvé-Perthes disease

Explanation

The clinical presentation of a 7-year-old boy with hip pain, limp, and decreased hip motion (especially internal rotation and abduction), combined with radiographic findings of increased density (sclerosis) and flattening (fragmentation) of the femoral epiphysis, is classic for Legg-Calvé-Perthes disease. Septic arthritis would present acutely with systemic signs and extreme pain, transient synovitis is usually self-limiting with normal radiographs after a few days, SCFE typically occurs in older, often obese adolescents, and DDH is usually diagnosed in infancy or early childhood.

Question 959

Topic: 4. Pediatrics

A 13-year-old obese boy presents with 3 weeks of progressive groin pain and an obligatory external rotation of the hip during flexion. Radiographs confirm a stable slipped capital femoral epiphysis (SCFE). What is the primary goal of immediate surgical intervention?

. Anatomic reduction of the epiphysis
. Prevention of further slippage
. Stimulation of continued physeal growth
. Prevention of avascular necrosis
. Restoration of the anterior offset

Correct Answer & Explanation

. Prevention of further slippage

Explanation

The primary goal of in situ pinning for a stable SCFE is to prevent further displacement of the epiphysis and promote physeal closure. Attempting anatomic reduction drastically increases the risk of avascular necrosis and is contraindicated in stable slips.

Question 960

Topic: Pediatric Lower Extremity

In the Ponseti method for treating idiopathic clubfoot (talipes equinovarus), what is the correct sequence of deformity correction?

. Cavus, Adductus, Varus, Equinus
. Equinus, Varus, Adductus, Cavus
. Adductus, Varus, Cavus, Equinus
. Cavus, Varus, Adductus, Equinus
. Varus, Cavus, Adductus, Equinus

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The Ponseti method corrects clubfoot deformities in the specific order of CAVE: Cavus, Adductus, Varus, and finally Equinus. The cavus is corrected first by elevating the first ray to align the forefoot with the hindfoot.

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