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4. Pediatrics MCQs

Practice Set 49 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 961

Topic: Pediatric Upper Extremity & Spine

A 13-year-old female with adolescent idiopathic scoliosis presents with a right thoracic curve measuring 48 degrees. Her Risser stage is 1. What is the most appropriate management?

. Observation with repeat radiographs in 6 months
. Thoracolumbosacral orthosis (TLSO) bracing for 23 hours/day
. Posterior spinal fusion
. Anterior vertebral body tethering
. Physiotherapy and core strengthening

Correct Answer & Explanation

. Posterior spinal fusion

Explanation

In a highly skeletally immature patient (Risser 1) with a curve greater than 45-50 degrees, the risk of progression is extreme. Posterior spinal fusion is the standard of care to correct the deformity, as bracing is generally ineffective for curves >45 degrees.

Question 962

Topic: Pediatric Hip

In the treatment of a young patient with an acute, unstable slipped capital femoral epiphysis (SCFE), what is the most significant iatrogenic risk associated with performing a forceful closed reduction prior to percutaneous pinning?

. Chondrolysis
. Avascular necrosis of the femoral head
. Ipsilateral femoral neck fracture
. Premature physeal closure
. Labral tear

Correct Answer & Explanation

. Avascular necrosis of the femoral head

Explanation

Forceful or aggressive closed reduction of an unstable SCFE disrupts the already tenuous retinacular blood supply, dramatically increasing the risk of avascular necrosis (AVN). Incidental pinning in situ or gentle reduction is preferred.

Question 963

Topic: Pediatric Hip

A 12-year-old obese male presents with acute-on-chronic left knee pain and inability to bear weight for the past 2 days. Examination reveals obligate external rotation of the left hip with passive flexion. Radiographs confirm a slipped capital femoral epiphysis (SCFE). Which of the following is the most significant risk factor for developing avascular necrosis (AVN) in this patient?

. Obesity
. The slip being unstable
. Prophylactic pinning of the contralateral hip
. Use of a single cannulated screw for fixation
. Capsulotomy performed at the time of surgery

Correct Answer & Explanation

. The slip being unstable

Explanation

The clinical instability of a SCFE, defined as the inability to bear weight with or without crutches, is the most significant predictor for the development of AVN. The rate of AVN is markedly higher in unstable slips compared to stable slips.

Question 964

Topic: 4. Pediatrics

A radiograph of a 14-year-old girl's knee obtained for a minor twisting injury shows an incidental 2 cm eccentric, lucent, metaphyseal lesion of the distal femur with a well-defined sclerotic border. The lesion does not involve the physis. Based on the most likely diagnosis, what is the natural history of this lesion?

. It will eventually ossify and remodel by skeletal maturity
. It will inevitably undergo malignant transformation in adulthood
. It will progress to destroy the adjacent articular cartilage
. It requires immediate surgical excision to prevent dissemination
. It will cause premature physeal closure

Correct Answer & Explanation

. It will eventually ossify and remodel by skeletal maturity

Explanation

The lesion describes a classic non-ossifying fibroma (NOF) or fibrous cortical defect. These are benign, self-limiting developmental anomalies that predictably ossify (fill in with bone) and disappear as the child reaches skeletal maturity.

Question 965

Topic: Pediatric Upper Extremity & Spine
A 9-year-old child presents with a Gartland Type III supracondylar humerus fracture, displaced posteromedially. During closed reduction, which of the following maneuvers is most critical for correcting the rotational component of this specific fracture pattern?
. Applying valgus stress to the elbow.
. Maintaining the forearm in supination.
. Pronating the forearm.
. Applying varus stress to the elbow.
. Hyperflexing the elbow beyond 120 degrees.

Correct Answer & Explanation

. Pronating the forearm.

Explanation

For posteromedial displacement, pronate the forearm. For posterolateral displacement, supinate the forearm. The common Type III extension fracture with posteromedial displacement often requires pronation to disengage the radial column.

Question 966

Topic: 4. Pediatrics
A 12-year-old adolescent sustains a Salter-Harris Type III fracture of the distal radial physis. Radiographs confirm intra-articular involvement and 2 mm of displacement. The patient is skeletally immature with significant remaining growth. What is the most critical aspect of management for this specific physeal injury?
. Immobilization in a short arm cast for 6 weeks.
. Aggressive physical therapy to prevent stiffness.
. Anatomical reduction to prevent growth arrest and articular incongruity.
. Observation for spontaneous remodeling of the displacement.
. Percutaneous pinning with pins crossing the physis for maximum stability.

Correct Answer & Explanation

. Anatomical reduction to prevent growth arrest and articular incongruity.

Explanation

Salter-Harris Type III and IV fractures, particularly intra-articular ones, require anatomical reduction to prevent growth arrest and articular incongruity. Any displacement can lead to a step-off in the joint, causing premature arthritis, and can also damage the growth plate, leading to angular deformity or limb length discrepancy.

Question 967

Topic: Pediatric Upper Extremity & Spine

A 5-year-old child is recovering from a successfully pinned Gartland Type II supracondylar humerus fracture. K-wires were removed at 3 weeks post-operatively. Which of the following is the most appropriate recommendation for the initial phase of rehabilitation?

. Initiate aggressive passive stretching of the elbow to regain full extension.
. Encourage gentle active range of motion (AROM) exercises for the elbow and wrist.
. Begin immediate weight-bearing activities to strengthen the arm.
. Maintain strict immobilization in a cast for an additional 3 weeks.
. Refer for immediate occupational therapy focusing on fine motor skills.

Correct Answer & Explanation

. Encourage gentle active range of motion (AROM) exercises for the elbow and wrist.

Explanation

Correct Answer: BThe 'Post-Operative Rehabilitation Protocols' section for Supracondylar Humerus Fracture (Pinned) states: 'After pin removal, a posterior splint may be used for comfort, but active range of motion of the elbow and wrist is immediately encouraged. Crucial: Avoid forceful passive stretching or manipulation of the elbow joint, as this can increase the risk of heterotopic ossification and myositis ossificans. Gravity-assisted gentle flexion/extension exercises.'Option A (Initiate aggressive passive stretching of the elbow to regain full extension):This is explicitly warned against in the text due to the risk of heterotopic ossification and myositis ossificans.Option B (Encourage gentle active range of motion (AROM) exercises for the elbow and wrist):This is the correct and recommended approach for early rehabilitation after pin removal, as it helps restore motion without the risks associated with passive stretching.Option C (Begin immediate weight-bearing activities to strengthen the arm):Weight-bearing and strengthening exercises are part of a later phase of rehabilitation (4-8+ weeks), not immediately after pin removal.Option D (Maintain strict immobilization in a cast for an additional 3 weeks):K-wires are typically removed when early callus formation is evident (around 3-4 weeks), and at that point, active motion is encouraged, not continued strict immobilization.Option E (Refer for immediate occupational therapy focusing on fine motor skills):While occupational therapy may be beneficial, the immediate focus after pin removal for an elbow fracture is on regaining elbow and wrist range of motion, not primarily fine motor skills, unless there are specific neurological deficits.

Question 968

Topic: Pediatric Upper Extremity & Spine
Based on the physical examination findings of the 15-year-old male (sensation not intact distal to the umbilicus, no sensation around the rectum, no voluntary rectal tone, 0/5 strength in bilateral lower extremities, and an intact bulbocavernosus reflex), what would be the patientโ€™s classification according to the American Spinal Injury Association (ASIA) impairment scale?
. A
. B
. C
. D
. E

Correct Answer & Explanation

. A

Explanation

The patient presents with complete motor and sensory loss below the level of the umbilicus, including the sacral segments S4-5 (no sensation around the rectum and no voluntary rectal tone). According to the ASIA classification, AIS A (Complete) indicates no sensory or motor function is preserved in the sacral segments S4โ€“5.

Question 969

Topic: 4. Pediatrics

A 5-year-old child sustains a displaced lateral condyle fracture of the humerus. Which of the following is the most common long-term complication if this fracture goes on to a delayed union or nonunion?

. Cubitus varus and tardy radial nerve palsy
. Cubitus valgus and tardy ulnar nerve palsy
. Premature closure of the entire distal humeral physis
. Avascular necrosis of the trochlea
. Heterotopic ossification of the brachialis

Correct Answer & Explanation

. Cubitus valgus and tardy ulnar nerve palsy

Explanation

Nonunion of a lateral condyle fracture typically leads to a progressive cubitus valgus deformity. This valgus angulation stretches the ulnar nerve over time, resulting in tardy ulnar nerve palsy.

Question 970

Topic: Pediatric Lower Extremity

When utilizing the Ponseti method for the correction of idiopathic clubfoot, what is the first deformity that must be addressed during the casting sequence?

. Equinus
. Varus
. Adductus
. Cavus
. Internal tibial torsion

Correct Answer & Explanation

. Equinus

Explanation

The Ponseti method corrects deformities in the CAVE sequence: Cavus, Adductus, Varus, and Equinus. Cavus is corrected first by supinating the forefoot and elevating the first ray to align it with the hindfoot.

Question 971

Topic: Pediatric Hip

A 6-month-old female with developmental dysplasia of the hip (DDH) has failed 6 weeks of treatment in a Pavlik harness, with persistent dislocation of the left hip. What is the most appropriate next step in management?

. Continue Pavlik harness for an additional 6 weeks
. Transition to a rigid abduction orthosis (e.g., Ilfeld brace)
. Closed reduction and spica casting under general anesthesia
. Open reduction via an anterior approach and pelvic osteotomy
. Femoral derotational osteotomy

Correct Answer & Explanation

. Closed reduction and spica casting under general anesthesia

Explanation

If a Pavlik harness fails to achieve reduction after 3-4 weeks in a young infant, it should be discontinued to avoid "Pavlik disease" (posterior acetabular wear). The next appropriate step is closed reduction and spica casting, often preceded by an arthrogram.

Question 972

Topic: 4. Pediatrics
A 14-year-old male sustains an isolated juvenile Tillaux fracture of the right ankle. Which of the following ligaments is responsible for avulsing the fracture fragment?
. Anterior talofibular ligament
. Calcaneofibular ligament
. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Deltoid ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

A juvenile Tillaux fracture is a Salter-Harris III fracture of the anterolateral distal tibia. It is caused by an external rotation force that avulses the bone via the anterior inferior tibiofibular ligament (AITFL) because the central and medial physis has already closed.

Question 973

Topic: Pediatric Hip

A 12-year-old obese boy presents with acute left groin pain and an inability to bear weight after a minor twisting injury. Radiographs confirm a slipped capital femoral epiphysis (SCFE). Which of the following defines this as an "unstable" SCFE?

. Slip angle greater than 50 degrees
. Presence of an effusion on ultrasound
. Inability to ambulate with or without crutches
. Physeal widening on the lateral radiograph
. Associated endocrine abnormality

Correct Answer & Explanation

. Inability to ambulate with or without crutches

Explanation

The Loder classification defines an unstable SCFE based strictly on clinical presentation: the patient's inability to ambulate on the affected limb, even with the use of crutches. Unstable SCFE carries a significantly higher risk of avascular necrosis (up to 50%).

Question 974

Topic: Pediatric Hip
A 6-year-old boy is diagnosed with Legg-Calvรฉ-Perthes disease. According to the modified lateral pillar classification (Herring), which of the following radiographic findings indicates the worst prognosis (Group C)?
. No involvement of the lateral pillar
. Greater than 50% maintenance of the lateral pillar height
. Less than 50% maintenance of the lateral pillar height
. Presence of a metaphyseal cyst
. Subchondral fracture line (Crescent sign) involving half of the epiphysis

Correct Answer & Explanation

. Less than 50% maintenance of the lateral pillar height

Explanation

In the Herring lateral pillar classification, Group C is defined as greater than 50% collapse (or less than 50% maintenance) of the lateral pillar height. This group has the highest risk of long-term deformity and poorest clinical outcomes.

Question 975

Topic: Pediatric Upper Extremity & Spine

A newborn is evaluated for a unilateral absent thumb and marked radial deviation of the wrist. Radiographs confirm radial longitudinal deficiency (radial clubhand). Which of the following tests is most critical to perform before any surgical intervention?

. Chromosomal breakage testing
. Serum lead levels
. Electromyography of the upper extremity
. Sweat chloride test
. Karyotype analysis for Trisomy 21

Correct Answer & Explanation

. Chromosomal breakage testing

Explanation

Radial longitudinal deficiency is highly associated with systemic syndromes, most notably Fanconi anemia. Chromosomal breakage testing is critical because Fanconi anemia carries a high risk of fatal aplastic anemia and necessitates specific perioperative and long-term medical management.

Question 976

Topic: Pediatric Hip

A 13-year-old male with a BMI of 35 presents with chronic left knee pain and an obligate external rotation of the hip during active flexion. An AP pelvis radiograph confirms a stable slipped capital femoral epiphysis (SCFE). Which of the following describes the most appropriate surgical intervention?

. In situ pinning with a single cannulated screw
. Open reduction and internal fixation
. Prophylactic pinning of the contralateral hip routinely
. Proximal femoral osteotomy
. Spica cast application

Correct Answer & Explanation

. In situ pinning with a single cannulated screw

Explanation

The standard of care for a stable SCFE is in situ pinning with a single, central cannulated screw. This provides stability to prevent further slip while minimizing the risk of avascular necrosis.

Question 977

Topic: 4. Pediatrics

A 7-month-old female is referred for a persistently dislocated left hip after 6 weeks of unsuccessful Pavlik harness treatment. Radiographs confirm a laterally displaced and superiorly migrated proximal femur. What is the most appropriate next step in management?

. Transition to a rigid abduction orthosis (Ilfeld brace)
. Closed reduction and spica casting under general anesthesia
. Open reduction via an anterior approach
. Femoral shortening osteotomy
. Observation until the child begins walking

Correct Answer & Explanation

. Closed reduction and spica casting under general anesthesia

Explanation

After failure of a Pavlik harness in an infant over 6 months of age, closed reduction and spica casting under general anesthesia with arthrogram confirmation is the standard next step. Continued bracing after failed Pavlik treatment risks further delay and iatrogenic dysplasia.

Question 978

Topic: Pediatric Hip

A 6-year-old male is diagnosed with Legg-Calve-Perthes disease. Radiographs show involvement of the entire epiphysis, but the lateral pillar maintains greater than 50% of its height. Which of the following is the most important prognostic factor for the development of late degenerative joint disease in this patient?

. Age at onset of symptoms
. Gender of the patient
. Use of non-weight-bearing crutches
. Body mass index
. Family history

Correct Answer & Explanation

. Age at onset of symptoms

Explanation

The most critical prognostic factor in Legg-Calve-Perthes disease is the age at the onset of symptoms, with children under 8 generally having a better prognosis due to greater remodeling potential. Lateral pillar classification is also important but secondary to age in overall long-term prognosis.

Question 979

Topic: Pediatric Lower Extremity

An infant is brought to the clinic for management of idiopathic clubfoot. According to the Ponseti method, the initial serial casting should primarily aim to correct which of the following deformities?

. Equinus
. Hindfoot varus
. Cavus
. Forefoot adductus
. Tibial torsion

Correct Answer & Explanation

. Cavus

Explanation

The first step in the Ponseti method is to correct the cavus deformity by elevating the first ray, which aligns the forefoot with the hindfoot. Subsequent casts correct adductus and varus simultaneously by abducting the foot around the fixed talar head.

Question 980

Topic: 4. Pediatrics

A 13-year-old obese male presents with a 4-week history of left knee pain and a limp. On examination, flexion of the left hip results in obligate external rotation. Radiographs confirm a slipped capital femoral epiphysis (SCFE). The slippage occurs through which zone of the physis?

. Reserve zone
. Proliferative zone
. Hypertrophic zone
. Zone of provisional calcification
. Primary spongiosa

Correct Answer & Explanation

. Hypertrophic zone

Explanation

Slipped capital femoral epiphysis (SCFE) occurs due to mechanical failure through the hypertrophic zone of the proximal femoral physis. This zone is the structurally weakest portion of the growth plate due to the lack of collagen framework matrix.

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