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4. Pediatrics MCQs

Practice Set 55 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 1081

Topic: 4. Pediatrics

If a biopsy of the medial proximal tibial physis were taken in a child with severe early-onset Blount disease, what characteristic histologic findings would most likely be observed?

. Normal physeal architecture with increased hypertrophic zone height
. Disruption of normal columnar architecture with islands of fibrocartilage and necrotic chondrocytes
. Avascular necrosis of the secondary center of ossification only
. Excessive proliferation of osteoclasts in the primary spongiosa
. Eosinophilic granulomas replacing the resting zone

Correct Answer & Explanation

. Disruption of normal columnar architecture with islands of fibrocartilage and necrotic chondrocytes

Explanation

The histology of Blount disease shows severely disorganized physeal cartilage due to compressive overload. Findings include loss of normal columnar architecture, islands of fibrovascular tissue, and areas of acellular or necrotic cartilage.

Question 1082

Topic: 4. Pediatrics

A 14-year-old boy with adolescent Blount disease requires a Taylor Spatial Frame correction. Pre-operative standing alignment films show the mechanical axis deviation (MAD) is situated in zone 3 of the medial plateau. Where is the center of rotation of angulation (CORA) most typically located in adolescent Blount disease?

. Distal tibial diaphysis
. Joint line of the knee
. Proximal tibial metaphysis/physis
. Distal femur
. Center of the talar dome

Correct Answer & Explanation

. Proximal tibial metaphysis/physis

Explanation

In adolescent Blount disease, the center of rotation of angulation (CORA) is typically located at or near the proximal tibial physis and metaphysis. This location dictates the ideal level for the corrective osteotomy to normalize the medial proximal tibial angle (MPTA).

Question 1083

Topic: Pediatric Upper Extremity & Spine

A 14-year-old female patient with adolescent idiopathic scoliosis (AIS) has a 35-degree right thoracic curve. She is premenarchal and has a Risser sign of 0. Based on the natural history of AIS, which of the following factors is the strongest indicator of a high likelihood of curve progression?

. Her female gender, as females are more prone to scoliosis.
. The curve magnitude of 35 degrees, classifying it as a moderate curve.
. Her premenarchal status and Risser 0, indicating significant skeletal immaturity.
. The right thoracic location of the curve, which is the most common pattern.
. The absence of severe back pain, suggesting a typical idiopathic presentation.

Correct Answer & Explanation

. Her premenarchal status and Risser 0, indicating significant skeletal immaturity.

Explanation

Correct Answer: CThe case states that 'The development and progression of scoliosis is related to skeletal growth, typically deteriorating most rapidly during the adolescent growth spurt. Features that indicate an increased likelihood of curve progression are therefore associated with but not limited to immaturity. They are: Young age at onset, Premenarchal status, Physical immaturity, Large curves, Female gender.' Premenarchal status combined with a Risser 0 indicates significant skeletal immaturity, meaning the patient has substantial growth remaining. This period of rapid growth is when curves are most likely to progress rapidly.Option A is incorrectbecause while female gender is a risk factor for progression (5.4:1 female to male for curves >20 degrees), skeletal immaturity (premenarchal, Risser 0) is a more direct and stronger predictor ofrapidprogression due to remaining growth potential.Option B is incorrectbecause a 35-degree curve is indeed moderate, and larger curves have a greater potential for progression. However, therateof progression is most strongly linked to the amount of remaining growth, which is best indicated by skeletal immaturity markers like premenarchal status and Risser 0.Option D is incorrectbecause a right thoracic curve is the most common pattern for AIS, but the location itself does not inherently indicate a higher likelihood of progression compared to other factors like skeletal maturity. Atypical curves (e.g., left thoracic) might suggest underlying pathology, but a typical right thoracic curve doesn't predict progression rate.Option E is incorrectbecause the absence of severe back pain is a typical feature of AIS and does not indicate a higher likelihood of progression. Severe pain would, in fact, be an 'atypical feature' suggesting possible underlying pathology, not a predictor of progression in typical AIS.

Question 1084

Topic: 4. Pediatrics

A 10-year-old girl with a newly diagnosed scoliosis undergoes a full-length standing AP radiograph of her spine. The radiograph reveals a Risser sign of 2. What does this finding primarily indicate?

. The severity of the spinal curvature in degrees.
. The presence of an underlying intraspinal anomaly.
. The patient's skeletal maturity and remaining growth potential.
. The flexibility of the primary scoliotic curve.
. The etiology of the scoliosis (e.g., idiopathic, congenital).

Correct Answer & Explanation

. The patient's skeletal maturity and remaining growth potential.

Explanation

Correct Answer: CThe case explicitly states under 'Investigations' that 'Risserโ€™s sign grades the progression of development and fusion of the iliac apophysis, is visible on plain X-rays and is a useful indication of maturity.' A Risser sign of 2 indicates that the iliac apophysis has ossified approximately 25-50% from lateral to medial, signifying that the patient is still skeletally immature and has significant growth remaining. This is a critical factor in predicting curve progression.Option A is incorrectbecause the severity of the spinal curvature is measured by the Cobb angle, not the Risser sign.Option B is incorrectbecause intraspinal anomalies are detected by MRI scanning, not the Risser sign.Option D is incorrectbecause the flexibility of the curve is assessed clinically (e.g., with lateral bending) and radiographically with lateral bending X-rays, not by the Risser sign.Option E is incorrectbecause the Risser sign indicates skeletal maturity, not the etiology of the scoliosis. The etiology is determined by clinical history, examination, and specific radiographic findings (like a hemivertebra for congenital scoliosis).

Question 1085

Topic: 4. Pediatrics

A 12-year-old child presents with persistent low back pain and some vague leg discomfort. Unlike adults, nerve root tension signs are equivocal, and the pain is predominantly axial. Based on the background knowledge provided, which statement best describes the typical presentation and natural history of disc prolapse in children compared to adults?

. A. Symptoms are more clearly defined, and nerve root tension signs are more prominent.
. B. Back pain is a less prominent feature, and spontaneous resolution is more likely.
. C. Back pain is a more prominent feature, and spontaneous resolution is less likely.
. D. Neurological deficits are typically more severe, requiring immediate surgical intervention.
. E. Thoracic disc prolapse is more common in children than in adults.

Correct Answer & Explanation

. C. Back pain is a more prominent feature, and spontaneous resolution is less likely.

Explanation

Correct Answer: CThe case provides specific background knowledge on pediatric disc prolapse: 'In children the symptoms and signs of disc prolapse are less well defined and back pain is a more prominent feature. Nerve root tension signs are also less likely to be positive and spontaneous resolution is less likely.' Therefore, option C accurately summarizes these differentiating features compared to adult presentations.

Question 1086

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarchal female with adolescent idiopathic scoliosis (AIS) is evaluated. She has a right thoracic curve of 32 degrees. Risser stage is 1.

What is the most appropriate next step in management?

. Observation with serial radiographs every 6 months
. Thoracolumbosacral orthosis (TLSO) bracing for 18 hours daily
. Posterior spinal fusion
. Anterior tethering procedure
. Nighttime-only bending brace

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing for 18 hours daily

Explanation

In a growing child (premenarchal, Risser 0-2) with an AIS curve between 25 and 44 degrees, full-time bracing (TLSO) is indicated. The BrAIST trial demonstrated that wearing a brace for at least 18 hours a day significantly decreases the risk of curve progression to surgical magnitude.

Question 1087

Topic: 4. Pediatrics

An infant is diagnosed with congenital scoliosis. Radiographs reveal a fully unsegmented bar on the left and a fully segmented hemivertebra on the right at the same level. Which of the following statements best describes the prognosis and management of this deformity?

. It has a low risk of progression and can be observed.
. It will progress rapidly and requires early surgical fusion.
. It is best managed with serial Mehta casting until age 5.
. It responds exceptionally well to TLSO bracing.
. It will spontaneously improve as the child reaches skeletal maturity.

Correct Answer & Explanation

. It will progress rapidly and requires early surgical fusion.

Explanation

A unilateral unsegmented bar with a contralateral hemivertebra represents the highest risk for rapid curve progression in congenital scoliosis. Early surgical intervention (in situ fusion or hemivertebra excision) is required to prevent severe, rigid deformity.

Question 1088

Topic: Pediatric Upper Extremity & Spine
A 14-year-old female with adolescent idiopathic scoliosis (AIS) has a 32-degree main thoracic curve. She is premenarchal with a Risser stage of 0. Which of the following is the most appropriate evidence-based management?
. Observation with full-spine radiographs in 6 months
. Physical therapy emphasizing core strengthening and Schroth methods
. Thoracolumbosacral orthosis (TLSO) wear for 18 hours daily
. Nighttime-only Providence bracing
. Posterior spinal fusion

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) wear for 18 hours daily

Explanation

The BRAIST trial demonstrated that bracing for at least 18 hours per day significantly decreases the progression of curves in skeletally immature patients (Risser 0-2) with a Cobb angle of 25 to 40 degrees.

Question 1089

Topic: Pediatric Upper Extremity & Spine

A 13-year-old premenarchal female with Adolescent Idiopathic Scoliosis (AIS) presents with a 32-degree right thoracic curve. Her Risser stage is 0. What is the most appropriate next step in management?

. Observation with radiographs in 6 months
. Thoracolumbosacral orthosis (TLSO) bracing
. Posterior spinal fusion
. Anterior vertebral body tethering
. Physical therapy focusing on core strengthening

Correct Answer & Explanation

. Thoracolumbosacral orthosis (TLSO) bracing

Explanation

TLSO bracing is indicated for growing children (Risser 0-2, premenarchal) with curves between 25 and 45 degrees to prevent curve progression.

Question 1090

Topic: Pediatric Upper Extremity & Spine

A 15-year-old female with AIS has a main thoracic curve of 50 degrees, a proximal thoracic curve of 20 degrees (which corrects to 10 degrees on side-bending), and a lumbar curve of 35 degrees (which corrects to 15 degrees on side-bending). According to the Lenke classification, what is her curve type?

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

Correct Answer & Explanation

. Lenke Type 1

Explanation

Lenke Type 1 curves have a structural main thoracic curve, while the proximal thoracic and lumbar curves are non-structural (bend out to <25 degrees).

Question 1091

Topic: Pediatric Upper Extremity & Spine
A 13-year-old premenarchal female with adolescent idiopathic scoliosis (AIS) presents with a right thoracic curve. Radiographs show a Cobb angle of 32 degrees and a Risser stage of 0. Which of the following is the most appropriate management, and what is the optimal duration of daily treatment to prevent curve progression?
. Observation with radiographs every 6 months
. Thoracolumbosacral orthosis (TLSO) bracing for 8-12 hours daily
. Thoracolumbosacral orthosis (TLSO) bracing for at least 18 hours daily
. Posterior spinal fusion with pedicle screw instrumentation
. Physical therapy focusing on core strengthening and Schroth exercises

Correct Answer & Explanation

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

Explanation

For a growing child (Risser 0-2) with an AIS curve between 25 and 45 degrees, bracing is the standard of care. The BRAIST study demonstrated a dose-response relationship, showing that wearing a brace for at least 18 hours a day significantly decreases the risk of curve progression to the surgical threshold.

Question 1092

Topic: 4. Pediatrics
A 6-month-old infant is diagnosed with congenital scoliosis secondary to a fully segmented hemivertebra at T8. Given the association of congenital scoliosis with other systemic anomalies, which of the following routine screening modalities is most appropriate?
. Pulmonary function tests and an abdominal CT scan
. Renal ultrasound and an echocardiogram
. Brain MRI and an electroencephalogram (EEG)
. Upper gastrointestinal series and a skeletal survey
. DEXA scan and an endocrinology consultation

Correct Answer & Explanation

. Renal ultrasound and an echocardiogram

Explanation

Congenital scoliosis is highly associated with VACTERL anomalies, particularly genitourinary and cardiovascular defects. All patients with a new diagnosis of congenital scoliosis should undergo a renal ultrasound and an echocardiogram to screen for these potentially life-threatening abnormalities.

Question 1093

Topic: Pediatric Upper Extremity & Spine

According to the Lenke Classification system for adolescent idiopathic scoliosis, which of the following criteria defines a 'structural' minor curve that must be included in the fusion construct?

. A Cobb angle greater than 40 degrees on standing radiographs
. A Cobb angle that fails to correct to less than 25 degrees on side-bending radiographs
. Apical vertebral rotation of grade II or higher on the Nash-Moe scale
. A curve with an apical vertebra above T4
. A curve associated with a thoracic kyphosis greater than 20 degrees

Correct Answer & Explanation

. A Cobb angle that fails to correct to less than 25 degrees on side-bending radiographs

Explanation

In the Lenke classification, a minor curve is considered structural (and therefore typically requires inclusion in the fusion) if it does not bend out to less than 25 degrees on supine maximum side-bending radiographs, or if there is regional kyphosis > 20 degrees.

Question 1094

Topic: 4. Pediatrics

A 19-year-old football player sustains an injury during a tackle where he is hit directly on the anterolateral aspect of his shoulder while his arm is adducted and flexed. He immediately reports severe pain and a prominent deformity at his sternoclavicular joint, with the medial clavicle appearing to be displaced posteriorly.

Based on the mechanism described, which type of sternoclavicular joint dislocation is MOST likely to have occurred?

. Anterior sternoclavicular joint dislocation
. Posterior sternoclavicular joint dislocation
. Superior sternoclavicular joint dislocation
. Inferior sternoclavicular joint dislocation
. Medial clavicular physeal fracture (Salter-Harris Type I)

Correct Answer & Explanation

. Posterior sternoclavicular joint dislocation

Explanation

Correct Answer: BThe case describes a classic mechanism for aposterior sternoclavicular joint dislocation. This typically results from an indirect force to the anterolateral shoulder, compressing the shoulder and driving the clavicle posteriorly and medially. Examples include dashboard injuries or, as in this case, a direct blow to the top of the shoulder with the arm adducted and flexed. Anterior dislocations (A) most commonly result from an indirect force to the posterolateral aspect of the shoulder, driving the clavicle anteriorly and medially (e.g., fall on an outstretched arm with the shoulder abducted and extended). Superior (C) and inferior (D) dislocations are not standard classifications. While a medial clavicular physeal fracture (E) can mimic a dislocation in skeletally immature patients, the described mechanism is a direct cause of a true posterior dislocation.

Question 1095

Topic: 4. Pediatrics

A 14-year-old male presents with a painful, prominent medial clavicle after a wrestling injury. Radiographs appear to show a posterior sternoclavicular joint dislocation. However, the orthopedic surgeon notes that in skeletally immature patients, this presentation can be misleading.

What is the MOST common underlying injury mimicking a true sternoclavicular joint dislocation in this age group?

. Acromioclavicular joint separation
. Medial clavicular physeal fracture (Salter-Harris Type I or II)
. Glenohumeral joint dislocation
. Scapular fracture
. First rib fracture

Correct Answer & Explanation

. Medial clavicular physeal fracture (Salter-Harris Type I or II)

Explanation

Correct Answer: BIn skeletally immature patients, what appears to be a sternoclavicular (SC) joint dislocation is often aSalter-Harris Type I or II epiphyseal fracture of the medial clavicle. The medial clavicular physis is the last physis to close, typically around 20-25 years of age, making it a common site of injury in adolescents. The epiphysis displaces relative to the metaphysis, mimicking a true joint dislocation. Posterior displacement of the epiphysis requires careful reduction due to the same risks as true posterior dislocations in adults. Acromioclavicular joint separation (A), glenohumeral joint dislocation (C), scapular fracture (D), and first rib fracture (E) are distinct injuries that do not typically mimic an SC joint dislocation in this specific manner.

Question 1096

Topic: 4. Pediatrics

A 16-year-old male presents with anterior sternoclavicular (SC) joint deformity after a wrestling match. Radiographs demonstrate medial clavicular swelling and apparent anterior subluxation. What is the most common actual pathology in this age group presenting with these findings?

. True anterior SC joint dislocation
. Medial clavicle physeal fracture (Salter-Harris I or II)
. Costoclavicular ligament rupture
. First rib fracture with SC joint extension
. Complete rupture of the intra-articular disc

Correct Answer & Explanation

. Medial clavicle physeal fracture (Salter-Harris I or II)

Explanation

The medial clavicle physis is the last to fuse in the human body, typically closing between ages 23 and 25. Injuries appearing as SC dislocations in adolescents and young adults are usually medial physeal fractures rather than true dislocations.

Question 1097

Topic: 4. Pediatrics

An 18-year-old male sustains a posterior medial clavicle displacement following a rugby tackle. Magnetic resonance imaging reveals that the medial epiphysis remains articulated with the sternum while the metaphysis is displaced posteriorly. In a hemodynamically stable patient with no neurovascular compromise, what is the most appropriate initial management?

. Immediate open reduction via a supraclavicular approach
. Closed reduction under procedural sedation in the emergency department
. Closed reduction in the operating room with cardiothoracic surgery backup
. Observation and sling immobilization with early physical therapy
. Resection arthroplasty of the medial clavicle

Correct Answer & Explanation

. Closed reduction in the operating room with cardiothoracic surgery backup

Explanation

This represents a Salter-Harris physeal injury, which can remodel or heal well, but given the posterior displacement and proximity to the great vessels, closed reduction must be performed in the operating room with cardiothoracic backup.

Question 1098

Topic: 4. Pediatrics

Which of the following statements regarding the normal anatomy and development of the sternoclavicular (SC) joint is accurate?

. It functions primarily as a rigid hinge joint
. An intra-articular fibrocartilaginous disc separates the joint into two distinct compartments
. The anterior capsule provides the primary resistance to superior clavicular displacement
. The SC joint undergoes roughly 10 degrees of elevation during full shoulder abduction
. The medial clavicle physis is typically the first secondary ossification center to close in the body

Correct Answer & Explanation

. An intra-articular fibrocartilaginous disc separates the joint into two distinct compartments

Explanation

The SC joint is a diarthrodial saddle joint containing an intra-articular fibrocartilaginous disc. This disc completely divides the joint into two separate synovial compartments and helps prevent medial displacement of the clavicle.

Question 1099

Topic: 4. Pediatrics

A 16-year-old male presents to the emergency department with severe pain and a posterior deformity at the medial aspect of his clavicle after a direct blow during a football game. Imaging suggests a posterior displacement of the medial clavicle. What is the most likely true anatomical nature of this injury?

. Pure sternoclavicular joint dislocation
. Salter-Harris type I or II fracture of the medial clavicle
. Complete rupture of the costoclavicular ligament
. Plastic deformation of the clavicular shaft
. Sternal fracture with posterior displacement

Correct Answer & Explanation

. Salter-Harris type I or II fracture of the medial clavicle

Explanation

The medial clavicular epiphysis is the last physis in the body to fuse, typically closing between 22 and 25 years of age. Therefore, what appears clinically and radiographically as a sternoclavicular dislocation in patients under 25 is most commonly a physeal fracture.

Question 1100

Topic: 4. Pediatrics

A 16-year-old male presents with acute shortness of breath, dysphagia, and right medial clavicle pain after being tackled. There is a palpable void at the medial clavicle. What is the most appropriate next step in management?

. Immediate closed reduction in the emergency department
. Application of a figure-of-eight brace
. Computed tomography (CT) scan of the chest and clavicle
. Magnetic resonance imaging (MRI) of the brachial plexus
. Sling immobilization and outpatient orthopedic follow-up

Correct Answer & Explanation

. Computed tomography (CT) scan of the chest and clavicle

Explanation

Symptoms of dysphagia and dyspnea indicate mediastinal compression, highly suspicious for a posterior sternoclavicular dislocation or medial physeal fracture. A CT chest is mandatory to assess the position of the clavicle relative to the great vessels and trachea before any reduction attempt.

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