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4. Pediatrics MCQs

Practice Set 70 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 1381

Topic: 4. Pediatrics

A 5-year-old boy presents with a completely displaced, extension-type supracondylar humerus fracture. The hand is pulseless and pale on presentation. Following closed reduction and percutaneous pinning, the hand becomes warm and pink with a capillary refill time of less than 2 seconds; however, the radial pulse remains unpalpable. What is the most appropriate next step in management?

. Immediate exploration of the brachial artery
. Observation and hospital admission for close clinical monitoring
. CT angiography of the upper extremity
. Removal of the pins and transition to open reduction
. Prophylactic volar forearm fasciotomy

Correct Answer & Explanation

. Observation and hospital admission for close clinical monitoring

Explanation

In a pulseless but well-perfused (pink) hand following reduction and stabilization of a pediatric supracondylar humerus fracture, immediate vascular exploration is not indicated. The correct management is hospital admission and close clinical monitoring, as collateral circulation is providing adequate perfusion.

Question 1382

Topic: Pediatric Upper Extremity & Spine
A 4-year-old girl falls from monkey bars. Radiographs of the elbow reveal a fracture of the distal humerus. The anterior humeral line passes completely anterior to the capitellum, indicating posterior displacement of the distal fragment, but the posterior cortex remains intact, functioning as a hinge. What is the correct Gartland classification for this fracture?
. Gartland Type I
. Gartland Type II
. Gartland Type III
. Gartland Type IV
. Milch Type II

Correct Answer & Explanation

. Gartland Type II

Explanation

The Gartland classification describes pediatric extension-type supracondylar humerus fractures. A Type II fracture is displaced (evidenced by the anterior humeral line passing anterior to the capitellum) but maintains an intact posterior cortical hinge.

Question 1383

Topic: Pediatric Upper Extremity & Spine
During intraoperative fluoroscopic evaluation of a reduced Gartland Type III supracondylar humerus fracture, the surgeon measures Baumann's angle on the anteroposterior (AP) view. What post-traumatic deformity is this measurement primarily designed to assess and prevent?
. Cubitus valgus
. Cubitus varus
. Recurvatum deformity
. Flexion contracture
. Pronation deformity

Correct Answer & Explanation

. Cubitus varus

Explanation

Baumann's angle (the angle between the longitudinal axis of the humerus and the physeal line of the capitellum) is critical for assessing coronal plane alignment. Failure to restore an appropriate Baumann's angle frequently results in a cubitus varus (gunstock) deformity.

Question 1384

Topic: 4. Pediatrics

A 6-year-old girl falls on an outstretched hand and sustains an extension-type supracondylar humerus fracture. Upon initial presentation, her hand is pink but pulseless. After closed reduction and percutaneous pinning in the operating room, her hand remains pink and well-perfused, but the radial pulse remains unpalpable. What is the most appropriate next step in management?

. Immediate open exploration of the brachial artery
. Observation and continuous pulse oximetry monitoring
. Removal of pins, extension of the elbow, and re-reduction
. Prophylactic volar fasciotomies of the forearm
. Emergent CT angiography of the upper extremity

Correct Answer & Explanation

. Observation and continuous pulse oximetry monitoring

Explanation

A pink, pulseless hand after adequate reduction and pinning of a pediatric supracondylar humerus fracture is generally well-perfused through collateral circulation. The standard of care is close observation with pulse oximetry for 24-48 hours; open exploration is only indicated if the hand becomes white and ischemic.

Question 1385

Topic: Pediatric Hip

A 28-year-old patient with a history of Slipped Capital Femoral Epiphysis (SCFE) requires a precise assessment of proximal femoral deformity for surgical planning. The surgeon needs a true lateral view of the femoral neck, perpendicular to its axis. Which of the following radiographic techniques, as described in Paley's principles, is the gold standard for this evaluation?

. A standard frog-leg lateral view with maximal hip external rotation.
. A full-length standing AP radiograph with the patella-forward rule applied.
. The Sugioka view, with the hip flexed 90 degrees and abducted approximately 45 degrees.
. A cross-table lateral view with the unaffected hip flexed to 90 degrees.
. A CT scan with 3D reconstruction for rotational analysis.

Correct Answer & Explanation

. The Sugioka view, with the hip flexed 90 degrees and abducted approximately 45 degrees.

Explanation

Correct Answer: CThe text explicitly states that 'The Sugioka view is an elegant, highly effective technique designed to achieve this true lateral projection' of the femoral neck. It describes the technique as placing the patient supine, flexing the affected hip to exactly 90 degrees, and then abducting approximately 45 degrees, followed by a standard AP radiograph. This maneuver places the femoral neck in a perfectly horizontal position relative to the x-ray beam, providing a crystal-clear Sugioka view, making it the gold standard for evaluating conditions like SCFE.Option A is incorrectbecause the text states that a standard 'frog-leg' lateral is 'highly variable and inadequate for precise, mathematical surgical planning' for proximal femoral deformities.Option B is incorrectbecause a full-length standing AP radiograph is for global lower limb alignment in the frontal plane, not for a true lateral view of the proximal femur.Option D is incorrectbecause a cross-table lateral is typically used for trauma or when the patient cannot move, and while it provides a lateral view, it does not achieve the precise perpendicularity to the femoral neck axis that the Sugioka view does for deformity analysis.Option E is incorrectbecause while CT scans can provide excellent 3D information, the question asks for the radiographic technique described in Paley's principles for a true lateral view of the femoral neck, which is the Sugioka view. The text focuses on radiographic methods.

Question 1386

Topic: Pediatric Hip

A 14-year-old male presents with a chronic, stable Slipped Capital Femoral Epiphysis (SCFE) and a measured Neck Shaft Angle (NSA) of 120 degrees on his initial AP hip radiograph (indicating coxa vara). The orthopedic surgeon plans to obtain a Sugioka view for precise preoperative planning. To achieve a true lateral projection of the femoral neck, what adjustment to the standard Sugioka positioning is required for this patient?

. The hip should be flexed to 90 degrees and abducted approximately 30 degrees.
. The hip should be flexed to 90 degrees and abducted approximately 45 degrees.
. The hip should be flexed to 90 degrees and abducted approximately 60 degrees.
. The hip should be flexed to 45 degrees and abducted approximately 45 degrees.
. The hip should be extended to 0 degrees and abducted approximately 45 degrees.

Correct Answer & Explanation

. The hip should be flexed to 90 degrees and abducted approximately 60 degrees.

Explanation

Correct Answer: CThe text provides specific guidance for adjusting the Sugioka view based on the Neck Shaft Angle (NSA). It states: 'The degree of abduction must be dynamically adjusted based on the patient's specific Neck Shaft Angle (NSA) measured on the initial AP view: Normal NSA (135°): Requires 45° of abduction. Coxa Valga (e.g., NSA 150°): Requires less abduction (e.g., 30°). Coxa Vara (e.g., NSA 120°): Requires more abduction (e.g., 60°).' Since the patient has a Coxa Vara with an NSA of 120 degrees, the hip should be flexed to 90 degrees and abducted approximately 60 degrees to achieve the true lateral projection of the femoral neck.Option A is incorrectas 30 degrees of abduction is indicated for coxa valga (e.g., NSA 150°), not coxa vara.Option B is incorrectas 45 degrees of abduction is indicated for a normal NSA of 135 degrees.Options D and E are incorrectbecause the Sugioka view requires the hip to be flexed to exactly 90 degrees, not 45 degrees or 0 degrees extension, to move the femoral neck's orientation into the transverse plane.

Question 1387

Topic: Pediatric Hip

A 14-year-old male presents with a suspected slipped capital femoral epiphysis (SCFE). To accurately assess the deformity between the femoral head and neck, a true lateral view of the femoral neck is crucial. The surgeon decides to use the Sugioka method for this specific radiographic projection, as depicted in the image. Which of the following describes the correct patient positioning for obtaining this view?

. The hip is extended 90° and abducted 45°.
. The hip is flexed 90° and adducted 45°.
. The hip is flexed 90° and abducted 45°.
. The hip is in 0° flexion/extension with the X-ray tube inclined 45° to the horizontal.
. The hip is internally rotated to neutralize femoral neck version, and an AP view is obtained.

Correct Answer & Explanation

. The hip is flexed 90° and abducted 45°.

Explanation

Correct Answer: CThe text explicitly describes the Sugioka method: 'The other method with which to obtain a true LAT view of the femoral neck is to flex the hip 90° and abduct the thigh 45°. This positions the femoral neck in the frontal plane. An AP view radiograph obtained with the patient in this position provides the true LAT view of the femoral neck, known as the Sugioka method (1978).' The image also visually represents this position.Option A is incorrectbecause the hip should be flexed, not extended.Option B is incorrectbecause the hip should be abducted, not adducted.Option D is incorrectbecause this describes an alternative method for obtaining a true lateral view of the femoral neck (with the tube inclined), not the Sugioka method, which involves specific patient positioning.Option E is incorrectbecause internally rotating the hip to neutralize version and obtaining an AP view provides a true AP view of the femoral neck and head, not a true lateral view.

Question 1388

Topic: 4. Pediatrics

A 12-year-old girl with adolescent Blount's disease undergoes evaluation for deformity correction. What is the classic triplanar deformity observed in the proximal tibia of patients with Blount's disease?

. Varus, recurvatum, and internal tibial torsion
. Varus, procurvatum, and internal tibial torsion
. Valgus, procurvatum, and external tibial torsion
. Valgus, recurvatum, and internal tibial torsion
. Varus, procurvatum, and external tibial torsion

Correct Answer & Explanation

. Varus, procurvatum, and internal tibial torsion

Explanation

Blount's disease involves a growth disturbance of the medial posterior proximal tibial physis. This typically results in a complex 3D deformity characterized by varus, procurvatum (flexion deformity of the proximal tibia), and internal tibial torsion.

Question 1389

Topic: 4. Pediatrics

A 5-year-old girl is evaluated for a congenital short femur, presenting with a 3 cm limb length discrepancy. Her parents ask about the expected discrepancy when she finishes growing. Using the Paley multiplier method with a standard multiplier of 2.0 for her age and gender, what is her projected limb length discrepancy at maturity?

. 3 cm
. 4.5 cm
. 6 cm
. 7.5 cm
. 9 cm

Correct Answer & Explanation

. 6 cm

Explanation

The multiplier method predicts limb length discrepancy at skeletal maturity by multiplying the current discrepancy by a calculated age- and sex-specific multiplier. For a current discrepancy of 3 cm and a multiplier of 2.0, the projected discrepancy at maturity is 6 cm.

Question 1390

Topic: 4. Pediatrics

A patient presents with a severe midshaft tibial deformity secondary to trauma. On the AP radiograph, a pure step-off translation of the diaphysis is observed without any angular deformity. According to Paley's principles, where is the Center of Rotation of Angulation (CORA) located in this specific scenario?

. At the exact center of the diaphyseal step-off
. At the nearest adjacent joint line
. At the metaphyseal-diaphyseal junction
. At infinity
. At the center of the proximal tibial physis

Correct Answer & Explanation

. At infinity

Explanation

In a pure translation deformity with no angulation, the proximal and distal anatomical axes are perfectly parallel and do not intersect on the film. Therefore, the CORA is considered to be located at infinity.

Question 1391

Topic: 4. Pediatrics

A 6-year-old child with progressive, pathologic genu varum is scheduled for guided growth using a tension band plate (eight-Plate). To achieve angular correction, where should the plate be properly positioned relative to the deformity?

. Medial side spanning the physis
. Lateral side spanning the physis
. Anterior side spanning the physis
. Posterior side spanning the physis
. Central physeal transfixation

Correct Answer & Explanation

. Lateral side spanning the physis

Explanation

In genu varum (bow legs), the mechanical axis falls medially. Guided growth dictates tethering the convex (lateral) side of the deformity. Placing the plate laterally restricts lateral physeal growth, allowing the medial side to catch up and correct the varus.

Question 1392

Topic: 4. Pediatrics

Paley's multiplier method is often utilized to predict limb length discrepancy at maturity. Which of the following statements is true regarding this method?

. It relies heavily on bone age rather than chronological age in all patients.
. The multiplier for a specific age is the exact same for both boys and girls.
. It predicts the ultimate discrepancy by multiplying the current discrepancy by a specific age- and gender-based factor.
. It is only valid for congenital deformities, not developmental ones.
. It is significantly less accurate than the Moseley straight-line graph.

Correct Answer & Explanation

. It predicts the ultimate discrepancy by multiplying the current discrepancy by a specific age- and gender-based factor.

Explanation

The multiplier method calculates the limb length discrepancy at skeletal maturity by multiplying the current discrepancy by an established multiplier based on the child's chronological age and gender.

Question 1393

Topic: 4. Pediatrics

In constructing an Ilizarov circular frame, which of the following mechanical adjustments is most effective for increasing the axial stiffness of the frame construct?

. Decreasing tension on the transverse wires
. Using smaller diameter rings to decrease the distance between the ring and the bone
. Decreasing the crossing angle of the wires to 30 degrees
. Placing the rings farther apart along the diaphysis
. Using a single wire per ring

Correct Answer & Explanation

. Using smaller diameter rings to decrease the distance between the ring and the bone

Explanation

Frame stability and axial stiffness are significantly increased by using smaller diameter rings. This minimizes the unsupported span of the tensioned wires between the bone and the ring.

Question 1394

Topic: 4. Pediatrics

A 4-year-old child with severe infantile Blount's disease undergoes a proximal tibial osteotomy. The deformity involves varus, internal tibial torsion, and procurvatum. Which osteotomy level is most appropriate to correct all deformities while minimizing secondary translation?

. Distal tibial metaphysis
. Mid-diaphysis of the tibia
. Distal to the tibial tubercle
. Through the proximal tibial physis
. In the proximal metaphysis, as close to the physis (CORA) as safely possible

Correct Answer & Explanation

. In the proximal metaphysis, as close to the physis (CORA) as safely possible

Explanation

The CORA in Blount's disease is located near the joint line at the medial physis. To minimize translation, the osteotomy should be placed as close to the CORA as safely possible, typically in the proximal metaphysis.

Question 1395

Topic: 4. Pediatrics

A 16-year-old male presents with a 'squinting patella' on a routine standing AP knee radiograph, as illustrated in figure (a) of the diagram. Based on the case, what is the most likely underlying issue and the implication for radiographic interpretation?

. A. The patient has severe patellofemoral instability, and the radiograph accurately depicts the subluxation.
. B. The patient likely has external tibial torsion, and the radiograph provides a true AP view of the knee.
. C. The patient was positioned with feet forward despite underlying internal tibial torsion, leading to a false radiographic image.
. D. The patient has a congenital absence of the patella, and the 'squinting' appearance is an artifact.
. E. The radiograph was taken with the knee in excessive flexion, obscuring the true patellar position.

Correct Answer & Explanation

. C. The patient was positioned with feet forward despite underlying internal tibial torsion, leading to a false radiographic image.

Explanation

Correct Answer: CThe text directly addresses this: "In figure (a), a patient with internal tibial torsion is positioned with their feet forward. This forces the knee into internal rotation, creating a 'squinting patella' and a false radiographic image." The 'squinting patella' is a direct sign of incorrect positioning in the presence of torsion, specifically internal tibial torsion when the foot is forced forward.Incorrect Options:A. The patient has severe patellofemoral instability, and the radiograph accurately depicts the subluxation:While patellofememoral instability can cause patellar maltracking, the 'squinting patella' in this context is specifically described as an artifact of incorrectpositioningfor a true AP view, not necessarily an accurate depiction of instability.B. The patient likely has external tibial torsion, and the radiograph provides a true AP view of the knee:External tibial torsion would typically cause the patella to face outward if the foot is forced forward, or the foot to point outward if the patella is correctly oriented. A 'squinting patella' (often implying internal rotation of the knee) is more characteristic of internal tibial torsion with feet-forward positioning. The radiograph is explicitly stated to be a 'false radiographic image'.D. The patient has a congenital absence of the patella, and the 'squinting' appearance is an artifact:This is a rare condition and not the explanation provided in the text for a 'squinting patella' in the context of positioning errors.E. The radiograph was taken with the knee in excessive flexion, obscuring the true patellar position:A standing AP radiograph for deformity analysis is typically taken in extension. While flexion can obscure views, the 'squinting patella' is specifically linked to rotational positioning errors in the AP view.

Question 1396

Topic: Pediatric Lower Extremity

A 28-year-old with Blount's disease sequelae has a complex proximal tibial deformity. When utilizing a hexapod external fixator, the software requires the identification of the "origin" and "corresponding point". These points fundamentally rely on defining which of the following?

. The anatomic axis of the femur
. The mechanical axis deviation
. The center of rotation of angulation (CORA)
. The joint line convergence angle
. The Paley multiplier

Correct Answer & Explanation

. The center of rotation of angulation (CORA)

Explanation

In 6-axis deformity correction systems, mounting parameters and deformity parameters must relate the rings to the bone segments and accurately locate the CORA for ideal correction.

Question 1397

Topic: 4. Pediatrics
A 10-year-old girl with a monoarticular pattern of juvenile rheumatoid arthritis (JRA) has had a 3-cm limb-length discrepancy since age 8 years when inflammation in the right knee came under good medical control. Because her right leg is longer, the patient states that she would like her legs to be close to equal in length in the future. A growth-remaining chart is shown in Figure 14. Management should consist of
. immediate proximal right tibial physeal arrest.
. immediate distal right femoral physeal arrest.
. a shoe lift and follow-up in 2 years.
. observation with the expectation that the discrepancy may correct itself and not require surgery.
. limb lengthening of the shorter left limb.

Correct Answer & Explanation

. observation with the expectation that the discrepancy may correct itself and not require surgery.

Explanation

DISCUSSION: In a subgroup of patients with monoarticular JRA and a limb-length discrepancy that developed before the age of 9 years, Simon and associates showed that a subsequent growth deceleration on the affected side may correct a large part of the difference in length. This possibility would make surgery unnecessary and should prompt further observation. REFERENCES: Simon S, Whiffen J, Shapiro F: Leg-length discrepancies in monoarticular and pauciarticular juvenile rheumatoid arthritis. J Bone Joint Surg Am 1981;63:209-215. Ansell BM, Bywaters EGL: Growth in Still’s disease. Ann Rheum Dis 1956;15:295-319.

Question 1398

Topic: 4. Pediatrics
A 12-year-old girl who plays softball has chronic lateral hindfoot aching pain that is aggravated by weight-bearing activity. She reports that the pain has recurred after initial improvement with cast immobilization, and it continues to limit her overall level of activity. Radiographs are seen in Figures 40a through 40c. What is the most appropriate surgical treatment?
. Correction of the flatfoot deformity
. Achilles tendon lengthening followed by orthotic support
. Excision of the tarsal coalition
. Sinus tarsi debridement
. Triple arthrodesis

Correct Answer & Explanation

. Excision of the tarsal coalition

Explanation

The patient has a calcaneonavicular tarsal coalition. Symptoms of calcaneonavicular coalitions typically are seen between the ages of 10 and 14 years. The cause of pain has not been clearly established. It has been postulated that the coalition stiffens with maturity and microfractures can result, producing pain. Resection of a calcaneonavicular coalition generally has been associated with a satisfactory result. Soft-tissue interposition, most commonly using the extensor digitorum brevis muscle, appears to be helpful. A hindfoot arthrodesis (usually triple) would be reserved if coalition resection proves to be unsuccessful. Achilles tendon lengthening and orthotic support, as well as debridement of the sinus tarsi, are not expected to result in a satisfactory outcome. The patient does not have a flatfoot deformity.

Question 1399

Topic: 4. Pediatrics
A 12-month-old boy has right congenital fibular intercalary hemimelia with a normal contralateral limb. A radiograph of the lower extremities shows a limb-length discrepancy of 2 cm. All of the shortening is in the right tibia. Assuming that no treatment is rendered prior to skeletal maturity, the limb-length discrepancy will most likely
. remain 2 cm at maturity.
. decrease slowly until the limb lengths equalize.
. increase at a constant rate of 2 cm per year.
. increase markedly because of complete failure of tibial growth.
. increase slowly, with the right lower extremity remaining in proportion to the left lower extremity.

Correct Answer & Explanation

. increase slowly, with the right lower extremity remaining in proportion to the left lower extremity.

Explanation

DISCUSSION: Many congenital limb deficiencies and bowing deformities result in growth retardation. If unilateral, a gradually progressive limb-length discrepancy will result; however, the proportional lengths of the lower extremities will remain at a relatively constant ratio. For example, if the right foot is at the level of the left knee at birth, this will still be true at maturity. This concept can be useful for early prediction of limb-length discrepancy by using a “multiplier method,” as described by Paley and associates. This method can facilitate early treatment decisions, such as the need for amputation, without having to wait for serial scanography measurements. REFERENCES: Paley D, Bhave A, Herzenberg JE, et al: Multiplier method for predicting limb-length discrepancy. J Bone Joint Surg Am 2000;82:1432-1446. Moseley CF: A straight-line graph for leg length discrepancies. Clin Orthop 1978;136:33-40.

Question 1400

Topic: 4. Pediatrics

A 3-year-old female presents with infantile Blount disease (Langenskiold Stage II). She has been compliant with full-time use of a Knee-Ankle-Foot Orthosis (KAFO) for 1 year, but her clinical and radiographic varus deformity has progressively worsened. What is the most appropriate next step in management?

. Continue full-time KAFO bracing until age 5
. Medial hemi-epiphysiodesis of the proximal tibia
. Proximal tibial and fibular valgus-producing osteotomy
. Resection of the medial physeal bar with fat interposition
. Lateral distal femoral opening wedge osteotomy

Correct Answer & Explanation

. Proximal tibial and fibular valgus-producing osteotomy

Explanation

For infantile Blount disease, bracing is generally attempted in children under age 3 with early-stage disease (Langenskiold I-II). If bracing fails and the deformity progresses, surgical intervention is indicated before age 4 to prevent permanent physeal damage. The standard procedure is a proximal tibial and fibular valgus-producing osteotomy (often with slight overcorrection). Physeal bar resection is reserved for older children with confirmed physeal bridging (Stage IV-VI).

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