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4. Pediatrics MCQs

Practice Set 73 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 1441

Topic: Pediatric Hip
Figure 54 shows the preoperative radiograph of a 45-year-old woman who is considering total hip arthroplasty with her orthopaedic surgeon. What femoral characteristic is a typical concern in this patient?
. Osteopenia
. Excessive anteversion
. Excessive varus
. Excessive bowing
. Stove-pipe femur

Correct Answer & Explanation

. Excessive anteversion

Explanation

Developmental dysplasia of the hip (DDH) leads to early arthritis of the hip as seen in this patient. Although DDH is believed to mostly affect the acetabulum, most patients with DDH also have anatomic aberrations of the femur. Using three-dimensional computer models generated by reconstruction of CT scans, dysplastic femurs were shown to have shorter necks and smaller, straighter canals than the controls. The shape of the canal became more abnormal with increasing subluxation. The studies also have shown that the primary deformity of the dysplastic femur is rotational, with an increase in anteversion of 5 degrees to 16 degrees, depending on the degree of subluxation of the hip. The rotational deformity of the dysplastic femur arises within the diaphysis between the lesser trochanter and the isthmus and is not attributable to a torsional deformity of the metaphysis. Osteopenia is not a concern in a patient with an excellent cortical index (thick cortices and narrow canal). Femoral varus or bowing of the femur is not a typical finding in patients with DDH.

Question 1442

Topic: 4. Pediatrics
A child presents with the radiograph shown in Figure A. Which of the following conditions is LEAST likely to be associated with this disorder?
. Unilateral absent kidney
. Sever's disease
. Ventricular septal defect
. Tethered cord
. Thumb hypoplasia

Correct Answer & Explanation

. Sever's disease

Explanation

Sever's disease (calcaneal apophysitis) is not associated with congenital scoliosis. Congenital scoliosis is associated with other anomalies 60% of the time. These anomalies can appear independently, or as part of the VACTERL syndrome (vertebral anomalies, anorectal atresia, tracheoesophageal fistula, and renal and vascular anomalies). Other associated orthopedic conditions include clubfoot, developmental dysplasia of the hip, limb hypoplasia, Sprengel’s deformity, Klippel-Feil syndrome, foot asymmetry, vertical tali, leg atrophy and pes cavus.

Question 1443

Topic: 4. Pediatrics
What is the most common problem seen following epiphysiodesis for limb-length discrepancy?
. Fracture through the site of the physeal resection
. Direct neurovascular injury
. Incomplete growth arrest from inadequate physeal excision
. Persistent discrepancy from an error in the timing of the surgery
. Cartilaginous injury because of inadvertent joint penetration

Correct Answer & Explanation

. Persistent discrepancy from an error in the timing of the surgery

Explanation

Errors in timing are by far the most common in this technically safe procedure. Incomplete growth arrest has been reported in up to 15% of patients versus timing errors in 61%. Fracture through the site has been reported rarely. Neurovascular and cartilaginous injury are extremely uncommon but always need to be considered when performing surgery in the vicinity of these structures.

Question 1444

Topic: 4. Pediatrics
Figures 36a and 36b show the radiographs of a 3-year-old child who has a congenital upper extremity deformity. Which of the following features would be a major contraindication to a centralization procedure?
. Complete absence of the thumb
. Thrombocytopenia
. Patient age of less than 5 years
. Lack of elbow motion
. Absence of the radial artery

Correct Answer & Explanation

. Lack of elbow motion

Explanation

The patient has bilateral absent radii or radial clubhand. Patients who lack elbow flexion take advantage of the hand position to reach their mouths, and a centralization procedure would take away that ability.

Question 1445

Topic: 4. Pediatrics
  • A 7-year old boy has a painless abductor limp and limited hip abduction. Radiographs show varus of the proximal femur, with a narrow upper femoral epiphysis that has the shape of an inverted "Y". Which of the following factors best predicts the risk that the deformity will become worse?
. Length of the femoral neck
. Retroversion of the upper femur
. Size of the proximal femoral epiphysis
. Size of the greater trochanteric apophysis
. Angle between the proximal femoral physis and Hilgenreiner's line

Correct Answer & Explanation

. Length of the femoral neck

Explanation

Hoffa in 1905 recognized a disturbance in the epiphyses as the cause of coxa vara deformity. The slip occurs on the metaphyseal side of the epiphyseal plate, breaking away from the plate at its distal end to separate off a flake (triangular fragment) of metaphysis (the inverted 'Y'). H-E angles >60 degrees, progression was documented (thought to be the result of increased bending moment or shear stress across the vertical defect

Question 1446

Topic: 4. Pediatrics
A 7-year-old boy with spastic diplegia is a limited community ambulator. He has a moderately severe crouched gait. The parents request a treatment that will result in a permanent decrease in lower extremity muscle tone. This is best accomplished with
. tone-reduction ankle-foot orthoses (AFOs).
. intramuscular injections of botulinum-A toxin.
. an intrathecal baclofen injection.
. selective posterior rhizotomy.
. fractional tendon lengthening of bilateral hamstring and gastrocnemius muscles.

Correct Answer & Explanation

. selective posterior rhizotomy.

Explanation

DISCUSSION: Posterior rhizotomy provides a permanent reduction in tone of spastic muscles. Potential drawbacks of the procedure include excessive muscle weakness, hip dislocation, and spinal deformity. Intramuscular botulinum-A toxin results in temporary blockade of presynaptic release of acetylcholine across the neuromuscular junction; the clinical effect usually resolves after 3 to 6 months due to neural regeneration. Tone-reduction AFOs have not been shown to reduce tone. A baclofen pump could offer prolonged reduction in tone, but not a single intrathecal injection.

Question 1447

Topic: 4. Pediatrics

The newborn foot deformity seen in Figures 64a and 64b should initially treated with Review Topic

. observation with possible stretching.
. serial casting.
. medial surgical release.
. posterior medial surgical release.
. dynamic ankle-foot orthosis.

Correct Answer & Explanation

. observation with possible stretching.

Explanation

Mild to moderate metatarsus adductus is best treated with observation and possible passive stretching exercises because most of these feet will self correct. Numerous types of shoes, braces, and splints have been devised but the efficacy of these have not been determined. Serial casting is reserved for severe metatarsus adductus in the infant, although a medial surgical release may be indicated if the deformity is symptomatic and persists beyond age 4 years.

Question 1448

Topic: 4. Pediatrics
The parents of a 3-year-old girl who has had pain and swelling in the right ankle for the past 3 months now report that she has a limp and that the right knee and both ankles are painful and swollen. The limp and difficulty walking are most severe in the morning when the child first gets out of bed and are also more severe after extended walking. The parents deny fever, chills, weight loss, or night pain. Examination shows mild swelling and slightly restricted motion of the right knee and both ankles but is otherwise normal. In addition to initiation of treatment, the child should be referred to which of the following specialists?
. Neurosurgeon
. Ophthalmologist
. Oncologist
. Otolaryngologist
. Urologist

Correct Answer & Explanation

. Ophthalmologist

Explanation

Pauciarticular juvenile rheumatoid arthritis (JRA) is the most common subgroup of JRA. It typically presents between the ages of 2 to 4 years with mild swelling of one to four joints. Girls are affected four times more often than boys. The ankle and knee are commonly involved, and limping is typically worse in the morning and after extended activity. The diagnosis of pauciarticular JRA is typically one of exclusion. Pauciarticular JRA has the highest incidence of chronic uveitis, and in the subgroup with elevated antinuclear antibody (ANA) titers, the incidence is 75%. In JRA, uveitis usually occurs after the onset of synovitis but may precede the joint symptoms. At the early stage of uveitis, the patient is asymptomatic. If the eye condition is not detected and treated, progressive loss of vision may occur.

Question 1449

Topic: Pediatric Hip
Figure 26 shows the radiograph of an otherwise healthy Caucasian 5-year-old boy who has a painless limp. What is the best treatment option?
. Shelf procedure
. Salter osteotomy
. Chiari osteotomy
. Varus derotation osteotomy
. Physical therapy and range-of-motion exercises

Correct Answer & Explanation

. Physical therapy and range-of-motion exercises

Explanation

The prognosis of Legg-Calve-Perthes disease in children younger than age 6 years is good. There is no indication that surgical treatment will improve the outcome. Range-of-motion exercises to prevent contracture may be helpful.

Question 1450

Topic: 4. Pediatrics
A 4-year-old child sustains a spiral fracture to the tibia in an unwitnessed fall. History reveals three other fractures to long bones, and the parents are vague about the etiology of each. There is no family history of bone disease. The parents ask if the child has osteogenesis imperfecta (OI); however, there are no clinical or radiographic indications of this diagnosis. In addition to fracture care, management should include
. notification of child protective services and hospital admission.
. a punch biopsy of skin for collagen analysis.
. DNA testing for OI.
. calcium, phosphate, and alkaline phosphatase studies.
. placement of intramedullary rods to prevent further fractures.

Correct Answer & Explanation

. notification of child protective services and hospital admission.

Explanation

Child abuse and OI are frequently both in the differential diagnosis of a child with multiple fractures. If OI is suspected, testing is appropriate to confirm this diagnosis. This may include skull radiographs to look for wormian bones and/or fibroblast culturing and collagen analysis of a punch biopsy. Unfortunately, because of the large number of mutations that can yield the disease, DNA testing is not commercially available for OI. In this patient, however, the physician suspects nonaccidental trauma and is legally obligated in most states to notify child protective services. Because the child may be at considerable risk of further injury, hospitalization is indicated to protect the child until child protective services can complete a home investigation and assess the degree of risk. Work-up for both OI and child abuse can be done during the hospitalization.

Question 1451

Topic: 4. Pediatrics
What is the most common foot deformity associated with myelomeningocele?
. Talipes equinovarus
. Congenital vertical talus
. Calcaneus valgus
. Calcaneus varus
. Cavus

Correct Answer & Explanation

. Talipes equinovarus

Explanation

All of the above can be associated with myelomeningocele, but talipes equinovarus occurs in 50% to 90% of patients with myelomeningocele. Congenital vertical talus is rarely associated with any neuromuscular diseases other than myelomeningocele but is not the most common deformity in myelomeningocele.

Question 1452

Topic: 4. Pediatrics

Which of the following conditions is most commonly associated with the congenital hand problem shown in Figure 33?

. Clubfeet
. Thrombocytopenia
. Congenital scoliosis
. Ventricular septal defect
. Arnold-Chiari malformation

Correct Answer & Explanation

. Clubfeet

Explanation

The condition shown in the figure is congenital constriction band syndrome. The probable causes of the syndrome are hemorrhages and necrosis in mesenchymal tissues caused by exogenous agents after the condensation of the digital rays. Patients have been grouped by Patterson in the following clinical types; simple ring constrictions, ring constrictions accompanied by fusion of the distal parts with or without lymphedema, ring constrictions accompanied by fusion of the distal parts ranging from fenestrated or terminal syndactyly, and intrauterine amputation. Congenital constriction band syndrome is an uncommon disorder that can present with many clinical features including constriction bands, intrauterine amputations, syndactyly, acrosyndactyly, caraniofacial defects such as cleft lip and palate, visceral anomalies from truncal bands, and fetal death. Clubfoot is a frequently associated anomaly.

Question 1453

Topic: 4. Pediatrics

A displaced pediatric supracondylar humerus fracture is treated with closed manipulation and placement of 2 Kirschner wires placed from the lateral side. What would be the effect of adding a third pin from the lateral side? Review Topic

. Increase risk for iatrogenic ulnar nerve injury
. Provide more construct stiffness than adding a medial pin
. Improve construct stiffness in the presence of medial column comminution
. Will not affect construct stiffness in the presence of residual distal fragment internal rotation

Correct Answer & Explanation

. Increase risk for iatrogenic ulnar nerve injury

Explanation

Multiple biomechanical studies have shown that the addition of a third pin from the lateral side improves construct stiffness in the presence of medial column loss or slight internal rotation of the distal fragment. The same studies show that addition of a medial pin (cross pinning) has essentially the same benefit. Placement of a medial pin increases risk for iatrogenic nerve injury.

Question 1454

Topic: 4. Pediatrics
A 2-year-old girl was born with the toe deformity shown in Figure 2. She has difficulty wearing shoes despite having adequate room in the toe box. Management at this time should consist of
. stretching exercises, followed by taping of the toes in a derotational maneuver.
. lengthening of the extensor digitorum longus tendon of the second toe and release of the metatarsophalangeal joint dorsal capsule.
. resection arthroplasty of the proximal interphalangeal joint of the third toe, with release of the volar plate.
. tenotomy of the flexor digitorum longus and brevis of the third toe.
. a Girdlestone-Taylor transfer of the flexor digitorum longus to the extensor digitorum longus of the third toe.

Correct Answer & Explanation

. tenotomy of the flexor digitorum longus and brevis of the third toe.

Explanation

DISCUSSION: The patient has a congenital curly toe deformity of the third toe, and tenotomy of the toe flexors is highly effective for this problem. Stretching and taping are ineffective for this deformity. The position of the second toe is secondary; therefore, procedures on that toe are unnecessary and ineffective. The flexor to extensor transfer is a more complicated procedure that produces negligible results, or may even worsen the deformity. Resection arthroplasty is contraindicated because it causes abnormal growth of the toes.

Question 1455

Topic: Pediatric Lower Extremity
A 5-year-old boy has had midfoot pain with activity for the past 3 months. He has no pain at rest. Radiographs are shown in Figures 29a and 29b. Management should consist of
. a vascularized pedicle bone graft.
. a short leg walking cast.
. a custom-molded orthotic.
. surgical debridement followed by antibiotics.
. a bone stimulator.

Correct Answer & Explanation

. a short leg walking cast.

Explanation

DISCUSSION: The radiographs show classic findings for Koehler’s disease (osteochondrosis of the navicular). The patient’s age and clinical history are typical for this self-limiting condition. Patients will improve with time, but the duration of symptoms is much shorter if the patient is placed in a cast. There is no role for surgery in this disease.

Question 1456

Topic: 4. Pediatrics

Figures 177a and 177b are the radiographs of a 7-year-old boy with spastic cerebral palsy. He has quadriparetic involvement and is unable to ambulate. He has very limited abduction, 30 degrees of flexion contractures, and pain on abduction. Bilateral varus osteotomies are scheduled with acetabular procedures to improve stability. Which type of acetabular osteotomy should be performed?

. Dega iliac
. Salter iliac
. Pemberton iliac
. Steele triple
. Ganz or Bernese periacetabular

Correct Answer & Explanation

. Dega iliac

Explanation

Question 1457

Topic: Pediatric Upper Extremity & Spine
A 7-year-old boy presents to the ED with visible right elbow deformity after a fall on the playground. His injury films are shown in figures A and B. The injury is closed, and there is a palpable radial pulse with a well-perfused hand. He undergoes multiple attempts at closed reduction and percutaneous pinning with 3 lateral pins in the operating room. Final radiographs show some gapping at the fracture site. At the end of the case, the radial pulse is no longer palpable and the hand appears pale. What is the next best step in management?
. Place a medial pin to further stabilize the fracture
. Remove all of the pins and displace the fracture
. Obtain an emergent CT angiogram to assess arterial flow
. Explore the artery
. Splint the arm in extension as the fracture is now stabilized

Correct Answer & Explanation

. Remove all of the pins and displace the fracture

Explanation

The patient has a type III supracondylar humerus fracture that lost a palpable radial pulse after closed reduction. Due to continued gapping at the fracture site, the next best step is to remove the pins, displace the fracture, and reassess perfusion as the brachial artery was likely interposed in the fracture site during the reduction maneuver. The management of supracondylar humerus fractures is dictated significantly by the neurovascular examination. Loss of pulse and a pale, cool hand warrants emergent closed reduction and percutaneous pinning. If the vascular status does not change, open exploration is warranted. When a hand becomes pulseless and cool after reduction, it is typically due to the brachial artery being interposed in the fracture site. Undoing the reduction can often help. If there is still evidence of vascular compromise, open exploration is warranted.

Question 1458

Topic: Pediatric Hip

Which of the following pelvic osteotomies used in the treatment of developmental dysplasia of the hip (DDH) involves a complete cut through the innominate bone without entering the true pelvis, relying on the pubic symphysis as a hinge to provide anterolateral acetabular coverage?

. Salter osteotomy
. Pemberton osteotomy
. Dega osteotomy
. Triple pelvic osteotomy (Steele)
. Ganz periacetabular osteotomy (PAO)

Correct Answer & Explanation

. Salter osteotomy

Explanation

The Salter innominate osteotomy is a complete, single transiliac cut extending from the sciatic notch to the AIIS. It uses the pubic symphysis as an intrinsic hinge, allowing the entire acetabulum to be rotated anterolaterally to improve coverage in DDH. In contrast, Pemberton and Dega osteotomies are incomplete pericapsular cuts that hinge on the triradiate cartilage.

Question 1459

Topic: Pediatric Hip

A 12-year-old obese male is diagnosed with an unstable slipped capital femoral epiphysis (SCFE). Current evidence suggests that which of the following surgical intra-operative interventions during fixation is most directly targeted at reducing the risk of avascular necrosis (AVN)?

. Placing the fixation screw exclusively in the anterior quadrant of the epiphysis
. Intentional closed over-reduction of the slip into a valgus position
. Routine anterior capsulotomy for hematoma decompression
. Advancing the screw threads past the subchondral bone into the joint space
. Utilizing two crossed screws instead of a single central screw

Correct Answer & Explanation

. Routine anterior capsulotomy for hematoma decompression

Explanation

Unstable SCFE has a high rate of avascular necrosis (AVN) due to kinking or tamponade of the retinacular vessels. Performing a routine anterior capsulotomy decompresses the intracapsular hematoma, significantly reducing intracapsular pressure and thereby restoring blood flow and minimizing the risk of AVN. Over-reduction forcefully stretches the vessels and actively increases AVN risk.

Question 1460

Topic: Pediatric Hip

A 4-year-old child with developmental dysplasia of the hip (DDH) is scheduled for a Pemberton osteotomy. Which of the following best describes the biomechanical effect and structure of this specific pelvic osteotomy?

. A complete osteotomy redirecting the entire acetabulum to improve anterior coverage
. An incomplete osteotomy hinging at the pubic symphysis to provide lateral coverage
. A true volume-reducing incomplete osteotomy hinging at the triradiate cartilage
. A redirectional osteotomy requiring a secondary structural bone graft for stability
. A salvage procedure aiming for spherical congruency in an aspherical head

Correct Answer & Explanation

. A complete osteotomy redirecting the entire acetabulum to improve anterior coverage

Explanation

The Pemberton osteotomy is an incomplete pericapsular osteotomy that hinges on the flexible triradiate cartilage. It changes the shape of the acetabular roof, effectively reducing acetabular volume and improving anterolateral coverage.

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