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4. Pediatrics MCQs

Practice Set 84 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 1661

Topic: 4. Pediatrics

A 3-year-old child presents with bilateral tibia vara. Standing AP radiographs reveal a metaphyseal-diaphyseal angle (Drennan angle) of 18 degrees on both sides. What is the most appropriate initial management for this patient?

. Observation with radiographs in 6 months
. Bilateral proximal tibial osteotomies
. Knee-ankle-foot orthoses (KAFOs)
. Guided growth using medial 8-plates

Correct Answer & Explanation

. Observation with radiographs in 6 months

Explanation

A Drennan angle >16 degrees indicates a high likelihood of true infantile Blount's disease rather than physiologic bowing. For a child under 4 years old, the initial standard of care is bracing with KAFOs.

Question 1662

Topic: Pediatric Lower Extremity
A 25-year-old man has ankle instability and a lateral foot callosity. Radiographs are shown. Management options are best determined by the
. patient’s response to physical therapy.
. patient’s response to casting.
. patient’s response to selective injections.
. results of Coleman block testing.
. results of Semmes-Weinstein monofilament testing.

Correct Answer & Explanation

. results of Coleman block testing.

Explanation

DISCUSSION: The patient has a cavovarus deformity that has resulted in lateral foot overload and stressing of the lateral ligaments. Further treatment depends on the ability to correct the deformity. The Coleman block test indicates whether a deformity is fixed or supple. A supple deformity will respond to orthotic management or soft-tissue procedures, while a fixed deformity requires corrective osteotomy or fusion.

Question 1663

Topic: 4. Pediatrics
A 3-year-old child with achondroplasia is hypotonic, and sleep studies reveal central apneic episodes. An initial workup should evaluate for what diagnosis?
. Foramen magnum stenosis
. C1-C2 instability
. Adenoid and tonsillar hypertrophy
. Tethered spinal cord

Correct Answer & Explanation

. Foramen magnum stenosis

Explanation

DISCUSSION: Foramen magnum stenosis can cause sudden death in young children with achondroplasia and must be ruled out with CT or MRI scans. C1-C2 instability does not occur in patients with achondroplasia. Lumbar stenosis and thoracolumbar kyphosis can be seen but are not life-threatening and would not cause apnea or global hypotonia. Although many children with achondroplasia have adenoid and tonsillar hypertrophy, this condition causes obstructive rather than central sleep apnea and does not cause hypotonia. A tethered spinal cord is not particularly associated with achondroplasia and would not cause central apnea.

Question 1664

Topic: Pediatric Upper Extremity & Spine
A 21-year-old right hand-dominant male collegiate swimmer reports painful clicking in the right shoulder. He states that he can occasionally feel his shoulder “slip out” when he is working out. AP, true AP, and axillary radiographs are shown in Figures 39a through 39c. What is the next most appropriate step in management?
. Echocardiography
. Abdominal ultrasound
. Skeletal survey
. Glenoid osteotomy
. Physical therapy

Correct Answer & Explanation

. Physical therapy

Explanation

DISCUSSION: The radiographs show glenoid hypoplasia. The common radiographic findings of glenoid hypoplasia include an inferior and posterior glenoid deficiency, enlargement of the distal end of the clavicle, and sometimes an indentation in the glenoid. It is usually bilateral and rarely associated with other syndromes; therefore, an echocardiogram, abdominal ultrasound, or a skeletal survey is unnecessary unless the patient has stigmata of a syndrome such as Holt-Oram or Apert’s. Although posterior instability has been reported, the results of glenoid osteotomy have been variable and should not be considered initially. Physical therapy is the mainstay of initial management, but the patient should be counseled that this may be a recurrent problem with early osteoarthritis developing in many patients. Radiographs of the contralateral side should be obtained because this is usually bilateral. REFERENCES: Wirth MA, Lyons FR, Rockwood CA Jr: Hypoplasia of the glenoid: A review of sixteen patients. J Bone Joint Surg Am 1993;75:1175-1184. Smith SP, Bunker TD: Primary glenoid dysplasia: A review of twelve patients. J Bone Joint Surg Br 2001;83:868-872.

Question 1665

Topic: Pediatric Hip
Figure 10 shows the radiograph of a 7-year-old patient who has a bilateral Trendelenburg limp and limited range of hip motion but no pain. His work-up should include
. a skeletal survey.
. genetic evaluation.
. cardiac evaluation.
. coagulation studies.
. MRI of the hips.

Correct Answer & Explanation

. a skeletal survey.

Explanation

DISCUSSION: The radiograph shows bilateral flattening of the femoral heads with mottling and “fragmentation” suggestive of Legg-Calve-Perthes disease. However, when these changes occur bilaterally and are symmetric, multiple epiphyseal dysplasia or spondyloepiphyseal dysplasia should be suspected. Skeletal survey will show irregularity of the secondary ossification centers. With these conditions, there is no true osteonecrosis and no evidence that orthotic or surgical “containment” will alter the outcome of progressive degenerative arthritis. Cardiac anomalies and coagulopathies are not associated with the epiphyseal dysplasias. REFERENCES: Crossan JF, Wynne-Davies R, Fulford GE: Bilateral failure of the capital femoral epiphysis: Bilateral Perthes disease, multiple epiphyseal dysplasia, pseudoachondroplasia, and spondyloepiphyseal dysplasia congenita and tarda. J Pediatr Orthop 1983;3:297-301. Sponseller PD: The skeletal dysplasias, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 269-270.

Question 1666

Topic: 4. Pediatrics
  • An MRI scan of the brain of a patient with spastic diplegia will most likely show
. Microcephaly
. A temporal lobe cyst
. An Arnold-Chiari type 1 malformation
. Periventricular leukomalacia
. Agnesis of the corpus callosum

Correct Answer & Explanation

. Microcephaly

Explanation

Microcephaly literally means small brain. This is used to identify certain primary developmental anomolies as well as secondary changes seen in neonatal hypoxia and encephalomalacia. These individuals demonstrate long survival, but with moderate mental retardation and variable spastic weakness. Though they can show the physical characteristics of the question above, it is not a diagnostic feature in spastic diplegics. Unless, of course, their spastic diplegia is specifically related to developmental anoxic event (cerebral palsy) causing a compromise in total mass brain tissues.Agnesis of the corpus callosum is a rare anomaly that is asymptomatic neurologically unless tests designed specifically to test the transfer of information from one cerebral hemisphere to another is employed. Additionally, the corpus callosum is intimately related to the development of the limbic system which governs major CNS roles as behavior, memory, and emotions. Therefore, this would not involve the neurologically challenged spastic diplegic individuals.

Question 1667

Topic: 4. Pediatrics
Split posterior tibial tendon transfer is used in the treatment of children with cerebral palsy. Which of the following patients is considered the most appropriate candidate for this procedure?
. A 6-year-old child with athetosis and a flexible equinovarus deformity of the foot
. A 6-year-old child with spastic hemiplegia and a rigid equinovarus deformity of the foot
. A 6-year-old child with spastic hemiplegia and a flexible equinovarus deformity of the foot
. A 10-year-old child with spastic quadriplegia and rigid valgus deformities of the feet
. A 15-year-old child with spastic diplegia and rigid equinovalgus deformities of the feet

Correct Answer & Explanation

. A 6-year-old child with spastic hemiplegia and a flexible equinovarus deformity of the foot

Explanation

DISCUSSION: Split posterior tibial tendon transfers are best performed in patients with spastic cerebral palsy who are between the ages of 4 and 7 years and have flexible equinovarus deformities. Rigid deformities typically require bony reconstruction procedures. Tendon transfers in patients with athetosis are unpredictable.

Question 1668

Topic: 4. Pediatrics
A 14-year-old boy sustains a twisting injury to his right shoulder and recalls feeling a snap during a wrestling match. Examination shows hesitancy to raise the arm away from the side, diffuse tenderness and swelling of the upper arm, and no evidence of neurovascular compromise. Figures 6a and 6b show an AP radiograph and MRI scan. What is the most likely diagnosis?
. Anterior dislocation of the shoulder
. Salter-Harris type I fracture of the proximal humeral physis
. Rupture of the subscapularis tendon
. Sprain of the acromioclavicular joint
. Fracture of the glenoid neck

Correct Answer & Explanation

. Salter-Harris type I fracture of the proximal humeral physis

Explanation

DISCUSSION: While difficult to appreciate on the AP radiograph of the shoulder, the increased physeal signal demonstrated on the axial MRI scan is consistent with a nondisplaced growth plate fracture. Proximal humeral fractures in children are somewhat unusual, representing less than 1% of all fractures seen in children and only 3% to 6% of all epiphyseal fractures. Physeal injuries are classified according to the Salter-Harris classification scheme. Salter-Harris type I fractures represent approximately 25% of physeal injuries to the proximal humerus in adolescents.

Question 1669

Topic: 4. Pediatrics
Osteonecrosis of the large joints may develop in patients with which of the following conditions?
. Collagen I disease
. Antiphospholipid syndrome (APS)
. Hemochromatosis
. Achondroplasia
. Paget’s disease

Correct Answer & Explanation

. Antiphospholipid syndrome (APS)

Explanation

DISCUSSION: Osteonecrosis of major joints can occur in patients exposed to corticosteroids, alcohol, and antiseizure medications, as well as patients with hemaglobulinopathy, such as sickle cell anemia. In addition, patients with primary APS who had not taken corticosteroids were also found to be at high risk for osteonecrosis of the hip. In one study of 30 patients with primary APS, asymptomatic osteonecrosis was evident in 20%. A recent article has also found a high association between idiopathic osteonecrosis of the hip and collagen II mutation.

Question 1670

Topic: 4. Pediatrics
Figure 24 shows the radiograph of a 10-year-old boy who sustained a valgus injury to the knee. Examination reveals grade III medial laxity. Initial management should consist of
. an MRI scan.
. stress radiographs of the knee.
. activities as tolerated.
. a hinged range-of-motion brace.
. a knee immobilizer.

Correct Answer & Explanation

. stress radiographs of the knee.

Explanation

DISCUSSION: Based on the mechanism of injury and findings of medial laxity, the most likely diagnosis is injury to either the growth plate or the medial collateral ligament. With the open physeal plate, this area of injury is presumed present until proven otherwise; therefore, stress radiographs should be obtained before implementing any treatment or ordering more extensive and expensive tests. REFERENCES: DeLee JC: Ligamentous injury of the knee, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, vol 3, pp 406-432. Clanton TO, DeLee JC, Sanders B, Neidre A: Knee ligament injuries in children. J Bone Joint Surg Am 1979;61:1195-1201. Torg JS, Pavlov H, Morris VB: Salter-Harris type III fracture of the medial femoral condyle occurring in the adolescent athlete. J Bone Joint Surg Am 1981;63:586-591.

Question 1671

Topic: 4. Pediatrics
A 14-year-old football player has had right knee pain for the past 2 months; however, he denies any history of trauma. Examination shows an abductor lurch and increased external rotation of the right lower extremity. The best course of action should be to
. apply a knee sleeve during sports.
. withdraw from football for 2 weeks.
. obtain AP and frog-lateral radiographs of the pelvis.
. obtain an MRI scan of the right knee.
. initiate physical therapy.

Correct Answer & Explanation

. obtain AP and frog-lateral radiographs of the pelvis.

Explanation

Discussion: Slipped capital femoral epiphysis is the most common pathology involving the hip in adolescents. While patients with acute slips may report severe pain and are unable to ambulate, those with chronic slips often have pain during ambulation, a limp, and increased external rotation of the hip. While 60% of the patients specifically report hip pain, the remainder have pain in the thigh or knee. The initial diagnostic study of choice is AP and frog-lateral radiographs of the pelvis; bilateral involvement is frequently seen. References: Boyer DW, Mickelson MR, Ponseti IV: Slipped capital femoral epiphysis: Long-term follow-up study of one hundred and twenty-one patients. J Bone Joint Surg Am 1981;63:85-95. Stasikelis PJ, Sullivan CM, Philips WA, Polard JA: Slipped capital femoral epiphysis: Prediction of contralateral involvement. J Bone Joint Surg Am 1996;78:1149-1155.

Question 1672

Topic: Pediatric Hip
A 15-year-old girl who swims the breaststroke has had hip pain after training excessively for a national level competition. Based on the MRI scans shown in Figures 5a through 5c, what is the most likely diagnosis?
. Femoral neck stress fracture
. External rotator muscle tear
. Slipped capital femoral epiphysis
. Superior acetabular labral tear
. Acetabular dysplasia

Correct Answer & Explanation

. External rotator muscle tear

Explanation

Discussion: The MRI scans reveal open physes but no evidence of a slipped capital femoral epiphysis, labral tear, or acetabular dysplasia. The femoral neck does not show evidence of a fracture. The muscle tear seen on the right side lies near the musculotendinous junction of the external rotators of the hip at the level of the lesser trochanter, representing the obturator externus. This is consistent with the forced motion required for the breaststroke kick.

Question 1673

Topic: 4. Pediatrics
A 14-year-old male sustains the injuries shown in Figures A and B after a fall off the roof of his house. What is the most appropriate management?
. Hip spica in abduction
. Dynamic hip screw with trochanteric side plate
. Cephalomedullary nail
. Physis-sparing cancellous screws
. Transphyseal cancellous screws

Correct Answer & Explanation

. Transphyseal cancellous screws

Explanation

The radiographs show a transcervical (Delbet II) femoral neck fracture. Transphyseal cancellous screws are indicated for fixation of the femoral neck fracture in this case. Pediatric femoral neck fractures are classified into transphyseal, transcervical, cervicotrochanteric and intertrochanteric (Delbets I-IV) respectively.

Question 1674

Topic: 4. Pediatrics
Figure 30 shows the AP radiograph of a 9-month-old girl who has been referred for evaluation of unequal leg lengths. Examination reveals symmetrical abduction of the hips. When the hips are flexed 90°, the right knee height is greater than the left knee. The girth of the right thigh and calf is larger than the contralateral side. There are no cutaneous lesions, and examination of the spine is normal. The infant is moving all extremities equally and spontaneously. Management should consist of
. assessment of the bone age in the left wrist and hand.
. an MRI scan of the spine.
. an ultrasound of the hips.
. a renal ultrasound.
. a Pavlik harness.

Correct Answer & Explanation

. a renal ultrasound.

Explanation

Hemihypertrophy or hemihypotrophy is usually idiopathic, and either the leg or the entire side of the body may be involved. In the infant or young child, it is often difficult to determine which side is abnormal if the condition is mild. Because of the association of Wilms’ tumor with hemihypertrophy, these patients should undergo a yearly renal ultrasound until at least age 5 years. Other conditions that may exhibit hemihypertrophy include Klippel-Trenaunay-Weber syndrome, Proteus syndrome, and neurofibromatosis. In this patient, the mild hemihypertrophy is idiopathic. Because of the normal spinal examination and absence of neurologic findings, an MRI scan is unnecessary. The absence of clinical and radiographic evidence of hip dysplasia makes both an ultrasound of the hips and application of a Pavlik harness unnecessary.

Question 1675

Topic: 4. Pediatrics

A 9-year-old boy is injured while playing soccer. His examination reveals painful range of motion between 5° and 75°. There is tenderness on the medial side of his knee. There is no effusion, a grade 1A Lachman test, and severe pain over the medial epicondyle of the knee. Varus stress is negative and pain is elicited with valgus stress. Initial radiographs were negative for abnormality. Stress radiographs show a 2-mm medial physeal widening with valgus stress. What is the best initial treatment strategy for this patient?

. Femoral medial collateral ligament repair, extraphyseal
. Arthroscopically assisted medial collateral ligament repair
. Crutch ambulation without immobilization and weight bearing as tolerated
. Protected weight bearing with cast immobilization

Correct Answer & Explanation

. Femoral medial collateral ligament repair, extraphyseal

Explanation

This patient likely has a physeal injury to the distal femoral physis. Stress radiographs or an MRI scan will most reliably reveal this diagnosis. The growth plate, when injured, is most commonly fractured through the hypertrophic zone of cartilage, its weakest point. This patient is optimally treated in acylindrical or long-leg cast.

Question 1676

Topic: 4. Pediatrics

A 40-year-old male undergoes excision of an infected tibial nonunion, resulting in a 6-cm diaphyseal defect. The defect is managed via distraction osteogenesis (bone transport) using a circular Ilizarov frame. Following the proximal corticotomy, what is the optimal protocol for latency and rate of distraction?

. No latency period, distract 2.0 mm per day
. 3-day latency period, distract 0.5 mm per day
. 7 to 10-day latency period, distract 1.0 mm per day in 4 divided increments
. 14 to 21-day latency period, distract 1.5 mm per day once daily
. 28-day latency period, distract 1.0 mm per day in 2 divided increments

Correct Answer & Explanation

. No latency period, distract 2.0 mm per day

Explanation

The classic Ilizarov protocol for bone transport and distraction osteogenesis involves a latency period of 7 to 10 days to allow early callus formation, followed by a distraction rate of 1.0 mm per day, optimally divided into four 0.25 mm increments.

Question 1677

Topic: 4. Pediatrics
A 2-year-old child presents with a limp, refusal to bear weight, and low-grade fever. Joint aspiration yields purulent fluid. Gram stain is negative, but the physician suspects an increasingly common fastidious Gram-negative organism. Inoculation of the synovial fluid into which specific medium significantly increases the yield for this particular pathogen?
. Lowenstein-Jensen agar
. MacConkey agar
. Aerobic blood culture vials (BACTEC)
. Thayer-Martin agar
. Sabouraud dextrose agar

Correct Answer & Explanation

. Aerobic blood culture vials (BACTEC)

Explanation

Kingella kingae is a fastidious Gram-negative organism that is now recognized as a leading cause of pediatric septic arthritis. Inoculating the synovial fluid directly into aerobic blood culture vials (e.g., BACTEC) significantly increases the isolation yield.

Question 1678

Topic: 4. Pediatrics

A 14-year-old patient has sustained a complete ACL tear of his right knee. Which of the following options has shown to be the most limiting factor for access to pediatric orthopaedic management in the United States?

. Sex of the patient
. Type of health insurance
. Child greater than 10 years of age
. Acute knee injuries requiring operative treatment
. Timing of the referral

Correct Answer & Explanation

. Sex of the patient

Explanation

The type of health insurance in the pediatric population has shown to be a significant factor for access to specialized healthcare in the United States.Access to pediatric orthopaedic management has been well investigated. Numerous Level 4 studies have shown that orthopaedic offices in urban and rural areas prefer treating patients with private insurance over patients with Medicaid.Iobst et al. telephoned 100 urban and rural orthopaedic outpatient offices to schedule an appointment for a 10-year-old patient with a forearm fracture. They showed that 8/100 offices would schedule an appointment within 1 week to the child with Medicaid insurance, as compared to 36/100 that gave an appointment to a child with private insurance.Pierce et al. contacted 42 orthopaedic practices to schedule an appointment for a 14-year-old patient with an ACL injury. They showed that 38/42 offices scheduled an appointment for the child within 2 weeks with private insurance. This compared to 6/42 that scheduled an appointment for a similar child with Medicaid.Incorrect Answers:

Question 1679

Topic: 4. Pediatrics

A pediatric orthopaedic surgeon refers a child to a neurologist. The neurologist’s office requests the office records of the pediatric orthopaedic surgeon. To maintain Health Insurance Portability and Accountability Act (HIPAA) compliance, what must the surgeon obtain from the parent(s) prior to sending records?

. No additional consent needed
. Verbal approval
. Written approval
. Written approval with notarization
. Telephone consent witnessed by a nurse

Correct Answer & Explanation

. No additional consent needed

Explanation

The privacy rules do not require an individual’s written authorization for certain permitted or required uses and disclosures of the medical records. Patient or parental authorization is not required for disclosures for certain purposes related to treatment, payment, or health care operations. Specifically, HIPAA does not require a covered entity to obtain patient authorization for many of the health care industry’s most fundamental activities such as providing care.

Question 1680

Topic: 4. Pediatrics

An 18-month-old child has a congenital anterolateral bowing of the tibia. The radiograph shown in Figure 13 reveals increased density with obliteration of the medullary canal at the apex of the 40-degree bow. Treatment should consist of

. Osteotomy and intramedullary rod fixation
. Electrical stimulation
. Strut-autografing the concavity the tibia
. A patellar tendon-bearing brace
. Percutaneous injection of demineralized bone matrix

Correct Answer & Explanation

. Osteotomy and intramedullary rod fixation

Explanation

Anterolateral Tibial Bowing-Congenital pseudoarthrosis of the tibia is the most common cause of anterolateral bowing. It is often accompanied by neurofibromatosis (50%-but only 10% of patients with neurofibromatosis have this disorder). Classification (Boyd) is based on bowing and the presence of cystic changes, sclerosis, or dysplasia and cystic changes are most common. Early treatment includes a total contact brace to protect from fractures, intramedullary fixation with excision of hamartomatous tissue, and autogenous bone grafting (osteosynthesis) for nonhealing fractures. Vascularized fibular graft or Ilizarov methods should be considered if bracing fails. Osteotomies and electrical stimulation alone are contraindicated. Amputation (Symes) and prosthetic fitting are indicated after two or three failed surgical attempts.

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