Multiple Choice Questions

Paediatric Orthopaedics

Please use the comments section at the bottom of the page if you have any query or feedback about any of the questions.

 

62. Which of the following conditions does not occur in the valgus of a 4-year-old child:

A) Physiologic valgus
B) Prior proximal metaphyseal fracture
C) Multiple exostoses
D) Chondroectodermal dysplasia 
E) Infantile Blount disease

Correct Answer: E

Physiologic valgus, prior proximal metaphyseal fracture, multiple exostoses, and chondroectodermal dysplasia produce valgus. Infantile Blount disease produces varus.

Author: Fouad Chaudery

 

61. In which muscle does Ely’s test detect spasticity or contracture:

A) Biceps femoris 
B) Rectus femoris
C) Gastrocnemius 
D) Soleus 
E) Semimembranosus 

Correct Answer: B

Ely’s test is performed while the patient is prone and his or her hip is at maximal extension. Ely’s test is positive if flexion of the patient’s knee causes the patient’s hip to flex. A positive Ely’s test indicates spasticity or contracture of the rectus femoris.

Author: Fouad Chaudery

 

60. A 1-year-old patient presents with a pseudarthrosis of the left clavicle. Which of the following conditions is most likely to coexist with pseudarthrosis of the left clavicle:

A) Neurofibromatosis
B) Proteus syndrome 
C) Osteogenesis imperfecta
D) Fibrous dysplasia
E) Dextrocardia

Correct Answer: E

Almost all cases of congenital pseudarthrosis involve the right clavicle. Cases of congenital pseudarthrosis involving the left clavicle often coexist with dextrocardia. Patients with pseudarthrosis of the clavicle respond well to standard orthopedic treatment, unlike patients with congenital pseudarthrosis of the tibia.

Author: Fouad Chaudery

 

59. All of the disorders listed below are examples of osteochondrosis except:

A) Legg-Calvé-Perthes disease
B) Scheuermann’s disease 
C) Osgood Schlatter disorder 
D) Gorham’s disease
E) Blount disease

Correct Answer: D

The term osteochondrosis refers to symptomatic disorders involving cartilage growth. Cartilage affected by osteochondrosis may be epiphyseal, physeal, or apophyseal. Gorham’s disease is not an example of osteochondrosis. Gorham’s disease is a lymphatic disorder known as disappearing bone disease.

Author: Fouad Chaudery

 

58. The parameter most often recommended to follow the reciprocal relationship of the femoral head to the acetabulum in patients with cerebral palsy is known as the:

A) Migration index
B) Epiphyseal extrusion index
C) Stulberg index 
D) Acetabular index
E) Tonnis index

Correct Answer: A

The migration index (of Reimer) is most commonly used to track the femoral-acetabular relationship in patients with cerebral palsy because it most accurately portrays the progressive migration of the femoral head that may occur. The acetabular index only measures the acetabular response. The epiphyseal extrusion index is used for patients with Perthes disease (where the epiphysis deforms). The Stulberg index is for late outcome of Perthes, and the Tonnis index is for developmental dysplasia of the hip.

Author: Fouad Chaudery

 

57. Which population of patients with cerebral palsy is at greatest risk of neuromuscular hip subluxation:

A) Monoplegics
B) Spastic hemiplegics
C) Spastic diplegics 
D) Total-involvement 
E) Athetoid

Correct Answer: D

Patients with total-involvement cerebral palsy are at the greatest risk of hip subluxation. The rate is documented to be between 25% and 60%.

Author: Fouad Chaudery

 

56. Which of the following iliac osteotomies provides the greatest freedom of mobilization of the acetabular segment:

A) Salter osteotomy
B) Pemberton osteotomy
C) Steel osteotomy
D) Chiari osteotomy
E) Ganz osteotomy

Correct Answer: E

Osteotomies that are made closest to the acetabulum provide the greatest freedom of mobilization. Of the choices provided, the Ganz or Bernese osteotomy is made closest to the acetabulum.

Author: Fouad Chaudery

 

55. Which of the following conditions does not have a risk of cervical deformity greater than the general population

A) Neurofibromatosis
B) Larsen syndrome
C) Diastrophic dysplasia
D) Achondroplas
E) Down syndrome

Correct Answer: D

Achondroplasia is associated with frequent stenosis of the foramen magnum in infancy, as well as lower cervical stenosis. However, it is not associated with an actual deformity of the cervical spine. By contrast, neurofibromatosis, Larsen syndrome, and diastrophic dysplasia are associated with infantile cervical kyphosis. Down syndrome is associated with the risk of upper cervical instability.

Author: Fouad Chaudery

 

54. In the absence of surgery, which of the following gait parameters in children with cerebral palsy tends to remain static with increasing age:

A) Knee range of motion
B) Ankle range of motion 
C) Normalized walking velocity
D) Femoral anteversion
E) Knee stiffness

Correct Answer: D

Most parameters of gait deteriorate over time in the absence of intervention in children with cerebral palsy. Knee and ankle range of motion decrease, as does walking velocity when normalized for height. Femoral anteversion remains unchanged. Knee stiffness increases.

Author: Fouad Chaudery

 

53. Macrodactyly is associated with all of the following syndromes except:

A) Neurofibromatosis
B) Proteus syndrome
C) Klippel-Trenaunay syndrome
D) Marfan syndrome
E) Multiple enchondromatosis

Correct Answer: D

Macrodactyly is an increase in length and width of a digit or two adjacent digits. It may be associated with all of the above syndromes except for Marfan syndrome. Macrodactyly is also a common isolated condition.

Author: Fouad Chaudery

 

52. Klippel-Trenaunay syndrome is characterized by cutaneous capillary venous malformation, varicose veins, and which of the following:

A) Multiple enchondromas
B) Multiple osteochondromas
C) Limb hypertrophy
D) Seizure disorder 
E) Congenital pseudarthrosis of the tibia 

Correct Answer: C

Klippel-Trenaunay syndrome has three essential features: cutaneous capillary venous malformation, varicose veins, and hypertrophy of the involved limb in length and/or width. The syndrome usually presents before adolescence. The tissue abnormalities typically do not cross the midline, and the entire limb is not uniformly affected.

Author: Fouad Chaudery

 

51. Which of the following conditions is least commonly seen in patients with congenital dislocation of the patella:

Congenital Dislocation of Patella - Pediatrics - Orthobullets

A) Fibrosis of the vastus lateralis 
B) Contracture of the iliotibial band
C) Hypoplasia of the vastus medialis
D) Enlarged patella 
E) Flexion contracture 

Correct Answer: D

Congenital dislocation of the patella is present from birth and diagnosed in childhood. It is not reducible with the knee in extension. Essential elements include contracture of the iliotibial band, vastus lateralis, hypoplasia of the vastus medialis, lateral insertion of the patellar tendon, decreased size of the patella, flexion contracture and valgus alignment of the knee, and hypoplasia of the patellar sulcus. Operative treatment is usually successful, and the success rate is increased with early surgery.

Author: Fouad Chaudery

 

50. A mutation in type II collagen is responsible for all of the following conditions except:

A) Stickler syndrome
B) Spondyloepiphyseal dysplasia congenita
C) Kniest syndrome
D) Strudwick dysplasia
E) Achondroplasia 

Correct Answer: E

Type II collagen is largely found in hyaline cartilage. All of the dysplasias, with the exception of achondroplasia, have significant abnormalities of articular cartilage. 

Achondroplasia results from a defect in fibroblast growth factor receptor protein.

Author: Fouad Chaudery

 

49. According to National Institutes of Health (NIH) criteria, what is the minimum number of 15-mm café-au-lait macules required as a diagnostic criterion for neurofibromatosis in postpubertal patients:

A) One
B) Two 
C) Three
D) Four
E) Six

Correct Answer: E

The NIH criteria require at least six 15-mm café-au-lait macules in postpubertal patients. Café-au-lait macules must be larger than 5 mm in prepubertal patients

Author: Fouad Chaudery

 

48. The protein neurofibromin normally acts in which of the following ways:

A) Inhibits fibroblast growth factor 
B) Promotes proteoglycan assembly
C) Down regulates Ras protein 
D) Causes nerve cells to divide
E) Promotes tumor formation

Correct Answer: C

If defective, neurofibromin is the protein that causes neurofibromatosis. Neurofibroma is coded on chromosome 17, and it acts as a tumor suppressor by downregulating Ras protein, which enhances cell growth and proliferation

Author: Fouad Chaudery

 

47. What is the histological difference between avascular necrosis of the femoral head in children versus adults:

A) Children have less creeping substitution than adults
B) Children do not demonstrate osseous collapse. 
C) Large areas of fibrovascular tissue do not form in children. 
D) There is no osteoclastic resorption in children. 
E) Children do not have any residual changes after 2 years. 

Correct Answer: A

Avascular necrosis models of the femoral head in immature animals show more osteoclastic resorption, fibroblastic response, and little creeping substitution when compared to models of mature animals. Osseous collapse is common, and there are often long-term residual changes in the shape of the femoral head.

Author: Fouad Chaudery

 

46. Polyostotic fibrous dysplasia is caused by a mutation in which of the following genes:

A) GNAS 1
B) EXT 1 
C) Fibroblast growth factor receptor protein
D) CFBA1
E) COL1A1 

Correct Answer: A

Fibrous dysplasia is due to a postzygotic mutation in the GNAS1 gene. By contrast, EXT 1 mutations can cause multiple exostoses, and fibroblast growth factor receptor protein mutations cause achondroplasia, among other disorders. CFBA1 mutations are responsible for cleidocranial dysplasia. COL1A1 mutations are responsible for osteogenesis imperfecta.

Author: Fouad Chaudery

 

45. The result of treatment of developmental dysplasia of the hip with Salter osteotomy is is worse with which of the following:

A) A higher degree of the dislocation before treatment (Tonnis grade)
B) Bilaterality 
C) Higher preoperative acetabular index
D) Increased age at surgery 
E) Performing open reduction at a separate surgery than the osteotomy

Correct Answer: A

Salter osteotomy is effective in treating developmental dysplasia of the hip in young children. The result is worse with higher degrees of dislocation as assessed by the Tonnis system. It is better if the open reduction (if needed) is performed as a separate step than the osteotomy. The other factors have not been shown to be predictive.

Author: Fouad Chaudery

 

44. Chronic recurrent multifocal osteomyelitis is caused by which of the following:

A) Staphylococcus epidermidis
B) Corynebacterium
C) Spirochetal infection
D) Viral infection
E) No organism has been isolated

Correct Answer: E

Chronic recurrent multifocal osteomyelitis presents as chronic joint pain at multiple locations and at different times. No organism has been isolated from patients presenting with chronic recurrent multifocal osteomyelitis. There is no role for surgery or antibiotics because symptoms generally resolve over a period of time.

Author: Fouad Chaudery

 

43. Which of the following is found less often in children with lumbosacral agenesis as compared to controls:

A) Cervical spine anomalies
B) Maternal diabetes 
C) Hip dislocation 
D) Spina bifida
E) Genu recurvatum

Correct Answer: E

Patients with lumbosacral agenesis often have knee flexion contractures as compared with controls. All of the other features listed are common in patients with lumbosacral agenesis.

Author: Fouad Chaudery

 

42. Which of the following by itself is not an indication for surgery in a child with acute hematogenous osteomyelitis:

A) Fever higher than 38.5°
B) Subperiosteal abscess
C) Presence of a sequestrum
D) Intramedullary abscess
E) Adjacent septic arthritis

Correct Answer: A

Surgery is indicated in situations in which antibiotics alone will not be curative, including subperiosteal abscess, sequestrum, intramedullary abscess, and adjacent septic arthritis. Fever alone is not an indication for surgery.

Author: Fouad Chaudery

 

41. A 13-year-old girl is seen in clinic for bunion. She is asymptomatic but has a hallux valgus angle of 29°, an intermetatarsal angle of 15°, and a medial prominence over the first metatarsal head. The family asks whether anything can be done to prevent future problems with the foot. 

You recommend:

A) Osteotomy of the first metatarsal base
B) Hemiepiphyseodesis of the medial physis of the first metatarsal 
C) Double osteotomy of the first metatarsal
D) Mitchell osteotomy
E) Shoe modifications if symptoms develop 

Correct Answer: E

Bunions may often be treated conservatively, and it is impossible to predict which ones will later develop symptoms. Surgical reconstruction of bunions in adolescents has a higher rate of recurrence than in adults in many reported series. For all of these reasons, nonoperative treatment is preferred for asymptomatic patients.

Author: Fouad Chaudery

 

40. Which of the following symptoms is not characteristic of McCune-Albright’s syndrome:

A) Café-au-lait spots with irregular borders 
B) Café-au-lait spots with smooth borders 
C) Precocious puberty
D) Diabetes mellitus
E) Hyperthyroidism

Correct Answer: B

The café-au-lait spots associated with McCune-Albright’s syndrome are described as “coast of Maine” spots because they have irregular borders. The café-au-lait spots associated with neurofibromatosis are described as “coast of California” spots because they have smooth borders.

Author: Fouad Chaudery

 

39. After the bone age of 15 years, boys will achieve the most growth from which of the following regions:

A) Distal femoral epiphysis
B) Proximal tibial epiphysis
C) Distal tibial epiphysis
D) Ilium and pelvis 
E) Spine

Correct Answer: E

After the age of 15 in boys (13 in girls), most of the growth (4.5 cm on average) occurs in the spine.

Author: Fouad Chaudery

 

38. In evaluating infants for Blount disease, which diagnostic parameter allows correct classification of the greatest number of children:

A) Langenskjold rating
B) Tibiofemoral angle
C) Tibial metaphyseal-diaphyseal (M-D) angle
D) Femoral M-D angle divided by tibial M-D angle
E) Femoral intercondylar distance divided by height

Correct Answer: D

The tibial metaphyseal-diaphyseal (M-D) angle, no matter what threshold is set, has a significant number of falsepositives or false-negatives. Using the ratio of femoral to tibial M-D angle improves diagnostic accuracy significantly. The Langenskjold rating, tibiofemoral angle, and intercondylar distances, although conceptually important, have low diagnostic accuracy for an individual patient.

Author: Fouad Chaudery

 

37. Nine days after surgery, a 16-year-old boy with idiopathic scoliosis has a temperature of 39.5° C. Wound aspiration reveals gram-positive cocci in clusters. 

Your next step in management is:

A) Begin intravenous cephalosporin and monitor the response
B) Begin intravenous vancomycin and monitor the response 
C) Begin hyperbaric oxygen and intravenous antibiotics
D) Open and debride the wound, leaving the instrumentation in place 
E) Open and debride the wound, and remove the instrumentation

Correct Answer: D

Open debridement is the treatment of choice if an early deep wound infection is confirmed after spinal fusion. The instrumentation is left in place to stabilize the wound and promote fusion. The wound is closed as long as it can be cleaned up adequately during surgery, and muscle has a healthy appearance. If this cannot be achieved or if several debridements fail, the wound may be left open

Author: Fouad Chaudery

 

36. Which of the following events typically occurs first in adolescent girls:

A) Risser sign turning to 1 
B) Peak height velocity
C) Menarche 
D) Skeletal maturity
E) Tanner sign of 3

Correct Answer: B

Explanation: Typically, the peak height velocity is the first of these events to occur in adolescent girls. Skeletal maturity is the last event to occur.

Author: Fouad Chaudery

 

35. Homeobox genes are best characterized by which of the following descriptions:

A) Homeobox genes regulate fracture healing. 
B) Homeobox genes are involved in immune system regulation.
C) Homeobox genes are a series of genes that regulate limb genesis.
D) Homeobox genes regulate spinal development.
E) Homeobox genes regulate vascular invasion of the physis. 

Correct Answer: C

Homeobox genes code for transcription factors involved in regulation of limb genesis in the embryonic period. Homeobox genes have a highly conserved 60-nucleotide sequence.

Author: Fouad Chaudery

 

34. Which of the following is known about the genetics of multiple hereditary exostosis (MHE):

A) There is no genetic pattern for this condition.
B) MHE follows an x-linked inheritance pattern. 
C) MHE follows an autosomal recessive pattern. 
D) MHE involves a defect in biosynthesis of heparan sulfate. 
E) MHE involves a defect in fibroblast growth factor. 

Correct Answer: D

Multiple hereditary exostosis (MHE) is inherited as an autosomal dominant condition. There are three genes known to be involved: EXT 1, 2, and 3. EXT 1 and 2 encode glycosyltransferases needed for biosynthesis of heparan sulfate. Fibroblast growth factor receptor is abnormal in achondroplasia.

Author: Fouad Chaudery

 

33. Which of the following best predicts the risk of nonaccidental injury in young children who sustain a fracture of the femur:

A) The fracture pattern
B) The location of the fracture
C) The socioeconomic status of the family
D) Whether the child was previously able to walk
E) Coexistence of other disabilities

Correct Answer: D

Although a spiral fracture is classically consistent with nonaccidental injury, this is not always true. A spiral fracture is often seen in accidental injuries. The location of the fracture in the femur, the socioeconomic status of the family, and the coexistence of other disabilities are all poor predictors. The ability of the child to walk has predictive ability. In one study, nonaccidental injury accounted for 42% of all femur fractures in children before walking age vs. only 2% of fractures after walking age.

Author: Fouad Chaudery

 

32. A patient with L4 level myelomeningocele has developed a full-thickness pressure sore on the heel that has a central necrosis and is draining. While undergoing debridement in the local emergency department, the patient develops labored respiration and a nondetectable blood pressure. 

The most likely cause is:

A) Latex allergy
B) Aortic dissection 
C) Septic shock
D) Spontaneous tension pneumothorax 
E) Shunt failure

Correct Answer: A

Latex sensitivity is common in patients with spina bifida because of frequent exposure through catherizations and procedures. Latex avoidance is becoming the standard in institutions that commonly treat patients with spina bifida, but community hospitals that rarely see such patients may not always be aware of this problem.

• Dissection is not likely unless the patient has a connective tissue disorder.
• Septic shock is not likely to develop from a freely draining peripheral ulcer.
• Tension pneumothorax is not any more likely in patients with spina bifida than in the general population.
• Although it is important to be aware of shunt failure, it is not likely in this procedure which is done without anesthetic.

Author: Fouad Chaudery

 

31. A 12-year-old boy with achondroplasia has a gradual 40° thoracolumbar kyphosis. He is unable to walk more than two blocks. Magnetic resonance imaging reveals spinal stenosis, and the patient is scheduled to undergo posterior decompression from T12-S1. 

In addition to this procedure, you recommend:

A) Observation with serial radiographs every 4 months 
B) Postoperative brace for 6 months
C) In situ fusion with bone graft 
D) Posterior fusion across the kyphosis with instrumentation
E) Anterior corpectomy and fusion of T12

Correct Answer: D

Extensive posterior decompression poses a high risk of postoperative increase in kyphosis because of both the patient’s age and pre-existing kyphosis.

• Observation would not be a good idea because the risk is already known to be high.
• Neither a brace nor an uninstrumented fusion would prevent the deformity from developing.
• Corpectomy is not indicated because the kyphosis is not focal.
• Posterior instrumented fusion at the time of decompression is indicated.

Author: Fouad Chaudery

 

30. Which of the following conditions is not associated with an increased risk of congenital vertical talus?

A) Cerebral palsy
B) Myelomeningocele
C) Arthrogryposis
D) Nail patella syndrome
E) Larsen syndrome 

Correct Answer: A

Patients with cerebral palsy do not have an increased risk of congenital vertical talus, but they may develop an acquired neuromuscular vertical talus.

Patients with myelomeningocele have approximately a 5% to 10% risk of vertical talus, far above that of the general population. 

Arthrogryposis is associated with an increased risk of vertical talus.

Nail patella syndrome and Larsen syndrome are associated with an increased risk of vertical talus.

Author: Fouad Chaudery

 

29. Pleiotropy is demonstrated by which of the following examples:

A) Patients with osteogenesis imperfecta differ in the number of fractures they have received.
B) Patients with hemophilia A have different target joints. 
C) Hurler syndrome is usually not present in prior generations of an affected patient. 
D) Some patients with Marfan syndrome have scoliosis or pectus carinatum, while other patients with Marfan syndrome do not. 
E) Patients with Ollier disease often have more involvement on one side of the body. 

Correct Answer: D

The term pleiotropy refers to a disease taking different shapes in various patients.

• Variation in the severity of a given problem is better termed "variable expressivity."
• Target joints are not genetically determined.
• Hurler syndrome usually not being present in prior generations of an affected patient is an example of autosomal recessive inheritance.
• The term pleiotropy refers to a disease taking different shapes in different subjects, whereas the cause of patients with Ollier disease having more involvement on one side of the body is unknown.

Author: Fouad Chaudery

 

28. Morquio syndrome is caused by a deficiency in:

A) Alpha-L-iduronidase
B) Galactose-6-sulfatase
C) Beta-glucuronidase
D) Fibroblast growth factor receptor protein
E) Sulfate transport protein

Correct Answer: B

Morquio syndrome is a member of the family of mucopolysaccharidoses. Morquio syndrome is a deficiency in the enzyme galactose-6-sulfatase. A deficiency in galactose-6-sulfatase results in increased urinary excretion of keratosulfate.

•Alpha-L-iduronidase is deficient in Hurler syndrome.
• Beta-glucuronidase is deficient in some rare mucopolysaccharidoses.
• Fibroblast growth factor receptor protein is deficient in achondroplasia. Sulfate transport protein is deficient in diastrophic dysplasia

Author: Fouad Chaudery

 

27. A 12-year-old girl is referred because of a positive school scoliosis screen. She has a curve of 16° from T5 to T12, convex to the right. She also complains of mild back pain over the region of the curve several times per week. Neurologic examination is normal. 

Recommended treatment includes:

A) Magnetic resonance imaging
B) Technetium bone scintigraphy with SPECT
C) Treatment with a thoracolumbosacral orthosis
D) Computed tomography of the thoracic spine 
E) Home exercises and re-examination in follow-up

Correct Answer: E

Home exercises and re-examination in follow-up is the most appropriate treatment in view of lack of any worrisome features. If this child had severe pain or significant night pain, then further imaging studies would be warranted.

• The magnetic resonance imaging is not indicated in this situation.
• The bone scan has a low likelihood of being positive.
• Bracing is not indicated for the curve or the pain.
• Computer tomography is unlikely to demonstrate any pathology.

Author: Fouad Chaudery

 

26. Which of the following is a true statement regarding the results of surgery for a contracted joint in arthrogryposis:

A) The joint range of motion can easily be doubled.
B) The joint cannot be changed. 
C) The beginning and end of the range may change, but the total amount of motion remains about the same. 
D) The joint usually becomes stiffer. 
E) There is not an indication for such surgery. 

Correct Answer: C

The beginning and end of the range may change, but the total amount of motion remains about the same.

• The amount of the range cannot be significantly increased.
• The endpoint can change, but not the amount of the range.
• The joint does not usually become stiffer.
• There may be an indication for surgery to put the joints in a functional position.

Author: Fouad Chaudery

 

25. Which of the following conditions is not associated with an increased risk of congenital vertical talus?

A) Sacral agenesis
B) Cerebral palsy
C) Myelomeningocele
D) ArthrogryposisV
E) Nail patella syndrome

Correct Answer: B

Patients with cerebral palsy do not have an increased risk of congenital vertical talus, but they may develop an acquired neuromuscular vertical talus.

• Patients with myelomeningocele have approximately a 5% to 10% risk of vertical talus, far above that of the general population. • Arthrogryposis is associated with an increased risk of vertical talus.
• Nail patella syndrome is associated with an increased risk of vertical talus.
• Sacral agenesis is associated with an increased risk of vertical talus.

Author: Fouad Chaudery

 

24. A 6-year-old girl with osteogenesis imperfecta has severe bowing of both femurs. The family is interested in surgery to correct the condition. 

This method will give her the longest interval between procedures in the future:

A) Closed osteoclasis and cast application
B) Multiple osteotomies and realignment over a single smooth rod
C) Multiple osteotomies and realignment over parallel rods 
D) Multiple osteotomies and realignment over telescoping rods
E) Excision of the abnormal bone and replacement with allograft

Correct Answer: B

Telescoping or Bailey-Dubow rods are able to grow with the patient and maintain stabilization for a mean of 4 years between operations in growing children.

• Without the addition of internal fixation, bowing is likely to resume.
• Although a single rod is likely to provide current stability, bowing is likely to occur as the patient grows and the bone becomes longer than the rod.
• Parallel rods do not interlock and are likely to splay and lose fixation.
• There are no reports of large segment allograft replacement for diaphyses in osteogenesis imperfecta. In the absence of internal fixation, bowing is likely to resume as growth occurs.

Author: Fouad Chaudery

 

23. Prior to treatment, this pathologic finding characterizes clubfoot:

A) The talar head and neck are deviated medially. 
B) The dome of the talus is flattened.
C) The navicular is positioned more laterally than normal.
D) The foot has a rocker deformity.
E) The tendoachilles inserts in a more lateral position than normal.

Correct Answer: A

The talar head and neck are deviated medially. This deformity cannot be corrected surgically but may improve with growth.

• The dome of the talus is not originally flattened, but it may become this way after repeated manipulation.
• The navicular is positioned more medially than normal and may touch the medial malleolus.
• The foot has either a normal arch or a cavus deformity (the opposite of a rocker bottom). The rocker bottom foot may develop as a result of over-vigorous manipulation of a clubfoot against a tight heelcord.
• The tendoachilles inserts are more medially positioned than normal on the calcaneus

Author: Fouad Chaudery

 

22. A 15-year-old basketball player has mild scoliosis, pes planus, pectus carinatum, and long slender fingers. In order to determine if he has Marfan syndrome and should be allowed to continue playing basketball, it is most useful to order a:

A) Cardiac echo 
B) Magnetic resonance image of the lumbosacral spine 
C) Slit lamp examination
D) Chest radiograph
E) Dermal fibroblast assay 

Correct Answer: A

Explanation: A cardiac echo will give information about enlargement of the ascending aorta, as well as the valves. This is the most important information for activity recommendations and patient prognosis.

• A magnetic resonance image (MRI) of the lumbosacral spine will either rule in or out dural ectasia, but a MRI has no clinical importance for activity recommendations.
• A slit lamp examination is not as important as a cardiac echo in making sport recommendations.
• A chest radiograph may be helpful, if the patient is suspected of having a pneumothorax.
• A dermal fibroblast assay is useful in assessing collagen, such as in osteogenesis imperfecta, but it is not helpful in diagnosing Marfan syndrome.

Author: Fouad Chaudery

 

21. A 12-year-old boy presents to the emergency department after being struck by a car. His only complaint at the time of presentation is right ankle pain. After obtaining an excellent reduction and casting the leg, the risks of a future growth disturbance through the involved physis must be discussed with the family. What are the chances of a significant growth disturbance of his leg:

A) < 1%
B) 2% to 3%
C) 10% to 15%
D) 45% to 55%
E) 80% to 90%

Correct Answer: C

Explanation: This is a Salter-Harris type II fracture of the distal tibia. The distal tibia is at moderate risk for growth arrest after physeal injury. The average incidence of growth disturbance is 15% for all physeal injuries in this area. The marked displacement and mechanism of injury in this patient increase the risk of permanent physeal damage. The patient’s age and remaining growth also increase the likelihood of a growth arrest causing a significant deformity or leg length discrepancy

Author: Fouad Chaudery

20. Which ancillary test is not helpful in the diagnosis of Charcot-Marie-Tooth disease (CMT):

A) Electromyography (EMG)
B) Nerve conduction velocity (NCV)
C) Nerve biopsy
D) Muscle biopsy
E) Muscle enzymes

Correct Answer: E

Explanation: Charcot-Marie-Tooth disease (CMT) is a neuropathic process resulting in muscle atrophy, therefore, muscle enzyme studies will not be helpful.

• Electromyography (EMG) will confirm the diagnosis by displaying increased amplitude and duration of signals, both of which are indicative of a neuropathic process.
• Nerve conduction velocity (NCV) will also confirm the diagnosis by displaying decreased motor and sensory conduction velocities.
• Nerve biopsy can be helpful by showing loss of myelinated fibers and fibrosis.
• Muscle biopsy will show diffuse atrophy, fibrosis, and adipose tissue within muscle.

Author: Fouad Chaudery

19. A 7-year-old boy presents with bilateral high arches. His parents report that they are having difficulty finding shoes that comfortably fit him. The patient denies any foot pain. The father had similar problems with his feet and was diagnosed with a “mild” neurologic condition. On exam, the child has bilateral pes cavus with a supple hindfoot. Treatment of the feet at this time should consist of:

A) Soft tissue procedures alone
B) Soft tissue procedures and calcaneal osteotomy
C) Triple arthrodesis 
D) Bracing 
E) Observation

Correct Answer: A

Explanation: The child has a supple deformity secondary to Charcot-Marie-Tooth disease that will progress if untreated. Soft tissue procedures, which may consist of claw toe correction, plantar release, and possibly tendon transfer, are recommended for children younger than 8 years old who have a supple hindfoot.

• The calcaneal osteotomy is reserved for patients with a rigid hindfoot.
• Triple arthrodesis is a salvage procedure reserved for a fixed, painful foot in older children.
• Bracing and observation are not preferred options due to the progressive nature of the disease, and the lack of ability to apply corrective forces to the foot in cavus.

Author: Fouad Chaudery

18. Following tibial eminence fractures in skeletally-immature patients, all of the following sequelae have been described except:

A) Residual anterior cruciate ligament laxity
B) Lengthening of the tibial spine
C) Loss of knee flexion
D) Hypertrophy of the tibial spine
E) Loss of terminal knee extension

Correct Answer: B

The overall results following adequate reduction of the tibial spine are good to excellent. Loss of terminal knee extension is thought to occur due to hyperemia, subsequent hypertrophy or displacement of the tibial spine and resultant bony blockage. Knee stiffness and loss of extension- very common, late anterior instability- upto 60%; possibly secondary to ligamentous stretch; unclear whether clinically significant. Malunion can lead to impingement ( similar to cyclops lesion after anterior cruciate ligament reconstruction)

Author: Fouad Chaudery

 

17. Placing a highly tensioned soft tissue graft across the open femoral physis during anterior cruciate ligament reconstruction results in which of the following outcomes

A) Premature closure of the physis 
B) No growth disturbance 
C) Development of femoral varus 
D) Development of femoral valgus 
E) Femoral overgrowth 

Correct Answer: D

An excessively tensioned soft tissue graft placed across the canine femoral physis causes inhibition of growth of the lateral aspect of the distal femur resulting in the development of femoral valgus. The physis remains open during this process. Although this canine model illustrates potential harm that may result in a similar situation the human, the precise clinical implications of this canine model are unclear at this time. 

Author: Fouad Chaudhry

 

16. A genetic mutation accounts for the manifestations of achondroplasia. Which of the following proteins has a genetic mutation that has been linked to achondroplasia:

A) Fibroblast growth factor (FGF) receptor 3
B) Type I collagen 
C) Fibrillin 
D) Type II collagen 
E) Cartilage oligomeric matrix protein (COMP) 

Correct Answer: D

The genetic defect in achondroplasia involves fibroblast growth factor (FGF) receptor 3.

The other answers refer to:

Osteogenesis imperfecta

Type I collagen

Marfan syndrome

Fibrillin

Spondyloepiphyseal dysplasia

Type II collagen

Pseudoachondroplasia

Cartilage oligomeric matrix protein (COMP)

Author: Fouad Chaudhry

 

15. 13y old boy injured his knee playing basketball and is now unable to bear weight. Examination reveals tenderness and swelling at the proximal anterior tibia, with a normal neurologic examina-ption. AP and lateral radiographs are shown in figures attached. 

Management should consist of

A) MRI.
B) a long leg cast.
C) fasciotomy of the anterior compartment.
D) open reduction and internal fixation.
E) patellar advancement.

Correct Answer: D

The patient has a displaced intra-articular tibial tuber-osity fracture; therefore, the treatment of choice is open reduction and internal fixation. Periosteum is often interposed between the fracture fragments and prevents satisfactory closed reduction. Fortunately, most patients with this injury are close to skeletal maturity and therefore, growth arrest and recurvatum are unusual. Non displaced fractures can be treated with a cast, but displaced fractures are best treated with open reduction and internal fixation. Intra-articular fractures can disrupt the joint surface and are sometimes associated with a meniscal tear; therefore, arthroscopy may be needed at the time of open reduction and internal fixation.

Author: Salam Al-Abayachi

 

14. A 6y old child sustained a closed nondisplaced proximal tibial metaphyseal fracture 1 year ago. She was treated with a long leg cast with a varus mold, and the fracture healed uneventfully. She now has a 15° valgus deformity. 

What is the next step in management?

A) Proximal tibial/fibular osteotomy with acute correction and pin f xation
B) Proximal tibial/fi bular osteotomy with gradual correction and external fi xation
C) MRI of the proximal tibial physis
D) Medial proximal tibial hemiepiphysiodesis
E) Continued observation

Correct Answer: E

Explanation: The tibia has grown into valgus secondary to the proximal fracture. This occurs in about one half of these injuries, and maximal deformity occurs at 18 months postinjury. The deformity gradu-ally improves over several years, with minimal residual deformity. Therefore, treatment at this age is unnecessary because there is a high rate of recurrence and complications regardless of technique. The valgus deformity is not a result of physeal injury or growth arrest. Medial proximal tibial hemiepiphys-iodesis is an excellent method of correcting the residual deformity but is best reserved until close to the end of growth.

Author: Salam Al-Abayachi

 

13. A 6y old girl is referred for the elbow injury seen in figure atrached. What is the most appropriate treatment?

A) Immobilization in a long arm cast for 3 weeks
B) Immobilization in a long arm cast for 8 weeks
C) Open reduction and immobilization in a long-arm cast for 3 weeks
D) Open reduction and internal fixation with smooth pins
E) Open reduction and internal fixation with a screw

Correct Answer: D

The patient has a displaced lateral condyle fracture; therefore, simple immobilization for 3 to 8 weeks is likely to result in malunion or nonunion. Closed reduction of such injuries is rarely successful. The fracture is unstable, so fi xation is required after open reduction. Because the fi xation must cross the physis, smooth pins are indicated for the skeletally immature elbow. Open reduction with fi xation has been shown to reduce the risk of delayed union and malunion.

Author: Salam Al-Abayachi

 

12. A 9y old child sustains a proximal tibial physeal fracture with a hyperextension mechanism. 

What structure is at most risk for serious injury?

A) Tibial nerve
B) Popliteal artery
C) Common peroneal nerve
D) Posterior cruciate ligament
E) Popliteus muscle

Correct Answer: B

The most serious injury associated with proximal tibial physeal fracture is vascular trauma. The popliteal artery is tethered by its major branches near the posterior surface of the proximal tibial epiphysis. During tibial physeal displacement, the popliteal artery is susceptible to injury. Injuries to the other structures are less common.

Author: Salam Al-Abayachi

 

11. In obstetric Brachial plexus injury, return of which of the following by 3 months is considered an indicator of plexus recovery:

A) Biceps
B)  Brachioradialis
C) Triceps
D) Latissimus
E) Brachialis 

Best answer: A

Biceps recovery at 3 months is considered the single most important indicator of recovery in obstetric plexus palsy. 

 

Author : Dr. S Mohamed Azeem

 

10. An 18 month old boy is brought with clawing deformity of his right hand. The parent’s informed that he was born full term after a difficult delivery by shoulder dystocia. The patient had right clavicle fracture. A week later the parents noticed the child did not flex the fingers of his right hand. After 2 years the child is brought to you. On Examination, his right hand has extension at all the metacarpophalangeal joint  of the fingers while his PIP and DIP joints are flexed. His thumb is adducted and is difficult to passively bring it to full abduction. There is obvious wasting of the hand and Forearm. The child is able to move the arm well with no abnormalities of the shoulder, elbow and wrist. There is no evidence of horner’s syndrome, diaphragmatic palsy and absent grasp reflex. 

The diagnosis of the boy’s condition is:

A) Erb’s Palsy
B) Cerebrovascular Accident
C) Klumpke’s palsy
D) Ulnar and Median combined nerve injury
E) Pseudoparalysis

Best answer: C

This is a case of obstetric Brachial palsy involving C8, T1 (Klumpke's Palsy).

Erb's palsy involves upper roots only. 

Combined nerve injuries can present in a similar fashion; however, low ulnar and Median nerve lesions will not have weakness of FDP and FDS. 

Author : Dr. S Mohamed Azeem

 

9. A 10 year old boy presents with a mobile, soft painless mass over the posteromedial aspect of his knee. MRI Shows a Simple cyst. 

How do you manage this patient?

A) Contrast CT
B) Bone Scan
C) Ultrasound
D) Radical Excision
E) Observation

Best answer:  E

The description of a soft, non-tender mass in the Posterior aspect of knee is classical of baker's cyst. Baker's cyst in children about one fifth disappear spontaneously in a mean period of one year and eight months. Those cysts which fail to regress spontaneously respond to aspiration, but have a high rate of recurrence. 

Since the child has lack of symptoms and the likelihood of resolution, observation is the first line treatment for most popliteal cysts. 

Author :Dr. S Mohamed Azeem

 

8. The ACL is mostly deficient in which of the following abnormalities:

A) Achondroplasia
B) Proximal Femoral Focal Deficiency
C) Congenital Radial Head Dislocation
D) Apert Syndrome
E) Cleidocranial dyslexia

Best answer: B


PFFD is associated with deficiency in the development of Proximal Femur, Cervical Pseudoarthrosis, Fibular Hemimelia, Coxa Vara and ACL deficiency. Cleidocranial Dysplasia is associated with Cranial abnormalities and absent development of clavicle.

Author : Dr. S Mohamed Azeem 

 

7. Which is most important function that needs to be restored in Brachial plexus injury?

A) Shoulder Abduction
B) Elbow Flexion
C) Shoulder Elevation
D) Wrist Extension
E) Wrist Flexion

Best Answer : B

Elbow Flexion is central to management of Brachial plexus management because it serves the most important function of feeding.

Author - Dr. S Mohamed Azeem

 

6.  A mother brought her 7 month old infant with a history congenital dislocation of knee. The infant was previously treated with serial casting in Flexion to 15°.Currently the patient presented with Recurrent Grade III Congenital Dislocation of Knee (CDK). 

What is the next step in the treatment?

A) Serial Above knee casting in extension for 4 weeks.
B) Serial above knee casting in Flexion for 4 weeks.
C) Percutaneous Quadriceps recession, followed by above knee casting.
D) Open VY Quadriceps platy, followed by above- knee casting.
E) Arthroscopic ACL Division, followed by above knee casting.

Answer : D

Tarek CDK Grading System:
Grade I - Range of Flexion - > 90°- Simple Recurvation (Radiology)
Grade II - Range of Flexion - 30°-90° - Subluxation/Dislocation (Radiology)
Grade III - Range of Flexion - < 30° - Dislocation (Radiology)
VY Quadricepsplasty is indicated in patients with Grade 3 CDK or in recurrent cases (Tarek CDK Grading). Percutaneous Quadriceps Recession (PQR) is performed in Grade 2 CDK in infants > 1 month of age. Serial Casting for Grade I regardless of age and in neonates with grade 2 < 1 month.

Author - Dr. S Mohamed Azeem

 

5.  A 15 year old boy presents with increasing foot deformity. The boy was diagnosed with cavovarus deformity associated with Charcot Marie Tooth Disease. Coleman block test reveals Correctable Hindfoot deformity and Achilles reflex is diminished bilaterally. 

Which procedure is associated with improved clinical outcome in patients with the above described condition?

A) Triple athrodesis
B) Split Tibialis Anterior Transfer to Lateral column
C) Transfer of peroneus brevis to peroneus longus
D) Lateral column lengthening calcaneal osteotomy
E) Posterior tibial tendon transfer through the interosseous membrane to dorsum of the foot

Answer : E

1. Poor outcome is associated with triple arthrodesis in CMT.
2.The anterior tibial muscle is weakened and therefore transfer provides no benefit
3. Peroneus Longus to brevis Transfer can be utilised since PL is typically preserved in CMT but PB is weak classically.
4. Lateral column lengthening is used for pes planovalgus deformities.
5. The Posterior tibial tendon retains its strength in CMT and can decrease the Hindfoot Varus while providing dorsiflexion of ankle when transferred to the dorsum of foot.

Author - Dr. S Mohamed Azeem

 

4. A 18 year old male patient presented with progressive foot deformity for one year. Has pain along the lateral border of the foot while walking. His father had similar problems with both feet throughout his life. On examination his foot showed cavo-varus deformity. 

Proper management includes evaluating for?

A) Cervical Stenosis
B) Acetabular Dysplasia
C) Uveitis
D) Hypoplastic thumb
E) Thrombocytopenia

Answer: B

The patients clinical presentation is consistent with Charcot - Marie - Tooth (CMT) Disease, also known as Hereditary Sensory Motor Neuropathy. 

The Cavovarus foot is secondary to Peroneus Brevis and Tibialis Anterior weakness. 

Acetabular Dysplasia is known to occur in association with CMT.

Author - Dr. S Mohamed Azeem

 

3.  A 12-year-old boy presented with the complaints of his knees knocking together and recurrent falls while running. Examination revealed separation of the medial malleoli by 3 inches when standing with the knees in contact with each other and the feet directed forwards. 

The probable diagnosis is :

A) Coxa Vara
B) Bilateral Flat foot
C) Genu varum.
D) Talipes calcaneovalgus.
E) Genu Valgum

Best Answer: E

Normal physiological between 2 - 8 year's (upto 20 degrees). Maximum valgus alignment is seen between 2 and 4 year's, with an expected slower improvement to milder normal valgus alignment of the adult. 

By 8 year's, skeletally mature tibio-femoral alignment of approximately 5 to 7 degree's of valgus is achieved. 

After the age of 7, the intermalleolar distance should be <8cm.

Ref:Tachdjian's Paediatric Orthopaedics 6th edition and orthobullets)

Author - Dr. S Mohamed Azeem

 

2. All of the following are treatment for genu valgum excluding :

A) Osteoclasis of Tibia
B) Wedged shoes.
C) Night splints.
D) Mc’Ewans Osteotomy of Femur
E) Physiotherapy

Best Answer : A

Osteoclasis of tibia is useful in case of blount's disease (Tibia Vara). 

The main stay treatment for genu valgum is Hemiepiphysiodesis or Physeal tethering (staples, screws or plate/screws).Distal Femoral Varus osteotomy is indicated if there's insufficient remaining growth for hemiepiphysiodesis.

Ref: Tachdjian's Paediatric Orthopaedics 6th edition and orthobullets)

Author - Dr. S Mohamed Azeem


1. The clinical features of coxa vara include the following except :

A) Shortening, adduction and eversion of the limb.
B) Raising of the greater trochanter above Nelaton’s line.
C) Limitation of all movements of the hip.
D) Positive Trendelenburg’s sign.
E) Limping and difficulty in kneeling, riding and separating the legs.

Best Answer: C

Global restriction of all movements is seen with arthritis and differential restriction of abduction and external rotation is seen with coxa vara.

Ref: Tachdjian's Paediatric Orthopaedics 6th edition

Author - Dr. S Mohamed Azeem

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