MCQs – Hip 1

Modern Study Review (AI-Generated)

High-Yield Summary

Slipped Capital Femoral Epiphysis (SCFE), Developmental Dysplasia of the Hip (DDH), and pediatric hip fractures are staple topics in orthopaedic board exams, focusing heavily on stability assessment, age-specific treatment thresholds, and complication avoidance. The single most important clinical decision in SCFE is hip stability versus symptom chronicity, which dictates urgency and treatment choice. For DDH, age thresholds (notably 6 months and 2.5 years) determine the shift from nonoperative to surgical management. While classic exam answers emphasize closed reduction and casting, modern practice increasingly favors early internal fixation and tailored osteotomies to optimize outcomes and minimize avascular necrosis (AVN). Prognostic signs in Legg-Calvé-Perthes disease and indications for salvage procedures like Chiari osteotomy remain critical for long-term planning.

High-Yield Decision Matrix

Active Recall Q&A

SCFE

Q: What determines treatment outcome in SCFE more significantly: chronicity of symptoms or hip stability?
A: Hip stability determines treatment outcome more than chronicity of symptoms.
Related Pearl: Stability assessment guides urgency and type of intervention, reflecting modern emphasis on mechanical factors over symptom duration.

Q: What is the typical bilaterality rate of SCFE in idiopathic cases?
A: 10-25% of idiopathic SCFE cases are bilateral.
Related Pearl: Bilaterality is lower in idiopathic SCFE compared to endocrinopathies, influencing surveillance strategies.

Q: How common is bilaterality of SCFE in patients with endocrinopathies?
A: Up to 70% of SCFE cases with endocrinopathies are bilateral.
Related Pearl: High bilaterality in endocrinopathies justifies prophylactic pinning consideration.

Q: Does transient pin penetration cause chondrolysis in SCFE?
A: No, transient pin penetration does NOT cause chondrolysis.
Related Pearl: Persistent retained pins are the main cause of chondrolysis, emphasizing timely hardware removal.

Q: When is prophylactic pinning indicated in SCFE?
A: Prophylactic pinning is indicated only in patients with endocrinopathies.
Related Pearl: Many endocrinopathic patients already have contralateral slips, so “prophylactic” pinning may be therapeutic.

Postoperative Management

Q: What is the recommended management for a patient with an abduction contracture after Salter innominate osteotomy?
A: Physiotherapy is usually sufficient for abduction contracture post-Salter osteotomy.
Related Pearl: Non-surgical management often resolves soft tissue contractures after pelvic osteotomies.

Congenital Dislocation of the Hip (CDH)

Q: What surgical procedure is recommended for a 2.5-year-old child with congenital dislocation of the hip (CDH)?
A: Femoral shortening osteotomy is recommended at 2.5 years of age.
Related Pearl: Femoral shortening reduces tension on soft tissues, facilitating reduction and decreasing AVN risk.

Q: What is the best treatment for CDH at 6 months of age?
A: Closed reduction with adductor tenotomy is best; Pavlik harness is at the upper limit of usefulness at this age.
Related Pearl: Pavlik harness efficacy declines after 6 months due to soft tissue contractures.

Q: What clinical signs are expected in a 4-day-old infant with a dislocated hip?
A: Ortolani and Barlow tests are positive or achievable; hip is relocatable; decreased abduction is present; capsule is not yet hourglass-shaped.
Related Pearl: Early diagnosis allows for less invasive treatment before capsular changes occur.

Q: What is the recommended treatment for a newly diagnosed hip dislocation in a 5-year-old child?
A: Open reduction, femoral shortening, and innominate osteotomy are usually required.
Related Pearl: Combined procedures address concentric reduction, avoid AVN, and correct acetabular dysplasia; innominate osteotomy remains controversial.

Developmental Dysplasia of the Hip (DDH)

Q: What is the treatment protocol for a 12-month-old with undiagnosed developmental dysplasia of the hip (DDH)?
A: Traction, adductor release, closed reduction, and spica casting.
Related Pearl: Older infants often require more invasive interventions due to soft tissue contractures.

Q: What is the preferred treatment for a 3-month-old with undiagnosed DDH?
A: Pavlik harness is preferred up to 6 months of age.
Related Pearl: Early harness use promotes acetabular development and reduces need for surgery.

Pediatric Hip Fractures

Q: How should a 6-year-old with an intertrochanteric hip fracture be managed?
A: Traction followed by spica casting is possible, but closed reduction and internal fixation with multiple screws followed by spica is preferred.
Related Pearl: Internal fixation allows earlier mobilization and better alignment in pediatric hip fractures.

Q: Why are subtrochanteric fractures difficult to manage in children?
A: Due to flexion, abduction, and external rotation deformity of the proximal fragment.
Related Pearl: 90-90 traction is the most popular method; ORIF is reserved for irreducible fractures or polytrauma.

Q: What is the main blood supply to the femoral head in a severely displaced femoral neck fracture?
A: The obturator artery supplies the head; retinacular vessels are likely torn.
Related Pearl: Understanding vascular anatomy is critical to predicting avascular necrosis risk.

Perthes Disease

Q: How should a 3.5-year-old child with Perthes disease who is asymptomatic but limping be managed?
A: Observe with range of motion exercises, weight management, and X-ray follow-up.
Related Pearl: Early asymptomatic cases may represent Meyer’s dysplasia and often resolve without surgery.

Chiari Osteotomy

Q: What are the indications for Chiari osteotomy?
A: Coxa magna with lateral subluxation; salvage procedure when congruous reduction is impossible.
Related Pearl: Chiari osteotomy medializes the acetabulum to improve femoral head coverage in salvage cases.

Legg-Calvé-Perthes Disease

Q: What are poor prognostic signs in Legg-Calvé-Perthes disease?
A: Loss of containment, whole head involvement, metaphyseal cysts, Gage’s sign, horizontal growth plate, lateral epiphyseal calcification.
Related Pearl: These radiographic signs correlate with worse long-term hip function.

Q: How does gender influence prognosis in Legg-Calvé-Perthes disease?
A: Girls tend to have lateral pillar involvement and a less favorable long-term prognosis.
Related Pearl: Gender differences may reflect variations in disease severity and response to treatment.

Classic Clinical Notes

• With respect to SCFE, the chronicity of symptoms does not seem to have a huge bearing on treatment outcome anymore – it is really based on how stable the hip is rather than how long the hip has been bothersome. There are a few things that are true – there is a narrow window just before skeletal maturity in which it occurs, it is bilateral in only 10-25% of idiopathics, up to 70% in those with endocrinopathies, and osteonecrosis remains the most common reason for a bad result (not sure if it is the most common complication though).

• Transient pin penetration is NOT felt to cause chondrolysis. If left in, however, it is the main reason for chondrolysis.

• Prophylactic pinning of SCFE is done in endocrinopathies only (many of these are not prophylactic, because they already have it on the other side!).

• A patient returning after a Salter innominate osteotomy that has an abduction contracture should probably just have physio.

• For a CDH at 2.5 years, the treatment plan should include a shortening osteotomy of the femur.

• Best treatment for CDH at 6 months is a closed reduction with adductor tenotomy (this age is right at the upper limit of usefulness for a Pavlik).

• In a 4-day-old with a dislocated hip, you would expect the Ortolani and Barlow to be positive (or achievable) and you would expect that the hip would be relocatable at this stage; and you would expect decreased abduction. It is too early for the capsule to really be “hourglass”.

• For a 5-year-old with a newly diagnosed dislocation, best treatment is an open reduction, femoral shortening, and innominate osteotomy. In children over 3, simultaneous open reduction, femoral shortening, and redirectional osteotomy of the innominate bone usually are required to achieve concentric reduction, avoid AVN, and address the secondary acetabular pathology. Note that the innominate osteotomy is controversial. Some would do it, others would let the acetabulum remodel once the hip is in.

• For a 12-month-old with undiagnosed DDH – traction, adductor release, closed reduction, spica cast.

• For a 3-month-old with undiagnosed DDH – Pavlik (up to the age of 6 months).

• 6-year-old with intertrochanteric hip fracture – can be treated in traction (the intertroch’s can be treated in traction) followed by spica cast, but probably better to do closed reduction and internal fixation with multiple screws, then spica. I think in contemporary pediatric trauma, although this can be treated in a cast, go with internal fixation.

• Subtrochanteric fractures are difficult to manage because of the flexion, abduction, external rotation deformity of the proximal fragment; 90-90 traction is safe, reliable, and the most popular method of management of these injuries. It is not uncommon to use ORIF when a reduction is not obtainable or with head/polytrauma. Again, sort of a stupid question, because unless very young I think I’d treat with ORIF.

• In a severely displaced femoral neck fracture, the remaining blood supply comes from probably the obturator artery. The main supply to the head is the posterosuperior and posteroinferior retinacular vessels, but in a displaced neck fracture, these are most likely torn.

• In a 3.5-year-old kid with Perthes, completely asymptomatic but with limp – observe. ROM, exercises, weight reduction, avoidance of weight bearing, x-ray follow-up. This is likely Meyer’s dysplasia and will probably resolve. The patient should be followed closely and management should follow his symptoms.

• Indications for Chiari – coxa magna with subluxation out laterally (extrusion); basically, this is a salvage osteotomy when a congruous reduction of the femoral head is impossible.

• For Legg Perthes, loss of containment is a bad sign. Also, whole head involvement, the presence of metaphyseal cysts, Gage’s sign, a horizontal growth plate, and lateral epiphyseal calcification is bad. Girls tend to have lateral pillar involvement and therefore may have a less favorable long term prognosis.

Last Updated on January 25, 2026 by Christian Veillette