MCQs – Upper Extremity Peds

Modern Study Review (AI-Generated)

High-Yield Summary

Pediatric elbow and distal humerus fractures, including supracondylar fractures, Monteggia lesions, and medial epicondyle injuries, are a staple of orthopaedic board exams, focusing heavily on reduction techniques, immobilization positions, and surgical indications. The single most important clinical decision often hinges on displacement thresholds (e.g., >1 cm for medial epicondyle fixation) or angulation limits (e.g., >25° for proximal humerus fractures near skeletal maturity). Examiners frequently test knowledge of immobilization positions tailored to fracture patterns (e.g., pronation vs. supination in supracondylar fractures). While classic teaching emphasizes prolonged immobilization, modern practice favors early mobilization to minimize stiffness and optimize functional recovery.

High-Yield Decision Matrix

Active Recall Q&A

Supracondylar Osteotomy & Malunion

Q: What is the most common reason for performing a supracondylar osteotomy after malunion and gunstock deformity?
A: Cosmetic correction.
Related Pearl: Functional impairment is less common; most patients seek surgery primarily for appearance rather than function.

Monteggia Fracture Treatment

Q: What is the best treatment sequence for a Monteggia fracture?
A: Closed reduction of the ulna, then closed reduction of the radial head, followed by casting.
Related Pearl: Proper ulna alignment is critical for stable radial head reduction; failure to restore ulna length leads to persistent radial head dislocation.

Lateral Condyle Fracture

Q: How should a lateral condyle fracture missed and seen at 3 weeks be managed?
A: It should probably be fixed surgically.
Related Pearl: Delayed fixation increases risk of nonunion and growth disturbances; early recognition is key.

Anterior Shoulder Dislocation in Children

Q: What is the risk of recurrent dislocation in a child with open growth plates after an anterior shoulder dislocation?
A: Nearly 90% chance of recurrent dislocations.
Related Pearl: Early surgical stabilization may be considered in high-risk children to prevent recurrent instability.

Proximal Humerus Fracture Angulation

Q: When should intervention be considered for a proximal humerus fracture near skeletal maturity?
A: If angulation is greater than 25 degrees.
Related Pearl: Remodeling potential decreases near skeletal maturity, making surgical correction more necessary.

Osteochondritis Dissecans (Elbow)

Q: What is the most common site of osteochondritis dissecans in the elbow?
A: The capitellum.
Related Pearl: Early radiographic changes are confined to the capitellum before joint arthritic changes develop.

Q: What radiographic changes are seen in osteochondritis dissecans of the capitellum?
A: Rarefaction, fragmentation, irregular ossification, localized crater defect, and sometimes an irregular articular surface.
Related Pearl: Occasionally, the radial head appears slightly larger than the contralateral side due to adaptive changes.

Medial Epicondyle Fracture Fixation

Q: When is fixation indicated for a medial epicondyle fracture?
A: If displacement is greater than 1 cm, ulnar nerve symptoms are present, the fragment is trapped in the joint, or valgus instability exists.
Related Pearl: Untreated displacement can lead to chronic valgus instability and ulnar neuropathy.

Elbow Fracture Radiographic Aid

Q: What is the most important radiographic aid to determine the fractured structure in elbow injuries?
A: Aligning the capitellum with the radial head.
Related Pearl: Disruption of this alignment suggests fracture or dislocation and guides further management.

Bado II Monteggia Fracture Immobilization

Q: How should a posterior dislocation of the radial head with ulna fracture (Bado II) be immobilized?
A: In extension and pronation.
Related Pearl: This contrasts with Bado I injuries, which are immobilized in flexion and supination to maintain reduction.

Bado I Monteggia Fracture Immobilization

Q: How are most Bado I Monteggia fractures treated in terms of immobilization?
A: Immobilized in flexion and supination.
Related Pearl: Positioning maintains radial head reduction and ulna alignment, preventing redislocation.

Supracondylar Fracture Flexion

Q: What happens if you flex a supracondylar fracture without first applying traction?
A: Neurovascular structures anteriorly kink, risking injury.
Related Pearl: Applying traction before flexion prevents neurovascular compromise during manipulation.

Posteromedial Supracondylar Fracture Immobilization

Q: How should a posteromedially displaced supracondylar fracture be immobilized?
A: In pronation to hinge on the intact medial side.
Related Pearl: Lateral collateral ligaments are assumed completely torn; pronation protects the intact medial hinge.

Posterolateral Supracondylar Fracture Immobilization

Q: How should a posterolaterally displaced supracondylar fracture be immobilized?
A: In supination due to medial side tear.
Related Pearl: Supination protects the injured medial collateral ligament and maintains stability.

Supracondylar Fracture Immobilization Duration

Q: What is the maximum recommended immobilization time for supracondylar fractures?
A: Immobilization beyond 4 weeks is probably excessive; 6 weeks risks stiffness.
Related Pearl: Early mobilization reduces joint stiffness and improves functional outcomes.

Cubitus Varus Correction Failure

Q: What is the most common cause of failure to correct cubitus varus with supracondylar osteotomy?
A: Inadequate correction of medial rotation.
Related Pearl: Rotational deformity correction is as important as angular correction to prevent recurrence.

Post-Traumatic Radioulnar Synostosis

Q: What factors increase the risk of post-traumatic radioulnar synostosis?
A: Open reduction and proximal fracture location.
Related Pearl: Minimizing soft tissue disruption during surgery reduces synostosis risk.

Q: When is resection of radioulnar synostosis recommended?
A: After waiting 1-2 years post-injury.
Related Pearl: Early resection risks recurrence; delayed surgery improves functional outcomes.

Mallet Deformities in Children

Q: What type of injury causes mallet deformities in 5-year-old children?
A: Salter I or II injuries.
Related Pearl: Younger children have more cartilaginous physes, influencing injury pattern and prognosis.

Q: What type of injury causes mallet deformities in older children?
A: Salter III injuries.
Related Pearl: Older children have more ossified physes, leading to intra-articular fractures.

Distal Phalanx Epiphyseal Separations

Q: Where do the flexor and extensor tendons insert in distal phalanx epiphyseal separations?
A: Flexor tendons insert into the metaphysis; extensor tendons insert into the epiphysis.
Related Pearl: This anatomical detail explains why mallet fingers are typically Salter I or II injuries.

Camptodactyly Management

Q: How should camptodactyly of 30 degrees correctable with MCP flexion be initially treated?
A: With dynamic splinting.
Related Pearl: Dynamic splinting targets abnormal lumbrical insertion causing the deformity and can improve correction without surgery.

Classic Clinical Notes

• The most common reason for supracondylar osteotomy following malunion and gunstock deformity is cosmetic.

• The best treatment for Monteggia fracture is to do a closed reduction of ulna, closed reduction of radial head, then cast.

• Lateral condyle fracture missed and seen at 3 weeks – probably fix it.

• A child with open growth plates who sustains an anterior shoulder dislocation has a nearly 90% chance of having recurrent dislocations.

• For a proximal humerus fracture with greater than 25 degrees of angulation near skeletal maturity – should probably do something.

• Most common site of osteochondritis dessicans in the elbow is the capitellum. X-ray changes are confined to the capitellum until joint becomes arthritic. Rarefaction, fragmentation, irregular ossification, and a localized crater defect can be seen. The articular surface may look irregular. Occasionally, the radial head looks a bit bigger than the other side.

• Fixation of a medial epicondyle fracture is indicated if displaced > 1 cm, if ulnar nerve symptoms present, if trapped within the joint, or if valgus instability is present.

• The most important radiographic aid in determining what is broken in elbow fractures is to line up the capitellum with the radial head.

• For the posterior dislocation of the radial head with ulna fracture (Bado II) – treat with reduction and then immobilization in EXTENSION and PRONATION. Most (Bado I) are treated in flexion and supination.

• If you flex a supracondylar fracture without first applying traction – you’ll kink the neurovascular structures anteriorly.

• For the posteromedially displaced supracondylar fracture – assume that the lateral structures are totally torn. So when immobilizing, you want to pronate them to hinge on the intact medial side.

• For posterolateral displaced supracondylar fracture – assume the medial side is torn – immobilize in supination.

• Immobilization of a supracondylar fracture for more than 4 weeks is probably too much – they might get stiff if left in for 6 weeks.

• Failure to correct cubitus varus with supracondylar osteotomy is most often due to inadequate correction of the medial rotation.

• For post-traumatic radioulnar synostosis, they are more common with open reduction, more likely with proximal fractures, and can be resected but only after waiting 1-2 years.

• Mallet deformities in a 5 year old are caused by salter I or II injuries. In older children, they end up being salter III injuries.

• In epiphyseal separations of the distal phalanx of the finger, it is important to know that the flexor tendons insert into the metaphysis, and the extensor tendons into the epiphysis (hence Mallet fingers are salter I or II injuries).

• Camptylodactyly of 30 degrees of the hand that is correctable with MCP flexion (indicating abnormal lumbrical insertion) should be treated initially with dynamic splinting. ???

Last Updated on January 25, 2026 by orthonet