Paediatrics - Warm Up

Question 1

1. Which of the following are true of non-accidental injury (NAI):
   a) Cerebral injury from shaking is most common over 2 years of age
   b) Diaphyseal fractures are more common than metaphyseal fractures
   c) Multiple rib fractures are highly suspicious of NAI
   d) Interhemispheric subdural haematoma is an atypical finding
   e) Spiral fracture of the tibia is highly suspicious

Answer 1

1.
a) False
b) True - overall, diaphyseal fractures are more common
c) True
d) False - interhemispheric subdural haematoma is a recognized feature
e) False - commonly occurs secondary to trivial twisting injuries

Question 2

2. Meckel’s diverticulum:
   a) Is the most common congenital anomaly of the gastrointestinal tract
   b) Represents failure of closure of the omphalomesenteric duct
   c) Is more common in males
   d) Most symptomatic cases arise in childhood
   e) Gastrointestinal bleeding is the most common complication

Answer 2

2.
a) True
b) True
c) False - equal sex incidence, but symptoms predominate in males
d) True - 60% by 10 years of age
e) True - intestinal obstruction is the second commonest

Question 3

@# 3. Paediatric intussusception:
a) Accounts for over 75% of paediatric intestinal obstruction
b) Typically occurs between 4-8 years of age
c) Plain films are typically abnormal
d) A lead point is identified in over 50% of cases
e) Pneumoperitoneum is a contraindication to air reduction

Answer 3

3.
a) True
b) False - highest incidence between 3 months and 4 years of age
c) False - plain films may be normal in up to 50%
d) False - in children, 95% are idiopathic, with no lead point
e) True - as are peritonitis and hypotension

Question 4

@# 4. Childhood rhabdomyosarcoma:
a) Is the most common soft tissue sarcoma in children
b) Is the most common pelvic malignant neoplasm in children
c) Genitourinary tumours account for 25% of cases
d) Orbital tumours are highly malignant
e) T2 weighted MRI is ideal for assessing tumours of prostatic origin

Answer 4

4.
a) True
b) True
c) True
d) False - non-invasive, with a good prognosis
e) False - tumours are hyperintense on T2 sequences, and may be obscured by adjacent high
signal urine

Question 5

5. Regarding Vesico-ureteric reflux:
   a) UTI is more common in male neonates
   b) Renal scarring is related to the degree of Vesico-ureteric reflux
   c) Radionuclide imaging may provide the diagnosis
   d) Posterior urethral valves represent vestiges of the Wolffian duct
   e) Hypertension is a known complicat

Answer 5

5.
a) True
b) True
c) True
d) True
e) True

Question 6

@# 6. Prune belly syndrome:
a) The bladder is hypoplastic
b) Is associated with abdominal wall deficiency
c) Is accompanied by cryptorchidism in males
d) Ureters are of normal calibre on IVU
e) Pulmonary hypoplasia is a complication

Answer 6

6.
a) False - large, distended bladder
b) True - with cryptorchidism, distended bladder and dilated ureters
c) True
d) False
e) True

Question 7

@# 7. Medullary calcification of the kidneys occurs in:
a) Hyperparathyroidism
b) Renal tubular acidosis
c) Pseudohyperparathyroidism
d) Medullary sponge kidney
e) Chronic glomerulonephritis

Answer 7

7.
a) True
b) True
c) False
d) True
e) False - cortical nephrocalcinosis

Question 8

8. Radiological features of achondroplasia include:
   a) Decreased interpedicular distance caudally within the spine
   b) Short ribs
   c) Dilatation of the lateral cerebral ventricles
   d) Anterior vertebral scalloping
   e) Relative shortening of the fibula

Answer 8

a) True
b) True
c) True - a narrow foramen magnum may cause obstructive hydrocephalus
d) False - posterior vertebra! scalloping
e) False - relative lengthening of the fibula

Question 9

@# 9. Slipped upper femoral epiphysis:
a) Is seen typically between 4-8 years of age
b) is bilateral in one third of cases
c) The Line of Klein should intersect the normal femoral head
d) The epiphysis slips posteromedially
e) Subchondral lucency is an early sign

Answer 9

a) False - typically 8-17 years of age
b) True
c) True
d) True
e) False - an early sign of Perthes’ disease

Question 10

@# 10. The radiological features of pyknodysostosis include:
a) Limb overgrowth
b) Multiple wormian bones
c) Reduced bone density
d) Resorption of the lateral end of the clavicle
e) Tapered distal phalanges

Answer 10

10.
a) False - short limbs
b) True
c) False - increased bone density
d) True
e) True

Question 11

@# 11. Regarding normal skeletal variants:
a) Bipartite patella typically involves the upper outer quadrant
b) The medial humeral epicondyle ossification centre appears after the lateral epicondyle
c) A prominent anterior fat pad indicates intra-articular injury
d) The scaphoid bone is the first carpal bone to ossify
e) Os radiale externum is the commonest supernumary bone around the wrist

Answer 11

11.
a) True
b) False - medial at 5 years, lateral at 13 years
c) False - a normal variant in up to 15%
d) False - capitate and hamate ossify in the 1st year; scaphoid in the 6th year
e) True

Question 12

@# 12. Multiple wormian bones are a feature of:
a) Rickets
b) Osteogenesis imperfecta
c) Down’s syndrome
d) Hypothyroidism
e) Chondrodysplasia punctata

Answer 12

12.
a) True
b) True
c) True
d) True - also in pyknodysostosis, kinky hair syndrome, cleidocranial dysostosis,
hypophosphatasia
e) False

Question 13

13. The following are CNS features of tuberous sclerosis:
    a) Presentation is usually with seizures
    b) Subependymal nodules are most common in the occipital horns of the lateral ventricles
    c) Cortical tubers are most prominent on T1 weighted MRI
    d) Pilocytic astrocytoma is a complication
    e) Calcification may be seen in up to 50% on skull X-ray

Answer 13

13.
a) True - myoclonic seizures in 80-100%
b) False - ventricular surface of the caudate nucleus
c) False - T2 weighted and FLAIR sequences
d) False - giant cell astrocytoma
e) True

Question 14

@# 14. Retinoblastoma:
a) Is the most common intra-ocular malignancy in childhood
b) Ultrasound demonstrates a hypoechoic mass in the posterior globe
c) CT shows calcification in 90%
d) Is associated with pineoblastoma
e) Is bilateral in 66%

Answer 14

14.
a) True
b) False - hyperechoic mass within the globe
c) True
d) True - the trilateral retinoblastoma
e) True

Question 15

15. Causes of perinatal hydrocephalus include:
    a) Aqueduct stenosis
    b) Toxoplasmosis
    c) Intraventricluar haemorrhage
    d) Vein of Galen aneurysm
    e) Choroid plexus papilloma

Answer 15

15.
a) True
b) True
c) True
d) True
e) True

Question 16

16. Regarding spinal anomalies:
    a) The conus medullaris should reach the adult position by 12 weeks of age
    b) Tethered cord is usually an isolated spinal anomaly
    c) A filum measuring 3 mm is within normal limits
    d) Neurofibromatosis is the commonest cause of developmental scoliosis
    e) Myelomeningocele is usually associated with a Chiari I malformation

Answer 16

16.
a) True
b) False - often associated with intraspinal abnormalities
c) False - 2 mm at the L5/S1 level is considered thickened
d) True
e) False - Chiari II malformation

Question 17

@# 17. Regarding pancreatic development:
a) The tail, body and neck of the pancreas develop in the dorsal mesogastrium
b) The ventral pancreatic bud forms the uncinate process
C) The accessory pancreatic duct drains into the duodenum distal to the Ampulla of Vater
D) Annular pancreas is associated with Turner’s syndrome
E) Pancreas divisum predisposes to chronic pancreatitis

Answer 17

17.
a) True
b) True
c) False - proximal to the Ampulla of Vater
d) False - Down’s syndrome, oesophageal atresia, imperforate anus, malrotation
e) True

Question 18

18. In imaging of intussusception:
    a) Plain radiographs can exclude the diagnosis
    b) Small bowel (ileo-ileal) intussusception is usually due to a malignant cause
    c) A target sign is seen on ultrasound
    d) Ultrasound is highly sensitive and specific in the paediatric population
    e) Air enema reduction should not exceed 120 mmHg

Answer 18

18.
a) False
b) False - usually benign aetiology, e.g. polyp, lipoma, coeliac disease
c) True
d) True
e) True

Question 19

19. Regarding abdominal cystic lesions in the newborn:
    a) Enteric duplication cysts typically communicate with the bowel lumen
    b) Duplication cysts are a known cause of gastrointestinal haemorrhage
    c) Meconium pseudocyst is usually calcified
    d) Choledochal cysts are associated with biliary atresia
    e) Fluid-debris levels are typical of haemorrhage into an ovarian cyst

Answer 19

19.
a) False
b) True - 10-20% contain ectopic gastric mucosa
c) True
d) True
e) True

Question 20

20. In imaging suspected acute appendicitis:
    a) The appendix is retrocaecal in one third of cases
    b) On ultrasound, luminal diameter of 8 mm is normal
    c) An inflamed appendix, if visualised, is usually non-compressible
    d) Pseuodcyst peritoneii is a complication of appendiceal obstruction
    e) A normal ultrasound excludes appendicitis as a diagnosis

Answer 20

20.
a) False - 15% of cases
b) False - >6 mm is abnormal
c) True
d) True
e) False

Question 21

21. Gallstones in the paediatric population may be secondary to:
    a) Sickle cell disease
    b) Cystic fibrosis
    c) Crohn’s disease
    d) Ileal resection
    e) Total parenteral nutrition

Answer 21

21.
a) True
b) True
c) True
d) True
e) True

Question 22

@# 22. Concerning congenital diaphragmatic hernias:
a) Most congenital hernias are of the Morgagni type
b) Bochdalek hernias are usually left-sided
c) Defective closure of the pleuroperitoneal membranes leads to a Bochdalek hernia
d) Right-sided hernias may have a delayed presentation
e) Congenital cystic adenomatoid malformation is a differential diagnosis

Answer 22

22.
a) False - 85-90% are Bochdalek hernias
b) True
c) True
d) True
e) True

Question 23

23. Congenital bronchial atresia:
    a) Bronchial development occurs during the 1st trimester
    b) Bronchial atresia leads to distal air trapping
    c) The right upper lobe is most commonly affected
    d) Other congenital anomalies are frequently associated
    e) A bronchocoele tends to radiate out from the hilar region

Answer 23

23.
a) True
b) True
c) False - left upper lobe in 64%
d) False - an incidental finding in 50%, and usually isolated
e) True

Question 24

24. Regarding congenital lobar emphysema:
    a) it commonly affects the lower lobes
    b) Bilateral involvement is rare
    c) Underlying vascular markings are present
    d) The affected lobe is opaque after birth
    e) It typically presents in the perinatal period

Answer 24

24.
a) False - lower lobes in only 2%. Left upper lobe most commonly
b) True
c) True
d) True
e) False - in 25%, presentation is delayed

Question 25

@# 25. Regarding normal lung anatomy:
a) The azygous fissure contains 2 layers of pleura
b) The inferior accessory fissure separates the medial and anterior basal segments of a lower
lobe
c) The right pulmonary artery passes posterior to the right main bronchus
d) The left superior pulmonary vein lies directly anterior to the left pulmonary artery
e) The anterior junctional line extends above the clavicles

Answer 25

25.
a) False - 4 layers
b) True
c) False - anterior
d) False - the bronchial tree lies in between the two structures
e) False - posterior junctional line

Question 26

@# 26. In bronchopulmonary sequestration:
a) Intralobar sequestration typically presents in the neonatal period
b) Sequestered segments have delayed contrast enhancement on dynamic CT scanning
c) The condition may be diagnosed antenatally
d) Intralobar sequestered segments are covered by visceral pleura
e) There is usually communication with the bronchial tree

Answer 26

26.
a) False - later presentation is typical, with 50% asymptomatic
b) False - early or normal enhancement
c) True
d) True
e) False - communication may occur following infection

Question 27

@# 27. Concerning mediastinal masses in childhood:
a) Lymphomatous hilar lymph node enlargement usually occurs without mediastinal
involvement
b) Paracardiac lymph nodes are a common site for primary hematological malignancy
c) Bronchogenic cysts are usually solitary
d) Pericardial cysts usually arise from the right cardiophrenic angle
e) Malignant teratomas are more common than benign teratomas

Answer 27

27.
a) False - rare without mediastinal involvement
b) False - an important site of lymph node recurrence
c) True
d) True
e) False - benign cystic teratomas are the commonest mediastinal germ cell tumour

Question 28

@# 28. The following are features of cystic fibrosis:
a) Meconium ileus is the most common mode of presentation
b) Lung involvement predominates in the lower zones
c) Skull X-ray shows generalised hypoplasia of the paranasal sinuses
d) There is a known association with situs inversus
e) Contrast enemas are often therapeutic with meconium ileus

Answer 28

28.
a) False - only 10-15% of cases present this way
b) False - upper zone predominance
c) False - frontal sinus hypoplasia. The remainder are normal
d) False - situs inversus and bronchiectasis are part of the immotile cilia syndrome
e) True

Question 29

29. Regarding lung disease in premature neonates:
    a) Respiratory distress syndrome is due to delayed clearance of lung fluid
    b) Chest X-ray demonstrates hyperinflation of the lungs
    c) Bilateral extensive consolidation is a feature
    d) Mechanical ventilation is associated with pulmonary interstitial emphysema
    e) Pulmonary interstitial emphysema may be unilateral

Answer 29

29.
a) False - respiratory distress syndrome is due to surfactant deficiency
b) False - underexpansion is typical
c) True
d) True
e) True

Question 30

@# 30. Causes of symmetrical periosteal reaction in childhood include:
a) Leukaemia
b) Juvenile idiopathic arthritis
c) Caffey’s disease
d) Rickets
e) Scurvy

Answer 30

30.
a) True - due to cortical involvement by tumour cells
b) True - in 25%
c) True - Caffey disease (Infantile cortical hyperostosis) is an osteosclerotic dysplasia characterized by acute inflammation with massive subperiosteal new bone formation usually involving the diaphyses of the long bones, as well as the ribs, mandible, scapulae, and clavicles
d) True
e) True

Question 31

31. Regarding hypoplastic left heart syndrome:
    a) Prenatal diagnosis is possible
    b) Pulmonary oligaemia is a feature
    c) The cardiac silhouette is small
    d) An ASD is commonly present
    e) Aortic coarctation is associated

Answer 31

31.
a) True
b) False - pulmonary venous hypertension
c) False - enlarged cardiac silhouette, notably the right atrium
d) True
e) True

Question 32

@# 32. Concerning the paediatric parotid gland:
a) The parotid gland is hyperechoic to muscle on ultrasound
b) Branchial cysts most often develop from the second branchial pouch
c) Parotid haemangiomas are usually hypoehoic on ultrasound
d) Warthin’s tumours are bilateral in 25-50%
e) Warthin’s tumours are poorly defined masses

Answer 32

32.
a) True
b) True
c) True
d) False - only 10% are bilateral
e) False - well circumscribed, homogenous masses

Question 33

33. Radiological features of Wilms’ tumours include:
    a) At CT, the tumour enhances to a greater degree than the surrounding renal parenchyma
    b) The tumour is hyperintense on T2 weighted MRI
    c) The tumour displaces midline structures
    d) Calcification is seen in up to 15% at CT
    e) Calcification, when present, tends to be curvilinear

Answer 33

33.
a) False - lesser degree to surrounding renal parenchyma
b) True - isointense to renal parenchyma on T1 sequences
c) True
d) True
e) True

Question 34

34. Regarding ischaemic stroke in children:
    a) Intraparenchymal haemorrhage is usually spontaneous
    b) Cerebral MR changes are common in sickle cell disease
    c) Arterial dissection is rare
    d) Varicella zoster infection predisposes to basal ganglia infarcts
    e) Intracranial aneurysms are rare

Answer 34

34.
a) False - 70% have an underlying cause
b) True
c) False - this is a leading cause of paediatric stroke
d) True
e) True

Question 35

35. Regarding congenital anomalies of the oesophagus:
    a) The oesophagus and trachea are a single tube during early foetal life
    b) Oesophageal atresia with a distal fistula is the most common form of atresia
    c) Atelectasis and right upper lobe pneumonia are seen in 50% of oesophageal atresia
    d) Oesophageal duplication is more common than ileal duplication
    e) Aberrant right subclavian artery causes an anterior oesophageal impression on barium
    swallow examination

Answer 35

35.
a) True - failure of division leads to tracheo-oesophageal fistula
b) True
c) True
d) False - ileal duplications are more common
e) False - posterior impression

Question 36

@# 36. In duodenal atresia:
a) The double bubble sign may be seen on ultrasound examination
b) The double bubble sign is specific for duodenal atresia
c) Polyhydramnios is typical in the 3rd trimester
d) Over 50% are associated with Down’s syndrome
e) Bowel gas is not seen distal to the atretic segment

Answer 36

36.
a) True - plain film, ultrasound and contrast studies may show this sign
b) False - also seen in duodenal stenosis, annular pancreas, preduodenal portal vein
c) True
d) False - one third are associated with trisomy 21
e) False - this may occur with a bifid CBD insertion

Question 37

@# 37. Causes of dense metaphyseal bands include:
a) Normal variant
b) Treated leukaemia
c) Healing rickets
d) Lead toxicity
e) Hypervitaminosis D

Answer 37

37.
a) True
b) True
c) True
d) True
e) True

Question 38

@# 38. Regarding congenital cardiac anomalies:
a) A left-sided SVC drains into the left atrium
b) A patent ductus arteriosus arises proximal to the left subclavian artery
c) In pulmonary artery sling, the aberrant left pulmonary artery passes between the trachea
and oesophagus
d) An aortopulmonary window connects the descending thoracic aorta to the pulmonary trunk
e) Ebstein anomaly affects the tricuspid valve

Answer 38

38.
a) False - drains into the right atrium via the coronary sinus
b) False - distal to the right subclavian artery
c) True
d) False - ascending thoracic aorta to the pulmonary trunk
e) True

Question 39

39. Jaundice in childhood:
    a) Physiological jaundice occurs in 60% of term infants
    b) Gallbladder length may normally exceed that of the adjacent kidney
    c) The normal paediatric pancreas is iso- to hyperechoic compared to the liver
    d) With biliary atresia, the intrahepatic bile ducts are dilated
    e) On hepatobiliary scintigraphy, some small bowel activity may be seen in mild cases of
    biliary atresia

Answer 39

39.
a) True
b) False
c) True
d) False
e) False - bowel activity excludes biliary atresia

Question 40

40. Causes of pulmonary plethora in the newborn include;
    a) Transposition of the great arteries
    b) Total anomalous pulmonary venous return
    c) Tetralogy of Fallot
    d) Pulmonary atresia
    e) Patent ductus arteriosus

Answer 40

40.
a) True
b) True
c) False - pulmonary oligaemia
d) False
e) True

Question 41

@# 41. Medulloblastoma:
a) Is the most common paediatric CNS malignancy
b) Typically has a brief history (< 3 months)
c) Typically arises within the cerebellar hemispheres
d) Is usually hypodense on pre-contrast CT
e) Post-contrast shows heterogenous enhancement

Answer 41

41.
a) True
b) True
c) False - cerebellar vermis
d) False - 89% show some degree of hyperattenuation pre-contrast
e) True

Question 42

@# 42. Regarding Sturge-Weber syndrome:
a) It involves a port-wine stain affecting the trigeminal nerve distribution
b) It is accompanied by leptomeningeal angiomas on the contralateral side
c) Underlying cortical calcification is common
d) Angiomas are more common over the frontotemporal regions
e) Cortical gliosis is a feature

Answer 42

42.
a) True
b) False - ipsilateral side
c) True
d) False - parieto-occipital region
e) True

Question 43

43. Regarding calvarial masses in childhood:
    a) The skull is the most common bone involved in Langerhans’ cell histiocytosis
    b) Sclerosis does not occur in Langerhans’ cell histiocytosis
    c) Monostotic fibrous dysplasia does not affect the skull
    d) Neuroblastoma metastases rarely spread to the skull vault
    e) Osteomas frequently arise from both the inner and outer calvarium

Answer 43

43.
a) True
b) False - sclerosis at the edge of lesions may be seen posttreatment
d) False - both poly and monostotic fibrous dysplasia may affect the skull
e) False - a common site of metastatic involvement
f) False - rarely arise from the inner table

Question 44

44. The radiological features of hepatocellular carcinoma include:
    a) Calcification in up to 50% of cases
    b) Portal vein involvement suggests an alternative diagnosis
    c) Bone marrow metastases tend to be expansile
    d) The tumour enhances during the arterial phase on dynamic CT
    e) Signal drop out is typical with ‘in and out of phase’ MRI

Answer 44

44.
a) False - up to 12% calcify
b) False
c) True
d) True
e) False - fatty change occurs in only 10%, hence signal drop out unlikely (unlike hepatic
adenoma)

Question 45

45. Concerning anatomy and pathology of the orbit:
    a) The optic foramen is formed by the greater wing of the sphenoid bone
    b) The orbital margin is formed by the zygomatic, frontal and maxillary bones
    c) Orbital pseudotumour frequently causes bone erosion
    d) Orbital lymphoma typically affects the lacrimal gland
    e) The lacrimal gland occupies a superolateral position within the orbital cavity

Answer 45

45.
a) False - lesser wing of sphenoid
b) True
c) False
d) True
e) True

Question 46

@# 46. Features of dysostosis multiplex include:
a) Calvarial thickening
b) J shaped sella
c) Narrow anterior rib ends
d) Odontoid hypoplasia
e) Dysplastic femoral heads

Answer 46

46.
a) True
b) True
c) False - narrow posterior ribs, with wide anterior rib ends
d) True
e) True

Question 47

47. Radiological features of Turner’s syndrome (XO) include:
    a) Tall stature
    b) Shortened 5th metacarpal
    c) Madelung’s deformity
    d) Enlarged medial femoral condyle
    e) Osteoporosis

Answer 47

47.
a) False - short stature
b) False - short 4th metacarpal
c) True
d) True
e) True

Question 48

48. Regarding choledochal cysts:
    a) They usually involve the cystic duct and gallbladder
    b) There is normal orientation of the distal CBD and pancreatic duct
    c) There is an association with gallbladder anomalies
    d) The cyst does not communicate with common and intrahepatic ducts
    e) There is increased incidence of cholangiocarcinoma

Answer 48

48.
a) False
b) False - abnormal orientation is frequent
c) True
d) False - the cyst is in continuity with common and intrahepatic ducts
e) True

Question 49

49. Regarding thyroglossal duct cysts:
    a) The thyroglossal tract passes posterior to the hyoid bone
    b) They are most commonly midline masses
    c) Most are suprahyoid in location
    d) Cysts are hypointense on T1 weighted MRI
    e) Uncomplicated (non-inflamed) cysts do not enhance

Answer 49

49.
a) False - anterior to the hyoid bone
b) True - 75% are midline
c) False - most are infrahyoid
d) True
e) True

Question 50

@# 50. Regarding brain development:
a) Adult sulcal pattern is obtained by 38 weeks gestation
b) On T2 weighted MRI, white matter maturation is seen as a reduction in signal intensity
c) Thinning of the corpus callosum is pathological
d) Myelination progresses uniformly throughout the brain
e) On MRI, the basilar cisterns remain prominent during infancy

Answer 50

50.
a) False - the sulci are formed, but will continue to obtain increasing depth
b) True
c) False - thinning between posterior body and splenium is a normal variant
d) False - pathways undergoing use mature first (e.g. motor pathways)
e) True