Pediatrics Flashcards
1
Q
- In children with spastic cerebral palsy, which intervention strengthens weak muscles? (a) Ankle-foot orthotics (b) Tendon transfer surgery (c) Intrathecal baclofen (d) Functional training program
A
- (d) Children with cerebral palsy often have weakness as part of their disorder. Treatments such as bracing, tendon lengthening or transfers, and medications such as botulinum toxin or intrathecal baclofen add to this weakness. Strengthening programs or functional training programs can help to strengthen weak muscles.
2
Q
- One of your 4-year-old patients exhibits the following characteristics: distress over minor changes in environment, echolalia, lack of awareness of the existence of feelings in others, nonparticipation in simple games. The most likely diagnosis is
(a) autism.
(b) cerebral palsy.
(c) hearing impairment.
(d) mental retardation.
A
- (a) Autism is characterized by echolalia, inability to play reciprocally, and abnormal relationships with people. While children with mental retardation, cerebral palsy, and hearing impairment may have some of these features, they do not have all of them in the absence of autism.
3
Q
- Which finding is normal in newborn infants?
(a) Extensor tone predominates
(b) Hands are kept fisted
(c) Spine is straight when held in sitting position
(d) Unable to turn head to side in prone position
A
- (b) In normal newborn infants flexor tone predominates and hands are kept fisted. In prone position a
normal newborn is able to turn the head to either side. The newborn has a rounded spine when
placed in supported sitting.
4
Q
- The family of your 10-year-old patient who had a severe traumatic brain injury 6 weeks ago asks you
if they may feed their son. You observe that he is agitated at times, has a hoarse voice, and drools.
You try to feed him applesauce and notice that he seems to swallow part of it and does not cough.
The most likely finding on the videofluoroscopic feeding study will be
(a) Silent aspiration.
(b) Reflux.
(c) Coughing and gagging.
(d) Normal swallow.
A
- (a) The lack of coughing in a patient with neurologic impairment when he/she is presented with food
may mean a normal swallow, but is more likely to mean silent aspiration. A normal
videofluoroscopic swallowing study is unlikely in a patient with a traumatic brain injury (TBI) who
is drooling and hoarse. Hoarseness may be a sign of reflux, but in a child with a TBI it is more
likely to mean vocal cord abnormality.
5
Q
- Which measure is the first sign of respiratory muscle dysfunction in boys with Duchenne muscular
dystrophy?
(a) Vital capacity
(b) Oxygen saturation
(c) Maximal expiratory force
(d) Negative inspiratory force
A
- (c) Recent studies by McDonald and by Bach showed that reduction of maximal expiratory force
(MEF) to 40%–60% of normal in the 7- to 14-year-old age group was the first sign of respiratory
muscle dysfunction in boys with Duchenne muscular dystrophy (DMD). The earlier and more
severe decreases of MEF that are greater than the decreases in maximal inspiratory force,
correspond to the clinically observed weakness of abdominal muscles, which like coughing are
important in forced expiration. Vital capacity was not found to decrease until an average of 15–16
years. Low oxygen saturation is a late manifestation in DMD, developing after hypercapnia.
6
Q
- A 10-year-old child with L4-5 myelodysplasia and shunted hydrocephalus develops spasticity in her
legs. The most likely cause of this spasticity is
(a) shunt malfunction.
(b) symptomatic Chiari malformation.
(c) growth.
(d) tethered cord.
A
- (d) Tethered cord is the most common cause of new onset spasticity in patients with myelodysplasia.
Linear growth does not cause new spasticity. Symptoms of Chiari malformation include cranial
nerve disorders and respiratory problems. Shunt malfunction may be associated with headaches,
vomiting, eye muscle abnormalities, and sometimes abdominal symptoms.
7
Q
- A 9-year-old girl with an L1 ASIA class A spinal cord injury that occurred at age 5 years presents in
your office with a 1-day history of a swollen left leg. History is that she woke up with the swollen
leg the day before. There is no history of trauma, fever, or shortness of breath. On examination, you
find a prepubertal girl in no distress with normal vital signs. Upper extremities are normal. Lower
extremities have moderate spasticity and no voluntary movement. Skin is normal. The left leg is
warm and swollen from the ankle to the knee. There is no sensation in the legs. Which test is most
likely to yield the correct diagnosis?
(a) Bone scan
(b) Plain radiograph
(c) Venous Doppler study
(d) White blood cell count with differential
A
- (b) Deep venous thromboses (DVTs) which can be diagnosed by Doppler study usually occur in the
first 3 months after spinal cord injury (SCI) and are rare in prepubertal children. In lower leg DVTs
the foot and leg are usually swollen. Heterotopic ossification (HO), which can be detected by bone
scan, occurs in about 3% of children with SCI and has onset an average of 14 months after injury.
Heterotopic ossification most commonly involves the hip. Cellulitis is usually associated with skin
lesions and usually involves a discrete area. A fracture is the most likely cause of swelling in this
case and can be diagnosed by plain radiographs.
8
Q
- Which positive effect of ankle-foot orthotics has been proven beneficial in the treatment of children
with cerebral palsy?
(a) Improved gait efficiency as measured by gait analysis
(b) Prevention of contractures
(c) Improved knee extensor strength
(d) Decreased plantar flexor posture
A
- (a) There are no large, randomized, controlled studies that show the long-term effects of any type of
Ankle-Foot Orthosis (AFO) on function or contracture formation. Small studies have shown that
both rigid and hinged AFOs improve gait efficiency by preventing plantar flexion.
9
Q
- Juvenile rheumatoid arthritis (JRA) differs from adult onset rheumatoid arthritis: in JRA
(a) joint destruction occurs earlier.
(b) large joint involvement is less frequent.
(c) the cervical spine is involved less frequently.
(d) systemic features are more common.
A
- (d) Children with juvenile rheumatoid arthritis are more likely to have systemic features, have large
joints involved, and have cervical spine involvement. Adults with rheumatoid arthritis have joint
destruction earlier.
10
Q
- Children with which physical disorder tend to have higher verbal skills compared to overall
cognitive ability?
(a) Muscular dystrophy
(b) Myelodysplasia
(c) Cerebral palsy
(d) Autism
A
- (b) Children with myelodysplasia have deceptively good verbal facility that creates the impression of
higher intellectual functioning than is found on formal testing (“cocktail party syndrome”).
Children with cerebral palsy, autism, and muscular dystrophy do not typically demonstrate this
finding.
11
Q
- Your 10-year old patient with T6 ASIA class B paraplegia complains of right knee pain. On
examination there is no swelling of the knee or leg. Knee examination is normal. The right leg
appears shorter when the hips and knees are flexed. What is the most likely cause of these findings?
(a) Knee sprain
(b) Right hip subluxation
(c) Hip adductor spasticity
(d) Dysesthetic pain
A
- (b) Hip subluxation is the most likely cause of knee pain in a child with T6 ASIA B SCI. Pain from
hip pathology is often referred to the knee in children. While hip adductor spasticity contributes to
subluxation or dislocation, the spasticity itself is not painful. Dysesthetic pain is usually
generalized. An abnormal knee examination is usually found in a knee injury that causes pain.
12
Q
- A 16-year-old girl who had a severe traumatic brain injury 4 weeks ago with left frontal contusion
and left basilar skull fracture demonstrates worse auditory than visual attention. Which diagnostic
test would be most likely to explain this finding?
(a) Magnetic resonance imaging
(b) Electroencephalogram
(c) Audiogram
(d) Visual evoked response
A
- (c) A basilar skull fracture is often associated with a permanent sensorineural hearing loss. Other
traumatic brain injuries may be associated with hearing loss, but this is less common. All patients
with basilar skull fracture should be assumed to have a hearing loss and have audiological
evaluation as soon as possible.
13
Q
- What condition casues the typical “myopathic gait” seen in a young boy with Duchenne muscular
dystrophy with accentuated lumbar lordosis and toe walking?
(a) Hip and knee extensor weakness
(b) Hip flexion and ankle plantar flexion contractures
(c) Hip extensor weakness and plantar flexion contracture
(d) Hip flexion contracture and knee extensor weakness
A
- (a) The typical “myopathic gait” seen in early Duchenne muscular dystrophy is caused by weakness of the gluteus maximus and quadriceps muscles. In order to maintain upright posture the child
assumes the hyperlordotic stance. Contractures of the gastrocsoleus and iliopsoas muscles occur
later in the disorder.
14
Q
- In which type of cerebral palsy is a seizure disorder most commonly seen?
(a) Tetraplegia
(b) Diplegia
(c) Athetosis
(d) Hemiplegia
A
- (d) Approximately 70% of children with hemiplegia have seizures. About 50% of children with
tetraplegic cerebral palsy have seizures. Seizures are rare in children with diplegia or athetosis.
15
Q
- A 1-year-old child with a midlength transfemoral limb deficiency presents for prosthetic
management. Which component should be in the prosthetic prescription?
(a) Socket with a growth liner
(b) Single action knee joint
(c) Vertical shock pylon
(d) Dynamic foot
A
- (a) The 1-year-old child should be fit with a simple prosthesis which suspends securely and allows for growth. The knee joint should be added between 3 and 5 years. The SACH foot is most commonly
prescribed because of its simple design and durability. All prostheses for growing children should
incorporate a removable growth liner in the socket.
16
Q
- A 2-year-old patient with spinal muscular atrophy type 2 (intermediate form) presents with a 25°,
C-shaped scoliosis. What is the best treatment option at this time?
(a) Muscle strengthening
(b) Electrical stimulation
(c) Spinal fusion
(d) Spinal orthosis
A
- (d) Muscle strengthening will not reduce the curve or prevent it from progressing and is not easily
accomplished in 2-year-old children. Posterior or anterior spinal fusion is not indicated with a
curve of this size and is to be avoided in a young child if at all possible. Spinal orthotics are used in
young children with spinal muscular atrophy to improve sitting balance and to attempt to halt curve
progression.
17
Q
- The most common spinal problem seen with achondroplasia during childhood is
(a) kyphosis.
(b) scoliosis.
(c) spinal stenosis.
(d) low back pain.
A
- (a) While scoliosis may occur in children with achondroplasia, it is less common than kyphosis, which
begins in infancy. Spinal stenosis occurs frequently in individuals with achondroplasia, with 38
years being the average age of symptom onset. Low back pain is extremely frequent in adults with
achondroplasia, but rare in children. Progressive kyphosis that occurs in infants and young children
with achondroplasia is treated with a spinal orthosis.
18
Q
- In which activity should a 16-year-old girl with C5 ASIA class A spinal cord injury be
independent with the use of assistive devices?
(a) Self catheterization
(b) Transfers to level surfaces
(c) Self feeding
(d) Bathing
A
- (c) While boys with C5 spinal cord injury (SCI) may learn to perform bladder self-catheterization with assistive devices, girls do not. Level transfers require active elbow and wrist extension, which
would not be present in a person with C5 SCI. Self-feeding with assistive devices such as a palmar
band can usually be done by persons with C5 tetraplegia.
19
Q
- Your 6-month-old patient had burns to his head and both arms in a house fire. What approximate
percent of his total body surface area (TBSA) was burned?
(a) 37
(b) 18
(c) 27
(d) 49
A
- (a) An infant’s head is approximately 19% and each arm constitutes 9% of the total body surface area
(TBSA). In adults and older children the head is approximately 9% of the TBSA.
20
Q
- Which joints are most commonly involved in juvenile rheumatoid arthritis?
(a) Shoulder, hip, fingers
(b) Atlantoaxial, costomanubrum, hip
(c) Sternomanubrum, shoulder, sacroiliac
(d) Elbow, hip, temporomandibular
A
- (d) The elbow is involved 90% of the time in juvenile rheumatoid arthritis (JRA), the
temporomandibular and hip 50% each. The shoulder is involved about 8% of the time in early JRA
and about 33% later.
21
Q
- Which of the following is part of neurodevelopmental therapy (NDT)?
(a) Promotion of primitive reflexes
(b) Use of taping and icing
(c) Strengthening exercises
(d) Facilitating automatic reactions
A
- (d) Neurodevelopmental therapy, developed by Bobath, emphasizes inhibition of reflex patterns,
normalizing tone, and facilitating automatic reactions. The therapy does not include strengthening
exercises.
22
Q
- Your 14-year-old patient with spastic diplegic cerebral palsy has increasing problems with
spasticity. He walks with ankle-foot orthoses (AFOs) and crutches and is independent in his
activities of daily living. Which medication would reduce his spasticity while minimizing
undesirable side effects?
(a) Diazepam (Valium)
(b) Baclofen (Lioresal)
(c) Dantrolene (Dantrium)
(d) Oxybutynin (Ditropan)
A
- (b) Diazepam has lethargy and sleepiness as major side effects. Dantrolene works at the level of the
muscle and often causes weakness, which can interfere with function. Oxybutynin relaxes the
muscles of the bladder, not skeletal muscles.
23
Q
- You are asked to evaluate an 8-month-old child with developmental delay. On exam you find low
tone, but brisk deep tendon reflexes at the knees and biceps, full passive range of motion, and poor
head and trunk control. This child’s diagnosis is likely
(a) myotonic dystrophy.
(b) cerebral palsy.
(c) spinal muscular atrophy.
(d) Hunter’s syndrome.
A
- (b) This patient presents with hypotonia, weakness, and hyperreflexia, a combination most commonly
seen in central nervous system lesions such as cerebral palsy. A child with a neuromuscular
disorder would not have hyperreflexia with the hypotonia and weakness. In severe cerebral palsy it
is common to see early hypotonia with brisk reflexes that changes to hypertonia as the child gets
older.
24
Q
- Which endocrine abnormality is most likely to occur 5 years after severe traumatic brain injury in a
2-year-old girl?
(a) Diabetes insipidus
(b) Precocious puberty
(c) Hypothyroidism
(d) Hyperparathyroidism
A
- (b) Precocious puberty occurs in up to 50% of girls who sustain a severe traumatic brain injury (TBI) in
early childhood. Diabetes insipidus is an early complication of TBI. While other endocrine
abnormalities may occur, they are less common.
25
Q
- On physical examination an 8-year-old patient stands on his toes and has increased lumbar
lordosis. He has a Trendelenburg gait with circumduction. What else would you expect to find on
his exam?
(a) Decreased sensation in his feet
(b) Anterior tibialis weakness
(c) Quadriceps weakness
(d) Hyperreflexia at the ankle
A
- (c) The exam describes typical findings in a boy with myopathy such as Duchenne muscular dystrophy
(DMD). The earliest weakness in DMD is proximally in the gluteus maximus. The boy assumes a
posture of lumbar lordosis to place the center of gravity posterior to the hip joint to prevent
hyperflexion of the hip and thus a fall. Toe walking is a compensatory adaptation to knee extensor
weakness.
26
Q
- You are asked to evaluate a child who was born at 25 weeks gestation and had a grade 4
intraventricular hemorrhage. What type of cerebral palsy are you most likely to find?
(a) Athetoid
(b) Hemiplegic
(c) Diplegic
(d) Hypotonic
A
- (c) Grade 4 intraventricular hemorrhages in premature infants are most commonly associated with
spastic diplegia.
27
Q
- You are asked to evaluate a child with arthrogryposis and equinovarus. Which treatment strategy
would be the best to employ?
(a) Short leg braces attached to orthopedic shoes
(b) Botulinum toxin injections, stretching, and plastic ankle-foot orthoses
(c) Oral baclofen (Lioresal), range of motion, and extra depth shoes
(d) Casting followed by surgical releases
A
c?
28
Q
- The Gross Motor Functional Measure (GMFM) is designed to measure
(a) motor changes over time.
(b) quality of motor performance.
(c) achievement of motor milestones.
(d) only walking, running, and jumping ability.
A
- (a) The Gross Motor Functional Measure (GMFM) evaluates motor changes over time in children with
cerebral palsy. It includes activities in prone and supine positions, rolling, sitting, crawling,
kneeling, standing, walking, running, and jumping. It does not measure the quality of motor
performance.
29
Q
- What percentage of American children with myelomeningocele requires a shunt to manage
hydrocephalus?
(a) 10–20
(b) 25–50
(c) 60–70
(d) 80–90
A
- (d) Seventy-five percent of lesions in spina bifida cystica (myelomeningocele) affect the lumbosacral
spine. Ninety percent of children with spina bifida have hydrocephalus that requires a shunt for
management.
30
Q
- A 9-year-old girl with C5 ASIA A spinal cord injury sustained 2 years ago is evaluated for upper
extremity splinting. Which statement regarding this scenario is TRUE?
(a) A resting hand splint should be prescribed for daytime use to preserve function.
(b) A wrist extension splint would be contraindicated for daytime use because it would interfere
with function.
(c) A mobile arm support or balanced forearm orthosis could be prescribed to make self-feeding
possible.
(d) A short hand splint should be prescribed to strengthen wrist extensor muscles.
A
69. (c) A mobile arm support or balanced forearm orthosis would enable the child with C5 ASIA A spinal cord injury (SCI) and weak arm muscles to move the arm through useful active range of motion and to position the hand for function. In patients with C5 SCI, these orthoses are typically combined with wrist extension splints or a universal or palmar cuff for feeding. A resting hand splint may be used at night to improve or maintain range of motion, but would interfere with daytime function. A short hand splint would not strengthen wrist extensor muscles, but may be useful to improve function.
31
Q
- A normal 6-month-old infant may demonstrate which reflex?
(a) Rooting
(b) Automatic walking
(c) Plantar grasp
(d) Posterior protective extension
A
- (c) Rooting and automatic walking reflexes are present at birth, and are integrated by 4 months of age.
Posterior protective extension does not appear until 7 to 8 months of age. Plantar grasp is present at
birth and not integrated until after independent walking occurs at approximately 12 months of age.
Reflex Age of Emergence Age of Suppression (or
Integration)
Moro Birth 4–6 months
Rooting Birth 4 months
Asymmetric tonic neck
reflex (ATNR)
1–3 months 6–7 months
Plantar grasp Birth 12–14 months–ie, when
walking well
Automatic walking Birth 3–4 months
Posterior protective
extension
7–8 months
