Chapter 45: Alterations of Musculoskeletal Function in Children

MULTIPLE CHOICE
1. Until the skeleton matures and adult stature is reached, where does growth in the length of

bone occur?
a. Epiphyseal line
b. Physeal plate

c. Epiphyseal cartilage
d. Metaphyseal plate

ANS: B

Until the skeleton matures and adult stature is reached, growth in the length of bone occurs
only at the physeal plate through endochondral ossification.
PTS: 1

REF: Page 1592

2. Which skeletal deformity is normal at birth but generally disappears by 21/2 years of age?
a. Genu varum (bowleg)
c. Equinovarus (clubfoot)
b. Genu valgum (knock knee)
d. Pes planus (flat feet)
ANS: A

Genu varum (bowleg) generally resolves itself by 21/2 years of age, whereas genu valgum
(knock knee) maximizes by 5 to 6 years of age. This statement is not true of either
equinovarus or pes planus.
PTS: 1

REF: Page 1593

3. The total mass of muscle in the body can be estimated from which serum laboratory test

value?
a. Albumin
b. Blood urea nitrogen

c. Creatinine
d. Creatine

ANS: C

Of the options available, the total mass of muscle in the body can be estimated from the
amount of creatinine excreted in the urine, because the conversion of creatine to creatinine
only takes place in muscle.
PTS: 1

REF: Page 1593

4. What is the most common congenital skeletal defect of the upper extremity?
a. Vestigial tabs
c. Rickets
b. Paget disease
d. Syndactyly
ANS: D

The most common congenital skeletal defect of the upper extremity is syndactyly, or webbing
of the fingers.
PTS: 1

REF: Page 1593

5. What diagnosis is given when the infants hip maintains contact with the acetabulum but is not

well seated within the hip joint?

a. Dislocatable hip

c. Dislocated hip

b. Subluxated hip

d. Subluxable hip

ANS: B

Subluxated hip is the only option used to identify the condition when the hip maintains
contact with the acetabulum but is not well seated within the hip joint.
PTS: 1

REF: Page 1594

6. Which sign or symptom is a very late indication of developmental dysplasia of the hip?
a. Asymmetry of the gluteal or thigh folds
b. Leg-length discrepancy
c. Waddling gait
d. Pain
ANS: D

Signs and symptoms of developmental dysplasia of the hip that should be noted include pain
very late in the process. This statement is not true of the other options.
PTS: 1

REF: Page 1595

7. Which serum laboratory test is elevated in all forms of osteogenesis imperfecta?

a. Phosphorus
c. Alkaline phosphatase
b. Calcium
d. Total protein
ANS: C

Of the available options, serum alkaline phosphatase is elevated in all forms of the disease.
PTS: 1

REF: Page 1598

8. The failure of bones to ossify, resulting in soft bones and skeletal deformity, characterizes

which disorder?
a. Osteogenesis imperfecta
b. Rickets

c. Osteochondrosis
d. Legg-Calv-Perthes disease

ANS: B

Of the available options, only rickets is a disorder in which growing bone fails to become
mineralized (ossified) and results in soft bones and skeletal deformity.
PTS: 1

REF: Page 1599

9. An insufficient dietary intake of which vitamin can lead to rickets in children?

a. C
c. B6
b. B12
d. D
ANS: D

Rickets results from either insufficient vitamin D, insensitivity to vitamin D, wasting of

vitamin D by the kidney, or inability to absorb vitamin D and calcium in the gut. Vitamin D is
the only vitamin associated with rickets.
PTS: 1

REF: Pages 1599-1600

10. In scoliosis, curves in the thoracic spine greater than how many degrees result in decreased

pulmonary function?

a. 40
b. 50

c. 60
d. 80

ANS: D

In scoliosis, curves in the thoracic spine greater than 80 degrees result in decreased pulmonary
function.
PTS: 1

REF: Page 1601

11. In osteomyelitis, bacteria gain access to the subperiosteal space in the metaphysis, which is

considered the path of least resistance. What factor makes this route for bacteria the path of
least resistance?
a. Cortex of the bone in this area is porous or mazelike.
b. Blood supply to the metaphysis is easily compromised.
c. Macrophages and lymphocytes have limited access to the subperiosteal space.
d. Bacteria usually spread down the medullary cavity of the bone.
ANS: A

The subperiosteal space in the metaphysis is the path of least resistance because the cortex of
the bone in this area is porous or mazelike, and the inflammatory response blocks spread
within the bone. This statement is not true of the other options.
PTS: 1

REF: Page 1602

12. How do the clinical manifestations and onset of juvenile rheumatoid arthritis (JRA) differ

from those of rheumatoid arthritis (RA) in adults?

a. JRA begins insidiously with systemic signs of inflammation.
b. JRA predominantly affects large joints.
c. JRA has more severe joint pain than adult RA.
d. JRA has a rapid onset of generalized aches as the first symptom.
ANS: B

The onset of JRA is less gradual than it is in adult RA. JRA also differs from the adult form in
that predominantly the large joints are affected in JRA. The remaining options are not accurate
since the statements are true of RA as well.
PTS: 1

REF: Page 1604

13. What is the cause of osteochondrosis?

a. Imbalance between calcitonin and parathyroid hormone
b. Nutritional deficiency of calcium and phosphorus
c. Bacterial infection of the bone
d. Vascular impairment and trauma to bone
ANS: D

Of the options available, only vascular impairment and trauma to bone, coupled with an
underlying developmental or genetic predisposition, have been identified as probable causes
of osteochondrosis.
PTS: 1

REF: Page 1604

14. Which bones are affected in Legg-Calv-Perthes disease?

a. Heads of the femur

b. Distal femurs

c. Heads of the humerus

d. Distal tibias

ANS: A

A recurrent interruption of the blood supply to only the femoral heads presumably produces
Legg-Calv-Perthes disease, which is a self-limited disease of the hip.
PTS: 1

REF: Page 1604

15. Which statement is true regarding the pain experienced with Legg-Calv-Perthes disease?
a. Pain experienced with Legg-Calv-Perthes disease in the elbows and upper and

lower arms is aggravated by activity and relieved by rest.

b. Pain experienced with Legg-Calv-Perthes disease in the knees, inner thighs, and

groin is described as a continuous ache and relieved by antiinflammatory drugs.

c. Pain experienced with Legg-Calv-Perthes disease in the knees, inner thighs, and

groin is aggravated by activity and relieved by rest.

d. Pain experienced with Legg-Calv-Perthes disease in the elbows and upper and

lower arms is described as a continuous ache and relieved by antiinflammatory

drugs.
ANS: C

The child with Legg-Calv-Perthes disease often complains of a limp or pain for several
months. The pain is usually referred to the knee, inner thigh, and groin and aggravated by
activity and relieved by rest. This selection is the only option that accurately describes the
pain associated with Legg-Calv-Perthes disease.
PTS: 1

REF: Page 1605

16. Which assessment finding characterizes Osgood-Schlatter disease?

a. Lateral epicondylitis of the elbow
b. Inflammation of the anterior cruciate ligament
c. Bursitis of the subscapular bursa in the glenohumeral joint
d. Tendinitis of the anterior patellar tendon
ANS: D

Tendinitis of the anterior patellar tendon, within which the patella (kneecap) is embedded, and
associated osteochondrosis of the tubercle of the tibia are characteristics of Osgood-Schlatter
disease. This selection is the only option that is associated with Osgood-Schlatter disease.
PTS: 1

REF: Page 1605

17. At birth, the diagnosis of cerebral palsy (CP) may be made based on what factor?
a. Brain trauma during birth
c. Major brain malformation
b. Prematurity
d. Genetic defect
ANS: A

The diagnosis of CP is often made when gross motor milestones are not met by predicted
ages. In some infants, diagnosis is made at birth because the child has an underlying
diagnosis, such as a major brain malformation that is known to be associated with CP. None of
the other options are known triggers for CP.
PTS: 1

REF: Page 1606

18. Which muscular dystrophy syndrome develops from an X-linked recessive mode of

inheritance?
a. Duchenne
b. Facioscapulohumeral

c. Myotonic
d. Limb girdle

ANS: A

A deletion of a segment of DNA or a single-gene defect on the short arm of the X

chromosome is believed to be the cause of the X-linked inherited type of Duchenne muscular
dystrophy. This statement is not true of the other options.
PTS: 1

REF: Pages 1606-1607 | Table 45-4

19. Which protein, absent in muscle cells of Duchenne muscular dystrophy, mediates the

anchoring of skeletal muscle fibers to the basement membrane?

c. Dystrophin
d. Troponin

a. Syntrophin
b. Laminin
ANS: C

Only dystrophin is present in normal muscle cells and absent in Duchenne muscular
dystrophy. Dystrophin mediates anchorage of the actin cytoskeleton of skeletal muscle fibers
to the basement membrane through a membrane glycoprotein complex.
PTS: 1

REF: Page 1607

20. What pulmonary complication in children with Duchenne muscular dystrophy contributes to

their death?
a. Infection
b. Kyphoscoliosis

c. Impaired formation of alveoli

d. Cancer

ANS: A

Although the life expectancy of boys with Duchenne continues to rise, death usually occurs
from respiratory infection and a compromised respiratory system, with the majority living into
their middle 20s. Some individuals who have chosen ventilatory support live a decade or more
longer. This selection is the only option that is associated with the death and pulmonary
complications experienced by children with this diagnosis.
PTS: 1

REF: Pages 1607-1608

21. Generally, what is the first symptom of facioscapulohumeral muscular dystrophy?

a. Inability to open the eyes completely c. Drooping shoulders
b. Difficulty standing
d. Facial pain
ANS: C

As the name implies, clinical manifestations begin with weakness and atrophy of facial and
shoulder girdle (scapulohumeral) muscles. The illness progresses slowly. An inability to close
the eyes completely may be noted in early childhood. The face is expressionless, and pouting
of the lips makes whistling impossible. The first symptoms usually include drooping of the
shoulders with difficulty in raising the arms above the head. The onset of weakness in the
lower limbs is often delayed for 20 to 30 years, and pseudohypertrophy of muscles is rare.
PTS: 1

REF: Page 1609

22. What is the most common malignant bone tumor diagnosed during childhood?
a. Chondrosarcoma
c. Ewing Sarcoma
b. Fibrosarcoma
d. Osteosarcoma
ANS: D

Of the options available, osteosarcoma is the most common bone tumor that occurs during
childhood; it originates from bone-producing mesenchymal cells.
PTS: 1

REF: Page 1610

23. Molecular analysis has demonstrated that osteosarcoma is associated with which gene?
a. TP53
c. myc
b. src
d. TSC2
ANS: B

Of the options available, only the oncogene src has been associated with osteosarcoma.
PTS: 1

REF: Page 1610

24. Osteosarcoma usually metastasizes to the:

a. Pancreas
c. Lungs
b. Liver
d. Brain
ANS: C

Osteosarcoma disseminates through the bloodstream, usually to the lung. As many as 25% of
children diagnosed with osteosarcoma exhibit lung metastases at diagnosis. This statement is
not true of any of the other options.
PTS: 1

REF: Page 1610

25. A Ewing sarcoma arises from the:

a. Bone marrow
b. Bone-producing mesenchymal cells

c. Metadiaphysis of long bones

d. Embryonal osteocytes

ANS: A

Arising only from bone marrow, Ewing sarcoma can break through the cortex of the bone to
form a soft-tissue mass.
PTS: 1

REF: Page 1611

26. Rhabdomyosarcoma can develop in which type of muscle?

a. Cardiac
c. Involuntary
b. Smooth
d. Striated
ANS: D

Rhabdomyosarcoma can develop anywhere striated muscle is located. This statement is not
true of the other options.
PTS: 1

REF: Page 1612

27. Which organism is the primary cause of osteomyelitis in a newborn?

a. Staphylococcus aureus
c. Group B streptococcus

b. Escherichia coli

d. Bacillus anthracis

ANS: A

S. aureus is the primary cause of osteomyelitis in a newborn. Group B streptococcus and E.

coli infections are responsible for some cases, especially those of multiple bone involvement
and in high-risk infants. S. aureus is the responsible microorganism in 80% to 90% of
osteomyelitis cases in older children. Bacillus anthracis (anthrax) is not associated with
osteomyelitis.
PTS: 1

REF: Page 1602

28. What is the cause of structural scoliosis?

a. Poor posture
b. Vertebral rotation

c. Poor calcium absorption

d. Intrauterine trauma

ANS: B

Structural scoliosis is the curvature of the spine associated with vertebral rotation. No research
data suggest that any of the other options results in structural scoliosis.
PTS: 1

REF: Page 1600

29. Which statements are true regarding bone growth before adulthood? (Select all that apply.)
a. Growth in the length of bone occurs at the physeal plate.
b. Growth occurs through endochondral ossification.
c. Bone growth takes place under hormonal control.
d. Cartilage cells at the epiphyseal side of the physeal plate multiply and enlarge.
e. Cartilage cells at the metaphyseal side of the plate are replaced by bone.
ANS: A

B, D, E
Until adult stature is reached, growth in the length of bone occurs at the physeal plate through
endochondral ossification. Cartilage cells at the epiphyseal side of the physeal plate multiply
and enlarge. As rapidly as new cartilage cells form, cartilage cells at the metaphyseal side of
the plate are destroyed and replaced by bone. Bone growth is not hormonally controlled.
PTS: 1

REF: Page 1592

30. The anatomic makeup of which bone structures make them susceptible locations for

osteomyelitis in children? (Select all that apply.)

Hip joint
Distal femur
Proximal humerus
Distal radius
Lateral ankle

a.
b.
c.
d.
e.

ANS: A

B, C, E
Spread of infection to contiguous joints is related to the childs age. Metaphyseal infection
may spread to contiguous joints if the fibrous joint capsule includes the metaphysis and
epiphysis. This special situation exists at the hip joint, distal femur, proximal humerus and
radius, and lateral ankle.

PTS: 1

REF: Page 1603

MATCHING

Match the type of muscular dystrophy with its description. Types may be used more than once.
______ A. Duchenne muscular dystrophy
______ B. Facioscapulohumeral muscular dystrophy
______ C. Myotonic dystrophy
______ D. Becker muscular dystrophy
31. Onset occurs at approximately 3 years of age with rapid progression and frequently mental

retardation.
32. The face is expressionless, and pouting of the lips makes whistling impossible.
33. Shares the X-linked inheritance pattern but produces milder symptoms.
34. Is an autosomal dominant condition with a slow rate of progression and frequently mental
retardation.
31. ANS: A
PTS: 1
REF: Pages 1606-1608 | Table 45-4
MSC: Duchenne muscular dystrophy is usually identified in children at approximately 3 years of age,
when the parents first notice slow motor development with progressive weakness and muscle wasting.
A moderate degree of mental retardation causes these children to have a mean intelligence quotient
(IQ) of approximately 85.
32. ANS: B
PTS: 1
REF: Page 1609
MSC: Facioscapulohumeral muscular dystrophy exhibits a face that is expressionless, and pouting of
the lips makes whistling impossible.
33. ANS: D
PTS: 1
REF: Page 1608
MSC: Becker muscular dystrophy shares the X-linked inheritance pattern but produces milder clinical
features.
34. ANS: C
PTS: 1
REF: Page 1606 | Table 45-4
MSC: Myotonic dystrophy is a result of an autosomal dominant gene exhibiting a slow rate of
progression and frequently mental retardation.