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ABPMR Pediatric Rehab study materials
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ABPMR Pediatric Rehab practice questions

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Question 1Pediatric Brain Injury

Among children younger than 4 years, which mechanism accounts for the largest share of traumatic brain injury?

  1. Sports-related impacts
  2. Falls Correct answer.
  3. Non-accidental trauma
  4. Motor vehicle collisions

Explanation

Population-based surveillance consistently identifies falls as the leading mechanism of traumatic brain injury in children under 4 years of age. Motor vehicle collisions account for a larger share in adolescents and more often produce high-energy injuries such as diffuse axonal injury.

Question 2Pediatric Brain Injury

A 3-year-old opens the eyes spontaneously, speaks in inappropriate words, and localizes painful stimulation. What is the Glasgow Coma Scale score?

  1. 12 Correct answer.
  2. 13
  3. 11
  4. 14

Explanation

The score is the sum of best eye opening (4, spontaneous), best verbal response (3, inappropriate words in a child old enough to speak), and best motor response (5, localizes to pain), giving 12. Age-appropriate verbal descriptors must be applied because preverbal infants are scored differently.

Question 3Pediatric Brain Injury

Duration of post-traumatic amnesia after pediatric traumatic brain injury is most strongly associated with which outcome?

  1. Need for surgical decompression
  2. Long-term cognitive outcome Correct answer.
  3. Risk of early post-traumatic seizure
  4. Likelihood of skull fracture

Explanation

Post-traumatic amnesia reflects the extent of diffuse cerebral dysfunction and correlates more strongly with long-term cognitive and functional outcome than the initial Glasgow Coma Scale score or duration of loss of consciousness. It is therefore a key prognostic variable to document during acute rehabilitation.

Question 4Pediatric Brain Injury

Current consensus guidance for the first 24 to 48 hours after pediatric concussion recommends which approach?

  1. Prolonged rest until symptom-free
  2. Immediate return to contact play
  3. Brief rest then light activity Correct answer.
  4. Strict bed rest in a dark room

Explanation

Guidelines now advise a short period of relative rest followed by gradual reintroduction of light cognitive and physical activity. Prolonged strict rest and dark-room isolation have been associated with slower recovery and more persistent symptoms.

Question 5Pediatric Brain Injury

Second impact syndrome is characterized by which sequence of events?

  1. Delayed epidural hematoma after lucid interval
  2. Diffuse cerebral swelling after a second impact Correct answer.
  3. Focal contusion at the site of impact
  4. Progressive dementia after repeated blows

Explanation

Second impact syndrome is rapid, diffuse cerebral swelling with loss of autoregulation after a second head injury sustained while the child is still symptomatic from the first. It is uncommon but frequently fatal and is the principal reason for strict stepwise return-to-play rules.

Question 6Pediatric Brain Injury

Diffuse axonal injury after pediatric traumatic brain injury most characteristically involves which location?

  1. Gray-white matter junction Correct answer.
  2. Choroid plexus of the fourth ventricle
  3. Pituitary stalk and gland
  4. Cerebellar hemisphere cortex

Explanation

Rotational acceleration creates shear strain greatest where tissues of differing density meet, so diffuse axonal injury characteristically involves the gray-white junction, the corpus callosum, and the dorsolateral brainstem. These lesions are often subtle on initial CT and better seen on susceptibility-weighted MRI.

Question 7Pediatric Brain Injury

Which cranial nerve is most frequently injured after traumatic brain injury?

  1. Oculomotor nerve
  2. Facial nerve
  3. Optic nerve
  4. Olfactory nerve Correct answer.

Explanation

The olfactory nerve is the most commonly injured cranial nerve because its fibers pass through the cribriform plate and are sheared by frontal impact. Anosmia is frequently unrecognized until formal testing, which is why it should be screened in children with frontal trauma.

Question 8Pediatric Brain Injury

Early post-traumatic seizures are defined as seizures occurring within what interval after injury?

  1. 7 days Correct answer.
  2. 1 month
  3. 72 hours
  4. 24 hours

Explanation

Early post-traumatic seizures occur within 7 days of injury and are attributed to acute metabolic and structural disturbance. Seizures arising after that window are classified as late and constitute post-traumatic epilepsy.

Question 9Pediatric Brain Injury

A 12-year-old with severe traumatic brain injury develops reduced hip range of motion, warmth, and swelling 8 weeks after injury, with elevated alkaline phosphatase. What is the most likely diagnosis?

  1. Heterotopic ossification Correct answer.
  2. Deep venous thrombosis
  3. Progressive hip subluxation
  4. Septic arthritis

Explanation

Heterotopic ossification typically appears weeks to months after severe brain injury with localized warmth, swelling, decreased joint range, and elevated alkaline phosphatase, and the hip is the most common site in children. Early recognition matters because it can mimic infection or thrombosis and because contracture prevention depends on prompt treatment.

Question 10Pediatric Brain Injury

A 6-year-old has spasticity confined to the gastrocnemius that interferes with gait after traumatic brain injury. Which intervention is most appropriate?

  1. Intrathecal baclofen pump
  2. Botulinum toxin injection Correct answer.
  3. Selective dorsal rhizotomy
  4. Oral baclofen

Explanation

Focal, gait-limiting spasticity of a single muscle group is best managed with chemodenervation using botulinum toxin, combined with stretching, casting, and orthoses. Systemic and intrathecal agents are reserved for generalized tone, and dorsal rhizotomy is irreversible and used only in carefully selected cases.

Question 11Pediatric Brain Injury

An infant presents with subdural hematoma, retinal hemorrhages, and metaphyseal corner fractures. Which diagnosis best fits this constellation?

  1. Accidental fall from a low height
  2. Osteogenesis imperfecta
  3. Glutaric aciduria type 1
  4. Abusive head trauma Correct answer.

Explanation

The triad of subdural hemorrhage, retinal hemorrhage, and metaphyseal corner fractures in a young infant is highly suggestive of abusive head trauma, because the forces required exceed those generated by a routine fall. Metabolic and genetic mimics are considered, but none explains the complete picture.

Question 12Pediatric Brain Injury

In children with arterial ischemic stroke beyond the neonatal period, which is the most frequently identified underlying cause?

  1. Sickle cell disease
  2. Moyamoya syndrome
  3. Congenital heart disease
  4. Cerebral arteriopathy Correct answer.

Explanation

Focal cerebral arteriopathy, whether post-varicella or idiopathic, is the most frequent identified cause of arterial ischemic stroke outside the neonatal period. Sickle cell disease and congenital heart disease remain important contributors but are less common overall.

Question 13Pediatric Brain Injury

In term infants with hypoxic-ischemic encephalopathy, which pattern of injury is most characteristic on MRI?

  1. Subcortical white matter cysts
  2. Periventricular white matter
  3. Basal ganglia and thalamus Correct answer.
  4. Cerebellar vermis atrophy

Explanation

In term infants the metabolically active deep gray nuclei are most vulnerable to acute hypoxia-ischemia, producing basal ganglia and thalamic injury. Periventricular leukomalacia is instead the characteristic pattern in preterm infants because of their immature periventricular vascular supply.

Question 14Pediatric Brain Injury

Which pituitary hormone deficiency is most commonly reported after pediatric traumatic brain injury?

  1. Growth hormone deficiency Correct answer.
  2. Central diabetes insipidus
  3. Central precocious puberty
  4. Prolactin-secreting adenoma

Explanation

Growth hormone deficiency is the most frequently reported anterior pituitary deficit after pediatric traumatic brain injury, followed by gonadotropin and thyroid abnormalities. Because effects on growth may appear years later, survivors of moderate to severe injury warrant periodic endocrine surveillance.

Question 15Pediatric Brain Injury

A 15-year-old is fully asymptomatic 3 days after a concussion. What is the next step in the return-to-sport progression?

  1. Light aerobic exercise as the next step Correct answer.
  2. Return to competition with a helmet
  3. Full-contact practice immediately
  4. Repeat neuroimaging before activity

Explanation

Return to sport follows a graded sequence in which each step lasts at least 24 hours and progression requires remaining asymptomatic at the current level. Light aerobic exercise precedes sport-specific drills, full-contact practice, and competition.

Question 16Pediatric Brain Injury

A child in a minimally conscious state after severe traumatic brain injury has recurrent episodes of tachycardia, diaphoresis, hyperthermia, and dystonic posturing. What do these episodes most likely represent?

  1. Neuroleptic malignant syndrome with rigidity
  2. Nonconvulsive status epilepticus
  3. Serotonin syndrome from a new medication
  4. Paroxysmal sympathetic hyperactivity Correct answer.

Explanation

Paroxysmal sympathetic hyperactivity consists of recurrent episodes of tachycardia, hypertension, tachypnea, hyperthermia, diaphoresis, and dystonic posturing during recovery from severe acquired brain injury. Episodes are often triggered by suctioning, positioning, or pain, and the electroencephalogram during an episode is typically unchanged.

Question 17Pediatric Brain Injury

In a child with severe traumatic brain injury, cerebral perfusion pressure is calculated as which of the following?

  1. Mean arterial pressure plus intracranial pressure
  2. Mean arterial pressure minus ICP Correct answer.
  3. Systolic pressure minus intracranial pressure
  4. Intracranial pressure minus central venous pressure

Explanation

Cerebral perfusion pressure equals mean arterial pressure minus intracranial pressure, and it must be kept above age-specific thresholds to limit secondary ischemic injury. Management therefore targets both intracranial pressure reduction and adequate systemic blood pressure.

Question 18Pediatric Brain Injury

Which cognitive domain is most commonly and persistently impaired after moderate to severe pediatric traumatic brain injury?

  1. Visuospatial construction
  2. Verbal fluency for letters
  3. Olfactory discrimination
  4. Processing speed Correct answer.

Explanation

Reduced processing speed is the most persistent and pervasive cognitive deficit after pediatric traumatic brain injury and underlies difficulties with attention, working memory, and classroom performance. It is often more disabling functionally than focal deficits in language or visuospatial skill.

Question 19Pediatric Brain Injury

Which school accommodation most directly addresses the fatigue and attention problems typical after pediatric traumatic brain injury?

  1. Extended foreign language instruction
  2. Daily physical education
  3. Scheduled rest breaks during class Correct answer.
  4. Grade retention

Explanation

Fatigue and reduced sustained attention are the most common barriers to classroom participation after pediatric brain injury, so rest breaks, shortened tasks, and paced workloads are first-line accommodations. Grade retention has not been shown to help and may worsen social and academic outcomes.

Question 20Pediatric Brain Injury

Which finding at 24 hours after severe pediatric traumatic brain injury most strongly predicts a poor outcome?

  1. Initial Glasgow Coma Scale score of 5
  2. Presence of a linear skull fracture
  3. Early post-traumatic seizure
  4. Absent pupillary light reflexes Correct answer.

Explanation

Bilaterally absent pupillary responses at 24 hours after severe injury indicate brainstem dysfunction and carry a very poor prognosis, and they are also part of brain death criteria. Skull fracture and early seizures influence acute management but are weaker independent predictors of long-term functional outcome.

Question 21Pediatric Brain Injury

An infant had a linear skull fracture at 3 months of age; at 6 months the fracture line has widened and the scalp is bulging. What is the most likely explanation?

  1. Growing skull fracture Correct answer.
  2. Cranial suture synostosis
  3. Chronic subdural hematoma
  4. Normal healing of an infant skull

Explanation

A growing skull fracture occurs when an underlying dural tear allows pulsatile brain and cerebrospinal fluid to widen the fracture progressively, producing a bulging scalp mass. It requires surgical dural repair, and MRI or CT confirms the dural defect and underlying brain herniation.

Question 22Pediatric Brain Injury

A child with severe traumatic brain injury receives levetiracetam for early post-traumatic seizures. What is the best evidence regarding prophylaxis against late post-traumatic epilepsy?

  1. Prophylaxis works only after one week
  2. Phenytoin prevents late epilepsy
  3. No agent prevents late epilepsy Correct answer.
  4. Prophylaxis halves late epilepsy risk

Explanation

Antiseizure medication given after severe traumatic brain injury reduces early post-traumatic seizures but has not been shown to prevent late post-traumatic epilepsy in children or adults. Duration beyond the acute period is therefore guided by whether seizures have actually occurred.

Question 23Pediatric Brain Injury

A 10-year-old with a right middle cerebral artery stroke has dense left hemiparesis and left neglect. Which rehabilitation principle best guides early therapy?

  1. Restraint of the affected arm
  2. Repetitive task practice of the weak arm Correct answer.
  3. Focus therapy only on the strong arm
  4. Delay therapy until spasticity develops

Explanation

Activity-dependent plasticity is greatest when the affected limb receives large numbers of repetitive, task-specific practice sessions, which is the basis of constraint-induced and bimanual training approaches. Constraint is applied to the less affected limb, never to the impaired side.

Question 24Pediatric Brain Injury

A child who fell from a height had a brief lucid interval followed by rapid neurologic deterioration. Which injury is most likely?

  1. Subdural hematoma
  2. Diffuse axonal injury
  3. Epidural hematoma Correct answer.
  4. Subarachnoid hemorrhage

Explanation

A lucid interval followed by rapid decline is the classic presentation of an epidural hematoma, usually from middle meningeal artery injury, and it constitutes a surgical emergency. Subdural hematomas more often produce progressive deficit without a clear lucid interval.

Question 25Pediatric Brain Injury

Which oral medication reduces spasticity primarily through agonist activity at spinal GABA-B receptors?

  1. Dantrolene
  2. Baclofen Correct answer.
  3. Tizanidine
  4. Diazepam

Explanation

Baclofen is a GABA-B receptor agonist that reduces spasticity at the spinal level, which is why it can also be delivered intrathecally for severe generalized tone. The other agents act through alpha-2 adrenergic, skeletal muscle calcium-release, or GABA-A mechanisms.

Question 26Pediatric Brain Injury

A 3-year-old is recovering from severe traumatic brain injury when, 4 weeks later, he develops worsening lethargy, repeated vomiting, increasing head circumference, and limited upward gaze. Which complication best explains this?

  1. Post-traumatic hydrocephalus Correct answer.
  2. Cerebral atrophy with ex vacuo ventricular enlargement
  3. Chronic subdural hematoma
  4. Syndrome of inappropriate antidiuretic hormone secretion

Explanation

Progressive macrocephaly, vomiting, lethargy, and limitation of upward gaze weeks after severe traumatic brain injury indicate raised intracranial pressure from accumulating cerebrospinal fluid. Ventricular enlargement out of proportion to sulcal enlargement, or with transependymal flow, supports post-traumatic hydrocephalus, which reflects impaired CSF absorption after subarachnoid blood. Prompt neuroimaging and neurosurgical evaluation are indicated.

Question 27Pediatric Spinal Cord Injury

A previously healthy 6-year-old falls from a swing and reports transient hand numbness and arm weakness that resolve over 30 minutes. Cervical spine radiographs and CT are normal. Which diagnosis is most likely?

  1. Cervical epidural hematoma
  2. SCIWORA Correct answer.
  3. Transient tic disorder
  4. Brachial plexus neurapraxia

Explanation

SCIWORA is spinal cord injury without radiographic abnormality. The young child's elastic ligamentous spine and incompletely ossified vertebrae permit transient cord deformation despite normal plain films and CT. MRI may later show cord edema or ligamentous injury.

Question 28Pediatric Spinal Cord Injury

Which spinal cord levels give rise to the phrenic nerve, which innervates the diaphragm?

  1. T1-T3
  2. C6-C8
  3. C1-C2
  4. C3-C5 Correct answer.

Explanation

The phrenic nerve arises from cervical roots C3, C4, and C5 and provides the main motor supply to the diaphragm. Injuries at or above these levels can therefore impair spontaneous ventilation. Lower cervical and thoracic injuries spare diaphragmatic innervation.

Question 29Pediatric Spinal Cord Injury

A 9-year-old with T6 SCI has detrusor overactivity and high bladder pressures on urodynamics. Which initial bladder management is most appropriate?

  1. Indwelling Foley catheter drainage
  2. Immediate augmentation cystoplasty
  3. Alpha-adrenergic blocker monotherapy
  4. Clean intermittent catheterization plus an anticholinergic Correct answer.

Explanation

A high-pressure neurogenic bladder threatens the upper urinary tract, so the initial goal is low-pressure storage and complete emptying. Clean intermittent catheterization combined with an anticholinergic reduces detrusor pressure and incontinence. Long-term indwelling catheters increase infection and stone risks, and surgery is reserved for failure of conservative care.

Question 30Pediatric Spinal Cord Injury

Autonomic dysreflexia is most likely when the spinal cord injury level is at or above which segment?

  1. T10
  2. T6 Correct answer.
  3. L1
  4. T8

Explanation

Autonomic dysreflexia occurs with lesions at or above T6 because splanchnic sympathetic outflow and supraspinal control are disrupted. A noxious stimulus below the lesion triggers a mass sympathetic response with severe hypertension. Injuries below T6 generally do not produce the syndrome.

Question 31Pediatric Spinal Cord Injury

Which location is the most common site of heterotopic ossification after pediatric spinal cord injury?

  1. Shoulder
  2. Knee
  3. Hip Correct answer.
  4. Elbow

Explanation

The hip is the most frequently involved site of heterotopic ossification after spinal cord injury, followed by the knee and shoulder. It can present with swelling, warmth, pain, and reduced joint motion. Early recognition matters because contracture and ankylosis can develop.

Question 32Pediatric Spinal Cord Injury

A child who uses a wheelchair full time is at highest risk for pressure injury over which area while seated?

  1. Ischial tuberosities Correct answer.
  2. Occiput
  3. Greater trochanter
  4. Heels

Explanation

While seated, the greatest sustained pressure over bony prominences occurs at the ischial tuberosities. Pressure relief maneuvers and appropriate cushioning are central to prevention. Occipital, heel, and trochanteric injuries are more associated with supine or side-lying positions.

Question 33Pediatric Spinal Cord Injury

A child with a complete C6 spinal cord injury is most likely to retain which movement?

  1. Finger flexion
  2. Elbow extension
  3. Wrist extension Correct answer.
  4. Thumb opposition

Explanation

The C6 myotome includes the wrist extensors, which are preserved in a complete C6 injury. Wrist extension enables tenodesis grasp, an important functional adaptation. Elbow extension is C7, finger flexion is C8, and thumb opposition is primarily T1.

Question 34Pediatric Spinal Cord Injury

Which finding on examination indicates that a spinal cord injury is incomplete rather than complete?

  1. Flaccid anal sphincter
  2. Absent ankle reflexes
  3. Perianal sensation present Correct answer.
  4. Loss of pain sensation below the level

Explanation

Sacral sparing, including perianal sensation, deep anal pressure, or voluntary anal contraction, defines an incomplete spinal cord injury. These findings indicate that long tract fibers to the sacral segments remain intact. Absent reflexes or flaccid tone can occur in complete injury or spinal shock.

Question 35Pediatric Spinal Cord Injury

After acute spinal cord injury, return of which reflex signals the end of spinal shock?

  1. Achilles reflex
  2. Cremasteric reflex
  3. Patellar reflex
  4. Bulbocavernosus reflex Correct answer.

Explanation

Spinal shock is a period of flaccid areflexia after acute injury, and return of the bulbocavernosus reflex marks its resolution. This reflex is mediated by S2-S4 and is the earliest reliable reflex to reappear. Once it returns, the neurologic examination can be used for ASIA classification.

Question 36Pediatric Spinal Cord Injury

A 10-year-old with C5 complete SCI develops a pounding headache, profuse sweating, and blood pressure 160/100 mm Hg. What is the most appropriate first step?

  1. Give a sublingual antihypertensive immediately
  2. Sit the child upright and check the urinary catheter and bowel regimen Correct answer.
  3. Place the child supine and administer oxygen
  4. Perform a lumbar puncture

Explanation

Autonomic dysreflexia is managed first by sitting the child upright to reduce blood pressure and by identifying and removing the noxious stimulus. Bladder distention and bowel impaction are common triggers. Antihypertensives are used if the pressure remains dangerously elevated after these measures.

Question 37Pediatric Spinal Cord Injury

A child with an intrathecal baclofen pump develops fever, rigidity, and severe spasms after the pump alarms. Which management is most appropriate?

  1. Support with benzodiazepines and restore baclofen delivery urgently Correct answer.
  2. Administer a dopamine agonist
  3. Increase oral baclofen only
  4. Start a quinolone antibiotic

Explanation

Abrupt interruption of intrathecal baclofen can cause a life-threatening withdrawal syndrome with fever, rigidity, and severe spasticity. Treatment requires supportive care, benzodiazepines, and urgent restoration of baclofen delivery. Oral baclofen alone is usually insufficient at the doses needed.

Question 38Pediatric Spinal Cord Injury

Which child has the highest risk of progressive scoliosis after spinal cord injury?

  1. A 5-year-old with T4 paraplegia Correct answer.
  2. A 16-year-old with T12 paraplegia
  3. A 14-year-old with L2 paraplegia
  4. A 12-year-old with T10 paraplegia

Explanation

Scoliosis risk is greatest with younger age at injury, higher neurologic level, and remaining growth. A young child with a high thoracic injury has both substantial growth remaining and marked trunk muscle imbalance. Older children with lower lesions have much lower risk.

Question 39Pediatric Spinal Cord Injury

A child with T6 SCI has thigh pain after a minor transfer, and radiographs show a distal femoral fracture. Which factor most directly predisposes to this injury?

  1. Autonomic dysreflexia
  2. Disuse osteoporosis Correct answer.
  3. Heterotopic ossification
  4. Spasticity

Explanation

Immobilization after spinal cord injury causes rapid disuse osteoporosis, especially in the lower extremities, leading to fragility fractures after minor trauma. Fractures may present with swelling, pain, or deformity and can be mistaken for other complications. Bone health surveillance and careful handling are important.

Question 40Pediatric Spinal Cord Injury

A child with C4 SCI becomes febrile after sitting outside on a hot day. Examination shows no source of infection. Which mechanism best explains the fever?

  1. Autonomic dysreflexia
  2. Increased sweat production below the lesion
  3. Impaired thermoregulation Correct answer.
  4. Neurogenic bladder infection

Explanation

High cervical spinal cord injury disrupts sympathetic control of sweating and vasomotor tone, producing poikilothermia and impaired thermoregulation. The child may become hyperthermic in a hot environment or hypothermic in a cold one. Infection must still be excluded, but environmental exposure is the likely cause here.

Question 41Pediatric Spinal Cord Injury

An adolescent with T10 SCI reports burning pain in the legs. Which medication is most appropriate first-line treatment for neuropathic pain?

  1. Ibuprofen
  2. Gabapentin Correct answer.
  3. Oxycodone
  4. Cyclobenzaprine

Explanation

Gabapentin or pregabalin is first-line pharmacologic therapy for neuropathic pain after spinal cord injury. Nonpharmacologic measures and careful reassessment are also important. Opioids are generally reserved for refractory pain because of tolerance, dependence, and adverse effects.

Question 42Pediatric Spinal Cord Injury

A child with a previous SCI develops ascending sensory loss and new upper-extremity weakness 3 years later. Which study is most appropriate?

  1. Repeat plain radiographs
  2. Lumbar puncture
  3. MRI of the spinal cord Correct answer.
  4. Electromyography

Explanation

Progressive neurologic decline months to years after spinal cord injury raises concern for a syrinx or other late complication. MRI of the spinal cord is the study of choice to evaluate for syringomyelia, tethering, or compression. Early diagnosis matters because untreated expansion can cause further deficits.

Question 43Pediatric Spinal Cord Injury

Which test is most sensitive for detecting heterotopic ossification before plain radiographs become abnormal?

  1. Triple-phase bone scan Correct answer.
  2. Serum calcium
  3. Ultrasound of the liver
  4. C-reactive protein

Explanation

A triple-phase bone scan can detect heterotopic ossification earlier than plain radiographs, often before calcification is visible. Alkaline phosphatase may also rise, but it is nonspecific. Early recognition allows prompt range-of-motion and anti-inflammatory treatment.

Question 44Pediatric Spinal Cord Injury

A child with a conus medullaris injury has an areflexic bowel with frequent impaction. Which bowel program is most appropriate?

  1. Manual evacuation with a scheduled bowel regimen Correct answer.
  2. No bowel program needed
  3. Digital stimulation alone
  4. Suppository alone

Explanation

A conus medullaris or cauda equina injury produces a lower motor neuron, areflexic bowel that does not respond reliably to suppositories or digital stimulation. A scheduled program with stool softeners and manual evacuation is usually needed. Upper motor neuron bowel programs rely more on reflex evacuation techniques.

Question 45Pediatric Spinal Cord Injury

Which intervention is most effective for preventing hip flexion contractures in a child with paraplegia who sits for most of the day?

  1. Bed rest in a flexed position
  2. Daily sitting without positioning
  3. Use of a reclining wheelchair only
  4. Daily prone positioning and hip extension stretching Correct answer.

Explanation

Prolonged sitting shortens the hip flexors, so regular prone positioning and hip extension stretching are key preventive measures. Appropriate wheelchair seating and standing programs also help maintain hip extension. A reclined wheelchair alone may reinforce flexion posture.

Question 46Pediatric Spinal Cord Injury

For a child with SCI and mild spasticity that interferes with hygiene, which treatment is usually first-line?

  1. Selective dorsal rhizotomy
  2. Intrathecal baclofen pump
  3. Botulinum toxin injections
  4. Oral baclofen with stretching Correct answer.

Explanation

Mild generalized spasticity is usually managed first with oral medications such as baclofen combined with stretching and positioning. Botulinum toxin is useful for focal problems, while intrathecal baclofen and dorsal rhizotomy are reserved for more severe or refractory spasticity. Treatment should be matched to functional goals.

Question 47Pediatric Spinal Cord Injury

A 3-year-old trauma patient has a lateral cervical radiograph showing anterior displacement of C2 on C3. The child is neurologically intact and the predental space is normal. Which is the most likely explanation?

  1. SCIWORA
  2. Odontoid fracture
  3. Physiologic pseudosubluxation Correct answer.
  4. Atlantoaxial dislocation

Explanation

Physiologic pseudosubluxation of C2 on C3 is a normal variant in young children caused by ligamentous laxity and incomplete ossification. It is distinguished from true injury by an intact neurologic examination, normal predental space, and smooth alignment lines. Misinterpretation can lead to unnecessary immobilization.

Question 48Pediatric Spinal Cord Injury

Which urodynamic measurement best predicts upper urinary tract deterioration in children with neurogenic bladder after SCI?

  1. Bladder capacity
  2. Detrusor leak point pressure Correct answer.
  3. Maximum urethral closure pressure
  4. Postvoid residual volume

Explanation

Detrusor leak point pressure reflects the pressure at which urine leaks around the sphincter and is a strong predictor of upper tract damage. Elevated leak point pressures, especially above 40 cm H2O, warrant pressure-lowering treatment. Capacity and residual volume alone do not capture storage pressure.

Question 49Pediatric Spinal Cord Injury

A child with C4 complete SCI has weak cough and retained secretions despite suctioning. Which intervention best augments cough clearance?

  1. Incentive spirometry
  2. Nasal continuous positive airway pressure
  3. Mechanical insufflation-exsufflation Correct answer.
  4. High-frequency chest wall oscillation

Explanation

Mechanical insufflation-exsufflation augments cough by delivering a deep insufflation followed by a rapid negative-pressure exsufflation. It is particularly useful when bulbar and expiratory muscle weakness impair secretion clearance. Airway clearance should be combined with positioning and suctioning as needed.

Question 50Pediatric Spinal Cord Injury

Which finding in an infant with spinal cord injury should raise concern for nonaccidental trauma?

  1. Multiple fractures of different ages with inconsistent history Correct answer.
  2. A single vertebral fracture after a high-speed motor vehicle crash
  3. Injury after a witnessed fall from a height
  4. SCIWORA after a sports collision

Explanation

Multiple fractures of differing ages with an inconsistent mechanism are red flags for nonaccidental trauma. Infants are especially vulnerable because their spines are elastic and injuries may occur without obvious external trauma. A thorough safety assessment and appropriate reporting are required.