Menu

Pediatric Lower Extremity MCQs

Practice Set 10 of 18

This practice set contains high-yield board review questions covering key concepts in Pediatric Lower Extremity. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 181

Topic: Pediatric Lower Extremity
A 3.5-year-old boy who was successfully treated in infancy for bilateral idiopathic clubfoot using the Ponseti method presents with a recurrent deformity. On physical examination, he demonstrates dynamic supination of the foot during the swing phase of gait. Passive range of motion demonstrates that the foot is fully correctable without fixed equinus or cavus. What is the most appropriate next step in management?
. Repeat percutaneous Achilles tenotomy
. Tibialis anterior tendon transfer to the lateral cuneiform
. Split anterior tibial tendon transfer (SPLATT)
. Lateral column lengthening (calcaneal osteotomy)
. Triple arthrodesis

Correct Answer & Explanation

. Tibialis anterior tendon transfer to the lateral cuneiform

Explanation

Dynamic supination in a previously treated clubfoot that remains passively correctable is a common sign of relapse in toddlers. It is driven by the strong pull of the tibialis anterior muscle acting without adequate antagonism. The definitive treatment for this specific dynamic deformity in a child over 2.5 to 3 years old is a full tibialis anterior tendon transfer (TATT) to the lateral cuneiform. If residual rigid equinus or cavus were present, a brief period of serial casting would precede the transfer.

Question 182

Topic: Pediatric Lower Extremity
A 4-year-old boy treated with the Ponseti method for idiopathic right clubfoot presents with relapsed deformity. The parents report he has been compliant with the bracing protocol. Examination reveals dynamic supination of the foot during the swing phase of gait. Passive range of motion shows completely correctable hindfoot varus and forefoot adduction. Which of the following is the most appropriate surgical intervention?
. Posteromedial release
. Split anterior tibial tendon transfer (SPLATT)
. Full anterior tibial tendon transfer to the lateral cuneiform
. Calcaneal sliding osteotomy
. Talonavicular arthrodesis

Correct Answer & Explanation

. Full anterior tibial tendon transfer to the lateral cuneiform

Explanation

Dynamic supination during the swing phase in a relapsed clubfoot treated previously with Ponseti casting is typically caused by a strong anterior tibial muscle combined with weak everters. The standard of care for this specific dynamic relapse is a full transfer of the anterior tibial tendon (TATT) to the lateral cuneiform (or cuboid). This procedure successfully rebalances the foot to prevent recurrent supination.

Question 183

Topic: Pediatric Lower Extremity

A 4-year-old boy who was successfully treated for idiopathic clubfoot as an infant using the Ponseti method presents with a dynamic supination deformity of the foot during the swing phase of gait. His ankles have 15 degrees of passive dorsiflexion. What is the treatment of choice?

. Repeat serial casting
. Tibialis anterior tendon transfer to the lateral cuneiform
. Achilles tendon lengthening
. Split tibialis posterior tendon transfer
. Triple arthrodesis

Correct Answer & Explanation

. Tibialis anterior tendon transfer to the lateral cuneiform

Explanation

Dynamic supination during gait in a previously corrected clubfoot is a classic sign of relapse caused by an overpowering tibialis anterior. Provided there is adequate ankle dorsiflexion, a full tibialis anterior tendon transfer to the lateral cuneiform is the treatment of choice.

Question 184

Topic: Pediatric Lower Extremity
A 4-year-old boy treated successfully for idiopathic clubfoot as an infant with the Ponseti method presents with a relapsed deformity. He walks with a dynamic supination of the foot during the swing phase of gait. His foot is completely passively correctable. What is the most appropriate surgical intervention?
. Split anterior tibial tendon transfer (SPLATT)
. Whole anterior tibial tendon transfer to the lateral cuneiform
. Achilles tendon lengthening alone
. Posterior medial release
. Calcaneal sliding osteotomy

Correct Answer & Explanation

. Whole anterior tibial tendon transfer to the lateral cuneiform

Explanation

Dynamic supination in a relapsed clubfoot that is passively correctable is treated with transferring the entire tibialis anterior tendon to the lateral cuneiform. This rebalances the foot and prevents further relapse.

Question 185

Topic: Pediatric Lower Extremity

A 4-year-old boy who was successfully treated for idiopathic clubfoot with the Ponseti method presents with a relapse. Examination reveals dynamic supination during the swing phase of gait and fixed equinus. He has been compliant with bracing. What is the most appropriate surgical intervention?

. Posteromedial release
. Split anterior tibial tendon transfer and Achilles tendon lengthening
. Cuboid decancellation
. Lateral column shortening
. Talonavicular arthrodesis

Correct Answer & Explanation

. Split anterior tibial tendon transfer and Achilles tendon lengthening

Explanation

Relapse in a young child treated with the Ponseti method often presents with dynamic supination. The treatment of choice is a split anterior tibial tendon transfer (to the lateral cuneiform) combined with Achilles tendon lengthening for the equinus contracture.

Question 186

Topic: Pediatric Lower Extremity
A 3-year-old child with a history of idiopathic clubfoot treated successfully with the Ponseti method presents with a dynamic supination deformity during the swing phase of gait. Passive range of motion is full, and the foot is plantigrade. What is the most appropriate surgical intervention?
. Achilles tendon lengthening
. Split anterior tibial tendon transfer (SPLATT)
. Complete anterior tibial tendon transfer to the lateral cuneiform
. Posteromedial soft tissue release
. Calcaneal sliding osteotomy

Correct Answer & Explanation

. Complete anterior tibial tendon transfer to the lateral cuneiform

Explanation

Dynamic supination of the foot in a toddler with a treated clubfoot represents a relapse often driven by an overactive anterior tibial tendon. Transfer of the entire anterior tibial tendon to the lateral cuneiform balances the foot and corrects the dynamic deformity.

Question 187

Topic: Pediatric Lower Extremity

A 2-week-old infant presents with idiopathic clubfoot. The Ponseti method is initiated. What is the correct sequence of deformity correction during serial casting?

. Cavus, Adductus, Varus, Equinus
. Adductus, Varus, Cavus, Equinus
. Cavus, Varus, Adductus, Equinus
. Equinus, Cavus, Adductus, Varus
. Varus, Cavus, Equinus, Adductus

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The Ponseti method corrects the deformities in a specific sequence summarized by the acronym CAVE: Cavus, Adductus, Varus, and finally Equinus.

Question 188

Topic: Pediatric Lower Extremity
A 4-year-old boy treated successfully in infancy for idiopathic clubfoot with the Ponseti method presents with an abnormal gait. Examination reveals dynamic supination of the foot during the swing phase of gait, with no fixed rigid deformities. What is the treatment of choice?
. Repeat Achilles tenotomy
. Complete transfer of the tibialis anterior tendon to the lateral cuneiform
. Split anterior tibial tendon transfer (SPLATT)
. Extensive posteromedial soft tissue release
. Calcaneocuboid fusion

Correct Answer & Explanation

. Complete transfer of the tibialis anterior tendon to the lateral cuneiform

Explanation

Dynamic supination in a relapsed Ponseti-treated clubfoot without rigid deformity is best treated with a complete transfer of the tibialis anterior tendon to the lateral cuneiform. A split transfer is less effective for this specific relapse pattern.

Question 189

Topic: Pediatric Lower Extremity

A 2-year-old child with a history of idiopathic clubfoot successfully treated with the Ponseti method presents with a dynamic supination deformity during the swing phase of gait. Passive range of motion is full, and the foot is completely correctable. What is the most appropriate surgical intervention?

. Tibialis anterior tendon transfer to the lateral cuneiform
. Achilles tendon lengthening alone
. Complete posteromedial release
. Talectomy
. Split tibialis posterior tendon transfer

Correct Answer & Explanation

. Tibialis anterior tendon transfer to the lateral cuneiform

Explanation

Relapsed clubfoot presenting as dynamic supination in a toddler with a flexible foot is best treated with a full transfer of the tibialis anterior tendon to the lateral cuneiform. This balances the foot by removing the supinating force and converting it to a dorsiflexing/everting force.

Question 190

Topic: Pediatric Lower Extremity

An infant with idiopathic clubfoot is undergoing serial casting using the Ponseti method. After sequential correction of the cavus, adductus, and varus deformities, the foot remains in 15 degrees of equinus. What is the most appropriate next step?

. Perform an extensive posteromedial release
. Perform a percutaneous Achilles tenotomy
. Continue weekly casting until equinus resolves naturally
. Apply an ankle-foot orthosis (AFO)
. Perform an anterior tibial tendon transfer

Correct Answer & Explanation

. Perform a percutaneous Achilles tenotomy

Explanation

The Ponseti method addresses deformities in the CAVE sequence: Cavus, Adductus, Varus, and Equinus. Once the midfoot score is 1 or less and only equinus remains, a percutaneous Achilles tenotomy is indicated to safely correct the equinus.

Question 191

Topic: Pediatric Lower Extremity

A newborn is diagnosed with severe unilateral fibular hemimelia. Which of the following knee anomalies is most commonly associated with this condition?

. Anterior cruciate ligament deficiency
. Discoid lateral meniscus
. Bipartite patella
. Posterior cruciate ligament deficiency
. Congenital patellar dislocation

Correct Answer & Explanation

. Anterior cruciate ligament deficiency

Explanation

Fibular hemimelia is a longitudinal deficiency characterized by partial or complete absence of the fibula. It is highly associated with anterior cruciate ligament (ACL) deficiency, absent lateral rays, and tarsal coalitions.

Question 192

Topic: Pediatric Lower Extremity

A 4-year-old boy with a history of idiopathic clubfoot treated successfully with the Ponseti method presents with a relapsed deformity. He walks with dynamic supination of the foot during the swing phase. Passive range of motion is full, and the foot is completely correctable. What is the most appropriate surgical management?

. Posteromedial release
. Complete subtalar release
. Tibialis anterior tendon transfer to the lateral cuneiform
. Split tibialis posterior tendon transfer
. Achilles tendon lengthening alone

Correct Answer & Explanation

. Tibialis anterior tendon transfer to the lateral cuneiform

Explanation

Dynamic supination in a relapsed clubfoot that is passively correctable is best treated with a full transfer of the tibialis anterior tendon to the lateral cuneiform. This procedure balances the muscular forces of the foot and prevents further relapse.

Question 193

Topic: Pediatric Lower Extremity

A newborn is evaluated for a short lower extremity. Radiographs show a very short femur, an absent proximal femur, and no hip joint articulation. According to the Aitken classification, which class does this represent?

. Class A
. Class B
. Class C
. Class D
. Class E

Correct Answer & Explanation

. Class D

Explanation

In Aitken Class D Proximal Focal Femoral Deficiency (PFFD), both the acetabulum and the proximal femur are severely dysplastic or absent. There is no bony connection between the femur and the pelvis.

Question 194

Topic: Pediatric Lower Extremity

A 4-week-old infant with an idiopathic clubfoot has undergone four weekly casts using the Ponseti method. The midfoot cavus, adductus, and heel varus are now fully corrected. However, ankle dorsiflexion is limited to 5 degrees of plantarflexion. What is the most appropriate next step in treatment?

. Two additional weeks of serial casting
. Percutaneous Achilles tenotomy
. Comprehensive posteromedial release
. Transfer of the anterior tibial tendon
. Immediate application of a foot abduction orthosis

Correct Answer & Explanation

. Percutaneous Achilles tenotomy

Explanation

According to the Ponseti method, once the midfoot deformities (cavus, adductus, varus) are fully corrected, residual equinus is addressed with a percutaneous Achilles tenotomy. This is typically required in over 80% of idiopathic clubfoot cases.

Question 195

Topic: Pediatric Lower Extremity

During the Ponseti method for the treatment of idiopathic clubfoot, what is the first component of the deformity that must be corrected?

. Equinus
. Hindfoot varus
. Forefoot adductus
. Midfoot cavus
. Forefoot pronation

Correct Answer & Explanation

. Midfoot cavus

Explanation

The CAVE acronym denotes the sequence of correction: Cavus, Adductus, Varus, Equinus. Cavus is corrected first by supinating the forefoot to align the first ray with the rest of the foot.

Question 196

Topic: Pediatric Lower Extremity

A newborn boy is noted to have a shortened right lower extremity. Radiographs reveal an absent fibula, anterior bowing of the tibia, and an equinovalgus foot with three toes. What is the most common ankle anomaly associated with this condition?

. Tarsal coalition
. Ball-and-socket ankle joint
. Congenital vertical talus
. Clubfoot
. Pes planovalgus

Correct Answer & Explanation

. Ball-and-socket ankle joint

Explanation

Fibular hemimelia is classically associated with an absent lateral ray, an equinovalgus foot deformity, and a ball-and-socket ankle joint.

Question 197

Topic: Pediatric Lower Extremity

A 3-year-old boy previously treated with the Ponseti method for bilateral idiopathic clubfeet presents with a relapsed deformity. Gait evaluation reveals dynamic supination of the foot during the swing phase. What is the most appropriate surgical intervention?

. Split tibialis posterior tendon transfer
. Tibialis anterior tendon transfer to the lateral cuneiform
. Triple arthrodesis
. Achilles tendon lengthening alone
. Lateral column lengthening osteotomy

Correct Answer & Explanation

. Tibialis anterior tendon transfer to the lateral cuneiform

Explanation

Dynamic supination during the swing phase is a classic sign of relapsed clubfoot following Ponseti casting. Transferring the tibialis anterior tendon to the lateral cuneiform balances the foot and minimizes further relapse.

Question 198

Topic: Pediatric Lower Extremity
A 4-year-old boy with a history of right idiopathic clubfoot treated successfully with the Ponseti method presents with a new gait abnormality. His parents note that he walks on the outside of his right foot. Examination reveals dynamic supination during the swing phase of gait, but the foot is passively correctable. What is the most appropriate surgical intervention?
. Achilles tendon lengthening
. Posteromedial release
. Split anterior tibial tendon transfer (SPLATT)
. Whole tibialis anterior tendon transfer to the lateral cuneiform
. Calcaneocuboid wedge osteotomy

Correct Answer & Explanation

. Whole tibialis anterior tendon transfer to the lateral cuneiform

Explanation

Dynamic supination in a previously corrected clubfoot is typically caused by an overactive tibialis anterior muscle. The treatment of choice for a flexible deformity in this age group is transfer of the entire tibialis anterior tendon to the lateral cuneiform.

Question 199

Topic: Pediatric Lower Extremity
A 4-year-old boy presents with a relapsed right clubfoot. He was initially treated with the Ponseti method as an infant. Examination reveals dynamic supination during the swing phase of gait. Passive range of motion is normal. What is the most appropriate next step in management?
. Repeat serial casting alone
. Anterior tibial tendon transfer to the third cuneiform
. Split posterior tibial tendon transfer
. Cuboid decancellation
. Talonavicular arthrodesis

Correct Answer & Explanation

. Anterior tibial tendon transfer to the third cuneiform

Explanation

Dynamic supination in a relapsed clubfoot previously treated with the Ponseti method is best managed with an anterior tibial tendon transfer (ATTT) to the lateral cuneiform, provided passive correction is achievable. This rebalances the foot to prevent further relapse.

Question 200

Topic: Pediatric Lower Extremity

A 3-year-old boy treated with the Ponseti method for idiopathic clubfoot presents with dynamic supination of the foot during the swing phase of gait. Passive range of motion is full, and dorsiflexion is 15 degrees. What is the most appropriate management?

. Anterior tibial tendon transfer to the lateral cuneiform
. Achilles tendon lengthening
. Posterior medial release
. Serial casting
. Split posterior tibial tendon transfer

Correct Answer & Explanation

. Anterior tibial tendon transfer to the lateral cuneiform

Explanation

Dynamic supination in a previously treated clubfoot with adequate passive dorsiflexion is best treated with an anterior tibial tendon transfer to the lateral cuneiform. This corrects the muscle imbalance causing the deformity.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page