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Pediatric Lower Extremity MCQs

Practice Set 11 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 201

Topic: Pediatric Lower Extremity
A 3-year-old boy, who was treated successfully for idiopathic clubfoot as an infant using the Ponseti method, now presents with recurrent dynamic supination of the foot during the swing phase of gait. Passive range of motion is fully correctable. What is the most appropriate surgical management?
. Achilles tendon lengthening
. Split anterior tibial tendon transfer (SPLATT)
. Tibialis anterior tendon transfer to the lateral cuneiform
. Extensive posterior-medial-lateral release
. Lateral closing wedge calcaneal osteotomy

Correct Answer & Explanation

. Tibialis anterior tendon transfer to the lateral cuneiform

Explanation

Dynamic supination during gait in a relapsed Ponseti-treated clubfoot, when passively correctable, is best treated with a full tibialis anterior tendon transfer to the lateral cuneiform. This functionally balances the foot during dorsiflexion and prevents further relapse.

Question 202

Topic: Pediatric Lower Extremity

An infant is undergoing serial casting for an idiopathic clubfoot utilizing the Ponseti method. To ensure successful correction and minimize the risk of a rocker-bottom deformity, what is the correct sequence of deformity correction?

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

Correct Answer & Explanation

. Adductus, Cavus, Varus, Equinus

Explanation

The Ponseti method corrects the clubfoot deformities in a specific sequence: Cavus, Adductus, Varus, and finally Equinus (the mnemonic CAVE). Attempting to correct equinus early can lead to a rocker-bottom foot.

Question 203

Topic: Pediatric Lower Extremity

During the initial application of the Ponseti method for a rigid idiopathic clubfoot in a 2-week-old infant, which of the following maneuvers is the essential first step in correcting the deformity?

. Pronation of the forefoot to correct the cavus
. Elevation of the first ray to correct the cavus
. Abduction of the midfoot with counter-pressure on the calcaneus
. Immediate percutaneous Achilles tenotomy to correct equinus
. Forced dorsiflexion of the midfoot to stretch the plantar fascia

Correct Answer & Explanation

. Elevation of the first ray to correct the cavus

Explanation

The first step in the Ponseti method is correcting the cavus deformity by supinating the forefoot (elevating the first ray) in alignment with the hindfoot. Pronating the forefoot will worsen the cavus and block subsequent correction.

Question 204

Topic: Pediatric Lower Extremity

A 4-year-old boy who was treated for a right idiopathic clubfoot with the Ponseti method presents with a recurrent deformity. Examination reveals active supination of the foot during the swing phase of gait and dynamic forefoot adductus. Ankle dorsiflexion is 10 degrees. What is the most appropriate treatment?

. Repeat Achilles tenotomy
. Posteromedial release
. Split anterior tibial tendon transfer
. Tibialis posterior tendon lengthening
. Derotational osteotomy of the tibia

Correct Answer & Explanation

. Split anterior tibial tendon transfer

Explanation

Dynamic supination in a relapsed clubfoot treated with the Ponseti method is best managed with a split anterior tibial tendon (STATT) transfer or full anterior tibial tendon transfer to the lateral cuneiform, provided the foot is passively correctable.

Question 205

Topic: Pediatric Lower Extremity
A 4-year-old boy previously treated with the Ponseti method for a right idiopathic clubfoot presents with dynamic supination of the foot during the swing phase of gait. Passive range of motion is normal. What is the most appropriate surgical intervention?
. Repeat percutaneous Achilles tenotomy
. Split anterior tibial tendon transfer (SPLATT)
. Complete anterior tibial tendon transfer to the lateral cuneiform
. Tibialis posterior lengthening
. Lateral column lengthening

Correct Answer & Explanation

. Complete anterior tibial tendon transfer to the lateral cuneiform

Explanation

Dynamic supination during the swing phase is a classic sign of clubfoot relapse caused by an overpowering tibialis anterior. It is treated with a complete anterior tibial tendon transfer (ATTT) to the lateral cuneiform.

Question 206

Topic: Pediatric Lower Extremity

A 3-year-old child who was successfully treated for idiopathic clubfoot using the Ponseti method presents with recurrent dynamic supination of the foot during the swing phase of gait. Passive range of motion reveals full dorsiflexion and neutral heel valgus. What is the most appropriate next step in management?

. Repeat serial casting
. Posterior medial release
. Tibialis anterior tendon transfer to the lateral cuneiform
. Split tibialis posterior tendon transfer
. Achilles tendon lengthening

Correct Answer & Explanation

. Tibialis anterior tendon transfer to the lateral cuneiform

Explanation

Dynamic supination in a previously corrected clubfoot indicates a muscle imbalance. A full passive range of motion with dynamic supination is best treated with a tibialis anterior tendon transfer to the lateral cuneiform.

Question 207

Topic: Pediatric Lower Extremity

An infant is born with Aitken Class C proximal focal femoral deficiency (PFFD) on the right. The acetabulum is severely dysplastic, the femoral head is absent, and there is a severe limb length discrepancy. What knee finding is most consistently associated with PFFD?

. Medial collateral ligament deficiency
. Cruciate ligament deficiency
. Patellar aplasia
. Genu varum
. Proximal tibiofibular synostosis

Correct Answer & Explanation

. Cruciate ligament deficiency

Explanation

PFFD is strongly associated with absence or hypoplasia of the cruciate ligaments, leading to anteroposterior knee instability. Fibular hemimelia is another extremely common concurrent finding.

Question 208

Topic: Pediatric Lower Extremity

A 3-month-old infant treated with the Ponseti method for idiopathic clubfoot has undergone five serial casts. The midfoot is now fully corrected and abducted to 70 degrees, but severe equinus persists. What is the next most appropriate step in management?

. Continue casting for 3 more weeks
. Percutaneous Achilles tenotomy
. Posterior capsulotomy of the ankle
. Tibialis anterior tendon transfer
. Extensive posteromedial release

Correct Answer & Explanation

. Percutaneous Achilles tenotomy

Explanation

Once the cavus, adductus, and varus deformities are fully corrected via serial casting in the Ponseti method, residual equinus is treated with a percutaneous Achilles tenotomy followed by a final cast for 3 weeks.

Question 209

Topic: Pediatric Lower Extremity

A 14-year-old boy with a history of recurrent ankle sprains presents with rigid, painful flatfeet and peroneal spasticity. A CT scan of the hindfoot is ordered to evaluate for a tarsal coalition. If a talocalcaneal coalition is present, which facet is most commonly involved?

. Anterior facet
. Middle facet
. Posterior facet
. Lateral facet
. Medial facet

Correct Answer & Explanation

. Middle facet

Explanation

The middle facet is the most commonly involved facet in talocalcaneal coalitions. It is best visualized on coronal CT scans of the hindfoot and is a frequent cause of rigid flatfoot in adolescents.

Question 210

Topic: Pediatric Lower Extremity
A 4-year-old girl presents with progressive bilateral genu varum. Radiographs show Langenskiold stage III changes of the proximal medial tibia with a metaphyseal-diaphyseal angle of 18 degrees. What is the recommended treatment?
. Reassurance and observation
. Knee-ankle-foot orthosis (KAFO) bracing
. Proximal tibial valgus osteotomy
. Medial tibial epiphysiodesis
. Lateral tibial hemiepiphysiodesis

Correct Answer & Explanation

. Proximal tibial valgus osteotomy

Explanation

In infantile Blount disease, children older than 3 years with advanced Langenskiold stages (II or III) and severe deformity require surgical correction via a proximal tibial valgus osteotomy. Bracing is generally ineffective after age 3.

Question 211

Topic: Pediatric Lower Extremity

During the initial casting for an infant with a rigid idiopathic clubfoot using the Ponseti method, what is the first deformity that must be corrected?

. Equinus
. Cavus
. Varus
. Adduction
. Tibial torsion

Correct Answer & Explanation

. Cavus

Explanation

The Ponseti method corrects the deformities of clubfoot in a specific sequence summarized by the acronym CAVE. Cavus is corrected first by elevating the first ray to align the forefoot with the hindfoot.

Question 212

Topic: Pediatric Lower Extremity
A 3-year-old boy treated for idiopathic clubfoot with the Ponseti method presents with a recurrence of the deformity. Examination reveals dynamic supination of the foot during the swing phase of gait. Passive range of motion demonstrates fully correctable deformities. What is the most appropriate next step in management?
. Posteromedial release
. Split anterior tibial tendon transfer (SPLATT)
. Talonavicular arthrodesis
. Tibialis posterior tendon transfer
. Achilles tendon lengthening alone

Correct Answer & Explanation

. Split anterior tibial tendon transfer (SPLATT)

Explanation

Dynamic supination in a relapsed Ponseti-treated clubfoot with a flexible deformity is typically managed with a split anterior tibial tendon transfer (SPLATT) to the lateral cuneiform. This is often combined with an Achilles tendon lengthening if equinus is present.

Question 213

Topic: Pediatric Lower Extremity

A 4-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 of the ankle and foot is full. What is the most appropriate management?

. Repeat manipulation and serial casting
. Full tibialis anterior tendon transfer to the lateral cuneiform
. Split tibialis anterior tendon transfer
. Extensor hallucis longus transfer to the first metatarsal head
. Tibialis posterior tendon lengthening

Correct Answer & Explanation

. Full tibialis anterior tendon transfer to the lateral cuneiform

Explanation

Dynamic supination in a relapsed clubfoot, without fixed deformity, is best managed with a full tibialis anterior tendon transfer to the lateral cuneiform. This converts the deforming supinating force into a corrective dorsiflexion force.

Question 214

Topic: Pediatric Lower Extremity

An infant with idiopathic clubfoot is being treated via the Ponseti casting method. The foot has been successfully abducted to 60 degrees, but dorsiflexion is limited to neutral. What is the most appropriate next step in management?

. Change the cast and continue abduction to 70 degrees
. Perform a percutaneous Achilles tenotomy
. Perform a tibialis anterior tendon transfer
. Perform a comprehensive posteromedial release
. Apply a dynamic ankle-foot orthosis

Correct Answer & Explanation

. Perform a percutaneous Achilles tenotomy

Explanation

Once abduction reaches 60 degrees and the heel is in valgus, residual equinus should be corrected with a percutaneous Achilles tenotomy. This is required in roughly 80 to 90 percent of idiopathic clubfeet treated with the Ponseti method.

Question 215

Topic: Pediatric Lower Extremity

A 2-week-old infant with idiopathic clubfoot is undergoing serial casting using the Ponseti method. The first casting maneuver should primarily aim to correct the cavus deformity. Which of the following describes the correct technique for this initial step?

. Pronate the forefoot and elevate the first ray
. Supinate the forefoot and elevate the first ray
. Dorsiflex the ankle and abduct the forefoot
. Plantarflex the ankle and evert the hindfoot
. Abduct the forefoot against pressure on the calcaneocuboid joint

Correct Answer & Explanation

. Supinate the forefoot and elevate the first ray

Explanation

The initial step in the Ponseti method is correcting the cavus deformity by supinating the forefoot to visually align it with the supinated hindfoot. This is achieved by elevating the first ray while applying counter-pressure to the head of the talus.

Question 216

Topic: Pediatric Lower Extremity

An infant with Proximal Focal Femoral Deficiency (PFFD) is evaluated. Radiographs show a severely dysplastic proximal femur with no radiographic evidence of a femoral head or acetabulum. According to the Aitken classification, what is the grade of this deformity?

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

Correct Answer & Explanation

. Class D

Explanation

Aitken Class D PFFD is characterized by the complete absence of both the acetabulum and the femoral head. It is also associated with a severely shortened and dysplastic femoral shaft.

Question 217

Topic: Pediatric Lower Extremity

Which of the following physical exam findings best differentiates a structural from a compensatory hindfoot varus in a patient with a rigid plantarflexed first ray (cavovarus foot)?

. Correction of the hindfoot varus on the Coleman block test
. Inability to stand on tiptoes
. Positive Silfverskiold test
. Correction of the varus with passive ankle dorsiflexion
. Absence of the windlass mechanism

Correct Answer & Explanation

. Correction of the hindfoot varus on the Coleman block test

Explanation

The Coleman block test drops the first ray off the block. If the hindfoot varus corrects to neutral or valgus, the deformity is flexible/compensatory (driven by the forefoot); if it remains in varus, the hindfoot deformity is fixed/structural.

Question 218

Topic: Pediatric Lower Extremity

During the Ponseti method for treating idiopathic clubfoot, the very first step in casting manipulation addresses which component of the deformity?

. Hindfoot equinus
. Forefoot adduction
. Midfoot cavus
. Hindfoot varus
. Tibial internal torsion

Correct Answer & Explanation

. Midfoot cavus

Explanation

The first step in the Ponseti method is to correct the cavus deformity. This is achieved by elevating the first ray and supinating the forefoot to align it with the hindfoot.

Question 219

Topic: Pediatric Lower Extremity

Which of the following lower extremity orthopedic conditions is most prevalent in the Down syndrome population due to underlying collagen defects and generalized ligamentous laxity?

. Blount's disease
. Patellofemoral instability
. Tarsal coalition
. Congenital vertical talus
. Clubfoot (talipes equinovarus)

Correct Answer & Explanation

. Patellofemoral instability

Explanation

Generalized ligamentous laxity and hypotonia in Down syndrome frequently lead to patellofemoral instability. Recurrent subluxation or dislocation often requires surgical soft tissue realignment if symptomatic.

Question 220

Topic: Pediatric Lower Extremity

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

. Equinus
. Varus
. Adductus
. Cavus
. Internal tibial torsion

Correct Answer & Explanation

. Cavus

Explanation

The sequence of correction in the Ponseti method follows the acronym CAVE: Cavus, Adductus, Varus, Equinus. The cavus deformity is corrected first by elevating the first ray to align the forefoot with the hindfoot.

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