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Pediatric Lower Extremity MCQs

Practice Set 12 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 221

Topic: Pediatric Lower Extremity

In the Ponseti method for the non-operative treatment of congenital talipes equinovarus (clubfoot), what is the correct anatomical 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, Adductus, Equinus

Correct Answer & Explanation

. Cavus, Varus, Adductus, Equinus

Explanation

The Ponseti method corrects the clubfoot deformities in a specific, sequential order remembered by the mnemonic CAVE: Cavus (corrected first by supinating the forefoot to align with the hindfoot), Adductus, Varus, and finally Equinus (which often requires a percutaneous Achilles tenotomy as the final step).

Question 222

Topic: Pediatric Lower Extremity

A U-osteotomy (calcaneal-cuboid-cuneiform osteotomy) for a severe cavovarus foot deformity primarily aims to correct deformity in which plane?

. Coronal plane only
. Sagittal plane only
. Axial plane only
. Multiplanar (sagittal, coronal, and transverse)
. Pure translation without angular change

Correct Answer & Explanation

. Multiplanar (sagittal, coronal, and transverse)

Explanation

The U-osteotomy is a powerful midfoot osteotomy that allows for simultaneous multiplanar correction. It effectively addresses the cavus (sagittal), varus (coronal), and forefoot adduction (transverse) components of the deformity.

Question 223

Topic: Pediatric Lower Extremity

A patient undergoes correction of a severe cavovarus foot using a Taylor Spatial Frame (TSF). During the correction process, the patient complains of progressive numbness and tingling over the plantar aspect of the foot. Which structure is at highest risk during acute/rapid correction of a cavovarus deformity?

. Deep peroneal nerve
. Tibial nerve
. Sural nerve
. Saphenous nerve
. Superficial peroneal nerve

Correct Answer & Explanation

. Tibial nerve

Explanation

The tibial nerve (and its plantar branches) courses medially and plantarly. As the severe cavovarus deformity is corrected (which involves lengthening the medial column and stretching the plantar tissues), the tibial nerve is at highest risk for traction injury.

Question 224

Topic: Pediatric Lower Extremity

A 16-year-old male presents with insidious onset of anterior knee pain, localized just below the patella, worse with activity. Physical examination reveals tenderness and a prominent bump over the tibial tubercle. Radiographs show fragmentation of the tibial tubercle apophysis. What is the most likely diagnosis?

. Patellofemoral pain syndrome
. Jumper's knee (patellar tendinopathy)
. Osgood-Schlatter disease
. Sinding-Larsen-Johansson disease
. Tibial stress fracture

Correct Answer & Explanation

. Osgood-Schlatter disease

Explanation

The clinical presentation (adolescent male, anterior knee pain, tenderness/prominence of tibial tubercle, pain with activity) and radiographic findings (fragmentation of the tibial tubercle apophysis) are classic for Osgood-Schlatter disease. This is a traction apophysitis of the tibial tubercle, often associated with growth spurts and repetitive quadriceps contraction. Sinding-Larsen-Johansson disease is similar but affects the inferior pole of the patella. Patellofemoral pain syndrome is typically diffuse anterior knee pain, and jumper's knee affects the patellar tendon itself.

Question 225

Topic: Pediatric Lower Extremity

During the initiation of the Ponseti method for a rigid idiopathic clubfoot in a 2-week-old infant, the first manipulative step prior to applying the first long-leg cast is designed to correct the cavus deformity. Which of the following maneuvers is correct to achieve this?

. Elevating the first ray to align the forefoot with the hindfoot
. Depressing the first ray to increase the medial arch
. Abducting the forefoot while applying counter-pressure over the calcaneocuboid joint
. Dorsiflexing the entire midfoot against a tight Achilles tendon
. Forced eversion of the hindfoot to correct the varus

Correct Answer & Explanation

. Elevating the first ray to align the forefoot with the hindfoot

Explanation

In the Ponseti method, the first step is correcting the cavus, which is driven by a relatively plantarflexed first ray compared to the lateral rays. The first ray must be elevated (dorsiflexed) to supinate the forefoot and align it with the hindfoot, establishing a proper mechanical block to further correct adductus and varus.

Question 226

Topic: Pediatric Lower Extremity

A 3-month-old presents with severe, atypical (complex) clubfoot characterized by a short, chubby foot, a deep transverse plantar crease, and severe equinus. Treatment via the modified Ponseti method should strictly emphasize which of the following?

. Maximum abduction of the foot to 70 degrees
. Immediate posteromedial release
. Serial casting with the knee in extension
. Application of an Ilizarov frame
. Early Achilles tenotomy and limiting abduction to 30-40 degrees

Correct Answer & Explanation

. Early Achilles tenotomy and limiting abduction to 30-40 degrees

Explanation

Atypical or complex clubfeet respond poorly to standard Ponseti casting and are prone to severe complications like iatrogenic midfoot break. The modified Ponseti technique involves recognizing the complex nature early, avoiding hyperabduction (limiting abduction to 30-40 degrees instead of the usual 60-70 degrees), and performing an early percutaneous Achilles tenotomy to correct the severe equinus.

Question 227

Topic: Pediatric Lower Extremity

A 4-week-old infant with idiopathic clubfoot is being treated with the Ponseti method. After 5 weeks of serial casting, the cavus, adductus, and varus deformities have completely resolved. However, passive ankle dorsiflexion is only 5 degrees. What is the next most appropriate step in management?

. Continue serial casting for 3 additional weeks to stretch the Achilles tendon
. Perform a percutaneous Achilles tenotomy
. Perform an open posterior medial release
. Transition directly to a foot abduction orthosis (boots and bar)
. Perform an anterior tibial tendon transfer

Correct Answer & Explanation

. Perform a percutaneous Achilles tenotomy

Explanation

In the Ponseti method, after the cavus, adductus, and varus deformities are corrected (which relies on abduction around the talar head), the equinus is addressed. If ankle dorsiflexion is less than 10 to 15 degrees, a percutaneous Achilles tenotomy is indicated. This is required in 80% to 90% of patients with idiopathic clubfoot.

Question 228

Topic: Pediatric Lower Extremity

A 2-year-old girl presents with progressive bowing of her left leg. Standing full-length radiographs demonstrate a marked varus deformity isolated to the proximal tibia. Which of the following radiographic parameters is most strongly predictive of progression to true infantile Blount's disease rather than physiological bowing?

. Tibiofemoral angle greater than 10 degrees
. Metaphyseal-diaphyseal angle greater than 16 degrees
. Mechanical axis deviation passing through the medial compartment
. Epiphyseal-metaphyseal angle greater than 20 degrees
. Lateral distal femoral angle greater than 90 degrees

Correct Answer & Explanation

. Metaphyseal-diaphyseal angle greater than 16 degrees

Explanation

The metaphyseal-diaphyseal angle (Drennan's angle) is the most reliable early radiographic predictor for infantile Blount's disease. An angle > 16 degrees indicates a high likelihood (up to 95%) of progression to Blount's disease, whereas an angle < 10 degrees strongly suggests physiological bowing. Angles between 10 and 16 degrees require close observation.

Question 229

Topic: Pediatric Lower Extremity
A 2.5-year-old boy treated successfully in infancy for a right idiopathic clubfoot using the Ponseti method returns to the clinic. His parents report worsening of his foot shape over the last 3 months and admit to discontinuing the foot abduction orthosis. Examination reveals dynamic supination and recurrent equinus. What is the most appropriate initial management?
. Achilles tendon lengthening and immediate AFO bracing
. Comprehensive posteromedial surgical release
. Anterior tibial tendon transfer (ATTT)
. Repeat manipulation and serial long-leg casting
. Talectomy

Correct Answer & Explanation

. Repeat manipulation and serial long-leg casting

Explanation

Relapse of clubfoot deformities after Ponseti treatment is most commonly due to poor compliance with bracing. Regardless of the child's age or the presence of a dynamic supination component, the first-line treatment for a relapse is always repeat manipulation and serial long-leg casting to correct the deformities. Once the foot is supple and plantigrade, a surgical procedure such as an Anterior Tibial Tendon Transfer (ATTT) may be indicated to prevent further relapse, but it should not be performed before recasting.

Question 230

Topic: Pediatric Lower Extremity
A 4-year-old boy, previously treated successfully with the Ponseti method for idiopathic clubfoot, presents with dynamic supination of the foot during the swing phase of gait. Passive range of motion of the ankle and subtalar joints is normal. What is the most appropriate surgical treatment?
. Repeat percutaneous Achilles tenotomy
. Split anterior tibial tendon transfer (SPLATT)
. Full anterior tibial tendon transfer to the lateral cuneiform
. Extensive posterior medial surgical release
. Lateral sliding calcaneal osteotomy

Correct Answer & Explanation

. Full anterior tibial tendon transfer to the lateral cuneiform

Explanation

Dynamic supination in a relapsed clubfoot that has maintained passive flexibility is treated with a full transfer of the anterior tibial tendon to the lateral cuneiform. A split transfer (SPLATT) does not provide enough eversion power in true clubfoot relapse.

Question 231

Topic: Pediatric Lower Extremity

The Ponseti method is the gold standard for the conservative management of idiopathic clubfoot, involving sequential manipulation and casting. Based on the Ponseti protocol, which of the following components of the clubfoot deformity is corrected LAST?

. Cavus
. Adductus
. Varus
. Equinus
. Forefoot supination

Correct Answer & Explanation

. Equinus

Explanation

The Ponseti method addresses clubfoot deformities in a specific sequence described by the acronym CAVE: Cavus (corrected first by elevating the first ray to supinate the forefoot), Adductus, Varus, and finally Equinus. Equinus is corrected last and in the vast majority of cases requires a percutaneous Achilles tenotomy to achieve adequate dorsiflexion.

Question 232

Topic: Pediatric Lower Extremity

According to the Ponseti method for the non-operative treatment of idiopathic clubfoot, serial casting must correct the components of the deformity in a highly specific order to prevent midfoot breach. What is the correct sequence of deformity correction?

. Cavus, Adductus, Varus, Equinus (CAVE)
. Equinus, Varus, Adductus, Cavus
. Cavus, Varus, Equinus, Adductus
. Adductus, Cavus, Varus, Equinus
. Varus, Adductus, Cavus, Equinus

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus (CAVE)

Explanation

The Ponseti method dictates that the deformities of clubfoot be corrected in the CAVE sequence: first the Cavus (by elevating the first ray to supinate the forefoot), then Adductus and Varus (simultaneously corrected by abducting the foot around the head of the talus), and finally Equinus (usually requiring a percutaneous Achilles tenotomy as the last step).

Question 233

Topic: Pediatric Lower Extremity

A newborn is diagnosed with idiopathic clubfoot (talipes equinovarus). What is the gold standard, non-surgical treatment approach?

. Surgical correction with posteromedial release
. Dynamic splinting with ankle-foot orthoses (AFOs)
. Ponseti method of serial manipulation and casting
. Observation and passive stretching exercises
. Kinesio taping and massage therapy

Correct Answer & Explanation

. Ponseti method of serial manipulation and casting

Explanation

The Ponseti method of serial manipulation and casting is the universally accepted gold standard non-surgical treatment for idiopathic clubfoot. It involves a specific sequence of gentle manipulations and plaster cast applications, typically weekly, followed by a percutaneous Achilles tenotomy and then bracing with a foot abduction orthosis. Surgical correction is reserved for failed Ponseti treatment or severe, rigid deformities. Other options are ineffective or not primary treatment.

Question 234

Topic: Pediatric Lower Extremity

A 14-year-old boy, active in sports, presents with anterior knee pain and tenderness over the tibial tubercle, exacerbated by jumping and kneeling. There is a palpable bump at the site. What is the MOST likely diagnosis?

. Patellofemoral pain syndrome
. Patellar tendonitis
. Sinding-Larsen-Johansson disease
. Osgood-Schlatter disease
. Osteochondritis dissecans

Correct Answer & Explanation

. Osgood-Schlatter disease

Explanation

The classic presentation of Osgood-Schlatter disease is anterior knee pain, localized tenderness, and a palpable bump over the tibial tubercle in an active adolescent, particularly during growth spurts. It is an apophysitis caused by repetitive traction of the patellar tendon on the tibial tubercle. Patellofemoral pain is diffuse anterior knee pain. Patellar tendonitis is pain at the inferior pole of the patella. Sinding-Larsen-Johansson is similar but affects the inferior pole of the patella. Osteochondritis dissecans involves articular cartilage and subchondral bone, usually in the femoral condyle.

Question 235

Topic: Pediatric Lower Extremity

Which of the following statements about clubfoot (congenital talipes equinovarus) is FALSE?

. It is characterized by hindfoot equinus, hindfoot varus, forefoot adduction, and forefoot supination.
. The Ponseti method is the gold standard for initial non-operative treatment.
. Correction involves serial casting with gentle manipulation, primarily addressing hindfoot equinus first.
. Percutaneous Achilles tenotomy is often performed as part of the Ponseti method.
. Surgical release is typically reserved for failed Ponseti treatment or recurrence.

Correct Answer & Explanation

. Correction involves serial casting with gentle manipulation, primarily addressing hindfoot equinus first.

Explanation

The statement that 'Correction involves serial casting with gentle manipulation, primarily addressing hindfoot equinus first' is FALSE. The Ponseti method, the gold standard for clubfoot correction, addresses the components of the deformity in a specific sequence: first correcting the cavus and adduction, then the varus, and finally the equinus. The hindfoot equinus is usually the last deformity addressed, often requiring a percutaneous Achilles tenotomy. If equinus is corrected first, it can lead to a 'rocker-bottom' foot. The other statements are true: clubfoot has characteristic deformities, Ponseti is the gold standard, Achilles tenotomy is common, and surgery is reserved for failures.

Question 236

Topic: Pediatric Lower Extremity

Which of the following conditions is characterized by anterior knee pain, often exacerbated by prolonged sitting or climbing stairs, due to abnormal tracking of the patella?

. Patellar tendinopathy
. Osgood-Schlatter disease
. Chondromalacia patellae / Patellofemoral pain syndrome
. Infrapatellar fat pad impingement
. Plica syndrome

Correct Answer & Explanation

. Chondromalacia patellae / Patellofemoral pain syndrome

Explanation

Anterior knee pain, especially worsened by activities that load the patellofemoral joint (e.g., prolonged sitting, climbing stairs, squatting), is characteristic of patellofemoral pain syndrome (PFPS), also historically known as chondromalacia patellae when referring to cartilage softening. This condition often stems from patellar maltracking or muscle imbalances. Patellar tendinopathy causes pain inferior to the patella. Osgood-Schlatter is tibial tubercle apophysitis in adolescents. Fat pad impingement and plica syndrome are less common causes of similar symptoms.

Question 237

Topic: Pediatric Lower Extremity

A 30-year-old male presents with chronic anterior knee pain, exacerbated by squatting and climbing stairs. He has a positive 'patellar grind test' and reproduces pain with compression of the patella into the trochlear groove. Radiographs are unremarkable. What is the most likely diagnosis?

. Meniscal tear.
. Patellar tendinopathy ('jumper's knee').
. Patellofemoral pain syndrome (chondromalacia patellae).
. Anterior cruciate ligament injury.
. Osgood-Schlatter disease.

Correct Answer & Explanation

. Patellofemoral pain syndrome (chondromalacia patellae).

Explanation

The symptoms (anterior knee pain exacerbated by squatting/stairs) and physical exam findings (patellar grind test, pain with patellar compression) are highly suggestive of Patellofemoral Pain Syndrome (PFPS), sometimes referred to as chondromalacia patellae although chondromalacia is a specific cartilage finding rather than a clinical syndrome. PFPS is caused by abnormal tracking or overload of the patellofemoral joint. Meniscal tears typically cause joint line pain, catching, or locking. Patellar tendinopathy causes localized pain at the inferior pole of the patella. ACL injury causes instability. Osgood-Schlatter disease is common in adolescents and causes pain and swelling at the tibial tubercle.

Question 238

Topic: Pediatric Lower Extremity

A 14-year-old male presents with chronic anterior knee pain, a prominent and tender bump at the tibial tubercle, exacerbated by sports activities. What is the most likely diagnosis?

. Patellofemoral pain syndrome.
. Sinding-Larsen-Johansson syndrome.
. Osgood-Schlatter disease.
. Patellar tendinopathy.
. Plica syndrome.

Correct Answer & Explanation

. Osgood-Schlatter disease.

Explanation

The patient's presentation (chronic anterior knee pain, prominent and tender tibial tubercle, exacerbated by sports in an adolescent male) is classic for Osgood-Schlatter disease. This condition is an apophysitis of the tibial tubercle due to repetitive traction of the patellar tendon on the developing growth plate. Sinding-Larsen-Johansson syndrome is similar but affects the inferior pole of the patella. Patellofemoral pain syndrome causes pain around or behind the patella, without a prominent tubercle. Patellar tendinopathy affects older adolescents or adults. Plica syndrome is less common and causes pain with knee flexion/extension.

Question 239

Topic: Pediatric Lower Extremity

Which of the following conditions is characterized by anterior knee pain, particularly aggravated by ascending/descending stairs or prolonged sitting, and often associated with crepitus?

. Patellar tendinopathy (Jumper's knee).
. Osgood-Schlatter disease.
. Patellofemoral pain syndrome (PFPS).
. Medial plica syndrome.
. IT band syndrome.

Correct Answer & Explanation

. Patellofemoral pain syndrome (PFPS).

Explanation

Patellofemoral pain syndrome (PFPS), also known as 'runner's knee,' is characterized by anterior knee pain, often worse with activities that load the patellofemoral joint (stairs, squatting, prolonged sitting - 'theater sign'). Crepitus is also a common finding. Patellar tendinopathy causes localized pain at the inferior pole of the patella. Osgood-Schlatter disease affects adolescents with pain at the tibial tubercle. Medial plica syndrome has specific medial knee pain and snapping. IT band syndrome causes lateral knee pain.

Question 240

Topic: Pediatric Lower Extremity

A 16-year-old female high school basketball player presents with chronic anterior knee pain, worse with jumping and running. Palpation reveals tenderness at the inferior pole of the patella. Radiographs are unremarkable. Which of the following is the most likely diagnosis?

. Osgood-Schlatter disease
. Sinding-Larsen-Johansson syndrome
. Patellar tendinopathy ('jumper's knee')
. Patellofemoral pain syndrome
. Chondromalacia patellae

Correct Answer & Explanation

. Patellar tendinopathy ('jumper's knee')

Explanation

Given the age (late adolescence), activity level (basketball, jumping), and specific location of pain (inferior pole of the patella), patellar tendinopathy, often called 'jumper's knee,' is the most likely diagnosis. Osgood-Schlatter disease affects the tibial tubercle and is typically seen in younger adolescents (pre-pubertal/early pubertal). Sinding-Larsen-Johansson syndrome affects the inferior pole of the patella but usually in a slightly younger age group (8-13) and involves apophysitis. Patellofemoral pain syndrome typically presents with diffuse anterior knee pain, worse with stairs, and patellar crepitus, but localized tenderness at the inferior pole is less characteristic. Chondromalacia patellae refers to softening of the articular cartilage, which is a pathological finding, not a clinical diagnosis, and would likely cause more diffuse retropatellar pain.

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