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Pediatric Lower Extremity MCQs

Practice Set 15 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 281

Topic: Pediatric Lower Extremity

In the Ponseti method for the treatment of idiopathic clubfoot, the sequence of correction is paramount. Which of the following components of the deformity is corrected first?

. Equinus
. Varus
. Adductus
. Cavus
. Internal rotation

Correct Answer & Explanation

. Equinus

Explanation

The Ponseti method follows a strict sequence of correction summarized by the acronym CAVE: Cavus, Adductus, Varus, Equinus. The first step is to correct the cavus deformity by supinating the forefoot to align it with the hindfoot, effectively elevating the first ray.

Question 282

Topic: Pediatric Lower Extremity

A 45-year-old female with a history of chronic, worsening midfoot pain presents with a severe, progressive flatfoot deformity. Radiographs show a unique comma-shaped deformity of the tarsal navicular characterized by fragmentation, lateral collapse, and medial protrusion. Which of the following diagnoses best describes this specific pathologic entity?

. Kohler disease
. Freiberg's infraction
. Muller-Weiss disease
. Charcot neuroarthropathy
. Sever's disease

Correct Answer & Explanation

. Kohler disease

Explanation

Muller-Weiss disease is a spontaneous osteonecrosis of the adult tarsal navicular. It classically presents bilaterally in middle-aged females. Radiographically, the navicular appears 'comma-shaped' due to lateral collapse, often resulting in a paradoxical planovarus deformity. In contrast, Kohler disease refers to osteonecrosis of the navicular occurring in early childhood.

Question 283

Topic: Pediatric Lower Extremity

A 16-year-old gymnast presents with chronic anterior knee pain. Examination shows a prominent and tender tibial tubercle. Radiographs demonstrate fragmentation of the tibial tubercle apophysis. The condition is caused by repetitive traction forces from which of the following structures?

. Medial patellofemoral ligament
. Quadriceps tendon
. Patellar tendon
. Anterior cruciate ligament
. Iliotibial band

Correct Answer & Explanation

. Medial patellofemoral ligament

Explanation

The clinical presentation describes Osgood-Schlatter disease, which is a traction apophysitis of the tibial tubercle. It is caused by repetitive microtrauma and traction forces exerted by the patellar tendon on the unossified or partially ossified tibial tubercle apophysis in growing adolescents.

Question 284

Topic: Pediatric Lower Extremity

What is the final deformity corrected in the serial casting phase of the Ponseti method for idiopathic clubfoot?

. Cavus
. Adductus
. Varus
. Equinus
. Supination

Correct Answer & Explanation

. Cavus

Explanation

The sequence of correction in Ponseti casting follows the acronym CAVE: Cavus, Adductus, Varus, and finally Equinus. The equinus deformity is typically the last to be addressed and often requires a percutaneous Achilles tenotomy to achieve adequate dorsiflexion.

Question 285

Topic: Pediatric Lower Extremity
A 3-year-old boy treated successfully for idiopathic clubfoot with the Ponseti method presents with a relapse. He demonstrates dynamic supination during the swing phase of gait without a fixed bony deformity. What is the most appropriate surgical management?
. Posteromedial soft tissue release
. Split anterior tibial tendon transfer (SPLATT)
. Transfer of the entire anterior tibial tendon to the third cuneiform
. Talonavicular arthrodesis
. Calcaneocuboid closing wedge osteotomy

Correct Answer & Explanation

. Transfer of the entire anterior tibial tendon to the third cuneiform

Explanation

Relapse in clubfoot often presents with dynamic supination due to an overpowering anterior tibial tendon in the setting of a corrected, but functionally weak, evertor complex. Transfer of the entire anterior tibial tendon to the third (lateral) cuneiform (TATT) is the treatment of choice for dynamic supination in a relapsed Ponseti-treated clubfoot in a child over 30 months of age.

Question 286

Topic: Pediatric Lower Extremity

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

. Perform a posteromedial soft tissue release
. Continue weekly casting until equinus fully resolves
. Perform a percutaneous Achilles tenotomy
. Apply a Denis Browne splint immediately
. Perform an anterior tibial tendon transfer

Correct Answer & Explanation

. Perform a posteromedial soft tissue release

Explanation

The Ponseti method corrects deformities in the CAVE order: Cavus, Adductus, Varus, and Equinus. A percutaneous Achilles tenotomy is required in approximately 80% of cases to correct the residual rigid equinus.

Question 287

Topic: Pediatric Lower Extremity

During the Ponseti method of serial casting for idiopathic clubfoot, the deformities must be corrected in a specific sequential order to avoid iatrogenic complications. Which deformity must be corrected first?

. Equinus
. Varus
. Adduction
. Cavus
. Internal tibial torsion

Correct Answer & Explanation

. Equinus

Explanation

The Ponseti method corrects deformities using the 'CAVE' sequence: Cavus, Adduction, Varus, and Equinus. The cavus is corrected first by supinating the forefoot to align it with the hindfoot.

Question 288

Topic: Pediatric Lower Extremity

A 4-year-old boy presents with dynamic supination of the foot during the swing phase of gait. He was successfully treated for clubfoot as an infant using the Ponseti method. What is the treatment of choice for this specific relapse?

. Extensive posteromedial release
. Tibialis posterior tendon transfer
. Tibialis anterior tendon transfer (TATT) to the lateral cuneiform
. Repeat percutaneous Achilles tenotomy
. Calcaneal sliding osteotomy

Correct Answer & Explanation

. Extensive posteromedial release

Explanation

Dynamic supination during gait in a relapsed clubfoot is driven by an overactive tibialis anterior muscle. Transferring the tibialis anterior tendon to the lateral cuneiform redirects its force to assist in dorsiflexion without supinating the foot.

Question 289

Topic: Pediatric Lower Extremity
A 4-year-old child previously treated for idiopathic clubfoot with the Ponseti method presents with a recurrent dynamic supination deformity during the swing phase of gait. Passive range of motion is full and the foot is plantigrade. Which of the following is the most appropriate surgical management?
. Repeat serial casting with percutaneous Achilles tenotomy
. Split anterior tibial tendon transfer (SPLATT)
. Full anterior tibial tendon transfer to the lateral cuneiform
. Extensive posteromedial soft tissue release
. Lateral column shortening osteotomy

Correct Answer & Explanation

. Full anterior tibial tendon transfer to the lateral cuneiform

Explanation

Dynamic supination in a relapsed clubfoot treated by the Ponseti method is usually caused by the overpull of a strong tibialis anterior against weak evertors. The standard treatment is transferring the entire tibialis anterior tendon to the third (lateral) cuneiform to balance foot biomechanics.

Question 290

Topic: Pediatric Lower Extremity

A newborn is diagnosed with fibular hemimelia characterized by anteromedial bowing of the tibia and absent lateral rays of the foot. Which of the following ligamentous anomalies of the knee is most likely present?

. Absent anterior cruciate ligament
. Absent posterior cruciate ligament
. Absent medial collateral ligament
. Absent lateral collateral ligament
. Congenital patellar tendon avulsion

Correct Answer & Explanation

. Absent anterior cruciate ligament

Explanation

Fibular hemimelia is a longitudinal deficiency spectrum that is strongly associated with an absent or hypoplastic anterior cruciate ligament (ACL). Other common associations include a ball-and-socket ankle joint and tarsal coalition.

Question 291

Topic: Pediatric Lower Extremity

During the Ponseti method for treating idiopathic clubfoot, what is the first step in the manipulative correction process?

. Correction of ankle equinus
. Abduction of the midfoot
. Elevation of the first ray to correct cavus
. Correction of heel varus
. Internal rotation of the forefoot

Correct Answer & Explanation

. Correction of ankle equinus

Explanation

The first step in the Ponseti method is correcting the cavus by elevating the first ray and supinating the forefoot to align it with the hindfoot. Further corrections follow the CAVE sequence: Cavus, Adductus, Varus, and Equinus.

Question 292

Topic: Pediatric Lower Extremity

A neonate is diagnosed with idiopathic clubfoot (talipes equinovarus) and is scheduled to begin serial casting using the Ponseti method. According to this technique, the initial cast must address the first element of the deformity by performing which specific manipulative maneuver?

. Supination of the forefoot and elevation of the first ray to correct cavus
. Pronation of the forefoot to align it with the hindfoot
. Forced dorsiflexion of the ankle to stretch the Achilles tendon
. Abduction of the forefoot with pressure over the cuboid
. Valgus directed pressure on the calcaneus to correct varus

Correct Answer & Explanation

. Supination of the forefoot and elevation of the first ray to correct cavus

Explanation

The Ponseti method addresses clubfoot deformities in the sequence C-A-V-E (Cavus, Adductus, Varus, Equinus). The very first step is to correct the cavus component. This is achieved by supinating the forefoot and elevating the first metatarsal, which aligns the forefoot with the already supinated hindfoot, providing a solid fulcrum for subsequent abduction.

Question 293

Topic: Pediatric Lower Extremity

In the Ponseti method for treating idiopathic clubfoot, which of the following components of the deformity is anatomically corrected last?

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

Correct Answer & Explanation

. Cavus

Explanation

In the Ponseti method, the mnemonic CAVE dictates the order of correction: Cavus, Adductus, Varus, and finally Equinus. Equinus is typically corrected last, nearly always requiring a percutaneous Achilles tenotomy.

Question 294

Topic: Pediatric Lower Extremity

According to the Ponseti method for treating congenital talipes equinovarus (clubfoot), what is the correct sequence of deformity correction?

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The Ponseti method corrects the clubfoot deformities in a specific sequence described by the acronym CAVE: Cavus (corrected first by elevating the first ray to align the forefoot with the hindfoot), Adductus, Varus, and finally Equinus (which often requires a percutaneous Achilles tenotomy as the final step).

Question 295

Topic: Pediatric Lower Extremity

Proximal focal femoral deficiency (PFFD) is most frequently associated with which of the following congenital anomalies?

. Tibial hemimelia
. Fibular hemimelia
. Congenital short femur
. Radioulnar synostosis
. Clubfoot

Correct Answer & Explanation

. Tibial hemimelia

Explanation

PFFD is highly associated with fibular hemimelia, occurring in approximately 50-70% of cases. Evaluation of a patient with PFFD must include careful assessment of the entire limb to check for fibular deficiency, absence of cruciate ligaments, and foot deformities.

Question 296

Topic: Pediatric Lower Extremity

Which of the following features accurately differentiates infantile Blount's disease from adolescent Blount's disease?

. Adolescent Blount's is more commonly bilateral
. Infantile Blount's is associated with lateral thrust and joint laxity
. Infantile Blount's primarily affects the distal femur
. Adolescent Blount's responds well to orthotic management
. Infantile Blount's is less likely to require surgical intervention if diagnosed early

Correct Answer & Explanation

. Adolescent Blount's is more commonly bilateral

Explanation

Infantile Blount's disease is often bilateral (up to 80%) and classically presents with a prominent lateral thrust during gait due to severe proximal medial tibial metaphyseal beaking and associated ligamentous laxity. Adolescent Blount's is usually unilateral, lacks the pronounced lateral thrust, and does not respond to orthotics.

Question 297

Topic: Pediatric Lower Extremity

A 4-year-old boy previously treated for clubfoot with the Ponseti method presents with a relapsed deformity. He exhibits dynamic supination of the foot during the swing phase of gait. What is the most appropriate definitive management?

. Repeat percutaneous Achilles tenotomy
. Transfer of the tibialis anterior to the lateral cuneiform
. Split tibialis posterior tendon transfer
. Triple arthrodesis
. Calcaneal sliding osteotomy

Correct Answer & Explanation

. Repeat percutaneous Achilles tenotomy

Explanation

Dynamic supination during the swing phase of gait is a common sign of a relapsed clubfoot treated with the Ponseti method. It is best managed by transferring the whole tibialis anterior tendon to the lateral cuneiform to balance eversion and inversion forces.

Question 298

Topic: Pediatric Lower Extremity

In the treatment of infant clubfoot (talipes equinovarus) using the Ponseti method, serial casting follows a specific sequence to gradually correct the complex multiplanar deformity. What is the correct sequential order of deformity correction?

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The Ponseti method requires sequential correction of the clubfoot deformity in the following order: Cavus, Adductus, Varus, and lastly Equinus (remembered by the mnemonic CAVE). The cavus is corrected first by elevating the first ray. The adductus and varus are corrected simultaneously by abducting the midfoot around the fixed head of the talus. Equinus is corrected last, often requiring a percutaneous Achilles tenotomy.

Question 299

Topic: Pediatric Lower Extremity

In the treatment of idiopathic clubfoot using the Ponseti method, the deformities must be sequentially addressed in a specific order. Which deformity is corrected first, and what is the specific maneuver used?

. Equinus, corrected by an Achilles tenotomy
. Varus, corrected by abducting the midfoot against the talus
. Adductus, corrected by applying lateral pressure on the cuboid
. Cavus, corrected by supinating the forefoot and elevating the first ray
. Cavus, corrected by depressing the first ray

Correct Answer & Explanation

. Cavus, corrected by supinating the forefoot and elevating the first ray

Explanation

The sequence of correction in the Ponseti method follows the acronym CAVE (Cavus, Adductus, Varus, Equinus). The cavus deformity is the first to be addressed. It is corrected by supinating the forefoot and elevating the first ray to align the forefoot with the already supinated hindfoot, thus unlocking the midtarsal joint for subsequent abduction.

Question 300

Topic: Pediatric Lower Extremity

During the correction of idiopathic clubfoot using the Ponseti method, manipulation and casting must follow a specific sequence. Which component of the deformity is corrected first, and what is the maneuver used to achieve it?

. Equinus; achieved by immediate dorsiflexion of the ankle
. Varus; achieved by everting the calcaneus
. Adductus; achieved by abducting the midfoot with counter-pressure on the calcaneocuboid joint
. Cavus; achieved by elevating the first ray to supinate the forefoot
. Equinus; achieved by a percutaneous Achilles tenotomy prior to any casting

Correct Answer & Explanation

. Cavus; achieved by elevating the first ray to supinate the forefoot

Explanation

The Ponseti method corrects deformities in the order of CAVE (Cavus, Adductus, Varus, Equinus). The cavus is corrected first by supinating the forefoot (elevating the first ray) to align it with the already supinated hindfoot.

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