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Pediatric Lower Extremity MCQs

Practice Set 16 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 301

Topic: Pediatric Lower Extremity

A newborn is noted to have a clubfoot (talipes equinovarus) deformity. What is the preferred initial treatment for idiopathic clubfoot in a neonate?

. Kite method of serial casting
. Surgical release
. Ponseti method of serial casting
. Physiotherapy and stretching
. Custom orthotics

Correct Answer & Explanation

. Ponseti method of serial casting

Explanation

The Ponseti method of serial casting is the universally accepted gold standard and preferred initial treatment for idiopathic clubfoot in neonates and young infants. It involves a specific sequence of gentle manipulations and weekly cast changes to gradually correct the deformity, often followed by a percutaneous Achilles tenotomy and then bracing. This method has largely superseded older casting techniques (like the Kite method) and initial surgical releases due to its high success rates and avoidance of extensive surgery.

Question 302

Topic: Pediatric Lower Extremity

A 4-year-old child presents with a limp, knee pain, and difficulty bearing weight. Radiographs show a small, irregular appearance of the medial femoral condyle. The child has no history of trauma, fever, or inflammatory markers. What is the most likely diagnosis?

. Osteochondritis dissecans (OCD)
. Juvenile idiopathic arthritis
. Septic arthritis
. Blount's disease
. Osgood-Schlatter disease

Correct Answer & Explanation

. Osteochondritis dissecans (OCD)

Explanation

Osteochondritis dissecans (OCD) commonly presents in children and adolescents with knee pain, limp, and mechanical symptoms. Radiographic findings of an irregular appearance or fragmentation of the medial femoral condyle are characteristic. While the exact etiology is unknown, it involves avascular changes in the subchondral bone. Juvenile idiopathic arthritis would present with more diffuse joint swelling and inflammatory markers. Septic arthritis would involve acute pain, fever, and markedly elevated inflammatory markers. Blount's disease affects the proximal tibia, causing bowing. Osgood-Schlatter disease causes pain at the tibial tubercle, typically in older adolescents.

Question 303

Topic: Pediatric Lower Extremity

A 16-year-old male presents with chronic anterior knee pain, worse with activity and stair climbing. Examination reveals generalized knee laxity, a positive apprehension test, and J-sign. Radiographs are normal. What is the most likely diagnosis?

. Patellar tendinopathy
. Osgood-Schlatter disease
. Recurrent patellar instability (patellar subluxation/dislocation)
. Chondromalacia patellae
. Plica syndrome

Correct Answer & Explanation

. Recurrent patellar instability (patellar subluxation/dislocation)

Explanation

The patient's age, chronic anterior knee pain, pain with activity, generalized knee laxity, a positive apprehension test (indicating fear of patellar dislocation), and J-sign (lateral patellar tracking during knee extension) are all characteristic of recurrent patellar instability (subluxation or dislocation). Patellar tendinopathy causes pain at the inferior pole of the patella. Osgood-Schlatter disease causes pain at the tibial tubercle. Chondromalacia patellae is a descriptive term for cartilage softening and is often a symptom, not a diagnosis. Plica syndrome presents with medial knee pain and snapping.

Question 304

Topic: Pediatric Lower Extremity

In a discussion about the management of clubfoot (talipes equinovarus) in an infant, what is the most important principle to articulate regarding initial treatment?

. Immediate surgical correction is always necessary.
. Ignoring the foot's flexibility.
. The Ponseti method of serial casting, initiated shortly after birth, to achieve gradual, non-operative correction, followed by bracing to maintain correction, with surgery reserved for failed non-operative treatment.
. Parents should stretch the foot themselves.
. Only observing the foot for spontaneous correction.

Correct Answer & Explanation

. The Ponseti method of serial casting, initiated shortly after birth, to achieve gradual, non-operative correction, followed by bracing to maintain correction, with surgery reserved for failed non-operative treatment.

Explanation

The Ponseti method is the universally accepted gold standard for initial treatment of clubfoot. A high-scoring answer will detail this method: serial manipulation and casting, initiated soon after birth, followed by tenotomy of the Achilles tendon (if needed) and bracing to maintain correction. Emphasizing the non-operative, gentle, and sequential nature of Ponseti, with surgery reserved for failures, demonstrates current best practice.

Question 305

Topic: Pediatric Lower Extremity

When correcting idiopathic clubfoot (talipes equinovarus) using the Ponseti method of serial casting, what is the correct physiological sequence in which the individual deformity components must be addressed?

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The Ponseti method follows a strict CAVE sequence: Cavus is corrected first (by supinating the forefoot to align with the midfoot), followed by Adductus and Varus simultaneously (by abducting the foot around the fixed talar head), and finally Equinus (which often requires a percutaneous Achilles tenotomy prior to the final cast).

Question 306

Topic: Pediatric Lower Extremity

In the treatment of congenital talipes equinovarus (clubfoot) using the Ponseti method, proper cast application must follow a specific sequence. What is the primary pathoanatomy that is addressed during the application of the very first cast?

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

Correct Answer & Explanation

. Midfoot cavus

Explanation

The Ponseti method addresses the deformities of clubfoot in a specific sequence: Cavus, Adductus, Varus, and Equinus (CAVE). The very first step is to correct the midfoot cavus. This is accomplished by elevating the first ray, which supinates the forefoot to align it with the hindfoot, effectively unlocking the midtarsal joint and allowing subsequent correction of the adductus and varus.

Question 307

Topic: Pediatric Lower Extremity

A 3-year-old child with Proximal Focal Femoral Deficiency (PFFD) has a severely shortened femur, an absent femoral head, and no true acetabulum evident on radiographs. 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 the Aitken classification of PFFD: Class A has a femoral head and normal acetabulum with a subtrochanteric defect that eventually ossifies. Class B has a femoral head and normal acetabulum, but the subtrochanteric pseudoarthrosis does not ossify. Class C lacks a femoral head and has severe acetabular dysplasia, but a small tuft of proximal femur exists. Class D is the most severe, with an absent femoral head, absent acetabulum, and a severely shortened femoral shaft with no proximal tuft.

Question 308

Topic: Pediatric Lower Extremity

A 3-year-old boy treated successfully with the Ponseti method for idiopathic clubfoot presents with an early relapse. He walks with a dynamic supination deformity of the foot during the swing phase of gait. Passive dorsiflexion is 15 degrees. After correcting any residual fixed deformities with a brief period of serial casting, what is the most appropriate surgical intervention?

. Fractional lengthening of the Achilles tendon
. Tibialis anterior tendon transfer to the lateral cuneiform
. Repeat percutaneous Achilles tenotomy
. Extensive posteromedial soft tissue release
. Lateral closing wedge calcaneal osteotomy

Correct Answer & Explanation

. Tibialis anterior tendon transfer to the lateral cuneiform

Explanation

Relapsed clubfoot presenting with dynamic supination in a child over 2.5 years of age is best treated with a tibialis anterior tendon transfer (TATT) to the lateral cuneiform. This eliminates the deforming supination force and balances the foot.

Question 309

Topic: Pediatric Lower Extremity
A 4-year-old boy, initially treated for idiopathic clubfoot with the Ponseti method, presents with recurrent deformity. During gait analysis, he demonstrates dynamic supination of the foot during the swing phase. Passive range of motion is full and symmetric to the contralateral side. Which of the following is the most appropriate surgical management?
. Posterior medial release
. Split anterior tibial tendon transfer (SPLATT)
. Anterior tibial tendon transfer to the lateral cuneiform
. Extensor hallucis longus transfer to the first metatarsal neck (Jones procedure)
. Calcaneal sliding osteotomy

Correct Answer & Explanation

. Anterior tibial tendon transfer to the lateral cuneiform

Explanation

Dynamic supination during the swing phase in a recurrent clubfoot with supple passive ROM is a classic indication for a whole anterior tibial tendon transfer to the lateral cuneiform (or cuboid). This rebalances the foot without tethering the dynamic inversion forces.

Question 310

Topic: Pediatric Lower Extremity

In the Ponseti method for treating idiopathic clubfoot (talipes equinovarus), correction of the deformity follows a specific sequence. Which component of the deformity is corrected first?

. Equinus
. Hindfoot Varus
. Midfoot Cavus
. Forefoot Adduction
. Tibial Torsion

Correct Answer & Explanation

. Midfoot Cavus

Explanation

The Ponseti method corrects clubfoot deformities in the mnemonic sequence CAVE: Cavus, Adductus, Varus, Equinus. The cavus is corrected first by elevating the first ray to align the forefoot with the hindfoot. Next, the adduction and varus are corrected simultaneously by abducting the foot around the head of the talus.

Question 311

Topic: Pediatric Lower Extremity

According to the Ponseti method for the conservative management of congenital talipes equinovarus (clubfoot), which component of the deformity must be addressed first during serial casting?

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

Correct Answer & Explanation

. Cavus

Explanation

The Ponseti method corrects the deformities of a clubfoot in a specific sequence, remembered by the acronym CAVE: Cavus, Adductus, Varus, Equinus. The cavus is corrected first by elevating the first ray to align the forefoot with the hindfoot. Equinus is corrected last.

Question 312

Topic: Pediatric Lower Extremity

When utilizing the Ponseti method for the serial casting of idiopathic clubfoot (talipes equinovarus), correction of the deformities follows a strict sequential order (CAVE). What is the critical first step in the manipulation and casting process?

. Percutaneous Achilles tenotomy to correct equinus
. Abduction of the forefoot against counter-pressure on the calcaneocuboid joint
. Elevation of the first ray to correct the cavus deformity
. Derotation of the calcaneus to correct hindfoot varus
. Pronation of the forefoot to align with the hindfoot

Correct Answer & Explanation

. Elevation of the first ray to correct the cavus deformity

Explanation

The CAVE acronym outlines the order of correction: Cavus, Adductus, Varus, Equinus. The very first step is to supinate the forefoot by elevating the first ray, which aligns the forefoot with the hindfoot and corrects the cavus. Pronating the forefoot is a common error that actually worsens the cavus deformity.

Question 313

Topic: Pediatric Lower Extremity

In the Ponseti method for the treatment of idiopathic clubfoot (talipes equinovarus), which component of the deformity is corrected FIRST?

. Equinus
. Hindfoot varus
. Midfoot cavus
. Forefoot adductus
. Tibial torsion

Correct Answer & Explanation

. Midfoot cavus

Explanation

The Ponseti method corrects the deformities in a specific sequence remembered by the acronym CAVE: Cavus, Adductus, Varus, Equinus. The first step is to elevate the first ray to correct the midfoot cavus, which aligns the forefoot with the hindfoot.

Question 314

Topic: Pediatric Lower Extremity

According to the Ponseti method for the treatment of idiopathic clubfoot, what is the correct sequence of deformity correction?

. Equinus, varus, adductus, cavus
. Cavus, adductus, varus, equinus
. Adductus, cavus, varus, equinus
. Varus, cavus, adductus, equinus
. Cavus, equinus, varus, adductus

Correct Answer & Explanation

. Cavus, adductus, varus, equinus

Explanation

The Ponseti method corrects idiopathic clubfoot deformities sequentially based on the acronym CAVE: Cavus, Adductus, Varus, and finally Equinus. Equinus is corrected last, frequently requiring a percutaneous Achilles tenotomy.

Question 315

Topic: Pediatric Lower Extremity

The Ponseti method is the gold standard for the conservative management of idiopathic clubfoot (talipes equinovarus). What is the correct sequence of deformity correction during serial casting?

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The Ponseti method requires sequential correction of the clubfoot deformities using the mnemonic CAVE: first Cavus (by elevating the first ray to supinate the forefoot), then Adductus, then Varus, and finally Equinus (which often requires a percutaneous Achilles tenotomy).

Question 316

Topic: Pediatric Lower Extremity

What is the correct sequence of deformity correction in the Ponseti method for idiopathic clubfoot?

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

Correct Answer & Explanation

. Cavus, Varus, Adductus, Equinus

Explanation

The mnemonic CAVE dictates the order of correction: Cavus (elevating the first ray to align the forefoot with the hindfoot), Adductus, Varus, and finally Equinus (often requiring a percutaneous Achilles tenotomy as the final step).

Question 317

Topic: Pediatric Lower Extremity

During the Ponseti method for correcting idiopathic clubfoot, the sequential correction of the deformity must strictly follow which of the following orders?

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The Ponseti method corrects the components of clubfoot in a specific sequence remembered by the acronym CAVE: Cavus, Adductus, Varus, and finally Equinus. The first cast elevates the first ray to correct the cavus by supinating the forefoot to match the hindfoot.

Question 318

Topic: Pediatric Lower Extremity

A 2-week-old male infant is brought to the clinic with bilateral idiopathic clubfoot. The parents elect to proceed with the Ponseti method of serial casting. What is the correct order of deformity correction in this technique?

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The Ponseti method corrects the clubfoot deformity in a specific sequence remembered by the acronym CAVE: Cavus, Adductus, Varus, and finally Equinus. The cavus is corrected first by elevating the first metatarsal to align the forefoot with the hindfoot.

Question 319

Topic: Pediatric Lower Extremity

According to the Ponseti method for the treatment of idiopathic clubfoot, what is the correct sequence of deformity correction?

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The correct sequence of correction in the Ponseti method is remembered by the acronym CAVE: Cavus (elevate the first ray to supinate the forefoot), Adductus, Varus, and finally Equinus. The equinus correction often requires a percutaneous Achilles tenotomy as the final step.

Question 320

Topic: Pediatric Lower Extremity

During the Ponseti method for correcting idiopathic clubfoot, what is the correct order of deformity correction?

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The Ponseti method follows the CAVE sequence: Cavus is corrected first by elevating the first ray. This is followed by correcting Adductus and Varus simultaneously via gradual abduction, with Equinus corrected last (often requiring a tenotomy).

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