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 321
Topic: Pediatric Lower Extremity
A 10-day-old infant is diagnosed with idiopathic clubfoot (talipes equinovarus). The orthopedic surgeon plans to initiate the Ponseti method of serial casting. What is the correct sequence of deformity correction in this method?
Correct Answer & Explanation
. Cavus, Adductus, Varus, Equinus
Explanation
The Ponseti method systematically corrects clubfoot deformities using the 'CAVE' sequence: first Cavus (by elevating the first ray), then Adductus, then Varus, and finally Equinus (often requiring a percutaneous Achilles tenotomy).
Question 322
Topic: Pediatric Lower Extremity
A 12-year-old male basketball player presents with anterior knee pain that worsens with jumping and running. Physical examination reveals point tenderness localized strictly to the inferior pole of the patella, with no tenderness at the tibial tubercle. Radiographs demonstrate fragmentation and sclerosis at the inferior patellar pole. What is the most likely diagnosis?
Correct Answer & Explanation
. Sinding-Larsen-Johansson syndrome
Explanation
Correct Answer: Sinding-Larsen-Johansson syndromeSinding-Larsen-Johansson (SLJ) syndrome is an osteochondrosis or traction apophysitis occurring at the inferior pole of the patella, where the proximal patellar tendon originates. It is common in active adolescents aged 10-14 years and presents with activity-related anterior knee pain and localized tenderness at the inferior patellar pole. Radiographs often show fragmentation or calcification at this site. It is clinically distinct from Osgood-Schlatter disease, which is a similar traction apophysitis but occurs distally at the insertion of the patellar tendon on the tibial tubercle.
Question 323
Topic: Pediatric Lower Extremity
A 16-year-old male presents with chronic anterior knee pain, exacerbated by kneeling and direct pressure. Examination reveals swelling and tenderness directly over the patellar tendon insertion on the tibial tubercle. Radiographs show fragmentation and irregularity of the tibial tubercle. What is the most likely diagnosis?
Correct Answer & Explanation
. Osgood-Schlatter disease
Explanation
The clinical picture of anterior knee pain, swelling, and tenderness over the tibial tubercle, along with radiographic fragmentation/irregularity of the tibial tubercle in an adolescent male, is classic for Osgood-Schlatter disease. This is an apophysitis (traction apophysitis) of the tibial tubercle due to repetitive stress from the quadriceps tendon pulling on the developing bone. Sinding-Larsen-Johansson syndrome is similar but affects the inferior pole of the patella. Patellofemoral pain syndrome and chondromalacia patellae involve the patellofemoral joint. Patellar tendinopathy (jumper's knee) affects the patellar tendon, usually in older adolescents or adults, without tibial tubercle fragmentation.
Question 324
Topic: Pediatric Lower Extremity
A 1-year-old is diagnosed with Aitken Class A proximal focal femoral deficiency (PFFD). The femoral head is present in the acetabulum, but a severe subtrochanteric varus pseudarthrosis is identified. What is the most important early surgical intervention to optimize the extremity for future lengthening?
Correct Answer & Explanation
. Valgus osteotomy to heal the pseudarthrosis
Explanation
In Aitken Class A PFFD, addressing the proximal varus deformity and healing the pseudarthrosis with a valgus osteotomy is critical early in life. This establishes a biomechanically sound proximal femur capable of withstanding future lengthening.
Question 325
Topic: Pediatric Lower Extremity
A 2-year-old child with Proximal Focal Femoral Deficiency (PFFD) has a severely short femur, but a normal, stable knee and ankle. The foot is at the level of the contralateral knee. To optimize the child for a functional prosthesis, the surgeon considers a Van Nes rotationplasty. What critical prerequisite must be met for this procedure to be successful?
Correct Answer & Explanation
. A functioning ankle joint capable of acting as a knee joint
Explanation
For a successful Van Nes rotationplasty, the ankle must be fully functional and have near-normal range of motion. Following the 180-degree rotation, the ankle joint will function as the new knee joint to power the prosthesis.
Question 326
Topic: Pediatric Lower Extremity
A 2-week-old infant with idiopathic clubfoot is undergoing serial manipulation and casting using the Ponseti method. Which component of the deformity is corrected LAST during this sequence?
Correct Answer & Explanation
. Ankle equinus
Explanation
The Ponseti method follows a specific sequence of correction summarized by the acronym CAVE: Cavus, Adductus, Varus, and finally Equinus. Equinus is corrected last, often requiring a percutaneous Achilles tenotomy.
Question 327
Topic: Pediatric Lower Extremity
A newborn is diagnosed with idiopathic clubfoot (talipes equinovarus) and treatment is initiated using the Ponseti method. What is the correct initial step in manipulating the foot prior to applying the first cast?
Correct Answer & Explanation
. Elevation of the first ray to correct the cavus deformity
Explanation
The Ponseti method requires a specific sequence of correction (CAVE: Cavus, Adductus, Varus, Equinus). The first step is to supinate the forefoot and elevate the first ray to align the forefoot with the hindfoot, correcting the cavus.
Question 328
Topic: Pediatric Lower Extremity
When treating a newborn with idiopathic clubfoot using the Ponseti method, what is the correct sequence of deformity correction?
Correct Answer & Explanation
. Cavus, Adduction, Varus, Equinus
Explanation
Correct Answer: Cavus, Adduction, Varus, EquinusThe Ponseti method corrects clubfoot deformities in a specific, sequential order, remembered 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 329
Topic: Pediatric Lower Extremity
When treating a congenital idiopathic clubfoot using the Ponseti method, what is the correct sequence of deformity correction?
Correct Answer & Explanation
. Cavus, Adductus, Varus, Equinus
Explanation
Correct Answer: Cavus, Adductus, Varus, EquinusThe Ponseti method corrects the deformities of clubfoot in a specific sequence summarized by the acronym CAVE: Cavus (corrected first by elevating the first ray to align the forefoot with the hindfoot), Adductus, Varus, and finally Equinus. Equinus is corrected last, often requiring a percutaneous Achilles tenotomy if dorsiflexion to 15 degrees cannot be achieved through casting alone.
Question 330
Topic: Pediatric Lower Extremity
When treating a newborn with idiopathic clubfoot using the Ponseti method, what is the correct sequence of deformity correction?
Correct Answer & Explanation
. Cavus, Varus, Adductus, Equinus
Explanation
Correct Answer: Cavus, Adductus, Varus, EquinusThe Ponseti method corrects clubfoot deformities in a specific, sequential order summarized by the acronym CAVE: Cavus, Adductus, Varus, and Equinus. The first step is to correct the cavus by elevating the first ray to align the forefoot with the hindfoot. Subsequent casts correct the adductus and varus by abducting the foot around the head of the talus. Finally, the equinus is corrected, which often requires a percutaneous Achilles tenotomy.
Question 331
Topic: Pediatric Lower Extremity
When treating a congenital idiopathic clubfoot using the Ponseti method, what is the correct sequence of deformity correction?
Correct Answer & Explanation
. Cavus, Adductus, Varus, Equinus
Explanation
Correct Answer: Cavus, Adductus, Varus, EquinusThe Ponseti method corrects clubfoot deformities in a specific, sequential order remembered by the acronym CAVE: Cavus (corrected first by elevating the first ray to align the forefoot with the hindfoot), Adductus, Varus, and finally Equinus. Equinus is corrected last, often requiring a percutaneous Achilles tenotomy once the other deformities are fully resolved.
Question 332
Topic: Pediatric Lower Extremity
A 3-year-old boy who was successfully treated for idiopathic clubfoot with the Ponseti method and an Achilles tenotomy presents with a recurrent equinovarus deformity. What is the most common cause of relapse in this patient population?
Correct Answer & Explanation
. Noncompliance with bracing
Explanation
Correct Answer: Noncompliance with bracingThe most common cause of clubfoot relapse after successful Ponseti casting and tenotomy is noncompliance with the foot abduction orthosis (bracing). Strict adherence to the bracing protocol (full-time for 3 months, then nights/naps until age 4) is critical to maintaining the correction.
Question 333
Topic: Pediatric Lower Extremity
An infant with a severe idiopathic clubfoot is undergoing serial manipulation and casting using the Ponseti method. According to the principles of this method, which of the following deformity components is corrected last?
Correct Answer & Explanation
. Equinus
Explanation
The Ponseti method corrects the components of clubfoot in a specific sequence summarized by the acronym CAVE: Cavus, Adductus, Varus, and finally Equinus. Equinus is typically corrected last and often requires a percutaneous Achilles tenotomy.
Question 334
Topic: Pediatric Lower Extremity
An infant with idiopathic clubfoot is undergoing the first stage of the Ponseti casting method. Which manipulative maneuver is required to correctly address the initial component of the deformity?
Correct Answer & Explanation
. Supination of the forefoot with elevation of the first ray
Explanation
The first step in the Ponseti method is correcting the cavus deformity by elevating the first ray to supinate the forefoot. This aligns the forefoot with the hindfoot, preventing the creation of a midfoot break.
Question 335
Topic: Pediatric Lower Extremity
A 2-week-old infant with idiopathic clubfoot is undergoing serial casting using the Ponseti method. The orthopaedic surgeon is preparing to apply the third cast. Which of the following describes the correct sequence of deformity correction in the Ponseti method?
Correct Answer & Explanation
. Cavus, Adductus, Varus, Equinus
Explanation
Correct Answer: Cavus, Adductus, Varus, EquinusThe Ponseti method is the gold standard for the treatment of idiopathic clubfoot. The correction follows a specific sequence, easily remembered by the acronym CAVE: Cavus, Adductus, Varus, and Equinus. The first step is to elevate the first ray to correct the cavus deformity, which aligns the forefoot with the hindfoot. Subsequent casts gradually abduct the supinated foot around the head of the talus, which simultaneously corrects the adductus and the varus deformities due to the kinematic coupling of the subtalar joint. The equinus deformity is corrected last; attempting to correct it too early can lead to a rocker-bottom foot deformity. If equinus cannot be fully corrected with casting, a percutaneous Achilles tenotomy is performed.
Question 336
Topic: Pediatric Lower Extremity
A 4-year-old child successfully treated for idiopathic clubfoot with the Ponseti method presents with a relapsed deformity. Gait analysis reveals dynamic supination during the swing phase. What is the most appropriate surgical intervention?
Correct Answer & Explanation
. Tibialis anterior tendon transfer to the lateral cuneiform
Explanation
Dynamic supination during the swing phase in a relapsed Ponseti-treated clubfoot is typically caused by an overactive tibialis anterior. Transferring the tibialis anterior tendon to the lateral cuneiform balances the foot dorsiflexion.
Question 337
Topic: Pediatric Lower Extremity
An infant with idiopathic clubfoot is treated with the Ponseti method. After sequential casting corrects the cavus, adductus, and varus deformities, the ankle remains in 15 degrees of equinus. What is the next most appropriate step in management?
Correct Answer & Explanation
. Perform a percutaneous Achilles tendon tenotomy
Explanation
Once the cavus, adductus, and varus are corrected, isolated equinus is typically addressed with a percutaneous Achilles tenotomy. This procedure is required in over 80% of idiopathic clubfoot cases treated with the Ponseti method to achieve adequate dorsiflexion.
Question 338
Topic: Pediatric Lower Extremity
A 2-week-old infant is undergoing Ponseti casting for idiopathic clubfoot. The treating orthopedic surgeon is manipulating the foot for the second cast. Which of the following represents the correct sequence of deformity correction in the Ponseti method?
Correct Answer & Explanation
. Cavus, Adduction, Varus, Equinus
Explanation
The Ponseti method corrects the deformities of clubfoot in a specific, sequential order: Cavus, Adductus, Varus, and finally Equinus (remembered by the acronym CAVE). The first cast specifically elevates the first ray to correct the cavus, creating a supinating forefoot to properly align with the hindfoot.
Question 339
Topic: Pediatric Lower Extremity
In a patient with Aitken Class A proximal focal femoral deficiency (PFFD), what is the most typical associated lower extremity anomaly?
Correct Answer & Explanation
. Fibular hemimelia
Explanation
PFFD is highly associated with fibular hemimelia, occurring in up to 70-80% of cases. These patients also frequently present with ACL deficiency and lateral ray foot deficiencies.
Question 340
Topic: Pediatric Lower Extremity
A newborn is diagnosed with Proximal Focal Femoral Deficiency (PFFD). Radiographs demonstrate absence of the proximal femur, but an MRI confirms a cartilaginous connection between the present femoral head and the femoral shaft. According to the Aitken classification, this represents which class, and what is the typical long-term functional procedure if a severe leg-length discrepancy is expected?
Correct Answer & Explanation
. Aitken A; rotationplasty or amputation/prosthesis.
Explanation
Aitken Class A PFFD is characterized by a present femoral head and a cartilaginous connection to the shaft that will eventually ossify. Due to severe leg-length discrepancies, early lengthening is often contraindicated, and definitive functional procedures like a Van Nes rotationplasty or Syme amputation with a prosthesis are commonly performed.
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