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Pediatric Lower Extremity MCQs

Practice Set 3 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 41

Topic: Pediatric Lower Extremity

An infant is born with absent fibulae bilaterally. Which foot deformity is most classically associated with fibular hemimelia?

. Equinocavovarus
. Calcaneovalgus
. Equinovalgus
. Rocker-bottom foot
. Metatarsus adductus

Correct Answer & Explanation

. Equinovalgus

Explanation

Fibular hemimelia typically presents with shortening of the limb, anterior bowing of the tibia, and an equinovalgus foot deformity due to the absent lateral structural support normally provided by the fibula.

Question 42

Topic: Pediatric Lower Extremity

A 5-year-old boy presents with a prominent bump on the medial aspect of his foot and in-toeing. Clinical examination reveals a "Z-foot" deformity. He has a history of treated clubfoot. What is the primary pathoanatomy of the "skewfoot" deformity?

. Metatarsus adductus, normal midfoot, and hindfoot varus
. Metatarsus adductus, midfoot lateral translation, and hindfoot valgus
. Metatarsus valgus, midfoot medial translation, and hindfoot varus
. Forefoot supination, midfoot cavus, and hindfoot equinus
. Metatarsus primus varus, midfoot normal, and hindfoot equinovarus

Correct Answer & Explanation

. Metatarsus adductus, midfoot lateral translation, and hindfoot valgus

Explanation

Skewfoot (or Z-foot) is a complex deformity characterized by severe metatarsus adductus, lateral translation/abduction of the midfoot at the Chopart joint, and hindfoot valgus.

Question 43

Topic: Pediatric Lower Extremity

A 4-year-old child successfully treated for bilateral idiopathic clubfeet with the Ponseti method presents with a dynamic supination deformity of the foot during the swing phase of gait. Passive range of motion is full. What is the most appropriate management?

. Posteromedial release
. Repeat serial casting
. Tibialis anterior tendon transfer
. Achilles tendon lengthening
. Split tibialis posterior tendon transfer

Correct Answer & Explanation

. Tibialis anterior tendon transfer

Explanation

Dynamic supination during the swing phase in a toddler previously treated for clubfoot is best managed by transferring the tibialis anterior tendon to the third cuneiform (TATT). This restores muscle balance and prevents fixed recurrent deformity.

Question 44

Topic: Pediatric Lower Extremity

A 2-year-old boy presents with relapsed clubfoot after initial successful Ponseti casting. What is the most common cause of this recurrence?

. Failure to perform an Achilles tenotomy initially
. Non-compliance with the foot abduction orthosis
. Unrecognized underlying neuromuscular disorder
. Premature removal of the final cast
. Over-correction of the forefoot during casting

Correct Answer & Explanation

. Non-compliance with the foot abduction orthosis

Explanation

Non-compliance with the foot abduction brace is the most common cause of clubfoot relapse after successful Ponseti casting. Bracing is crucial up to age 4 to prevent recurrence.

Question 45

Topic: Pediatric Lower Extremity
A 4-year-old boy with a relapsed clubfoot presents with dynamic forefoot supination during the swing phase of gait. His hindfoot remains plantigrade. Which of the following is the most appropriate surgical intervention?
. Repeat percutaneous Achilles tenotomy
. Full tibialis anterior tendon transfer to the lateral cuneiform
. Tibialis posterior tendon transfer through the interosseous membrane
. Split anterior tibial tendon transfer (SPLATT)
. Calcaneocuboid wedge osteotomy

Correct Answer & Explanation

. Full tibialis anterior tendon transfer to the lateral cuneiform

Explanation

Dynamic forefoot supination in a relapsed clubfoot with a flexible hindfoot is best treated with a full tibialis anterior tendon transfer to the lateral cuneiform. This converts the deforming supinating force into a corrective dorsiflexor.

Question 46

Topic: Pediatric Lower Extremity

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

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The mnemonic CAVE dictates the standard Ponseti sequence: Cavus, Adductus, Varus, and finally Equinus. The cavus is corrected first by supinating the forefoot and elevating the first ray to align it with the hindfoot.

Question 47

Topic: Pediatric Lower Extremity

A 10-year-old boy presents with anterior knee pain and a high-riding patella after forcefully jumping during a basketball game. Radiographs show a small bony fragment distal to the inferior pole of the patella. What is the most likely diagnosis?

. Osgood-Schlatter disease
. Sinding-Larsen-Johansson syndrome
. Patellar sleeve fracture
. Tibial tubercle avulsion fracture
. Bipartite patella

Correct Answer & Explanation

. Patellar sleeve fracture

Explanation

A patellar sleeve fracture is a chondrous or osteochondrous avulsion of the inferior pole of the patella seen in skeletally immature patients. A high-riding patella (patella alta) distinguishes it from Sinding-Larsen-Johansson syndrome, which is an overuse apophysitis without disruption of the extensor mechanism.

Question 48

Topic: Pediatric Lower Extremity

During the Ponseti casting technique for the treatment of idiopathic clubfoot, what is the correct order 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 acronym CAVE dictates the sequence of clubfoot correction in the Ponseti method: Cavus (corrected by supinating the forefoot to align with the hindfoot), Adductus, Varus, and finally Equinus (often requiring a percutaneous Achilles tenotomy).

Question 49

Topic: Pediatric Lower Extremity

A 10-year-old boy presents to the emergency department after a forceful jumping injury. He has a massive knee effusion, a palpable defect at the inferior pole of the patella, and cannot perform a straight leg raise. Lateral radiographs show a high-riding patella with a tiny bony fleck distally. What is the most likely diagnosis?

. Osgood-Schlatter disease
. Sinding-Larsen-Johansson syndrome
. Bipartite patella
. Patellar sleeve fracture
. Tibial tubercle avulsion fracture

Correct Answer & Explanation

. Patellar sleeve fracture

Explanation

The presentation is classic for a patellar sleeve fracture, an avulsion of the unossified distal patellar cartilage along with a small bony fragment. It disrupts the extensor mechanism and requires surgical repair.

Question 50

Topic: Pediatric Lower Extremity

A newborn is evaluated for a shortened lower extremity. Radiographs show a shortened femur with a hypoplastic proximal segment and an absent fibula. This presentation is most consistent with Proximal Focal Femoral Deficiency (PFFD). Which of the following conditions is most commonly associated with PFFD?

. Fibular hemimelia
. Tibial hemimelia
. Radioulnar synostosis
. Developmental dysplasia of the hip
. Clubfoot

Correct Answer & Explanation

. Fibular hemimelia

Explanation

Fibular hemimelia is the most common associated anomaly in patients with Proximal Focal Femoral Deficiency (PFFD), occurring in 50% to 80% of cases. Cruciate ligament deficiency in the knee is also frequently seen.

Question 51

Topic: Pediatric Lower Extremity

Which of the following is a principle of the Ponseti technique for correction of a clubfoot:

. Avoid use of casts
. Avoid use of braces
. Perform a comprehensive release
. Osteotomies produce correction
. Minimize surgery to bones and joints

Correct Answer & Explanation

. Minimize surgery to bones and joints

Explanation

The Ponseti technique, which was developed and tested by Ignacio Ponseti, MD, involves slow, gradual correction of a clubfoot using casts, a tenotomy if necessary to release the Achilles tendon, and maintenance of correction using braces (foot abduction orthoses) for several years. The technique avoids dissection of the growing bones and joints of a childs foot because of the associated risks of stiffness and growth disturbance.

Question 52

Topic: Pediatric Lower Extremity

During the Ponseti method of serial casting for idiopathic clubfoot, what is the first deformity that must be actively corrected?

. Equinus
. Hindfoot varus
. Forefoot adduction
. Cavus
. Tibial torsion

Correct Answer & Explanation

. Cavus

Explanation

The cavus deformity must be corrected first by elevating the first ray to align the forefoot with the hindfoot. Correction of the remaining deformities (adduction, varus, and finally equinus) follows sequentially in subsequent casts.

Question 53

Topic: Pediatric Lower Extremity

When utilizing the Ponseti method for the correction of idiopathic clubfoot, which deformity should be addressed first?

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

Correct Answer & Explanation

. Cavus

Explanation

The Ponseti method follows the CAVE sequence: Cavus, Adductus, Varus, Equinus. Cavus is corrected first by elevating the first ray to supinate the forefoot, aligning it with the midfoot.

Question 54

Topic: Pediatric Lower Extremity

An orthopedic surgeon is utilizing the Ponseti method to correct an idiopathic clubfoot in a 2-week-old infant. According to this protocol, which component of the deformity must be corrected last?

. Cavus
. Adductus
. Varus
. Equinus
. Supination

Correct Answer & Explanation

. Equinus

Explanation

In the Ponseti method, the components of the clubfoot deformity are corrected in a specific sequence summarized by the acronym CAVE: Cavus, Adductus, Varus, and finally Equinus. Equinus is typically corrected last, often requiring a percutaneous Achilles tenotomy.

Question 55

Topic: Pediatric Lower Extremity

In the Ponseti method for treating idiopathic clubfoot, which of the following represents the correct sequence of deformity correction?

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

Correct Answer & Explanation

. Cavus, Varus, Adductus, Equinus

Explanation

The sequence of correction in the Ponseti method follows the acronym CAVE: Cavus, Adductus, Varus, and finally Equinus.

Question 56

Topic: Pediatric Lower Extremity

An infant with idiopathic clubfoot is undergoing serial casting using the Ponseti method. According to the principles of this method, which component of the deformity is corrected first?

. Equinus
. Varus
. Adductus
. Cavus
. Internal rotation

Correct Answer & Explanation

. Cavus

Explanation

The Cavus deformity is corrected first in the Ponseti method by elevating the first ray to supinate the forefoot and align it with the hindfoot. Equinus is the final deformity corrected, often requiring a percutaneous Achilles tenotomy.

Question 57

Topic: Pediatric Lower Extremity

During the initial phase of the Ponseti casting technique for the treatment of idiopathic clubfoot, which component of the deformity must be addressed first?

. Cavus
. Adduction
. Varus
. Equinus
. Tibial torsion

Correct Answer & Explanation

. Cavus

Explanation

The Ponseti method corrects deformities in a specific order summarized by the acronym CAVE: Cavus, Adductus, Varus, then Equinus. The cavus is corrected first by elevating the first ray to align the forefoot with the hindfoot.

Question 58

Topic: Pediatric Lower Extremity

The Ponseti method of clubfoot cast treatment starts with which of the following steps:

. Pronation of the forefoot
. Dorsiflexion of the first ray
. Dorsiflexion of the ankle
. External rotation of the foot
. Internal rotation of the foot

Correct Answer & Explanation

. Dorsiflexion of the first ray

Explanation

Dorsiflexion of the first ray is the first step in the Ponseti method of cast treatment. Dorsiflexion decreases the cavus component. Pronation of the forefoot is the opposite of dorsiflexion and produces the opposite desired motion. Dorsiflexion of the ankle should be performed after the Achilles tenotomy. External rotation of the foot is performed later. Internal rotation of the clubfoot is never done.

Question 59

Topic: Pediatric Lower Extremity
A 4-year-old boy, initially treated successfully for idiopathic clubfoot using the Ponseti method, presents with a relapse. He demonstrates dynamic supination of the foot during the swing phase of gait but passive range of motion is fully correctable. Which of the following is the most appropriate definitive management?
. Repeat serial casting followed by Achilles tendon lengthening
. Split anterior tibial tendon transfer (SPLATT)
. Tibialis anterior tendon transfer to the lateral cuneiform
. Triple arthrodesis
. Calcaneal sliding osteotomy

Correct Answer & Explanation

. Tibialis anterior tendon transfer to the lateral cuneiform

Explanation

Dynamic supination during the swing phase in a relapsed, previously corrected Ponseti clubfoot is caused by an overactive tibialis anterior tendon. The definitive treatment for a flexible foot in a child over age 2.5 is a whole tibialis anterior tendon transfer (TATT) to the lateral cuneiform.

Question 60

Topic: Pediatric Lower Extremity
A 4-year-old child successfully treated with the Ponseti method for idiopathic clubfoot presents with a relapse characterized by dynamic supination during the swing phase of gait. Which of the following is the most appropriate management?
. Complete surgical soft tissue release
. Split anterior tibial tendon transfer (SPLATT)
. Calcaneal osteotomy
. Repeat casting followed by full anterior tibial tendon transfer
. Talectomy

Correct Answer & Explanation

. Repeat casting followed by full anterior tibial tendon transfer

Explanation

Relapsing dynamic supination in a Ponseti-treated clubfoot is best managed by a period of corrective casting to achieve a plantigrade foot, followed by a full transfer of the anterior tibial tendon to the lateral cuneiform.

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