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Pediatric Lower Extremity MCQs

Practice Set 4 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 61

Topic: Pediatric Lower Extremity

A 4-year-old boy treated successfully in infancy for a right clubfoot with the Ponseti method presents with recurrent dynamic supination of the foot during the swing phase of gait. Passive range of motion is normal. What is the surgical treatment of choice?

. Repeat Achilles tenotomy
. Calcaneal sliding osteotomy
. Tibialis anterior tendon transfer
. Split tibialis posterior tendon transfer
. Triple arthrodesis

Correct Answer & Explanation

. Tibialis anterior tendon transfer

Explanation

Dynamic supination in a previously corrected clubfoot is a classic presentation of relapse. If the foot remains passively correctable, a full tibialis anterior tendon transfer (TATT) to the lateral cuneiform is the treatment of choice to balance the foot.

Question 62

Topic: Pediatric Lower Extremity

A 4-year-old child previously treated for idiopathic clubfoot with the Ponseti method presents with dynamic supination deformity during the swing phase of gait. There is no fixed deformity. What is the most appropriate next step in management?

. Achilles tendon lengthening
. Tibialis anterior tendon transfer to the lateral cuneiform
. Split tibialis posterior tendon transfer
. Calcaneocuboid fusion
. Application of a hinged ankle-foot orthosis

Correct Answer & Explanation

. Tibialis anterior tendon transfer to the lateral cuneiform

Explanation

Dynamic supination during the swing phase in a previously corrected clubfoot is typically caused by a strong tibialis anterior acting on a flexible foot. The standard treatment is transferring the tibialis anterior tendon to the lateral cuneiform to balance the foot.

Question 63

Topic: Pediatric Lower Extremity

Equinovarus positioning of the foot is normal during which stage of embryonic life:

. No stage
. Eighth to tenth week
. Thirteenth to fifteenth week
. Seventeenth to nineteenth week
. Twentieth to twenty-third week

Correct Answer & Explanation

. Eighth to tenth week

Explanation

As the foot matures, it passes through a normal stage when it resembles a clubfoot in the eighth to tenth week. After this, the foot normally corrects itself.

Question 64

Topic: Pediatric Lower Extremity

In the Ponseti method for correcting idiopathic clubfoot, which deformity is the first to be addressed during serial casting?

. Equinus
. Varus
. Cavus
. Adduction
. Supination

Correct Answer & Explanation

. Cavus

Explanation

The Ponseti method dictates that the cavus deformity must be corrected first by elevating the first metatarsal to align the forefoot with the hindfoot. Adduction and varus are corrected next, with equinus corrected last.

Question 65

Topic: Pediatric Lower Extremity

Which of the following statements best characterizes the natural history of metatarsus adductus in a newborn:

. Metatarsus adductus is likely to become fixed if not treated with casts.
. Metatarsus adductus is likely to become fixed if not treated by 6 months.
. Metatarsus adductus is likely to become fixed if not surgically corrected.
. Metatarsus adductus is likely to later develop hindfoot equinus.
. Most infants will improve spontaneously.

Correct Answer & Explanation

. Most infants will improve spontaneously.

Explanation

Virtually all patients with metatarsus adductus will improve with time in the absence of active treatment. Casts are not needed for the majority of cases because spontaneous improvement is by far the most common outcome. Reverse last shoes are not needed in the majority of patients with metatarsus adductus. Most patients will not need surgery. Equinus of the hindfoot is not part of the pathology in metatarsus adductus.

Question 66

Topic: Pediatric Lower Extremity

Fibular hemimelia (FH) can be associated with which of the following abnormalities:

. Femoral shortening
. Anterior cruciate ligament (AC L) deficiency
. Equinovalgus foot
. Tarsal coalition
. All of the above

Correct Answer & Explanation

. All of the above

Explanation

All of the stated abnormalities can be found with femoral hemimelia. It is estimated that 15% of cases have femoral deficiency. Commonly seen in the condition are tarsal coalition, anterior cruciate ligament deficiency, and an equinovalgus foot.

Question 67

Topic: Pediatric Lower Extremity

In the Ponseti method for the conservative management of idiopathic clubfoot, the sequence of deformity correction is strictly protocolized. Which of the following represents the correct order of correction?

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus (CAVE)

Explanation

The Ponseti technique follows the CAVE sequence: Cavus is corrected first by elevating the first ray, followed simultaneously by Adductus and Varus correction by abducting the foot around the talar head, and finally Equinus is addressed (often requiring an Achilles tenotomy).

Question 68

Topic: Pediatric Lower Extremity

In the Ponseti method for the treatment of idiopathic clubfoot, what is the final component of the deformity to be corrected before proceeding with an Achilles tenotomy?

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

Correct Answer & Explanation

. Equinus

Explanation

The Ponseti method addresses deformities in a specific sequence: Cavus, Adductus, Varus, and finally Equinus (CAVE). A percutaneous Achilles tenotomy is frequently performed at the end to correct residual equinus contracture.

Question 69

Topic: Pediatric Lower Extremity

In the Ponseti method for the treatment of idiopathic clubfoot, what is the correct sequential order of deformity correction?

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

Correct Answer & Explanation

. Cavus, Varus, Adductus, Equinus

Explanation

The Ponseti method utilizes the CAVE sequence: Cavus (by elevating the first ray), Adductus, Varus, and finally Equinus (which often requires a percutaneous Achilles tenotomy).

Question 70

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

Correct Answer & Explanation

. Cavus, Varus, Adductus, Equinus

Explanation

The Ponseti method sequentially corrects the CAVE deformities: Cavus (by elevating the first ray), Adductus, Varus, and finally Equinus. Equinus correction frequently requires a percutaneous Achilles tenotomy.

Question 71

Topic: Pediatric Lower Extremity

Which of the following clinical examination findings is most characteristic of a patient with a tethered spinal cord presenting with a progressive scoliotic deformity?

. Hyporeflexia in the upper extremities
. Asymmetric abdominal reflexes and cavovarus foot deformity
. Unilateral ptosis and miosis
. Saddle anesthesia and loss of bowel control as early signs
. Symmetric, brisk patellar reflexes with flexor plantar responses

Correct Answer & Explanation

. Asymmetric abdominal reflexes and cavovarus foot deformity

Explanation

Tethered cord syndrome often presents subtly in children with asymmetric abdominal reflexes, lower extremity hyperreflexia, asymmetric foot deformities (like cavovarus), or cutaneous stigmata. Bowel/bladder incontinence are typically late findings.

Question 72

Topic: Pediatric Lower Extremity

A newborn is diagnosed with congenital talipes equinovarus (clubfoot) characterized by ankle equinus, hindfoot varus, forefoot adduction, and internal rotation. The foot is rigid and cannot be passively corrected. Which of the following is the most appropriate initial treatment?

. Immediate surgical correction with soft tissue release
. Serial casting using the Ponseti method
. Custom orthotics and bracing for 12 months
. Intensive physical therapy and stretching exercises
. Observation with serial radiographs to monitor progression

Correct Answer & Explanation

. Serial casting using the Ponseti method

Explanation

Correct Answer: BFor congenital talipes equinovarus (clubfoot), the Ponseti method of serial casting is the gold standard and most appropriate initial treatment. This non-surgical technique involves a series of gentle manipulations and plaster casts applied weekly over several weeks, followed by a percutaneous Achilles tenotomy in most cases, and then maintenance with a foot abduction brace. The Ponseti method has a high success rate in achieving correction and avoiding extensive surgery. Immediate surgical correction is typically reserved for cases that fail Ponseti treatment or are diagnosed later in childhood. Custom orthotics and physical therapy alone are insufficient for rigid clubfoot. Observation is inappropriate for a condition that requires active correction.

Question 73

Topic: Pediatric Lower Extremity

In the Ponseti method for treating idiopathic clubfoot (talipes equinovarus), what is the correct sequence of deformity correction?

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The Ponseti method corrects clubfoot deformities in the specific order of CAVE: Cavus, Adductus, Varus, and finally Equinus. The cavus is corrected first by elevating the first ray to align the forefoot with the hindfoot.

Question 74

Topic: Pediatric Lower Extremity

When utilizing the Ponseti method for the correction of idiopathic clubfoot, what is the first deformity that must be addressed during the casting sequence?

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

Correct Answer & Explanation

. Equinus

Explanation

The Ponseti method corrects deformities in the CAVE sequence: Cavus, Adductus, Varus, and Equinus. Cavus is corrected first by supinating the forefoot and elevating the first ray to align it with the hindfoot.

Question 75

Topic: Pediatric Lower Extremity

An infant is brought to the clinic for management of idiopathic clubfoot. According to the Ponseti method, the initial serial casting should primarily aim to correct which of the following deformities?

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

Correct Answer & Explanation

. Cavus

Explanation

The first step in the Ponseti method is to correct the cavus deformity by elevating the first ray, which aligns the forefoot with the hindfoot. Subsequent casts correct adductus and varus simultaneously by abducting the foot around the fixed talar head.

Question 76

Topic: Pediatric Lower Extremity

In addition to a missing or hypoplastic fibula, patients with fibular hemimelia frequently have specific anomalies of the foot and ankle. Which of the following is most commonly observed in these patients?

. Tarsal coalition
. Clubfoot (talipes equinovarus)
. Cavovarus deformity
. Vertical talus
. Polydactyly

Correct Answer & Explanation

. Tarsal coalition

Explanation

Fibular deficiency is part of a spectrum of postaxial limb deficiencies. It is frequently associated with tarsal coalitions (most commonly talocalcaneal), a ball-and-socket ankle joint, and absent lateral rays.

Question 77

Topic: Pediatric Lower Extremity

The understanding and surgical management of tarsal coalitions have been significantly influenced by foundational studies. Which of the following statements accurately attributes a key contribution to the specified researcher or group?

. Cowell's work established the critical threshold of 50% posterior facet involvement for talocalcaneal coalitions, dictating primary arthrodesis for larger lesions.
. Mubarak and colleagues emphasized the necessity of a wide, rectangular resection and EDB interposition for calcaneonavicular coalitions.
. Wilde et al. detailed the medial approach for middle facet talocalcaneal coalitions and the importance of preserving the FHL tendon and neurovascular bundle.
. Modern literature primarily advocates for simple resection without interposition grafts to minimize donor site morbidity.
. Current guidelines recommend immediate surgical intervention for all newly diagnosed tarsal coalitions, regardless of symptoms or arthrosis.

Correct Answer & Explanation

. Wilde et al. detailed the medial approach for middle facet talocalcaneal coalitions and the importance of preserving the FHL tendon and neurovascular bundle.

Explanation

Correct Answer: CThe "Summary of Key Literature and Guidelines" section directly attributes the following: Wilde et al. "contributed significantly to the understanding of the middle facet's role in TC coalitions, detailing the medial approach and the importance of preserving the FHL tendon and the neurovascular bundle."Option A is incorrect: Mubarak and colleagues established the 50% posterior facet involvement rule for TC coalitions. Cowell's work focused on CN coalitions.Option B is incorrect: Cowell's seminal work established the lateral approach and EDB interposition for CN coalitions.Option D is incorrect: Modern literature supports the use of interposition grafts (EDB, fat, FHL) to prevent recurrence. Simple resection alone is associated with higher recurrence rates.Option E is incorrect: Current guidelines recommend an initial trial of non-operative management for all newly diagnosed, non-arthritic tarsal coalitions.

Question 78

Topic: Pediatric Lower Extremity

When treating a 2-week-old infant with idiopathic clubfoot using the Ponseti method, what is the correct sequence of deformity correction?

. Equinus, Varus, Adductus, Cavus
. Cavus, Adductus, Varus, Equinus
. Varus, Cavus, Equinus, Adductus
. Adductus, Varus, Cavus, 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 summarized by the acronym CAVE: Cavus, Adductus, Varus, and finally Equinus. The cavus is corrected first by elevating the first ray to supinate the forefoot.

Question 79

Topic: Pediatric Lower Extremity

Which radiographic index for evaluating patella alta is calculated by dividing the distance from the lower articular margin of the patella to the upper tibial articular margin by the articular length of the patella?

. Insall-Salvati index
. Modified Insall-Salvati index
. Caton-Deschamps index
. Blackburne-Peel index
. Blumensaat index

Correct Answer & Explanation

. Caton-Deschamps index

Explanation

The Caton-Deschamps index relies entirely on articular margins to measure patellar height. This makes it particularly useful because it is not affected by alterations to the tibial tubercle, such as previous osteotomies or Osgood-Schlatter disease.

Question 80

Topic: Pediatric Lower Extremity

Which of the following measurements is the most reliable method for assessing patella alta in a patient who has previously undergone an Osgood-Schlatter procedure?

. Insall-Salvati ratio
. Modified Insall-Salvati ratio
. Caton-Deschamps index
. Blumensaat line method
. Trochlear depth measurement

Correct Answer & Explanation

. Caton-Deschamps index

Explanation

The Caton-Deschamps index relies on the articular surface of the patella and the anterior-superior angle of the tibial plateau, making it independent of the tibial tubercle position. This makes it ideal for patients with prior tubercle surgery or pathology like Osgood-Schlatter disease.

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