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Pediatric Lower Extremity MCQs

Practice Set 6 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 101

Topic: Pediatric Lower Extremity

During the Ponseti method for treating idiopathic clubfoot, a specific sequence of deformity correction must be strictly followed. Which of the following components of the deformity is corrected last?

. Midfoot cavus
. Forefoot adductus
. Hindfoot varus
. Ankle equinus
. Tibial internal torsion

Correct Answer & Explanation

. Ankle equinus

Explanation

The Ponseti method corrects clubfoot in the sequence of CAVE: Cavus, Adductus, Varus, and finally Equinus. Equinus is addressed last, often requiring a percutaneous Achilles tenotomy.

Question 102

Topic: Pediatric Lower Extremity
A 55-year-old woman presents with chronic, insidious midfoot pain and a progressive flatfoot. Radiographs demonstrate a comma-shaped deformity of the tarsal navicular with lateral subluxation of the talar head and dorsal fragmentation. What is the most likely diagnosis?
. Köhler disease
. Freiberg's infraction
. Sever's disease
. Müller-Weiss disease
. Charcot neuroarthropathy

Correct Answer & Explanation

. Müller-Weiss disease

Explanation

Müller-Weiss disease is spontaneous osteonecrosis of the tarsal navicular in adults, presenting with midfoot pain, a characteristic comma-shaped navicular, and lateral talar subluxation. Köhler disease is navicular osteonecrosis but occurs in young children.

Question 103

Topic: Pediatric Lower Extremity

Figure 29 shows the AP radiograph of a 14-year-old boy. The radiographic findings are most consistent with what pathologic process?

Pediatrics 2007 Practice Questions: Set 3 (Solved) - Figure 12

. Septic arthritis
. Hemophilia
. Juvenile rheumatoid arthritis (JRA)
. Adolescent Blount's disease
. Infantile Blount's disease

Correct Answer & Explanation

. Infantile Blount's disease

Explanation

The severe depression of the proximal medial tibial epiphysis is most consistent with the diagnosis of neglected infantile Blount's disease. Blount's disease in adolescents produces a deformity in the metaphyseal region. Septic arthritis and JRA affect both sides of the joint. Hemophilia produces a characteristic widening of the intercondylar notch. Thompson GH, Carter JR: Late-onset tibia vara (Blount's Disease). Clin Orthop 1990;255:24-35.

Question 104

Topic: Pediatric Lower Extremity

A 5-year-old boy has had midfoot pain with activity for the past 3 months. He has no pain at rest. Radiographs are shown in Figures 29a and 29b. Management should consist of

. a vascularized pedicle bone graft.
. a short leg walking cast.
. a custom-molded orthotic.
. surgical debridement followed by antibiotics.
. a bone stimulator.

Correct Answer & Explanation

. a short leg walking cast.

Explanation

The radiographs show classic findings for Koehler's disease (osteochondrosis of the navicular). The patient's age and clinical history are typical for this self-limiting condition. Patients will improve with time, but the duration of symptoms is much shorter if the patient is placed in a cast. There is no role for surgery in this disease.

Question 105

Topic: Pediatric Lower Extremity

Figure 11 shows the lateral radiograph of a 16-year-old boy who has been unable to participate in sports activities because of pain in the anterior aspect of the knee. He states that the pain is aching in nature and is located in the region of the tibial tuberosity. He denies having joint effusion or symptoms of instability. Management should consist of

Pediatrics 2001 Practice Questions: Set 1 (Solved) - Figure 19

. phonophoresis treatment and a program of quadriceps stretching.
. application of a hinge, post, and shell design functional knee brace.
. application of a hinge, post, and strap design functional knee brace.
. an MRI scan of the knee, a CT scan of the chest, a technetium Tc 99m bone scan, liver function tests, and a biopsy of the proximal tibia.
. excision of the ossicle and prominence of the tibial tuberosity.

Correct Answer & Explanation

. excision of the ossicle and prominence of the tibial tuberosity.

Explanation

The prognosis for most patients with Osgood-Schlatter disease is good. When the secondary ossification center unites with the main body of the tibial tubercle, the patellar tendon has a more rigid anchor, and heterotopic ossification and its associated reaction often become quiescent. However, even after closure of the growth plates, some patients have persistent symptoms. Excision of the ossicle and prominence of the tibial tuberosity decompresses the patellar tendon and allows most patients to resume sports activities. Nonsurgical modalities are ineffective. Better results have been reported after excision than after drilling of the tubercle. Excision of the ossicle is not indicated prior to skeletal maturity because symptoms will resolve in most patients when the secondary ossification center unites. Flowers MJ, Bhadreshwar DR: Tibial tuberosity excision for symptomatic Osgood-Schlatter disease. J Pediatr Orthop 1995;15:292-297.

Question 106

Topic: Pediatric Lower Extremity

When managing a congenital talipes equinovarus (clubfoot) using the Ponseti method, the first step in the casting sequence aims to correct which deformity?

. Equinus
. Cavus
. Varus
. Adductus
. Forefoot pronation

Correct Answer & Explanation

. Cavus

Explanation

The Ponseti method corrects the deformities of clubfoot in a specific sequence (CAVE). The first step is the correction of Cavus by elevating the first ray to align the forefoot with the hindfoot, supinating the forefoot.

Question 107

Topic: Pediatric Lower Extremity

A 2-week-old infant with idiopathic clubfoot (talipes equinovarus) is brought to the clinic to begin the Ponseti method of serial casting. According to the Ponseti principles, what is the proper sequence of correcting the components of the clubfoot deformity?

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

Correct Answer & Explanation

. Cavus, then Adductus, then Varus, then Equinus

Explanation

The Ponseti method strictly follows a specific sequence of correction, remembered by the acronym CAVE: Cavus, Adductus, Varus, Equinus. The first step is to correct the cavus by elevating the first ray, which aligns the forefoot with the hindfoot. Next, the forefoot is abducted (supinated) around the head of the talus, which simultaneously corrects the adductus and the hindfoot varus. Finally, once the foot is fully abducted, the equinus is addressed, typically requiring a percutaneous Achilles tenotomy.

Question 108

Topic: Pediatric Lower Extremity

When treating a rigid idiopathic clubfoot using the Ponseti method of serial casting, what is the correct sequence of deformity correction?

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

Correct Answer & Explanation

. Cavus, Equinus, Varus, Adductus

Explanation

The Ponseti method dictates a specific sequence of correction commonly remembered by the acronym CAVE. Cavus is corrected first by elevating the first ray (supinating the forefoot). Then the midfoot Adductus and hindfoot Varus are corrected simultaneously by gradually abducting the foot around the fixed talar head. Equinus is corrected last, often requiring a percutaneous Achilles tenotomy.

Question 109

Topic: Pediatric Lower Extremity

The Ponseti method is the gold standard for the treatment of idiopathic clubfoot (talipes equinovarus). To avoid a 'rocker-bottom' deformity, in what precise order must the components of the clubfoot deformity be corrected?

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The components of clubfoot are corrected sequentially according to the mnemonic CAVE: Cavus (by elevating the first ray to supinate the forefoot), Adductus, Varus, and lastly Equinus. Attempting to correct equinus too early, before the calcaneus is fully abducted, leads to a midfoot breach and a rocker-bottom foot deformity. Equinus is often addressed at the end with an Achilles tenotomy.

Question 110

Topic: Pediatric Lower Extremity

An infant with severe idiopathic clubfoot (talipes equinovarus) is managed with serial casting according to the Ponseti method.

According to this treatment protocol, which component of the deformity is corrected last?

. Cavus
. Adductus
. Varus
. Equinus
. Supination

Correct Answer & Explanation

. Equinus

Explanation

The Ponseti method follows a strict sequence of deformity correction summarized by the acronym CAVE: Cavus (elevating the first ray to match the forefoot supination), Adductus, Varus, and finally Equinus. The equinus contracture is addressed last, and in about 80% of cases, correction requires a percutaneous Achilles tenotomy prior to the final cast application.

Question 111

Topic: Pediatric Lower Extremity

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

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The correct sequence of correction in the Ponseti method follows the acronym CAVE: Cavus (corrected by elevating the first ray), Adductus, Varus, and finally Equinus (which often requires a percutaneous tendoachilles lengthening).

Question 112

Topic: Pediatric Lower Extremity

An 8-week-old infant with rigid, idiopathic clubfoot is undergoing serial casting using the Ponseti method. To achieve a plantigrade, functional foot, the deformity must be systematically corrected in a specific sequence. Which of the following accurately represents the correct sequence of correction?

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

Correct Answer & Explanation

. Cavus, varus, adductus, equinus

Explanation

The Ponseti method dictates that clubfoot deformities should be corrected in the specific order summarized by the mnemonic CAVE: Cavus (corrected first by elevating the first ray to supinate the forefoot), Adductus, Varus, and finally Equinus (which often requires a percutaneous Achilles tenotomy as the final step).

Question 113

Topic: Pediatric Lower Extremity

A 2-year-old girl is evaluated for severe bowing of her lower extremities. You suspect infantile Blount's disease rather than physiologic bowing. Which of the following radiographic parameters is the most reliable predictor that the deformity will progress to clinical Blount's disease and likely require intervention?

. Tibiofemoral angle > 10 degrees
. Metaphyseal-diaphyseal angle (Drennan angle) > 16 degrees
. Mechanical axis deviation > 2 cm
. Epiphyseal-metaphyseal angle > 20 degrees
. Neck-shaft angle < 120 degrees

Correct Answer & Explanation

. Metaphyseal-diaphyseal angle (Drennan angle) > 16 degrees

Explanation

The metaphyseal-diaphyseal angle (Drennan's angle) is used to differentiate physiologic genu varum from infantile Blount's disease. An angle > 16 degrees is highly predictive of progressive infantile Blount's disease. An angle < 10 degrees is typical for physiologic bowing, which usually resolves spontaneously. Angles between 10 and 16 degrees represent a gray area requiring close clinical and radiographic observation.

Question 114

Topic: Pediatric Lower Extremity

An infant is treated with serial casting for idiopathic clubfoot using the Ponseti method.

During the manipulative correction of the adductus and varus deformities, the physician's thumb must apply counter-pressure to which specific osseous structure to serve as a fulcrum?

. Medial aspect of the navicular
. Lateral aspect of the calcaneocuboid joint
. Head of the talus
. Sustentaculum tali
. Lateral malleolus

Correct Answer & Explanation

. Head of the talus

Explanation

In the Ponseti method, the key to successful manipulation is applying counter-pressure with the thumb on the lateral aspect of the head of the talus. Pressure on the calcaneocuboid joint or lateral malleolus blocks abduction of the calcaneus, preventing correction of the heel varus and forefoot adductus.

Question 115

Topic: Pediatric Lower Extremity

When applying the Ponseti method for the serial casting of idiopathic clubfoot (talipes equinovarus), the deformity must be corrected in a specific sequence to unlock the subtalar joint. What is the correct order of deformity correction?

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The Ponseti method dictates sequential correction following the CAVE acronym: Cavus (by elevating the first ray), Adductus, Varus, and finally Equinus (often requiring a percutaneous Achilles tenotomy). Correcting the cavus first aligns the forefoot with the hindfoot, allowing the talonavicular joint to be reduced.

Question 116

Topic: Pediatric Lower Extremity

In the Ponseti method for the conservative management of idiopathic clubfoot, the sequence of deformity correction is strictly ordered to avoid creating a midfoot break. What is the correct sequence of correction?

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

Correct Answer & Explanation

. Cavus, Varus, Adductus, Equinus

Explanation

The Ponseti method systematically corrects clubfoot deformities following the acronym CAVE: Cavus (corrected first by supinating the forefoot to align it with the hindfoot), followed simultaneously by Adductus and Varus (by abducting the foot around the head of the talus), and finally Equinus (often requiring a percutaneous Achilles tenotomy).

Question 117

Topic: Pediatric Lower Extremity

A 15-year-old male presents with persistent anterior knee pain and a palpable tender mass just distal to the patella. He is active in basketball and gymnastics. Radiographs show fragmentation and irregularity of the patellar tendon insertion onto the tibial tuberosity, consistent with Osgood-Schlatter disease. Despite 6 months of conservative treatment including rest, NSAIDs, and physical therapy, his pain persists, significantly limiting his athletic activities. What is the MOST appropriate next step in management?

. Continued conservative management with activity modification until skeletal maturity.
. Surgical excision of ossicles and debridement of the patellar tendon insertion.
. Corticosteroid injection into the patellar tendon.
. Patellar tendon realignment surgery.
. High tibial osteotomy to alter mechanical axis.

Correct Answer & Explanation

. Continued conservative management with activity modification until skeletal maturity.

Explanation

The patient presents with Osgood-Schlatter disease, an apophysitis of the tibial tuberosity. It is a self-limiting condition that typically resolves with skeletal maturity. While conservative management has failed to provide complete relief, the first line of treatment remains non-surgical. Surgical intervention is rarely indicated and only considered after skeletal maturity for persistent, debilitating pain due to ununited ossicles that act as a mechanical irritant.Given the patient is 15 years old and still skeletally immature (implied by the active apophysis), the MOST appropriate next step is typically continued, often more intensive, conservative management. This could include further activity modification, specific bracing, eccentric quadriceps strengthening, or temporary immobilization. Corticosteroid injections are contraindicated due to the risk of tendon rupture.Rationale for options:A. Continued conservative management, with specific focus on activity modification, pain management, and physical therapy, remains the cornerstone until skeletal maturity. The condition is self-limiting and surgical intervention is typically reserved for those who have failed all conservative measuresafterskeletal maturity. This is the correct answer.B. Surgical excision of ossicles and debridement of the patellar tendon insertion is a rare indication, reserved for patients who have persistent, debilitating pain from ununited ossiclesafterskeletal maturity and failed extensive conservative management.C. Corticosteroid injection into the patellar tendon or tibial tuberosity is contraindicated due to the risk of tendon weakening, rupture, and skin atrophy.D. Patellar tendon realignment surgery is typically for patellar instability, not for Osgood-Schlatter disease.E. High tibial osteotomy is performed for unicompartmental knee osteoarthritis with varus deformity, not Osgood-Schlatter disease.

Question 118

Topic: Pediatric Lower Extremity

In the Ponseti method for the treatment of idiopathic clubfoot, a specific sequence of deformity correction is strictly followed to avoid creating a midfoot breach (rocker-bottom deformity). Which of the following represents the correct sequential order of correction?

. Cavus, Adduction, Varus, Equinus (CAVE)
. Equinus, Varus, Adduction, Cavus (EVAC)
. Varus, Equinus, Cavus, Adduction (VECA)
. Adduction, Cavus, Equinus, Varus (ACEV)
. Cavus, Equinus, Varus, Adduction (CEVA)

Correct Answer & Explanation

. Cavus, Equinus, Varus, Adduction (CEVA)

Explanation

The Ponseti method dictates a very specific sequence for the manipulation and casting of idiopathic clubfoot, easily remembered by the acronym CAVE: Cavus (corrected first by elevating the first ray to align the forefoot with the hindfoot), Adduction (abducting the forefoot around the talar head), Varus (the heel varus corrects passively as the forefoot is abducted), and finally Equinus (which often requires a percutaneous Achilles tenotomy as the final step).

Question 119

Topic: Pediatric Lower Extremity

When initiating the Ponseti method of serial casting for an infant born with idiopathic talipes equinovarus (clubfoot), what is the correct sequence of deformity correction?

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

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

Question 120

Topic: Pediatric Lower Extremity

An infant is diagnosed with idiopathic clubfoot (talipes equinovarus) and is set to undergo serial casting using the Ponseti method. What is the correct chronological sequence of deformity correction using this technique?

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The Ponseti method follows the CAVE sequence: Cavus is corrected first by supinating the forefoot, followed by Adductus and Varus by abducting the foot around the talar head, and finally Equinus with dorsiflexion and often a percutaneous Achilles tenotomy.

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