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Pediatric Lower Extremity MCQs

Practice Set 9 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 161

Topic: Pediatric Lower Extremity

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

. Cavus, Adductus, Varus, Equinus (CAVE)
. Cavus, Varus, Adductus, Equinus (CVAE)
. Equinus, Varus, Adductus, Cavus (EVAC)
. Adductus, Varus, Cavus, Equinus (AVCE)
. Varus, Adductus, Cavus, Equinus (VACE)

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus (CAVE)

Explanation

The Ponseti method sequentially corrects the deformities of clubfoot in the order of the acronym CAVE: Cavus (by elevating the first ray), Adductus, Varus, and finally Equinus (which often requires a percutaneous Achilles tenotomy).

Question 162

Topic: Pediatric Lower Extremity

An infant is undergoing serial casting for idiopathic clubfoot using the Ponseti method. After the fifth cast, the midfoot cavus, forefoot adductus, and hindfoot varus have been fully corrected. However, evaluation reveals only 0 degrees of ankle dorsiflexion. What is the most appropriate next step in management?

. Continue serial casting until 15 degrees of dorsiflexion is achieved
. Perform a percutaneous Achilles tenotomy
. Perform a formal posteromedial release
. Apply a Denis Browne splint immediately
. Perform a tibialis anterior tendon transfer

Correct Answer & Explanation

. Perform a percutaneous Achilles tenotomy

Explanation

In the Ponseti method for clubfoot, the deformities are corrected in a specific order: cavus, adductus, varus, and finally equinus. Once the midfoot and hindfoot are corrected (abducted to about 60 degrees), equinus often persists. If there is less than 15 degrees of ankle dorsiflexion, a percutaneous Achilles tenotomy is indicated. Attempting to forcefully cast out the equinus without a tenotomy risks creating a iatrogenic rocker-bottom foot deformity.

Question 163

Topic: Pediatric Lower Extremity

A 2-year-old boy who was successfully treated for idiopathic right clubfoot with the Ponseti method presents with a recurrent deformity. Examination shows dynamic supination of the foot during the swing phase of gait and fixed equinus of 10 degrees. The parents report poor compliance with the abduction brace. What is the most appropriate surgical management?

. Posteromedial soft tissue release
. Repeat Achilles tenotomy and anterior tibial tendon transfer to the lateral cuneiform
. Calcaneal sliding osteotomy
. Triple arthrodesis
. Serial casting followed by a repeat Achilles tenotomy and anterior tibial tendon transfer

Correct Answer & Explanation

. Serial casting followed by a repeat Achilles tenotomy and anterior tibial tendon transfer

Explanation

Recurrent clubfoot following Ponseti management often presents with dynamic supination and equinus. The correct protocol is to first perform serial casting to correct any recurrent cavus, adductus, and varus deformities, followed by an anterior tibial tendon transfer (ATTT) to balance the foot and a repeat Achilles tenotomy to correct the residual fixed equinus.

Question 164

Topic: Pediatric Lower Extremity

A 4-year-old boy presents for follow-up of a right idiopathic clubfoot that was treated in infancy with the Ponseti method.

His parents report he walks with a persistent inward turn of the foot. Examination reveals correctable forefoot adductus, a neutral hindfoot, and dynamic supination of the foot during the swing phase of gait. What is the most appropriate next step in management?

. Repeat percutaneous Achilles tenotomy
. Lateral column lengthening
. Split anterior tibial tendon transfer (SPLATT) to the lateral cuneiform
. Complete anterior tibial tendon transfer to the cuboid
. Triple arthrodesis

Correct Answer & Explanation

. Split anterior tibial tendon transfer (SPLATT) to the lateral cuneiform

Explanation

Dynamic supination during the swing phase of gait in a relapsed clubfoot treated via the Ponseti method is classically managed with a split anterior tibial tendon transfer (SPLATT) or full tibialis anterior tendon transfer to the lateral cuneiform (often after a brief period of serial casting to correct residual passive deformity). It addresses the muscle imbalance caused by an overactive tibialis anterior and weak peroneal muscles. Bony procedures like triple arthrodesis are salvage procedures for older children.

Question 165

Topic: Pediatric Lower Extremity

A 3-year-old boy presents with a relapsed right idiopathic clubfoot. He was initially treated successfully with the Ponseti method, including an Achilles tenotomy. He now walks with a dynamic supination of the foot during the swing phase of gait and has a fixed varus deformity of the hindfoot. Passive correction of the hindfoot is not possible. What is the most appropriate next step in management?

. Immediate anterior tibial tendon transfer (ATTT) to the lateral cuneiform
. Repeat serial long-leg casting followed by an anterior tibial tendon transfer (ATTT)
. Split anterior tibial tendon transfer (SPLATT)
. Triple arthrodesis of the right foot
. Calcaneal sliding osteotomy and plantar fascia release

Correct Answer & Explanation

. Repeat serial long-leg casting followed by an anterior tibial tendon transfer (ATTT)

Explanation

Relapses in clubfoot treated with the Ponseti method are relatively common and usually present with dynamic supination and recurrent equinovarus. The anterior tibial tendon transfer (ATTT) is the treatment of choice for dynamic supination. However, an ATTT should never be performed on a foot with a fixed deformity. The fixed deformity (varus/equinus) must first be corrected with a brief period of repeat serial long-leg Ponseti casting. Once the foot is passively correctable, the ATTT can be performed to maintain the correction.

Question 166

Topic: Pediatric Lower Extremity

A 3-year-old boy, initially treated with the Ponseti method for idiopathic right clubfoot, presents with a relapse.

His parents report that he walks on the outside border of his right foot. Gait analysis shows dynamic supination of the foot during the swing phase. Passive range of motion indicates the deformity is fully correctable. What is the most appropriate next step in management?

. Posteromedial soft tissue release
. Tibialis anterior tendon transfer to the lateral cuneiform
. Split tibialis posterior tendon transfer
. Calcaneal closing wedge osteotomy
. Talonavicular arthrodesis

Correct Answer & Explanation

. Tibialis anterior tendon transfer to the lateral cuneiform

Explanation

Dynamic supination during the swing phase in a toddler who has previously undergone successful Ponseti casting is caused by an overactive tibialis anterior pulling against weakened evertors. If the foot is passively correctable, the treatment of choice is the transfer of the entire tibialis anterior tendon (TATT) to the lateral cuneiform. This procedure rebalances the foot and prevents further recurrence.

Question 167

Topic: Pediatric Lower Extremity

A 4-year-old boy who was successfully treated for an idiopathic clubfoot with the Ponseti method presents with a relapse. His parents report that he walks on the outside of his foot. On examination, he demonstrates dynamic supination of the foot during the swing phase of gait. However, his passive ankle dorsiflexion is 15 degrees with the knee extended, and his heel is in neutral alignment. What is the most appropriate next step in management?

. Repeat percutaneous Achilles tenotomy and serial casting
. Full anterior tibial tendon transfer (TATT) to the lateral cuneiform
. Split anterior tibial tendon transfer (SPLATT)
. Calcaneocuboid fusion (Evans procedure)
. Triple arthrodesis

Correct Answer & Explanation

. Full anterior tibial tendon transfer (TATT) to the lateral cuneiform

Explanation

Dynamic supination during the swing phase in a toddler with a previously corrected clubfoot is a classic presentation of a localized relapse caused by a strong over-pull of the tibialis anterior muscle. Because passive dorsiflexion is well maintained (no fixed equinus), an Achilles tenotomy is not required. The treatment of choice in children (typically aged 2.5 to 5 years) is a full transfer of the anterior tibial tendon (TATT) to the lateral (third) cuneiform. A split transfer (SPLATT) is generally reserved for adult patients with upper motor neuron lesions (e.g., stroke, traumatic brain injury) and is not the standard of care for pediatric clubfoot relapses.

Question 168

Topic: Pediatric Lower Extremity

A 4-year-old boy treated previously for idiopathic clubfoot with the Ponseti method presents with a relapsed dynamic supination deformity during the swing phase of gait. His passive ankle dorsiflexion is 15 degrees, and the hindfoot is flexible. What is the most appropriate next step in management?

. Tendo-Achilles lengthening alone
. Tibialis anterior tendon transfer to the lateral cuneiform
. Split tibialis posterior tendon transfer
. Talonavicular fusion
. Repeat serial casting followed by percutaneous tenotomy

Correct Answer & Explanation

. Tibialis anterior tendon transfer to the lateral cuneiform

Explanation

For a relapsed dynamic supination deformity in a child who has previously undergone successful Ponseti casting and has flexible deformity and adequate dorsiflexion, a tibialis anterior tendon transfer (TATT) to the lateral cuneiform is the treatment of choice.

Question 169

Topic: Pediatric Lower Extremity

A 2-week-old newborn with idiopathic clubfoot is being treated with serial casting via the Ponseti method. During the manipulative phase, to correct the deformity, the forefoot must be abducted. To prevent a common technical error and properly correct the deformity, counter-pressure must be applied directly to which of the following structures?

. Calcaneocuboid joint
. Lateral aspect of the talar head
. Medial malleolus
. Navicular
. Base of the fifth metatarsal

Correct Answer & Explanation

. Lateral aspect of the talar head

Explanation

The Ponseti method is the gold standard for correcting idiopathic clubfoot. The correction sequence is CAVE (Cavus, Adductus, Varus, Equinus). When correcting the adductus and varus by abducting the forefoot, the fulcrum for correction is the lateral aspect of the talar head. A common error is applying counter-pressure to the calcaneocuboid joint or the base of the fifth metatarsal, which fails to correct the talonavicular subluxation and can cause a spurious correction or midfoot breach.

Question 170

Topic: Pediatric Lower Extremity

An infant is undergoing serial casting for a right idiopathic clubfoot using the Ponseti method.

After 5 weeks of casting, the cavus, adductus, and varus deformities have been fully corrected. However, on examination, there is only 5 degrees of passive ankle dorsiflexion. What is the most appropriate next step?

. Continue serial casting for another 4 weeks
. Perform a percutaneous Achilles tendon lengthening
. Perform a complete posteromedial release
. Discontinue casting and apply a foot abduction orthosis
. Perform an anterior tibial tendon transfer

Correct Answer & Explanation

. Perform a percutaneous Achilles tendon lengthening

Explanation

In the Ponseti method, once the cavus, adductus, and varus have been corrected (typically indicated by 60 degrees of foot abduction), the equinus contracture is addressed. If ankle dorsiflexion is less than 15 degrees, a percutaneous Achilles tendon lengthening (TAL) is indicated. Over 80% of idiopathic clubfeet treated with the Ponseti method require a TAL. Casting alone will not adequately correct persistent equinus, and attempting to force dorsiflexion through casting can cause a rocker-bottom deformity.

Question 171

Topic: Pediatric Lower Extremity

A 4-year-old boy with a history of idiopathic right clubfoot successfully treated with the Ponseti method during infancy presents with a relapsed deformity. His parents report that he frequently trips when running. Gait analysis and clinical examination reveal dynamic supination of the foot during the swing phase of gait. Passive range of motion demonstrates that the deformity is flexible and fully correctable. Which of the following is the most appropriate surgical treatment?

. Achilles tendon lengthening alone
. Extensive posteromedial soft tissue release
. Split tibialis posterior tendon transfer
. Tibialis anterior tendon transfer to the lateral cuneiform
. Calcaneal sliding osteotomy

Correct Answer & Explanation

. Tibialis anterior tendon transfer to the lateral cuneiform

Explanation

Dynamic supination during the swing phase of gait in a relapsed Ponseti-treated clubfoot is a classic indication for a full Tibialis Anterior Tendon Transfer (TATT) to the lateral cuneiform. This procedure transfers the deforming supinatory force of the tibialis anterior and converts it into an eversion force, balancing the foot dynamically. An Achilles tendon lengthening may be performed concurrently if there is residual fixed equinus, but TATT is specifically required to address the dynamic supination. Extensive posteromedial releases are historically associated with severe stiffness and recurrence, and are no longer standard for this presentation.

Question 172

Topic: Pediatric Lower Extremity
A 4-year-old boy who was treated successfully for idiopathic clubfoot during infancy with the Ponseti method presents with a dynamic supination deformity of the foot during the swing phase of gait. On examination, his ankle passive dorsiflexion is 15 degrees past neutral with the knee extended, and the foot is completely flexible. What is the most appropriate management for this patient?
. Achilles tendon lengthening
. Split tibialis anterior tendon transfer (SPLATT)
. Complete tibialis anterior tendon transfer to the lateral cuneiform
. Triple arthrodesis
. Repeated serial casting without surgery

Correct Answer & Explanation

. Complete tibialis anterior tendon transfer to the lateral cuneiform

Explanation

The child presents with a relapsing clubfoot characterized by a dynamic supination deformity. This is common after Ponseti casting and is driven by a strong tibialis anterior muscle overpowering the weak evertors. For a flexible deformity with adequate passive dorsiflexion, a complete tibialis anterior tendon transfer to the lateral cuneiform is the gold standard treatment to balance the foot. A split transfer is not recommended in idiopathic clubfoot relapse.

Question 173

Topic: Pediatric Lower Extremity

A 2-year-old boy who was treated for idiopathic clubfoot with the Ponseti method presents with recurrent equinovarus deformity. What is the most common cause of relapse in this clinical scenario?

. Under-correction of the cavus deformity initially
. Non-compliance with the foot abduction orthosis
. Failure to perform a percutaneous Achilles tenotomy
. Premature cessation of serial casting
. Extensor hallucis longus overactivity

Correct Answer & Explanation

. Non-compliance with the foot abduction orthosis

Explanation

Non-compliance with the foot abduction orthosis (FAO) is widely recognized as the most common cause of relapse in clubfoot treated with the Ponseti method. Bracing protocols typically require 23-hour wear for 3 months, followed by nighttime wear until 4-5 years of age. Without bracing, relapse rates can exceed 80%.

Question 174

Topic: Pediatric Lower Extremity

A 2-week-old infant is undergoing serial casting for a severe right idiopathic clubfoot using the Ponseti method. After 5 weeks of weekly cast changes, the cavus, adductus, and varus deformities have been fully corrected, but there is residual equinus of 15 degrees. What is the most appropriate next step in management?

. Continue serial casting until the equinus is fully corrected
. Percutaneous Achilles tendon lengthening followed by a final cast for 3 weeks
. Posteromedial soft tissue release
. Immediate application of a Denis Browne bar and shoes
. Anterior tibial tendon transfer

Correct Answer & Explanation

. Percutaneous Achilles tendon lengthening followed by a final cast for 3 weeks

Explanation

In the Ponseti method, the components of the clubfoot deformity are corrected sequentially: Cavus, Adductus, Varus, and finally Equinus. Once the forefoot and midfoot are fully abducted (typically ~70 degrees) and the heel is in valgus, residual equinus is usually present and cannot be fully corrected with casting alone without causing a iatrogenic rocker-bottom foot deformity. The standard treatment for this residual equinus is a percutaneous Achilles tenotomy, followed by the application of a final long-leg cast with the foot in maximum dorsiflexion and abduction for 3 weeks.

Question 175

Topic: Pediatric Lower Extremity

A 2-week-old infant with idiopathic bilateral clubfoot is undergoing serial casting using the Ponseti method. After correcting the cavus, adductus, and varus deformities, the foot demonstrates 15 degrees of residual equinus. What is the next most appropriate step?

. Continue serial weekly casting until the equinus is fully corrected
. Perform a complete posteromedial release
. Perform a percutaneous Achilles tenotomy
. Transfer the anterior tibial tendon to the lateral cuneiform
. Discontinue casting and prescribe a Denis Browne bar immediately

Correct Answer & Explanation

. Perform a percutaneous Achilles tenotomy

Explanation

In the Ponseti method for treating clubfoot, deformities are corrected in the sequence of Cavus, Adductus, Varus, and finally Equinus (CAVE). Once the midfoot and forefoot are appropriately abducted and the heel is in valgus, the residual equinus is addressed. The vast majority of infants (over 80-90%) require a percutaneous Achilles tenotomy to achieve dorsiflexion, followed by a final cast applied for 3 weeks.

Question 176

Topic: Pediatric Lower Extremity

An infant is born with idiopathic clubfoot. The treating surgeon begins Ponseti casting. What specific technical maneuver dictates the correct treatment of the cavus deformity in the application of the first cast?

. Plantarflexion of the first ray and pronation of the forefoot
. Dorsiflexion of the first ray and pronation of the forefoot
. Eversion of the hindfoot
. Dorsiflexion of the entire forefoot
. Dorsiflexion of the first ray and supination of the forefoot

Correct Answer & Explanation

. Dorsiflexion of the first ray and supination of the forefoot

Explanation

The first step in the Ponseti method (CAVE) corrects the cavus by elevating (dorsiflexing) the first ray to align the forefoot with the hindfoot, effectively supinating the forefoot. This unlocks the transverse tarsal joint allowing subsequent abduction.

Question 177

Topic: Pediatric Lower Extremity

An infant with a severe, rigid, idiopathic clubfoot is treated with the Ponseti casting method. To prevent recurrence and effectively correct the deformity, what is the correct anatomical sequence of deformity correction?

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The Ponseti method sequentially corrects clubfoot deformities in the specific order of Cavus, Adductus, Varus, and finally Equinus (remembered by the acronym CAVE). Equinus is corrected last, typically requiring a percutaneous Achilles tenotomy.

Question 178

Topic: Pediatric Lower Extremity

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

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

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The correct sequence of correction in the Ponseti method is Cavus, Adductus, Varus, and finally Equinus (acronym CAVE). The cavus is corrected first by supinating the forefoot to align it with the hindfoot.

Question 179

Topic: Pediatric Lower Extremity

In the treatment of idiopathic congenital talipes equinovarus (clubfoot) using the Ponseti method, 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 corrects clubfoot deformities in a specific sequence: Cavus, Adductus, Varus, and finally Equinus (CAVE). The equinus is typically corrected last, often requiring a percutaneous Achilles tenotomy.

Question 180

Topic: Pediatric Lower Extremity

A 4-year-old boy presents with a relapsed left idiopathic clubfoot. The deformity was initially treated successfully in infancy with the Ponseti method. The parents report he is now walking on the outside of his foot. Gait analysis demonstrates dynamic supination of the foot during the swing phase. Physical examination reveals an easily correctable deformity with completely passive plantigrade positioning. What is the most appropriate surgical treatment?

. Achilles tendon lengthening and plantar fascia release
. Transfer of the anterior tibial tendon to the lateral cuneiform
. Lateral column lengthening osteotomy
. Split posterior tibial tendon transfer to the peroneus brevis
. A short period of Ponseti casting followed by anterior tibial tendon transfer

Correct Answer & Explanation

. Transfer of the anterior tibial tendon to the lateral cuneiform

Explanation

Relapsed clubfoot frequently presents with dynamic supination due to muscle imbalance, predominantly overactivity of the anterior tibial tendon (ATT) overpowering the peroneal muscles. The definitive treatment for dynamic supination in a relapsed clubfoot is a transfer of the entire ATT to the lateral cuneiform. However, a strict prerequisite for this tendon transfer is that the foot must be completely passively correctable. Any residual fixed deformity must first be corrected by a short period of serial Ponseti casting before the tendon transfer is performed.

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