Clubfoot — MCQs
Complications of sling procedures (TVT) for USI are all except:
The clinical manifestations of cauda equina lesion include the following EXCEPT:
Patellar tendon-bearing P.O.P. cast is indicated in the following fracture:
Combination of appearance in CTEV
What splint is used in CTEV after correction?
Foot eversion is caused by
A 41-year-old man is admitted to the emergency department with a swollen and painful foot. Radiographic examination reveals that the head of the talus has become displaced inferiorly, thereby causing the medial longitudinal arch of the foot to fall. What is the most likely cause in this case?
Slipped capital femoral epiphysis is seen most commonly in which age group?
A 4-year-old child sustained a fall on an outstretched hand. X-rays revealed a fracture line at the physis with a small metaphyseal fragment. There was no epiphyseal fracture. What type of injury, according to the Salter-Harris classification, is this?
Osgood-Schlatter disease is osteochondritis of which bone?
Clubfoot Indian Medical PG Practice Questions and MCQs
Question 1: Complications of sling procedures (TVT) for USI are all except:
- A. Obturator nerve injury is about 10% (Correct Answer)
- B. Overactive bladder in about 7% cases
- C. Injury to bladder and wound haematoma
- D. Sling erosion particularly with polytetrafluoroethylene (Goretex)
Explanation: ***Obturator nerve injury is about 10%*** ✓ **CORRECT ANSWER (NOT a complication of TVT)** - **Obturator nerve injury** is exceedingly rare during **TVT (Tension-free Vaginal Tape)** procedures, which use a retropubic approach through the space of Retzius. - This complication is primarily associated with **TOT (Trans-Obturator Tape)** procedures where the tape passes near the obturator foramen, not with standard retropubic TVT. - The incidence of obturator nerve injury in TVT is essentially negligible (<0.1%), nowhere near 10%. *Overactive bladder in about 7% cases* - **De novo overactive bladder (OAB)** symptoms or worsening of pre-existing OAB can occur in 3-15% of patients after TVT procedures, with 7% being a commonly cited figure. - This occurs due to changes in bladder neck support, urethral kinking, or irritation from the sling material. *Injury to bladder and wound haematoma* - **Bladder injury/perforation** occurs in 2-5% of TVT cases due to the retropubic passage of needles close to the bladder, which is why intraoperative cystoscopy is routinely performed. - **Wound hematoma** can occur at the vaginal or suprapubic incision sites as a common surgical complication from tissue dissection and bleeding. *Sling erosion particularly with polytetrafluoroethylene (Goretex)* - **Sling erosion** into the vagina or urethra is a documented complication of synthetic slings, with rates of 0.5-3% for modern materials. - **Polytetrafluoroethylene (Goretex)**, an older first-generation mesh material, was associated with significantly higher rates of erosion (up to 10%) and infection compared to modern monofilament polypropylene meshes, which is why it has been largely discontinued for sling procedures.
Question 2: The clinical manifestations of cauda equina lesion include the following EXCEPT:
- A. Saddle anesthesia
- B. Radicular pain
- C. Urinary retention
- D. Extensor plantar reflexes (Correct Answer)
Explanation: ***Extensor plantar reflexes*** - Extensor plantar reflexes (Babinski sign) are indicative of an **upper motor neuron lesion**, typically affecting the **corticospinal tract**, not the cauda equina [4]. - The cauda equina comprises **lower motor neurons**; therefore, a lesion here would more likely result in absent or diminished deep tendon reflexes, and a flexor plantar response or no response [4]. *Saddle anesthesia* - This is a classic symptom of cauda equina syndrome, involving numbness or sensory loss in the **perineal and gluteal regions** due to compression of sacral nerve roots. - It results from damage to the **sensory fibers** of the cauda equina innervating these areas [1]. *Radicular pain* - Cauda equina syndrome often causes severe **low back pain** radiating down the legs, similar to sciatica, due to compression or irritation of the **nerve roots** [1]. - This pain can be bilateral and is a significant symptom, reflecting the involvement of multiple nerve roots [3]. *Urinary retention* - **Bladder dysfunction**, particularly urinary retention, is a critical red flag for cauda equina syndrome, caused by damage to the **sacral nerve roots** responsible for bladder control [2], [3]. - It signifies significant neurological compromise affecting **autonomic function** [2].
Question 3: Patellar tendon-bearing P.O.P. cast is indicated in the following fracture:
- A. Fracture of the tibia (Correct Answer)
- B. Fracture of the patella
- C. Fracture of the femur
- D. Fracture of the medial malleolus
Explanation: ***Fracture of the tibia*** - A **patellar tendon-bearing (PTB) cast** is specifically designed to bypass the knee joint and transfer weight from the patellar tendon to the cast, offloading the tibia. - This design is particularly useful for **stable, distal tibia fractures** where partial weight-bearing is desired to promote healing. *Fracture of the patella* - A PTB cast would place direct pressure on the **patella**, which is contraindicated in a patellar fracture. - Patellar fractures often require a **cylinder cast** or surgical fixation to immobilize the knee. *Fracture of the femur* - Femoral fractures are typically **more proximal** and require **traction**, **internal fixation**, or a **spica cast** for stabilization. - A PTB cast would not provide adequate immobilization or weight-bearing relief for a femoral fracture due to its design. *Fracture of the medial malleolus* - Medial malleolus fractures involve the **ankle joint**, which is distal to the area covered by a PTB cast. - These fractures typically require a **short leg cast** or surgical repair, focusing on ankle stabilization.
Question 4: Combination of appearance in CTEV
- A. Equinus, eversion, forefoot adduction, cavus
- B. Equinus, inversion, forefoot adduction, planus
- C. Equinus, inversion, forefoot adduction, cavus (Correct Answer)
- D. Equinus, eversion, forefoot abduction, cavus
Explanation: ***Equinus, inversion, forefoot adduction, cavus*** - The classic presentation of **clubfoot** (CTEV) involves a characteristic combination of deformities: **equinus** (fixed plantarflexion of the ankle), **inversion** (tilting of the heel inward), **forefoot adduction** (inward turning of the front of the foot), and **cavus** (an abnormally high arch). - These four components are essential for the diagnosis and classification of CTEV. *Equinus, eversion, forefoot adduction, cavus* - This option incorrectly lists **eversion** instead of inversion. Eversion involves the outward tilting of the heel and is not a feature of CTEV. - While equinus, forefoot adduction, and cavus are typical, the presence of eversion rules out classic CTEV. *Equinus, inversion, forefoot adduction, planus* - This option incorrectly lists **planus** (pes planus or flatfoot) instead of cavus. Cavus (high arch) is a defining characteristic of CTEV, not a flatfoot. - While equinus, inversion, and forefoot adduction are correct, the presence of planus makes this option incorrect. *Equinus, eversion, forefoot abduction, cavus* - This option incorrectly lists both **eversion** and **forefoot abduction**. Eversion is the outward tilting of the heel, and forefoot abduction is the outward turning of the front of the foot. - Both eversion and forefoot abduction are opposite to the deformities seen in classical CTEV.
Question 5: What splint is used in CTEV after correction?
- A. Bohler-Brown splint
- B. Thomas splint
- C. Dennis Brown splint (Correct Answer)
- D. None of the options
Explanation: ***Dennis Brown splint*** - The **Dennis Brown splint** is specifically designed for maintaining the correction of **clubfoot (CTEV)** in infants to prevent recurrence. - It consists of a bar connecting two shoes that hold the feet in an **external rotation** and **abduction** position. *Bohler-Brown splint* - The **Bohler-Brown splint** is primarily used for the management of **tibial shaft fractures**. - It is a **traction splint** designed to maintain alignment and length of the fractured bone. *Thomas splint* - The **Thomas splint** is typically used for **femoral shaft fractures** to provide traction and reduce muscle spasm. - It is not indicated for the long-term management of clubfoot. *None of the options* - This option is incorrect as the **Dennis Brown splint** is a well-established and a primary splint used for CTEV after correction.
Question 6: Foot eversion is caused by
- A. Tibialis anterior
- B. Tibialis posterior
- C. Peroneus longus (Correct Answer)
- D. Extensor digitorum
Explanation: ***Peroneus longus*** - The **peroneus longus** muscle (fibularis longus) is a primary evertor of the foot. - It originates from the head and upper lateral surface of the fibula, inserts into the medial cuneiform and first metatarsal, and its contraction pulls the foot outwards and downwards. *Tibialis anterior* - The **tibialis anterior** is the primary dorsiflexor and invertor of the foot. - It pulls the foot upwards and inwards, which is the opposite action of eversion. *Tibialis posterior* - The **tibialis posterior** is a strong invertor and plantar flexor of the foot. - It contributes to maintaining the arch of the foot and does not cause eversion. *Extensor digitorum* - The **extensor digitorum longus** primarily extends the toes and assists in dorsiflexion of the ankle. - While it may have a slight eversion component, it is not the primary muscle responsible for foot eversion.
Question 7: A 41-year-old man is admitted to the emergency department with a swollen and painful foot. Radiographic examination reveals that the head of the talus has become displaced inferiorly, thereby causing the medial longitudinal arch of the foot to fall. What is the most likely cause in this case?
- A. Tearing of the plantar calcaneonavicular (spring) ligament (Correct Answer)
- B. Fracture of the navicular bone
- C. Tearing of the deltoid ligament
- D. Sprain of the calcaneocuboid ligament
Explanation: ***Tearing of the plantar calcaneonavicular (spring) ligament*** - The **plantar calcaneonavicular ligament**, also known as the **spring ligament**, is crucial for supporting the head of the talus and maintaining the **medial longitudinal arch** of the foot. - Tearing of this ligament leads to the **inferior displacement of the talar head** and subsequent collapse of the arch, consistent with the symptoms described. *Fracture of the navicular bone* - A fracture of the **navicular bone** would typically cause localized pain and tenderness over the navicular, and while it could contribute to arch instability, it wouldn't primarily cause the **talar head** to *inferiorly displace* in this specific manner. - While a navicular fracture might lead to secondary arch collapse, the primary issue described is the displacement of the **talar head**, which is more directly related to spring ligament integrity. *Tearing of the deltoid ligament* - The **deltoid ligament** is located on the medial side of the ankle and primarily stabilizes the **talocrural joint**, preventing excessive eversion of the foot. - Its rupture would lead to ankle instability and pain, but it doesn't directly support the **medial longitudinal arch** in the same way the spring ligament does, nor would its tearing directly cause the talar head to displace inferiorly as described. *Sprain of the calcaneocuboid ligament* - The **calcaneocuboid ligament** is a component of the **lateral longitudinal arch** of the foot and connects the calcaneus to the cuboid bone. - A sprain of this ligament would primarily affect the *lateral* foot stability and lead to pain in that region, not the described collapse of the **medial longitudinal arch** or inferior displacement of the talar head.
Question 8: Slipped capital femoral epiphysis is seen most commonly in which age group?
- A. Infants
- B. Adolescents (Correct Answer)
- C. Old age
- D. Childhood
Explanation: **Explanation:** **Slipped Capital Femoral Epiphysis (SCFE)** is a classic hip disorder characterized by the displacement of the capital femoral epiphysis from the femoral neck through the physeal plate. 1. **Why Adolescents is correct:** The condition occurs most commonly during the **adolescent growth spurt** (typically ages 10–16 years). During this period, the growth plate (physis) thickens and weakens under the influence of growth hormones, while the periosteum thins. This mechanical instability, often combined with **obesity**, leads to a "slip" where the epiphysis remains in the acetabulum while the neck moves anteriorly and superiorly. 2. **Why other options are incorrect:** * **Infants:** Hip pathology in this group is usually Developmental Dysplasia of the Hip (DDH) or Septic Arthritis. * **Childhood:** The most common hip pathology in younger children (ages 4–8) is **Legg-Calvé-Perthes disease** (avascular necrosis). * **Old age:** Hip issues in the elderly are typically related to Osteoarthritis or Neck of Femur fractures. **High-Yield Clinical Pearls for NEET-PG:** * **Typical Profile:** An obese adolescent male presenting with a limp and hip or **referred knee pain**. * **Clinical Sign:** **Drehmann Sign** (obligate external rotation of the hip during passive flexion). * **Radiology:** Look for **Trethowan’s Sign** (Klein’s line fails to intersect the femoral head). * **Associated Conditions:** If seen in younger children, suspect endocrine disorders like **Hypothyroidism** or Growth Hormone deficiency. * **Management:** The definitive treatment is **In-situ pinning** (Internal fixation with a single cannulated screw).
Question 9: A 4-year-old child sustained a fall on an outstretched hand. X-rays revealed a fracture line at the physis with a small metaphyseal fragment. There was no epiphyseal fracture. What type of injury, according to the Salter-Harris classification, is this?
- A. Type I
- B. Type II (Correct Answer)
- C. Type III
- D. Type IV
Explanation: ### Explanation The **Salter-Harris classification** is the standard system used to describe physeal (growth plate) injuries in children. The key to identifying the correct type lies in observing which anatomical components (Physis, Metaphysis, or Epiphysis) are involved. **Why Type II is Correct:** In this case, the fracture line travels through the **physis** and exits through the **metaphysis**, creating a triangular metaphyseal fragment known as the **Thurston-Holland sign**. Crucially, the epiphysis remains uninvolved. Type II is the **most common** type of physeal injury, typically occurring in children over 10 years old, though it can occur at any age. **Analysis of Incorrect Options:** * **Type I (S):** The fracture occurs purely through the physis (Separation). There is no bony fragment from the metaphysis or epiphysis. It is often a clinical diagnosis as X-rays may appear normal. * **Type III (A):** The fracture runs through the physis and exits through the **epiphysis** (Above/Articular). This is an intra-articular fracture and requires anatomical reduction. * **Type IV (T):** The fracture line passes **Through** all three elements: the metaphysis, the physis, and the epiphysis. It carries a high risk of growth disturbance. **NEET-PG High-Yield Pearls:** * **Mnemonic (SALTER):** * **S** (Type I): **S**traight across/Separated. * **A** (Type II): **A**bove (Metaphysis). * **L** (Type III): **L**ower (Epiphysis). * **T** (Type IV): **T**hrough everything. * **ER** (Type V): **ER**asure/Crush of the growth plate (worst prognosis). * **Thurston-Holland Sign:** Pathognomonic for Salter-Harris Type II. * **Prognosis:** Generally, Types I and II have a good prognosis and can be managed closed, while Types III and IV often require ORIF (Open Reduction Internal Fixation) to prevent growth arrest and joint incongruity.
Question 10: Osgood-Schlatter disease is osteochondritis of which bone?
- A. Tibial tuberosity (Correct Answer)
- B. Lunate
- C. Calcaneus
- D. Navicular
Explanation: **Explanation:** **Osgood-Schlatter disease** is a common cause of knee pain in active adolescents. It is a traction-induced **apophysitis** (osteochondritis) of the **tibial tuberosity**. The underlying mechanism involves repetitive strain from the quadriceps muscle pulling on the patellar tendon at its insertion point on the immature tibial tuberosity. This occurs during growth spurts when bones grow faster than muscles/tendons, leading to micro-avulsions and subsequent inflammation. **Analysis of Options:** * **A. Tibial tuberosity (Correct):** This is the site of the secondary ossification center where the patellar tendon attaches. * **B. Lunate:** Osteochondritis of the lunate is known as **Kienböck's disease**, which typically presents with wrist pain and decreased grip strength. * **C. Calcaneus:** Osteochondritis (apophysitis) of the calcaneus is known as **Sever’s disease**, the most common cause of heel pain in children. * **D. Navicular:** Osteochondritis of the tarsal navicular bone is known as **Köhler’s disease**, usually seen in younger children (ages 4–7). **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Presents as localized pain, swelling, and tenderness over the tibial tuberosity, exacerbated by jumping, running, or kneeling. * **Radiology:** May show fragmentation or prominence of the tibial tuberosity and soft tissue swelling (though diagnosis is primarily clinical). * **Management:** Conservative treatment is the mainstay (Rest, Ice, NSAIDs, and activity modification). It is self-limiting and resolves once the physis closes. * **Association:** Often seen in children involved in sports requiring repetitive jumping (e.g., basketball, volleyball).
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