The Lower Extremity Orthopedic Evaluation of the Infant

Home , Foot deformity, Lordosis, Rocker bottom foot

MedicalContinuing Education

Goals and Objectives TheThe LowerLower After reading this article, the physi- cian should be able to: 1) Perform an orthopedic exami- ExtremityExtremity nation on a pre-walking child 2) Understand the purpose and Orthopedic significance of each part of the ex- Orthopedic amination 3) Differentiate between normal EvaluationEvaluation and abnormal orthopedic findings 4) Develop an appreciation for the significance of abnormal neurologic ofof thethe InfantInfant findings 5) Recognize the presenting ap- EarlyEarly examinationexamination cancan minimizeminimize thethe effectseffects ofof pearance of common lower extremi- bothboth orthopedicorthopedic andand neurologicneurologic conditions.conditions. ty deformities

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By Mark A. Caselli, DPM well as the possible pathologies that parts of this orthopedic evaluation might be present. The necessary include a medical history, family his- he earlier the detection of an tory, musculoskeletal examination, orthopedic problem, the bet- and neurologic examination. Tter the chances of making a The earlier the A prenatal, intrapartum, and significant change in the prognosis postnatal history is of paramount of that condition. Many lower ex- detection of an importance in ruling out neuromo- tremity orthopedic pathologies are orthopedic problem, tor disease. The prenatal history best treated during the earliest peri- should include family as well as ma- od of life, that of infancy, before the better the chances ternal history. It is important to as- ambulation begins. In order to de- of making a significant certain whether or not other mem- tect an orthopedic problem at this bers of the family have lower ex- stage of life, the podiatric practi- change in the prognosis tremity orthopedic problems. Preg- tioner must be familiar with both of that condition. nant women at both extremes of the the method of performing a thor- age group, under 16 and over 30, are ough lower extremity evaluation as Continued on page 162 www.podiatrym.com SEPTEMBER 2005 • PODIATRY MANAGEMENT 161 CME Infant... mediate postnatal course, including fetal distress and hypoxic Continuingin the obstetric high-risk episodes, can indicate injury to group, which may lead to neuro- the central nervous system. Birth Medical Education logic deficit in the newborn. Previ- weight and length of hospital ous obstetric history, including num- stay is important and easily-ob- ber of pregnancies, miscarriages, tained historical information. birth weight, and health status of other children, should be obtained. Examination of the Spine A history of having taken any The infant is placed on his ab- medicines or home remedies during domen. The hand is run lightly over the spine, and palpitation for scoliosis and Figure 3: Polydactyly kyphosis is performed. Possible swelling on the back covered by spina bifida is sought skin or sometimes by a thin mem- (Figure 1). Congeni- brane. It is flaccid and capable of tal scoliosis is associ- being transilluminated. There is a ated with congenital failure of fusion of the vertebral vertebral anomalies. arches with cystic distention of the Some children with meninges. The swelling consists of congenital scoliosis a herniation of dura and arachnoid, show curvature at filled with cerebral spinal fluid. The birth, but many do lower extremities may show no de- not. The anomalies formity and normal spontaneous and variations in de- movements can often be elicited in velopment of the ver- all muscles in the lower limbs. Figure 1: Examination of the lumbosacral region for tebrae may be single There may be no abnormal reflexes spina bifida or multiple, and may or abnormal neurologic signs. pregnancy as well as drug abuse, be associated with other anomalies, 2) In open myelomeningocele, both narcotic and non-narcotic, is especially in the ribs, and are fre- the most common site is the lum- important since they may affect the quently combined with spina bifida. bar or lumbosacral spine. In pa- fetus and the newborn. Length of Minor abnormalities of develop- tients seen on the first day of life, gestation information should be ment of the lubrosacral and sacral there is an oval area of red, glisten- obtained because premature and region are common. Spina bifida oc- ing tissue constituting the dysplas- post-mature infants are most at curs in one of about every 1,000 live tic portion of the spinal cord at the risk. The mother's own measure of births. Minor degrees of spina bifida center of the lesion. Surrounding it fetal activity is sometimes helpful affecting the fifth lumbar or first and attached to its edges is a thin in assessing maturity and vigor of sacral vertebrae are seldom of any epithelial membrane that merges the fetus. clinical significance. More severe peripherally with the skin. The skin Intrapartum events, such as fetal abnormalities of development of is often thin or shows pigmenta- heart rate, rupture of membranes, the vertebral column are often asso- tion in the region adjoining its length of labor, and other complica- ciated with paralytic defects and de- junction with the membranous tions of labor and delivery should formities in the lower limb. Verte- area. There is a failure of fusion of be obtained. The history of the im- bral agenesis, though uncommon, verebral arches, and the spinal cord has been seen to range is opened out as a neural plaque from the absence of only that lies almost flush with the sur- the lower coccygeal seg- face of the body. ment to absence of lum- The lower limbs may be unde- bar and sacral vertebrae. formed in about 50 percent of the children born with myelomeningo- Spina Bifida cele, or may show one or more of a Spina bifida can be variety or deformities, depending grouped into three clini- on cord level; at the hips, knees, or cal entities: feet, including fixed or non-fixed 1) The first is simple flexion, adduction, and lateral rota- meningocele, which may tion of the hip; fixed or limited be present anywhere in flexion of the knee or fixed recura- the spine, though it is tum; equinus, equinovarus, calca- most common in the lu- neovarus, calcaneus, calcaneoval- bosacral and sacral re- gus, equinovalgus, vertical talus de- Figure 2: Ectrodactly combined with syndactyly gions. It presents as a Continued on page 163

162 PODIATRY MANAGEMENT • SEPTEMBER 2005 www.podiatrym.com MedicalContinuing Education CME Infant... dislocated. Ortolani's test (as modified by Barlow) is then performed. The thigh is turned in the externally rotated position with the hip abducted; if the hip is dislocated, there is a click as the femur slides in and out of the acetabulum. In young infants, if the hip is all the way out, the Or- tolani sign may not be Figure 5: Hip abduction is examined for limitation obtained. Other clinical of motion signs of possible hip Examination of the Lower dysplasia include the following: 1) Extremities the inguinal crease is deeper on the The infant is placed on his back normal side; 2) the buttock contour and any gross abnormalities in the is flatter and wider on the involved extremities are noted. These may side (appearance of a lopsided an- include congenital absence of part chor); 3) the flexed knee height is Figure 4: Evaluation of legs for exces- or all of the femur, fibula, or tibia, at different levels, lower on the in- sive thigh skin folds that can indicate ectrodactly (lobster claw foot in volved side. a dislocated hip which there is an absence of two or Radiologic and ultrasound ex- formities, or clawing of the toes. three digits) (Figure 2), absence of amination in the infant should be The deformity is frequently bilater- metatarsals or digits, syndactly, used to confirm the diagnosis. al and symmetrical. polydactly (Figure 3), or fractures. 3) Closed myelomeningocele The infant is then placed on his Congenital Dislocation and spinal bifida occulta present abdomen. A difference in the skin of the Hip with a lipomatous or cystic folds of the two thighs should be There are three forms of con- swelling, abnormal pigmentation, sought (Figure 4). The presence of genital dislocation of the hip. The coarse hair formation, or a dermal excessive folds on one side is not a bony and cartilaginous tissues of sinus on the lower back. The verte- completely reliable sign, but it does the acetabulum can be malformed bral arches are unfused, but there is point to the possibility of a dislo- at birth resulting in congenital ac- no gross distention of the cated hip on that side. etabular dysplasia. In this condition meninges. The spinal cord and its The baby is then turned over the head of the femur is severely roots may or may not be abnormal. on his back to see if the legs are displaced and the acetabulum rep- It occurs most frequently at the equal in length. Hip motion is resented by a dimple on the side of fifth lumbar or first sacral level. tested and any limitation of mo- the pelvis. Congenital dislocation tion is determined (Figure 5). of the hip can also be secondary to Piston mobility of the hips is a muscular or neuromuscular ab- tested by pushing the thighs normality, as in myelomeningo- up and down with the hip cele, or the dislocation can be due flexed; mobility greater than a to capsular laxity. half inch means that the hip is The range of internal and external rotation of the hip should be tested. The infant should present with greater external than internal hip rotation. Greater internal hip rotation is associated with femoral antetor- sion which can Figure 6: The foot is slightly externally ro- result in in-toe tated on the leg when the knee is held in a gait. Any indica- straight anterolateral position Figure 7: Evaluation of ankle plantarflexion Continued on page 164 www.podiatrym.com SEPTEMBER 2005 • PODIATRY MANAGEMENT 163 CME Infant... ron damage such as seen in cerebral or metatarsus varus, calcaneoval- palsy. The presence of an anterior gus, convex pes valgus, and talipes Continuingtion of spasticity, fracture, or angulation of the tibia can be a sign equinovarus. other anomaly should also be of pending congenital pseu- Medical Education noted. doarthrosis of the tibia. There can Congenital Metatarsus Adductus Knee motion is examined next. be a posterior angulation, which is Congenital metatarsus adductus If the knee cannot be flexed, it may not as serious a deformity. Bowing or metatarsus varus (the latter be a sign of posterior dislocation of of the tibia in the infant is present being a more severe form of the for- the knee. If the knee cannot be ex- in achondroplasia. When the knee mer) is a condition in which the tended, it may be a sign of spastici- of the newborn is held in a straight anterior part of the foot deviates ty resulting from upper motor neu- anterolateral position, the foot will medially and there is a varus angu- be found slightly exter- lation at the tarsometatarsal joints nally rotated by not (Figure 10). The heel may be in more that 10 degrees neutral or valgus position. When (Figure 6). The absence the heel is in valgus, the varus de- of this relationship formity of the forefoot is invariably may indicate either in- severe. To diagnose this condition, ternal or external tibia the V-finger test can be used. Place torsion. the infant's foot between the first In the normal foot two fingers and look for a C curve of the newborn the (Figures 11a and b). Sometimes heel is in neutral posi- there is only a varus of the first tion in relation to the metatarsal where the big toe alone ankle. On plantar-flex- is separated and curved inward ion, there are 50 de- (metatarsus varus primus). Figure 8: Evaluation of ankle dorsiflexion grees of motion from Metatarsus adductus problems are usually not noticed before 4 to 8 weeks, unless they are ex- treme at birth. In an antereo- posterior radiographic view, there is a varus devia- tion of all five metatarsals, and the angle Figure 9: (a) Determination of eversion of the foot (b) Determination of inversion of the foot between the talus and cal- the neutral position (Figure 7). The caneus (angle of kite) is often more skin should not appear tight on the than 35 degrees. The incidence of anterior aspect of the ankle and the congenital metatarsus adductus has midtarsal region of the foot. There increased fourfold in the past 25 is 30-45 degrees of relative passive years. dorsiflexion from the neutral right angle position (Figure 8). The foot Calcaneovalgus Foot can be everted and inverted pas- The type of flatfoot deformity sively from the neutral position be- most frequently found at birth is tween 20 to 30 degrees in each di- the calcaneovalgus foot. The foot rection (Figures 9 a and b). lies in acute extension and slight On radiographic examination, valgus. The dorsal surface of the the following bones are visible: The foot is in contact with the anterior talus, the calcaneus, the cuboid, all surface of the lower leg (Figure 12). of the metatarsals, and all of the Dorsiflexion is practically absent at phalanges except for the distal two birth and plantar flexion is limited phalanges of the fifth toe. There are to the neutral position with the an- four major congenital foot disor- terior soft tissue structures appear- ders that produce a significant vari- ing tight and preventing further Figure 10: Congenital metatarsus ad- ation from the normal foot. These plantar flexion of the foot (Figure ductus conditions are metatarsus adductus, Continued on page 165

164 PODIATRY MANAGEMENT • SEPTEMBER 2005 www.podiatrym.com MedicalContinuing Education The only radiographic difference between the two types of feet is that the talus is plantar-flexed in the calcaneovalgus foot while it is vertical in the rigid flatfoot.

Talipes Equinovarus (Clubfoot) Talipes equinovarus (clubfoot) constitutes about 25 percent for all congenital anomalies seen in clin- ics for crippled children, and occurs once in each 700 to 1,000 live births. It is twice as common in males and bilateral in about 50 percent of cases. The heel in this condition is in an equinus position with the tuberosity of the calcaneus pointing cephalad, forming a con- Figure 11: (a) “V”-finger test demonstration of a normal foot (b) “V”-finger spicuous prominence behind the test demonstration of metatarsus adductus ankle joint (Figure 15). The heel 13). The heel, as well as the entire (congenital rigid flatfoot) is a con- and the forepart of the foot are foot, is in a valgus position. The ra- dition that presents an appearance swung medially in inversion, with diographic examination shows defi- at birth similar to congenital calca- supination of the forepart. The nite mal-alignment of the visible neovalgus, and thus must be differ- forepart of the foot is adducted, tarsal bones. In the lateral radio- entiated. The distinctive features of supinated, and flexed on the hind gram of a normal foot, the line bi- congenital rigid flatfoot are as fol- part. secting the talus transverses lows: 1) The foot has a C-shaped The total picture is one of equi- through the upper half of the appearance and there is a valgus re- nus position of the entire foot with cuboid and there is no overlap be- lationship of the rear portion of the varus position of the heel in rela- tween the talus and calcaneus. foot with the mid and forefoot. 2) tion to the leg and varus position In the calcaneovalgus foot, the The heel is not in valgus as in a cal- of the forepart of the foot in rela- talus is plantar-flexed, and the line caneovalgus condition, but is in a tion to the heel (Figure 16). This bisecting the talus extends below neutral position. 3) The heel is tilt- position of equinovarus is fixed and the plantar surface of the cuboid. In ed downward in flexion. 4) The rigid and cannot be manually al- addition, there is overlapping of foot is only in mild dorsiflexion, tered. A severe metatarsus adductus the head of the talus and the ante- and if the foot is dorsiflexed com- may simulate a clubfoot, but shows riorsuperior edge of the calcaneous. pletely, a convexity on the plantar no fixed varus or fixed equinus po- surface is produced (rocker bottom sition of the heel and therefore the Congenital Convex Pes Valgus deformity)5) (Figure 14) The foot is heel can be manually placed into a Congenital convex pes valgus rigidly fixed, and cannot be easily valgus position and the foot easily inverted on manipulation. 6) The dorsi-flexed. head of the talus is palpable as a medioplantar prominence, but it Neurological Evaluation cannot be easily reduced as in the Limb symmetry, muscle bulk, calcaneovalgus foot. tone, strength, and reflexes should be compared on each side, both proximally and distally. Muscle strength can be tested in groups. In the lower limbs L1, 2, 3 supply the hip flexors (iliop- soas), L4, 5, S1 innervate the hip extensors (glutei), L2, 3, 4 supplies the knee extensors (quadriceps), L5, S1, 2 innervate the knee flexors (hamstrings), L4, 5 supplies ankle dorsi- Figure 12: Congenital calcaneovalgus Figure 13: Limitation of plantar flexion in a calcaneo- flexion (tibialis anteri- foot deformity valgus deformity Continued on page 166 www.podiatrym.com SEPTEMBER 2005 • PODIATRY MANAGEMENT 165 CME Infant... with successive tap- ping of the patellar Continuingor), and S1, 2 plantar flexion tendon is due to fail- (gastrocnemius). Ankle inversion ure of the leg to return Medical Education is supplied by L4 nerve root and ev- to the resting position. ersion by L5, S1 root. This may occur in chorea and is called a Deep Tendon Reflexes pendular knee jerk. A Individual deep tendon reflexes normal contraction of the lower extremity should be with delayed relax- performed as follows: ation of the knee may occur in hypothy- Patellar (Quadriceps) Reflex (Knee Jerk) roidism. The leg is flexed to about mid- way between contraction and relax- Achilles (Triceps Surae) ation, approximately 120 degrees. Reflex (Ankle Jerk) Figure 16: Bilateral talipes equinovarus One strikes the quadriceps tendon In young children, just below the patella, and the leg the foot is held at right angles to Cerebellar damage will result in jumps into extension. In very the leg, and the Achilles tendon is slurred speech, nystagamus, incoor- strong reactions one may elicit the tapped. As the soleus and gastroc- dination in the upper and lower patella-adductor reflex, in which nemius contract, the foot goes into limbs, and a wide based ataxic gait. there is also a tendency to adduct plantarflexion. This reflex is gov- Lower motor neuron disorders the thigh. Loss of the patellar reflex erned by the internal popliteal produce wasting, fasciculations is referred to as Westphal's sign, nerve, and first and second sacral (spontaneous contraction of motor where there is interference with the segments. units), hypotonia, weakness, ar- reflex arc. The anterior crural nerve reflexia, and flexor plantar responses and second, third, and fourth lum- UMN Damage without sensory changes, e.g., anteri- bar segments are involved. Upper motor neuron (UMN) or horn cell or motor root diseases. ■ Progressive extension of the leg damage characteristically produces weakness of extensor References muscle groups in the 1 Giannestras NJ. Foot Disorders: upper limb and of the Medical and Surgical Management. flexor groups in the Philadelphia, Lea and Febiger, 1973. lower limb with spas- 2 Grant R, Harris EJ. Neurology. In ticity, hyperreflexia, Thomson P (ed). Introduction to and extensor plantar Podopaediatrics. London, W.B. Saun- ders Company Ltd, 1993. response. When spas- 3 Green A, Norman W, Ponseti V, et ticity is unilateral, the al. Pediatric foot and leg conditions: arm is held flexed and when therapy is urgent. Patient Care, the leg extended. There July 15, 1970. pp 2-12 is circumduction at the 4 Sharrad WJW. Paediatrics Orthope- hip and the toes. dics and Fractures. Oxford, Blackwell When there is bilateral Scientific Publications, 1979. UMN damage, there is 5 Tachdjian MO. Pediatric Orthope- dics 2nd Edition. W. B. Saunders Com- Figure 14: Rocker bottom foot deformity seen in delayed gait which is characteristically scis- pany, 1990. congenital convex pes valgus 6 Tax HR, Podopediatrics. Baltimore, sored with increased Williams & Wilkins, 1985. adductor tone resulting in the knees rubbing when walking, coupled Dr. Caselli is with plantarflexion Staff Podiatrist and inversion of the at the VA Hud- feet. There may also be son Valley lordosis and a rather Health Care festinant precarious System and is gait as is seen in cere- Adjunct Profes- bral palsy. sor at NYCPM. Damage to the He is a Fellow of the Ameri- basal ganglia produces can College of tremor, increased tone Sports Medicine and Former Chair- (rigidity), slowed man, Department of Orthopedic Sci- Figure 15: Equinus position of the heel seen in tal- movement (hypokine- ences and Director, Department of ipes equinovarus sia) and flexed posture. Pediatrics, NYCPM

166 PODIATRY MANAGEMENT • SEPTEMBER 2005 www.podiatrym.com MedicalContinuing Education EXAMINATION

See answer sheet on page 169.

1) The most important reason 5) Which one of the following 10) Congenital metatarsus ad- for examining the spine in a conditions is not an etiological ductus is a condition in which: pre-walking infant is that: factor in creating a dislocated A) The forefoot deviates later- A) Spinal abnormalities may hip? ally and is in varus result in an asymmetric gait A) Congenitally short femur. B) The forefoot deviates me- pattern and excessive B) Malformed acetabulum dially and is in valgus pronation. C) Myelomeningocele C) The forefoot deviates me- B) Scoliosis should be treat- D) Capsular laxity dially and is in varus ed before the child starts to D) The forefoot deviates later- walk. 6) Which one of the following is ally and is in valgus C) Spinal abnormalities not an abnormal finding when may be responsible for se- evaluating the internal and ex- 11) The heel position in a child vere hip, leg, and foot ternal rotation of the hip? with congenital metatarsus ad- deformities. A) Spasticity ductus is usually: D) It promotes the appear- B) Greater internal rotation A) Neutral or valgus ance to parents that you are than external rotation B) Slight varus being thorough in your C) Greater external rotation C) Severe varus examination. than internal rotation D) In equinus D) Ecchymosis and swelling 2) Which one of the following 12) The type of flatfoot deformi- spinal abnormalities is the most 7) A knee that cannot be flexed ty most commonly found in the pathologic? on examination may indicate: infant is: A) Kyphosis A) Severe ligamentous A) Convex pes valgus B) Meningocele laxity B) Peroneal spastic flatfoot C) Spina bifida occulta B) Spasticity C) Spastic equinovalgus D) Open myelomeningocele C) Posterior dislocation D) Calcaneovalgus D) Hypotonia 3) Ectrodactly is a congenital 13) The V-finger test is used to foot deformity in which the 8) When the knee of an infant is diagnose which one of the fol- foot presents with: held in a straight anterolateral lowing conditions? A) One or more accessory position, the position of the foot A) Talipes equinovarus digits. should be: B) Convex pes planovalgus B) The absence of two A) Slightly externally rotated. C) Metatarsus adductus or three digits and B) Slightly internally rotated. D) Calcaneovalgus often their associated C) Externally rotated 13 to metatarsals. 18 degrees. 14) Which one of the following, if C) A severe equinus and D) Internally rotated 13 to 18 any, is NOT typical of the radio- valgus deformity. degrees. graphic signs of the calcaneoval- D) Gigantism of the toes. gus foot? 9) Which one of the following A) Plantar flexed talus 4) Asymmetry of the thigh represents an abnormal foot B) Overlapping of the head of folds may be an indication of: range of motion in an infant? the talus and calcaneus A) Cerebral palsy. A) Ankle dorsi-flexion 30 de- C) Line bisecting talus trans- B) A dislocated hip. grees verses through upper half of C) A lower motor neuron B) Ankle plantar-flexion 10 cuboid disorder. degrees D) All above are radiographic D) A talipes equinovarus C) Foot inversion 30 degrees signs of a calcaneovalgus foot. deformity. D) Foot eversion 20 degrees Continued on page 168 www.podiatrym.com SEPTEMBER 2005 • PODIATRY MANAGEMENT 167 EXAMINATION PM’s Continuing (cont’d) Medical Education CPME Program 15) Which one of the following is NOT a term Welcome to the innovative Continuing Education commonly used to describe a congenital convex Program brought to you by Podiatry Management pes valgus foot? Magazine. Our journal has been approved as a A) Congenital flexible flatfoot sponsor of Continuing Medical Education by the B) Congenital rocker bottom foot Council on Podiatric Medical Education. C) Congenital vertical talus D) Congenital rigid flatfoot Now it’s even easier and more convenient to enroll in PM’s CE program! 16) The position of the heel in a congenital con- You can now enroll at any time during the year vex pes valgus foot is in what position? A) Varus and submit eligible exams at any time during your B) Valgus enrollment period. C) Neutral PM enrollees are entitled to submit ten exams D) Any of the above published during their consecutive, twelve–month enrollment period. Your enrollment period begins 17) Which one of the following is true concern- with the month payment is received. For example, ing congenital talipes equinovarus? if your payment is received on September 1, 2003, A) It can result from open myelomeningo- your enrollment is valid through August 31, 2004. cele If you’re not enrolled, you may also submit any B) It is more common in females than males exam(s) published in PM magazine within the past C) It is most often unilateral twelve months. CME articles and examination D) It resolves spontaneously questions from past issues of Podiatry Man- agement can be found on the Internet at 18) Which one of the following is not a compo- nent of talipes equinovarus? http://www.podiatrym.com/cme. All lessons A) Forefoot adductus are approved for 1.5 hours of CE credit. Please read B) Forefoot supination the testing, grading and payment instructions to de- C) Heel inversion cide which method of participation is best for you. D) Tuberosity of calcaneus pointing plantar- Please call (631) 563-1604 if you have any ques- ly tions. A personal operator will be happy to assist you. Each of the 10 lessons will count as 1.5 credits; 19) Which one of the following findings is not thus a maximum of 15 CME credits may be typical of upper motor neuron damage in an in- earned during any 12-month period. You may se- fant? lect any 10 in a 24-month period. A) Spasticity B) Fasciculations The Podiatry Management Magazine CME C) Hyperreflexia program is approved by the Council on Podiatric D) Increased muscle tone Education in all states where credits in instruction- 20) Which one of the following findings is NOT al media are accepted. This article is approved for typical of basal ganglia damage in an infant? 1.5 Continuing Education Contact Hours (or 0.15 A) Flacidity CEU’s) for each examination successfully completed. B) Tremors C) Flexed posture PM’s CME program is valid in all states D) Rigidity except Kentucky.

Home Study CME credits now See answer sheet on page 169. accepted in Pennsylvania

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Check one: ______I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be charged to your credit card.) ______I am not enrolled. Enclosed is a $17.50 check payable to Podiatry Management Magazine for each exam submitted. (plus $2.50 for each exam if submitting by fax or phone). ______I am not enrolled and I wish to enroll for 10 courses at $109.00 (thus saving me $66 over the cost of 10 individual exam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone. Over, please 169 ✄ (cont’d) www.podiatrym.com 11. A12. B A13. C B A14. D C B A15. D C B A16. D C B A17. D C B A18. D C B A19. D C B A20. D C B A D C B D C D (Caselli) EXAM #7/05 Evaluation of the Infant Evaluation of the The Lower Extremity Orthopedic The Lower 1. A2. B A3. C B A4. D C B A5. D C B A6. D C B A7. D C B A8. D C B A9. D C B A D C B D C D 10. A B C D LESSON EVALUATION exam Please indicate the date you completed this ______the lesson? How much time did it take you to complete ______hours ______minutes How well did this lesson achieve its educational objectives? ______Very well ______Well all ______Somewhat ______Not at lesson? What overall grade would you assign this A B C D Degree______Additional comments and suggestions for future exams: ______Circle: ENROLLMENT FORM & ANSWER SHEET & ANSWER FORM ENROLLMENT PODIATRY MANAGEMENT • SEPTEMBER 2005

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