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M C e o d n i t ca in l u SURGICAL Ed in u g c at io n

The Lower Objectives After reading this article, the physi - cian should be able to: Extremity 1) Perform an orthopedic examination on a pre-walking child 2) Understand the purpose and Orthopedic significance of each part of the ex - amination 3) Differentiate between normal and Evaluation abnormal orthopedic findings 4) Develop an appreciation for the sig - of the Infant nificance of abnormal neurologic findings 5) Recognize the presenting ap - Early examination can minimize the effects of pearance of common lower extremity both orthopedic and neurologic conditions. deformities

Welcome to Podiatry Management ’s CME Instructional program. Our journal has been approved as a sponsor of Contin - uing Medical Education by the Council on Podiatric Medical Education. You may enroll: 1) on a per issue basis (at $20.00 per topic) or 2) per year, for the special introductory rate of $149 (you save $51). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the near future, you may be able to submit via the Internet. If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned credits. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 180 . Other than those entities currently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be acceptable by any state licensing agency, hospital, man - aged care organization or other entity. PM will, however, use its best efforts to ensure the widest acceptance of this program possible. This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts by noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected]. Following this article, an answer sheet and full set of instructions are provided (p. 180 ).— Editor

Mark A. Caselli, DPM gies that might be present. The tory, family history, musculoskele - necessary parts of this orthopedic tal examination, and neurologic he earlier the detection of evaluation include a medical his - examination. an orthopedic problem, A prenatal, intrapartum, and Tthe better the chances of postnatal history is of paramount making a significant change in The earlier importance in ruling out neuro - the prognosis of that condition. motor disease. The prenatal histo - Many lower extremity orthopedic the detection of an ry should include family as well pathologies are best treated dur - orthopedic problem, the as maternal history. It is impor - ing the earliest period of life, tant to ascertain whether or not that of infancy, before ambula - better the chances of other members of the family have tion begins. In order to detect an lower extremity orthopedic prob - orthopedic problem at this stage making a significant lems. Pregnant women at both ex - of life, the podiatric practitioner change in the prognosis tremes of the age group, under 16 must be familiar with both the and over 30, are in the obstetric method of performing a thor - of that condition. high-risk group, which may lead ough lower extremity evaluation to neurologic deficit in the new - as well as the possible patholo - Continued on page 174 www.podiatrym.com MARCH 2011 • PODIATRY MANAGEMENT 173 n g o in ti u a n c hypoxic episodes, can indicate ti u CME Infant... n d o E injury to the central nervous C al ic born. Previous obstetric histo - system. Birth weight and length d e ry, including number of preg - of hospital stay is important M nancies, miscarriages, birth weight, and easily-obtained historical and health status of other children, information. should be obtained. A history of having taken any Examination of the Spine medicines or home remedies during The infant is placed on his pregnancy as well as drug abuse, . The hand is run light - both narcotic and non-narcotic, is ly over the spine, and palpita - tion for and is performed. Possi - Figure 3: ble is sought (Figure 1). swelling on the covered by Congenital scoliosis skin or sometimes by a thin mem - is associated with brane. It is flaccid and capable of congenital vertebral being transilluminated. There is a anomalies. Some failure of fusion of the vertebral children with con - arches with cystic distention of the genital scoliosis meninges. The swelling consists of show curvature at a herniation of dura and arachnoid, birth, but many do filled with cerebral spinal fluid. The not. The anomalies lower extremities may show no de - and variations in de - formity and normal spontaneous velopment of the movements can often be elicited in vertebrae may be all muscles in the lower limbs. Figure 1: Examination of the lumbosacral region for single or multiple, There may be no abnormal reflexes spina bifida and may be associat - or abnormal neurologic signs. important since they may affect the ed with other anomalies, especially 2) In open myelomeningocele, fetus and the newborn. Length of in the , and are frequently com - the most common site is the lum - gestation information should be bined with spina bifida. bar or lumbosacral spine. In pa - obtained because premature and Minor abnormalities of develop - tients seen on the first day of life, post-mature infants are most at ment of the lubrosacral and sacral there is an oval area of red, glisten - risk. The mother's own measure of region are common. Spina bifida oc - ing tissue constituting the dysplas - fetal activity is sometimes helpful curs in one of about every 1,000 live tic portion of the spinal cord at the in assessing maturity and vigor of births. Minor degrees of spina bifida center of the lesion. Surrounding it the fetus. affecting the fifth or first and attached to its edges is a thin Intrapartum events, such as sacral vertebrae are seldom of any epithelial membrane that merges fetal heart rate, rupture of mem - clinical significance. More severe peripherally with the skin. The skin branes, length of labor, and other abnormalities of development of is often thin or shows pigmenta - complications of labor and deliv - the are often asso - tion in the region adjoining its ery should be obtained. The histo - ciated with paralytic defects and de - junction with the membranous ry of the immediate postnatal formities in the lower limb. Verte - area. There is a failure of fusion of course, including fetal distress and 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 , , 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 ; fixed or limited be present anywhere in flexion of the or fixed recurva - 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 gions. It presents as a Continued on page 175

174 PODIATRY MANAGEMENT • MARCH 2011 www.podiatrym.com M C e o d n i t is dislocated. ca in CME Infant... l u Ed in Ortolani's u g c test (as modified at io by Barlow) is then n performed. The 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 of obtained. Other clinical motion signs of possible hip Examination of the Lower dysplasia include the following: Extremities 1) the inguinal crease is deeper on The infant is placed on his back the normal side; 2) the buttock and any gross abnormalities in the contour is flatter and wider on the extremities are noted. These may involved side (appearance of a lop - include congenital absence of part sided anchor); 3) the flexed knee Figure 4: Evaluation of legs for excessive or all of the femur, fibula, or tibia, height is at different levels, lower thigh skin folds that can indicate a dis - ectrodactly (lobster claw foot in on the involved side. located 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 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 . 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 The range of internal and exter - nal 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 rotated result in in-toe on the leg when the knee is held in a straight gait. Any indica - anterolateral position Figure 7: Evaluation of ankle plantarflexion Continued on page 176 www.podiatrym.com MARCH 2011 • PODIATRY MANAGEMENT 175 n g o in ti u a n c ron damage such as seen in cerebral or metatarsus varus, calcaneoval - ti u CME Infant... n d o E palsy. The presence of an anterior gus, convex pes valgus, and talipes C al ic tion of spasticity, fracture, or angulation of the tibia can be a sign equinovarus. d e other anomaly should also be of pending congenital pseu - M noted. doarthrosis of the tibia. There can Congenital Metatarsus Knee motion is examined next. be a posterior angulation, which is Adductus If the knee cannot be flexed, it may not as serious a deformity. Bowing Congenital metatarsus adductus be a sign of posterior dislocation of of the tibia in the infant is present or metatarsus varus (the latter being the knee. If the knee cannot be ex - in . When the knee a more severe form of the former) is tended, it may be a sign of spastici - of the newborn is held in a straight a condition in which the anterior ty resulting from upper motor neu - anterolateral position, the foot will part of the foot deviates medially be found slightly exter - and there is a varus angulation at nally rotated by not the tarsometatarsal joints (Figure more that 10 degrees 10). The heel may be in neutral or (Figure 6). The absence valgus position. When the heel is in of this relationship valgus, the of the may indicate either in - forefoot is invariably severe. To diag - ternal or external tibia nose this condition, the V-finger test torsion. can be used. Place the infant's foot In the normal foot between the first two fingers and of the newborn the look for a C curve (Figures 11a and heel is in neutral posi - b). Sometimes there is only a varus tion in relation to the of the first metatarsal where the big ankle. On plantar-flex - toe alone is separated and curved in - ion, there are 50 de - ward (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 ra - diographic 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 adduc - ation from the normal foot. These plantar flexion of the foot (Figure tus conditions are metatarsus adductus, Continued on page 177

176 PODIATRY MANAGEMENT • MARCH 2011 www.podiatrym.com M C e o d n i t The only radiograph - ca in l u Ed in ic difference between the u g c two types of feet is that the at io talus is plantar-flexed in the cal - n caneovalgus foot while it is vertical in the rigid flatfoot.

Talipes Equinovarus () Talipes equinovarus (clubfoot) constitutes about 25 percent for all congenital anomalies seen in clinics 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 per - cent of cases. The heel in this condi - tion is in an equinus position with the tuberosity of the calcaneus Figure 11: (a) “V”-finger test demonstration of a normal foot (b) “V”-finger test pointing cephalad, forming a con - demonstration of metatarsus adductus spicuous prominence behind the 13). The heel, as well as the entire (congenital rigid flatfoot) is a con - ankle joint (Figure 15). The heel and foot, is in a valgus position. The ra - dition that presents an appearance the forepart of the foot are swung diographic examination shows defi - at birth similar to congenital calca - medially in inversion, with supina - nite mal-alignment of the visible neovalgus, and thus must be differ - tion of the forepart. The forepart of tarsal bones. In the lateral radio - entiated. The distinctive features of the foot is adducted, supinated, and gram of a normal foot, the line bi - congenital rigid flatfoot are as fol - flexed on the hind 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 )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 inner - vate the hip extensors (glutei), L2, 3, 4 sup - plies the knee extensors (quadriceps), L5, S1, 2 innervate the knee flex - ors (), L4, 5 supplies ankle dorsi - Figure 12: Congenital calcaneovalgus Figure 13: Limitation of plantar flexion in a calcaneoval - flexion (tibialis anteri - gus deformity Continued on page 178 www.podiatrym.com MARCH 2011 • PODIATRY MANAGEMENT 177 n g o in ti u a n c with successive tapping ti u CME Infant... n d o E of the patellar tendon C al ic or), and S1, 2 plantar flexion is due to failure of the d e (gastrocnemius). Ankle inversion leg to return to the M is supplied by L4 and ev - resting position. This ersion by L5, S1 root. may occur in chorea and is called a pendular Deep Tendon Reflexes knee jerk. A normal Individual deep tendon reflexes contraction with de - of the lower extremity should be layed relaxation of the performed as follows: knee may occur in hy - pothyroidism. Patellar (Quadriceps) Reflex (Knee Jerk) Achilles (Triceps The leg is flexed to about midway Surae) Reflex (Ankle between contraction and relaxation, Jerk) Figure 16: Bilateral talipes equinovarus approximately 120 degrees. One In young children, strikes the quadriceps tendon just the foot is held at right angles to Cerebellar damage will result in below the patella, and the leg jumps the leg, and the Achilles tendon is slurred speech, nystagamus, inco - into extension. In very strong reac - tapped. As the soleus and gastroc - ordination in the upper and lower tions one may elicit the patella-ad - nemius contract, the foot goes into limbs, and a wide based ataxic ductor reflex, in which there is also a plantarflexion. This reflex is gov - gait. tendency to adduct the thigh. Loss of erned by the internal popliteal Lower motor neuron disorders the patellar reflex is referred to as nerve, and first and second sacral produce wasting, fasciculations Westphal's sign, where there is inter - segments. (spontaneous contraction of motor ference with the reflex arc. The anteri - units), hypotonia, weakness, ar - or crural nerve and second, third, and UMN Damage reflexia, and flexor plantar re - fourth lumbar segments are involved. Upper motor neuron (UMN) sponses without sensory changes, Progressive extension of the leg damage characteristically produces e.g., anterior horn cell or motor weakness of extensor root diseases. I muscle groups in the upper limb and of the References 1 flexor groups in the Giannestras NJ. Foot Disorders: Med - lower limb with spas - ical and Surgical Management. Philadel - phia, Lea and Febiger, 1973. ticity, hyperreflexia, 2 Grant R, Harris EJ. Neurology. In and extensor plantar Thomson P (ed). Introduction to Podopae - response. When spas - diatrics. London, W.B. Saunders Company ticity is unilateral, the Ltd, 1993. is held flexed and 3 Green A, Norman W, Ponseti V, et al. the leg extended. There Pediatric foot and leg conditions: when is circumduction at the therapy is urgent. Patient Care, July 15, hip and the toes. 1970. pp 2-12 4 When there is bilateral Sharrad WJW. Paediatrics Orthope - UMN damage, there is dics and Fractures. Oxford, Blackwell Sci - entific Publications, 1979. delayed gait which is Figure 14: deformity seen in congen - 5 Tachdjian MO. Pediatric Orthopedics ital convex pes valgus characteristically scis - 2nd Edition. W. B. Saunders Company, sored with increased 1990. adductor tone resulting 6 Tax HR, Podopediatrics. Baltimore, in the knees rubbing Williams & Wilkins, 1985. when walking, coupled with plantarflexion Dr. Caselli is Staff and inversion of the Podiatrist at the feet. There may also be VA Hudson Valley and a rather Health Care Sys - festinant precarious tem and is Ad - gait as is seen in cere - junct Professor at bral palsy. NYCPM. He is a Fellow of the Damage to the American College basal ganglia produces of Sports Medicine tremor, increased tone and Former Chair - (rigidity), slowed man, Department of Orthopedic Sciences Figure 15: Equinus position of the heel seen in talipes movement (hypokine - and Director, Department of Pediatrics, equinovarus sia) and flexed posture. NYCPM

178 PODIATRY MANAGEMENT • MARCH 2011 www.podiatrym.com M C e o d n i t ca in l u Ed in EXAMINATION u g c at io n See answer sheet on page 181 .

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 lat - A) Spinal abnormalities may hip? erally 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 lat - walk. 6) Which one of the following is erally 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 18 metatarsals. degrees. 14) Which one of the following, C) A severe equinus and D) Internally rotated 13 to 18 if any, is NOT typical of the ra - valgus deformity. degrees. diographic signs of the calcaneo - D) Gigantism of the toes. valgus foot? 9) Which one of the following A) Plantar flexed talus 4) Asymmetry of the thigh folds represents an abnormal foot B) Overlapping of the head of 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 deformity. D) Foot eversion 20 degrees foot. Continued on page 180 www.podiatrym.com MARCH 2011 • PODIATRY MANAGEMENT 179 n g o in ti u a n c ti u n d o E EXAMINATION PM ’s C al ic ed (cont’d) M CPME Program Welcome to the innovative Continuing Education 15) Which one of the following is NOT a term Program brought to you by Podiatry Management commonly used to describe a congenital convex Magazine . Our journal has been approved as a pes valgus foot? sponsor of Continuing Medical Education by the A) Congenital flexible flatfoot Council on Podiatric Medical Education. B) Congenital rocker bottom foot C) Congenital vertical talus Now it’s even easier and more convenient D) Congenital rigid flatfoot 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? and submit eligible exams at any time during your A) Varus enrollment period. B) Valgus PM enrollees are entitled to submit ten exams C) Neutral published during their consecutive, twelve–month D) Any of the above enrollment period. Your enrollment period begins with the month payment is received. For example, 17) Which one of the following is true concern - if your payment is received on September 1, 2006, ing congenital talipes equinovarus? your enrollment is valid through August 31, 2007. A) It can result from open myelomeningo - If you’re not enrolled, you may also submit any cele exam(s) published in PM magazine within the past B) It is more common in females than males twelve months. CME articles and examination C) It is most often unilateral 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 - http://www.podiatrym.com/cme. Each lesson nent of talipes equinovarus? is approved for 1.5 hours continuing education con - A) Forefoot adductus tact hours. Please read the testing, grading and pay - B) Forefoot supination ment instructions to decide which method of partici - C) Heel inversion pation is best for you. D) Tuberosity of calcaneus pointing plantarly Please call (631) 563-1604 if you have any ques - tions. A personal operator will be happy to assist you. 19) Which one of the following findings is not Each of the 10 lessons will count as 1.5 credits; typical of upper motor neuron damage in an in - thus a maximum of 15 CME credits may be fant? earned during any 12-month period. You may se - A) Spasticity lect any 10 in a 24-month period. B) Fasciculations C) Hyperreflexia D) Increased muscle tone The Podiatry Management Magazine CME program is approved by the Council on Podiatric 20) Which one of the following findings is NOT Education in all states where credits in instruction - typical of basal ganglia damage in an infant? al media are accepted. This article is approved for A) Flacidity 1.5 Continuing Education Contact Hours (or 0.15 B) Tremors CEU’s) for each examination successfully completed. C) Flexed posture D) Rigidity

Home Study CME credits now See answer sheet on page 181 . accepted in Pennsylvania

180 PODIATRY MANAGEMENT www.podiatrym.com £ M C e o d n i t ca in l u Ed in Enrollment/Testing Information u g c at io and Answer Sheet n Note: If you are mailing your answer sheet, you must complete exam during your current enrollment period. If you are not en - all info. on the front and back of this page and mail with your rolled, please send $20.00 per exam, or $149 to cover all 10 exams credit card information to: Podiatry Management , P.O. Box (thus saving $51* over the cost of 10 individual exam fees). 490, East Islip, NY 11730. Facsimile Grading To receive your CPME certificate, complete all information and TESTING, GRADING AND PAYMENT INSTRUCTIONS fax 24 hours a day to 1-631-563-1907. Your CPME certificate will (1) Each participant achieving a passing grade of 70% or be dated and mailed within 48 hours. This service is available for higher on any examination will receive an official computer form $2.50 per exam if you are currently enrolled in the annual 10-exam stating the number of CE credits earned. This form should be safe - CPME program (and this exam falls within your enrollment period), guarded and may be used as documentation of credits earned. and can be charged to your Visa, MasterCard, or American Express. (2) Participants receiving a failing grade on any exam will be If you are not enrolled in the annual 10-exam CPME pro - notified and permitted to take one re-examination at no extra cost. gram, the fee is $20 per exam. (3) All answers should be recorded on the answer form below. For each question, decide which choice is the best an - Phone-In Grading swer, and circle the letter representing your choice. You may also complete your exam by using the toll-free ser - (4) Complete all other information on the front and back of vice. Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Monday this page. through Friday. Your CPME certificate will be dated the same day (5) Choose one out of the 3 options for testgrading: mail-in, you call and mailed within 48 hours. There is a $2.50 charge for fax, or phone. To select the type of service that best suits your this service if you are currently enrolled in the annual 10-exam needs, please read the following section, “Test Grading Options”. CPME program (and this exam falls within your enrollment peri - od), and this fee can be charged to your Visa, Mastercard, Ameri - TEST GRADING OPTIONS can Express, or Discover. If you are not currently enrolled, the fee Mail-In Grading is $20 per exam. When you call, please have ready: To receive your CME certificate, complete all information 1. Program number (Month and Year) and mail with your credit card information to: 2. The answers to the test Podiatry Management 3. Your social security number P.O. Box 490, East Islip, NY 11730 4. Credit card information There is no charge for the mail-in service if you have already In the event you require additional CPME information, enrolled in the annual exam CPME program, and we receive this please contact PMS, Inc., at 1-631-563-1604 .

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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 my credit card information. Please charge my credit card $20.00 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 $139.00 (thus saving me $61 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 181 £ t’d) con ( www.podiatrym.com EET SH c i d exam SWER n? t n a e p o h this N t r ed f n I lesso O A y ) e h the t i l t #3/11 & l e complet i m M f o N A e r you s a C X IO ( n o t x complete E E i t RM _____ to date r e a u l the you FO w o a v E educational L T LUA A EV cate 2011 take T its it : e h indi all ON le T eve did at hi c ir ease MARCH ESS me ac L Pl C • ti lesson? ____Well his t ENT lesson exams: much LLM EN ______s ______minutes s _____ thi ______Not assign d How future RO di hour for you MANAGEM at well well Y uld EN ions ______

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