tory, family history, musculoskele-tal examination, and neurologicexamination.A prenatal, intrapartum, and

postnatal history is of paramountimportance in ruling out neuro-motor disease. The prenatal histo-ry should include family as wellas maternal history. It is impor-tant to ascertain whether or notother members of the family havelower extremity orthopedic prob-lems. Pregnant women at both ex-tremes of the age group, under 16and over 30, are in the obstetrichigh-risk group, which may leadto neurologic deficit in the new-

Continued on page 174

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MARCH 2011 • PODIATRY MANAGEMENTwww.podiatrym.com 173

gies that might be present. Thenecessary parts of this orthopedicevaluation include a medical his-The earlier the detection of

an orthopedic problem,the better the chances of

making a significant change inthe prognosis of that condition.Many lower extremity orthopedicpathologies are best treated dur-ing the earliest period of life,that of infancy, before ambula-tion begins. In order to detect anorthopedic problem at this stageof life, the podiatric practitionermust be familiar with both themethod of performing a thor-ough lower extremity evaluationas well as the possible patholo-

ObjectivesAfter reading this article, the physi-

cian should be able to:

1) Perform an orthopedic examinationon a pre-walking child

2) Understand the purpose andsignificance of each part of the ex-amination

3) Differentiate between normal andabnormal orthopedic findings

4) Develop an appreciation for the sig-nificance of abnormal neurologic findings

5) Recognize the presenting ap-pearance of common lower extremitydeformities

Continuing

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Mark A. Caselli, DPM

Early examination can minimize the effects ofboth orthopedic and neurologic conditions.

The LowerExtremityOrthopedicEvaluationof the Infant

The earlier

the detection of an

orthopedic problem, the

better the chances of

making a significant

change in the prognosis

of that condition.

S U R G I C A L P O D I A T R YS U R G I C A L P O D I A T R Y

hypoxic episodes, can indicateinjury to the central nervoussystem. Birth weight and lengthof hospital stay is importantand easily-obtained historicalinformation.

Examination of the SpineThe infant is placed on his

abdomen. The hand is run light-ly over the spine, and palpita-

tion for scoliosisand kyphosis isperformed. Possi-ble spina bifida issought (Figure 1).Congenital scoliosisis associated withcongenital vertebralanomalies. Somechildren with con-genital scoliosisshow curvature atbirth, but many donot. The anomaliesand variations in de-velopment of thevertebrae may besingle or multiple,and may be associat-

ed with other anomalies, especiallyin the ribs, and are frequently com-bined with spina bifida.Minor abnormalities of develop-

ment of the lubrosacral and sacralregion are common. Spina bifida oc-curs in one of about every 1,000 livebirths. Minor degrees of spina bifidaaffecting the fifth lumbar or firstsacral vertebrae are seldom of anyclinical significance. More severeabnormalities of development ofthe vertebral column are often asso-ciated with paralytic defects and de-formities in the lower limb. Verte-bral agenesis, though uncommon,

has been seen to rangefrom the absence of onlythe lower coccygeal seg-ment to absence of lum-bar and sacral vertebrae.

Spina BifidaSpina bifida can be

grouped into three clini-cal entities:1) The first is simple

meningocele, which maybe present anywhere inthe spine, though it ismost common in the lu-bosacral and sacral re-gions. It presents as a

swelling on the back covered byskin or sometimes by a thin mem-brane. It is flaccid and capable ofbeing transilluminated. There is afailure of fusion of the vertebralarches with cystic distention of themeninges. The swelling consists ofa herniation of dura and arachnoid,filled with cerebral spinal fluid. Thelower extremities may show no de-formity and normal spontaneousmovements can often be elicited inall muscles in the lower limbs.There may be no abnormal reflexesor abnormal neurologic signs.2) In open myelomeningocele,

the most common site is the lum-bar or lumbosacral spine. In pa-tients seen on the first day of life,there is an oval area of red, glisten-ing tissue constituting the dysplas-tic portion of the spinal cord at thecenter of the lesion. Surrounding itand attached to its edges is a thinepithelial membrane that mergesperipherally with the skin. The skinis often thin or shows pigmenta-tion in the region adjoining itsjunction with the membranousarea. There is a failure of fusion ofverebral arches, and the spinal cordis opened out as a neural plaquethat lies almost flush with the sur-face of the body.The lower limbs may be unde-

formed in about 50 percent of thechildren born with myelomeningo-cele, or may show one or more of avariety or deformities, dependingon cord level; at the hips, knees, orfeet, including fixed or non-fixedflexion, adduction, and lateral rota-tion of the hip; fixed or limitedflexion of the knee or fixed recurva-tum; equinus, equinovarus, calca-neovarus, calcaneus, calcaneoval-gus, equinovalgus, vertical talus de-

Continued on page 175

174 www.podiatrym.comPODIATRY MANAGEMENT • MARCH 2011

CME Infant...

born. Previous obstetric histo-ry, including number of preg-

nancies, miscarriages, birth weight,and health status of other children,should be obtained.A history of having taken any

medicines or home remedies duringpregnancy as well as drug abuse,both narcotic and non-narcotic, is

important since they may affect thefetus and the newborn. Length ofgestation information should beobtained because premature andpost-mature infants are most atrisk. The mother's own measure offetal activity is sometimes helpfulin assessing maturity and vigor ofthe fetus.Intrapartum events, such as

fetal heart rate, rupture of mem-branes, length of labor, and othercomplications of labor and deliv-ery should be obtained. The histo-ry of the immediate postnatalcourse, including fetal distress and

Continuing

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Figure 2: Ectrodactly combined with syndactyly

Figure 3: Polydactyly

Figure 1: Examination of the lumbosacral region forspina bifida

MARCH 2011 • PODIATRY MANAGEMENTwww.podiatrym.com 175

Examination of the LowerExtremitiesThe infant is placed on his back

and any gross abnormalities in theextremities are noted. These mayinclude congenital absence of partor all of the femur, fibula, or tibia,ectrodactly (lobster claw foot inwhich there is an absence of two orthree digits) (Figure 2), absence ofmetatarsals or digits, syndactly,polydactly (Figure 3), or fractures.The infant is then placed on his

abdomen. A difference in the skinfolds of the two thighs should besought (Figure 4). The presence ofexcessive folds on one side is not acompletely reliable sign, but it doespoint to the possibility of a dislo-cated hip on that side.The baby is then turned over

on his back to see if the legs areequal in length. Hip motion istested and any limitation of mo-

tion is determined (Figure 5).Piston mobility of the hips istested by pushing the thighsup and down with the hipflexed; mobility greater than ahalf inch means that the hip

formities, or clawing of the toes.The deformity is frequently bilater-al and symmetrical.3) Closed myelomeningocele

and spinal bifida occulta presentwith a lipomatous or cysticswelling, abnormal pigmentation,coarse hair formation, or a dermalsinus on the lower back. The verte-bral arches are unfused, but there isno gross distention of themeninges. The spinal cord and itsroots may or may not be abnormal.It occurs most frequently at thefifth lumbar or first sacral level.

CME Infant... is dislocated.O r t o l an i ' s

test (as modifiedby Barlow) is thenperformed. The thigh isturned in the externallyrotated position withthe hip abducted; if thehip is dislocated, thereis a click as the femurslides in and out of theacetabulum. In younginfants, if the hip is allthe way out, the Or-tolani sign may not beobtained. Other clinicalsigns of possible hip

dysplasia include the following:1) the inguinal crease is deeper onthe normal side; 2) the buttockcontour is flatter and wider on theinvolved side (appearance of a lop-sided anchor); 3) the flexed kneeheight is at different levels, loweron the involved side.Radiologic and ultrasound ex-

amination in the infant should beused to confirm the diagnosis.

Congenital Dislocationof the HipThere are three forms of con-

genital dislocation of the hip. Thebony and cartilaginous tissues ofthe acetabulum can be malformedat birth resulting in congenital ac-etabular dysplasia. In this conditionthe head of the femur is severelydisplaced and the acetabulum rep-resented by a dimple on the side ofthe pelvis. Congenital dislocationof the hip can also be secondary toa muscular or neuromuscular ab-normality, as in myelomeningo-cele, or the dislocation can be dueto capsular laxity.The range of internal and exter-

nal rotation ofthe hip shouldbe tested. Theinfant shouldpresent withgreater externalthan internalhip rotation.Greater internalhip rotation isassociated withfemoral antetor-sion which canresult in in-toegait. Any indica-Continued on page 176

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Medical Education

Figure 7: Evaluation of ankle plantarflexion

Figure 5: Hip abduction is examined for limitation ofmotion

Figure 4: Evaluation of legs for excessivethigh skin folds that can indicate a dis-located hip

Figure 6: The foot is slightly externally rotatedon the leg when the knee is held in a straightanterolateral position

ron damage such as seen in cerebralpalsy. The presence of an anteriorangulation of the tibia can be a signof pending congenital pseu-doarthrosis of the tibia. There canbe a posterior angulation, which isnot as serious a deformity. Bowingof the tibia in the infant is presentin achondroplasia. When the kneeof the newborn is held in a straightanterolateral position, the foot will

be found slightly exter-nally rotated by notmore that 10 degrees(Figure 6). The absenceof this relationshipmay indicate either in-ternal or external tibiatorsion.

In the normal footof the newborn theheel is in neutral posi-tion in relation to theankle. On plantar-flex-ion, there are 50 de-grees of motion from

the neutral position (Figure 7). Theskin should not appear tight on theanterior aspect of the ankle and themidtarsal region of the foot. Thereis 30-45 degrees of relative passivedorsiflexion from the neutral rightangle position (Figure 8). The footcan be everted and inverted pas-sively from the neutral position be-tween 20 to 30 degrees in each di-rection (Figures 9 a and b).On radiographic examination,

the following bones are visible: Thetalus, the calcaneus, the cuboid, allof the metatarsals, and all of thephalanges except for the distal twophalanges of the fifth toe. There arefour major congenital foot disor-ders that produce a significant vari-ation from the normal foot. Theseconditions are metatarsus adductus,

or metatarsus varus, calcaneoval-gus, convex pes valgus, and talipesequinovarus.

Congenital MetatarsusAdductusCongenital metatarsus adductus

or metatarsus varus (the latter beinga more severe form of the former) isa condition in which the anteriorpart of the foot deviates mediallyand there is a varus angulation atthe tarsometatarsal joints (Figure10). The heel may be in neutral orvalgus position. When the heel is invalgus, the varus deformity of theforefoot is invariably severe. To diag-nose this condition, the V-finger testcan be used. Place the infant's footbetween the first two fingers andlook for a C curve (Figures 11a andb). Sometimes there is only a varusof the first metatarsal where the bigtoe alone is separated and curved in-ward (metatarsus varus primus).Metatarsus adductus problems

are usuallynot noticedbefore 4 to 8weeks, unlessthey are ex-treme at birth.In an antereo-posterior ra-d i o g r a p h i cview, there isa varus devia-tion of all fivemetatar sa l s ,and the anglebetween thetalus and cal-

caneus (angle of kite) is often morethan 35 degrees. The incidence ofcongenital metatarsus adductus hasincreased fourfold in the past 25years.

Calcaneovalgus FootThe type of flatfoot deformity

most frequently found at birth isthe calcaneovalgus foot. The footlies in acute extension and slightvalgus. The dorsal surface of thefoot is in contact with the anteriorsurface of the lower leg (Figure 12).Dorsiflexion is practically absent atbirth and plantar flexion is limitedto the neutral position with the an-terior soft tissue structures appear-ing tight and preventing furtherplantar flexion of the foot (Figure

Continued on page 177

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CME Infant...

tion of spasticity, fracture, orother anomaly should also be

noted.Knee motion is examined next.

If the knee cannot be flexed, it maybe a sign of posterior dislocation ofthe knee. If the knee cannot be ex-tended, it may be a sign of spastici-ty resulting from upper motor neu-

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MedicalEducation

Figure 9: (a) Determination of eversion of the foot (b) Determination of inversion of the foot

Figure 10: Congenital metatarsus adduc-tus

Figure 8: Evaluation of ankle dorsiflexion

MARCH 2011 • PODIATRY MANAGEMENTwww.podiatrym.com 177

(congenital rigid flatfoot) is a con-dition that presents an appearanceat birth similar to congenital calca-neovalgus, and thus must be differ-entiated. The distinctive features ofcongenital rigid flatfoot are as fol-lows: 1) The foot has a C-shapedappearance and there is a valgus re-lationship of the rear portion of thefoot with the mid and forefoot. 2)The heel is not in valgus as in a cal-caneovalgus condition, but is in aneutral position. 3) The heel is tilt-ed downward in flexion. 4) Thefoot is only in mild dorsiflexion,and if the foot is dorsiflexed com-pletely, a convexity on the plantarsurface is produced (rocker bottomdeformity)5) (Figure 14) The foot isrigidly fixed, and cannot be easilyinverted on manipulation. 6) Thehead of the talus is palpable as amedioplantar prominence, but itcannot be easily reduced as in thecalcaneovalgus foot.

13). The heel, as well as the entirefoot, is in a valgus position. The ra-diographic examination shows defi-nite mal-alignment of the visibletarsal bones. In the lateral radio-gram of a normal foot, the line bi-secting the talus transversesthrough the upper half of thecuboid and there is no overlap be-tween the talus and calcaneus.In the calcaneovalgus foot, the

talus is plantar-flexed, and the linebisecting the talus extends belowthe plantar surface of the cuboid. Inaddition, there is overlapping ofthe head of the talus and the ante-riorsuperior edge of the calcaneous.

Congenital Convex Pes ValgusCongenital convex pes valgus

The only radiograph-ic difference between thetwo types of feet is that thetalus is plantar-flexed in the cal-caneovalgus foot while it is verticalin the rigid flatfoot.

Talipes Equinovarus(Clubfoot)Talipes equinovarus (clubfoot)

constitutes about 25 percent for allcongenital anomalies seen in clinicsfor crippled children, and occursonce in each 700 to 1,000 livebirths. It is twice as common inmales and bilateral in about 50 per-cent of cases. The heel in this condi-tion is in an equinus position withthe tuberosity of the calcaneuspointing cephalad, forming a con-spicuous prominence behind theankle joint (Figure 15). The heel andthe forepart of the foot are swungmedially in inversion, with supina-tion of the forepart. The forepart ofthe foot is adducted, supinated, andflexed on the hind part.The total picture is one of equi-

nus position of the entire foot withvarus position of the heel in rela-tion to the leg and varus positionof the forepart of the foot in rela-tion to the heel (Figure 16). Thisposition of equinovarus is fixed andrigid and cannot be manually al-tered. A severe metatarsus adductusmay simulate a clubfoot, but showsno fixed varus or fixed equinus po-sition of the heel and therefore theheel can be manually placed into avalgus position and the foot easilydorsi-flexed.

Neurological EvaluationLimb symmetry, muscle bulk,

tone, strength, and reflexes shouldbe compared on eachside, both proximallyand distally. Musclestrength can be testedin groups. In the lowerlimbs L1, 2, 3 supplythe hip flexors (iliop-soas), L4, 5, S1 inner-vate the hip extensors(glutei), L2, 3, 4 sup-plies the knee extensors(quadriceps), L5, S1, 2innervate the knee flex-ors (hamstrings), L4, 5supplies ankle dorsi-flexion (tibialis anteri-

Continued on page 178

Continuing

Medical Education

Figure 12: Congenital calcaneovalgusfoot deformity

Figure 13: Limitation of plantar flexion in a calcaneoval-gus deformity

Figure 11: (a) “V”-finger test demonstration of a normal foot (b) “V”-finger testdemonstration of metatarsus adductus

Dr. Caselli is StaffPodiatrist at theVA Hudson ValleyHealth Care Sys-tem and is Ad-junct Professor atNYCPM. He is aFellow of theAmerican Collegeof Sports Medicineand Former Chair-man, Department of Orthopedic Sciencesand Director, Department of Pediatrics,NYCPM

with successive tappingof the patellar tendonis due to failure of theleg to return to theresting position. Thismay occur in choreaand is called a pendularknee jerk. A normalcontraction with de-layed relaxation of theknee may occur in hy-pothyroidism.

Achilles (TricepsSurae) Reflex (AnkleJerk)In young children,

the foot is held at right angles tothe leg, and the Achilles tendon istapped. As the soleus and gastroc-nemius contract, the foot goes intoplantarflexion. This reflex is gov-erned by the internal poplitealnerve, and first and second sacralsegments.

UMN DamageUpper motor neuron (UMN)

damage characteristically producesweakness of extensormuscle groups in theupper limb and of theflexor groups in thelower limb with spas-ticity, hyperreflexia,and extensor plantarresponse. When spas-ticity is unilateral, thearm is held flexed andthe leg extended. Thereis circumduction at thehip and the toes.When there is bilateralUMN damage, there isdelayed gait which ischaracteristically scis-sored with increasedadductor tone resultingin the knees rubbingwhen walking, coupledwith plantarflexionand inversion of thefeet. There may also belordosis and a ratherfestinant precariousgait as is seen in cere-bral palsy.

Damage to thebasal ganglia producestremor, increased tone( r i g id i t y ) , s l owedmovement (hypokine-sia) and flexed posture.

Cerebellar damage will result inslurred speech, nystagamus, inco-ordination in the upper and lowerlimbs, and a wide based ataxicgait.Lower motor neuron disorders

produce wasting, fasciculations(spontaneous contraction of motorunits), hypotonia, weakness, ar-reflexia, and flexor plantar re-sponses without sensory changes,e.g., anterior horn cell or motorroot diseases. �

References1 Giannestras NJ. Foot Disorders: Med-

ical and Surgical Management. Philadel-phia, Lea and Febiger, 1973.

2 Grant R, Harris EJ. Neurology. InThomson P (ed). Introduction to Podopae-diatrics. London, W.B. Saunders CompanyLtd, 1993.

3 Green A, NormanW, Ponseti V, et al.Pediatric foot and leg conditions: whentherapy is urgent. Patient Care, July 15,1970. pp 2-12

4 Sharrad WJW. Paediatrics Orthope-dics and Fractures. Oxford, Blackwell Sci-entific Publications, 1979.

5 Tachdjian MO. Pediatric Orthopedics2nd Edition. W. B. Saunders Company,1990.

6 Tax HR, Podopediatrics. Baltimore,Williams &Wilkins, 1985.

178 www.podiatrym.comPODIATRY MANAGEMENT • MARCH 2011

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or), and S1, 2 plantar flexion(gastrocnemius). Ankle inversion

is supplied by L4 nerve root and ev-ersion by L5, S1 root.

Deep Tendon ReflexesIndividual deep tendon reflexes

of the lower extremity should beperformed as follows:

Patellar (Quadriceps) Reflex(Knee Jerk)The leg is flexed to about midway

between contraction and relaxation,approximately 120 degrees. Onestrikes the quadriceps tendon justbelow the patella, and the leg jumpsinto extension. In very strong reac-tions one may elicit the patella-ad-ductor reflex, in which there is also atendency to adduct the thigh. Loss ofthe patellar reflex is referred to asWestphal's sign, where there is inter-ference with the reflex arc. The anteri-or crural nerve and second, third, andfourth lumbar segments are involved.Progressive extension of the leg

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Figure 15: Equinus position of the heel seen in talipesequinovarus

Figure 16: Bilateral talipes equinovarus

Figure 14: Rocker bottom foot deformity seen in congen-ital convex pes valgus

MARCH 2011 • PODIATRY MANAGEMENTwww.podiatrym.com 179

5) Which one of the followingconditions is not an etiologicalfactor in creating a dislocatedhip?

A) Congenitally short femur.B) Malformed acetabulumC) MyelomeningoceleD) Capsular laxity

6) Which one of the following isnot an abnormal finding whenevaluating the internal and ex-ternal rotation of the hip?

A) SpasticityB) Greater internal rotationthan external rotationC) Greater external rotationthan internal rotationD) Ecchymosis and swelling

7) A knee that cannot be flexedon examination may indicate:

A) Severe ligamentouslaxityB) SpasticityC) Posterior dislocationD) Hypotonia

8) When the knee of an infant isheld in a straight anterolateralposition, the position of the footshould be:

A) Slightly externally rotated.B) Slightly internally rotated.C) Externally rotated 13 to 18degrees.D) Internally rotated 13 to 18degrees.

9) Which one of the followingrepresents an abnormal footrange of motion in an infant?

A) Ankle dorsi-flexion 30 de-greesB) Ankle plantar-flexion 10degreesC) Foot inversion 30 degreesD) Foot eversion 20 degrees

1) The most important reasonfor examining the spine in apre-walking infant is that:

A) Spinal abnormalities mayresult in an asymmetric gaitpattern and excessivepronation.B) Scoliosis should be treat-ed before the child starts towalk.C) Spinal abnormalitiesmay be responsible for se-vere hip, leg, and footdeformities.D) It promotes the appear-ance to parents that you arebeing thorough in yourexamination.

2) Which one of the followingspinal abnormalities is the mostpathologic?

A) KyphosisB) MeningoceleC) Spina bifida occultaD) Open myelomeningocele

3) Ectrodactly is a congenitalfoot deformity in which thefoot presents with:

A) One or more accessorydigits.B) The absence of twoor three digits andoften their associatedmetatarsals.C) A severe equinus andvalgus deformity.D) Gigantism of the toes.

4) Asymmetry of the thigh foldsmay be an indication of:

A) Cerebral palsy.B) A dislocated hip.C) A lower motor neurondisorder.D) A talipes equinovarusdeformity.

10) Congenital metatarsus ad-ductus is a condition in which:

A) The forefoot deviates lat-erally and is in varusB) The forefoot deviates me-dially and is in valgusC) The forefoot deviates me-dially and is in varusD) The forefoot deviates lat-erally and is in valgus

11) The heel position in a childwith congenital metatarsus ad-ductus is usually:

A) Neutral or valgusB) Slight varusC) Severe varusD) In equinus

12) The type of flatfoot deformi-ty most commonly found in theinfant is:

A) Convex pes valgusB) Peroneal spastic flatfootC) Spastic equinovalgusD) Calcaneovalgus

13) The V-finger test is used todiagnose which one of the fol-lowing conditions?

A) Talipes equinovarusB) Convex pes planovalgusC) Metatarsus adductusD) Calcaneovalgus

14) Which one of the following,if any, is NOT typical of the ra-diographic signs of the calcaneo-valgus foot?

A) Plantar flexed talusB) Overlapping of the head ofthe talus and calcaneusC) Line bisecting talus trans-verses through upper half ofcuboidD) All above are radiographicsigns of a calcaneovalgusfoot.

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E X A M I N A T I O N

See answer sheet on page 181.

Continued on page 180

180 PODIATRY MANAGEMENT

15) Which one of the following is NOT a termcommonly used to describe a congenital convexpes valgus foot?

A) Congenital flexible flatfootB) Congenital rocker bottom footC) Congenital vertical talusD) Congenital rigid flatfoot

16) The position of the heel in a congenital con-vex pes valgus foot is in what position?

A) VarusB) ValgusC) NeutralD) Any of the above

17) Which one of the following is true concern-ing congenital talipes equinovarus?

A) It can result from open myelomeningo-celeB) It is more common in females than malesC) It is most often unilateralD) It resolves spontaneously

18) Which one of the following is not a compo-nent of talipes equinovarus?

A) Forefoot adductusB) Forefoot supinationC) Heel inversionD) Tuberosity of calcaneus pointing plantarly

19) Which one of the following findings is nottypical of upper motor neuron damage in an in-fant?

A) SpasticityB) FasciculationsC) HyperreflexiaD) Increased muscle tone

20) Which one of the following findings is NOTtypical of basal ganglia damage in an infant?

A) FlacidityB) TremorsC) Flexed postureD) Rigidity

E X A M I N A T I O N

(cont’d)

See answer sheet on page 181.

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(3) All answers should be recorded on the answer formbelow. For each question, decide which choice is the best an-swer, and circle the letter representing your choice.

(4) Complete all other information on the front and back ofthis page.

(5) Choose one out of the 3 options for testgrading: mail-in,fax, or phone. To select the type of service that best suits yourneeds, please read the following section, “Test Grading Options”.

TEST GRADING OPTIONSMail-In GradingTo receive your CME certificate, complete all information

and mail with your credit card information to:Podiatry Management

P.O. Box 490, East Islip, NY 11730There is no charge for the mail-in service if you have already

enrolled in the annual exam CPME program, and we receive this

ENROL LMENT FORM & ANSWER SH E E T

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181

Continuing

Medical Education

exam during your current enrollment period. If you are not en-rolled, please send $20.00 per exam, or $149 to cover all 10 exams(thus saving $51* over the cost of 10 individual exam fees).

Facsimile GradingTo receive your CPME certificate, complete all information and

fax 24 hours a day to 1-631-563-1907. Your CPME certificate willbe dated and mailed within 48 hours. This service is available for$2.50 per exam if you are currently enrolled in the annual 10-examCPME program (and this exam falls within your enrollment period),and can be charged to your Visa, MasterCard, or American Express.

If you are not enrolled in the annual 10-exam CPME pro-gram, the fee is $20 per exam.

Phone-In GradingYou may also complete your exam by using the toll-free ser-

vice. Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Mondaythrough Friday. Your CPME certificate will be dated the same dayyou call and mailed within 48 hours. There is a $2.50 charge forthis service if you are currently enrolled in the annual 10-examCPME program (and this exam falls within your enrollment peri-od), and this fee can be charged to your Visa, Mastercard, Ameri-can Express, or Discover. If you are not currently enrolled, the feeis $20 per exam. When you call, please have ready:

1. Program number (Month and Year)2. The answers to the test3. Your social security number4. Credit card information

In the event you require additional CPME information,please contact PMS, Inc., at 1-631-563-1604.

Enrollment/Testing Informationand Answer Sheet

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182 www.podiatrym.comPODIATRY MANAGEMENT • MARCH 2011

ENROL LMENT FORM & ANSWER SH E E T (cont’d)Continuing

MedicalEducation

LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educationalobjectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

EXAM #3/11The Lower Extremity Orthopedic

Evaluation of the Infant(Caselli)