This practice set contains high-yield board review questions covering key concepts in Ankle Trauma & Sports. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.
Question 1
Topic: Ankle Trauma & Sports
During an arthroscopic Brostrom-Gould procedure for chronic ankle instability, which structure is utilized to augment the repair of the anterior talofibular ligament?
Correct Answer & Explanation
. Inferior extensor retinaculum
Explanation
The modified Brostrom-Gould procedure involves an anatomic repair of the ATFL and CFL, augmented by pulling the inferior extensor retinaculum over the repair. This provides a secondary restraint and limits excessive inversion.
Question 2
Topic: Ankle Trauma & Sports
A 13-year-old girl sustains an ankle injury. Radiographs show a Salter-Harris III fracture of the anterolateral distal tibial epiphysis. What ligament is responsible for the avulsion of this bony fragment?
Correct Answer & Explanation
. Anterior inferior tibiofibular ligament (AITFL)
Explanation
A juvenile Tillaux fracture is an avulsion of the anterolateral distal tibial epiphysis. It is caused by tension on the anterior inferior tibiofibular ligament (AITFL) during an external rotation injury.
Question 3
Topic: Ankle Trauma & Sports
A 14-year-old boy sustains an ankle injury. Radiographs demonstrate a Salter-Harris III fracture of the anterolateral distal tibia. Which ligament's avulsion force is responsible for this specific fracture pattern?
Correct Answer & Explanation
. Anterior inferior tibiofibular ligament (AITFL)
Explanation
This describes a juvenile Tillaux fracture, which occurs due to avulsion of the anterolateral tibial epiphysis by the anterior inferior tibiofibular ligament (AITFL) during external rotation injuries in adolescents.
Question 4
Topic: Ankle Trauma & Sports
A 13-year-old boy sustains a juvenile Tillaux fracture. Which of the following ligaments is primarily responsible for the avulsion of this specific fracture fragment?
Correct Answer & Explanation
. Anterior inferior tibiofibular ligament (AITFL)
Explanation
A juvenile Tillaux fracture is a Salter-Harris III fracture of the anterolateral distal tibial epiphysis. It is caused by an avulsion force from the anterior inferior tibiofibular ligament (AITFL) as the medial physis closes before the lateral physis.
Question 5
Topic: Ankle Trauma & Sports
A 13-year-old boy sustains a twisting ankle injury resulting in a juvenile Tillaux fracture. Avulsion by which of the following ligaments is primarily responsible for this specific fracture pattern?
Correct Answer & Explanation
. Anterior inferior tibiofibular ligament (AITFL)
Explanation
The juvenile Tillaux fracture is a Salter-Harris III fracture of the anterolateral distal tibial epiphysis. It is caused by avulsion of the anterior inferior tibiofibular ligament (AITFL) as the physis closes asymmetrically.
Question 6
Topic: Ankle Trauma & Sports
The distinction between a Lauge-Hansen supination-external rotation III injury and a Lauge-Hansen supination-external rotation IV injury is:
Correct Answer & Explanation
. Deltoid ligament disruption or medial malleolus fracture
Explanation
The sequence of injury according to the Lauge-Hansen classification system in supination-external rotation injuries is AITFL disruption, spiral oblique fracture of the lateral malleolus, PITFL disruption or posterior malleolus fracture, and finally stage IV, which is a deltoid ligament disruption or medial malleolus fracture.
Question 7
Topic: Ankle Trauma & Sports
During open reduction and internal fixation of a Weber C ankle fracture, the syndesmosis is reduced and clamped. Which of the following radiographic parameters best confirms accurate reduction of the syndesmosis on a standard mortise view?
Correct Answer & Explanation
. Tibiofibular clear space less than 5 mm
Explanation
On the anteroposterior and mortise views, the tibiofibular clear space should be less than 5 mm when measured 1 cm proximal to the joint line. This is the most reliable and consistent two-dimensional radiographic indicator of syndesmotic reduction.
Question 8
Topic: Ankle Trauma & Sports
A 45-year-old male sustains an ankle injury during a fall. Radiographs show widening of the medial clear space and a proximal fibular fracture, but no lateral malleolus fracture at the ankle level. According to the Lauge-Hansen Pronation-External Rotation (PER) classification, which of the following structures is injured last in the sequence?
Correct Answer & Explanation
. Posterior inferior tibiofibular ligament (PITFL) or posterior malleolus
Explanation
In a Lauge-Hansen Pronation-External Rotation (PER) mechanism, the sequence of injury is: 1) Deltoid/Medial malleolus, 2) AITFL/Syndesmosis, 3) High fibular fracture, and 4) PITFL or posterior malleolus fracture. Therefore, the posterior structures are the final to fail in this high-energy pattern.
Question 9
Topic: Ankle Trauma & Sports
A 14-year-old female presents after an acute ankle twisting injury. Radiographs show a Salter-Harris III fracture of the anterolateral aspect of the distal tibial epiphysis, with 3 mm of displacement. Which of the following ligaments is primarily responsible for avulsing this fracture fragment?
Correct Answer & Explanation
. Anterior inferior tibiofibular ligament (AITFL)
Explanation
This describes a juvenile Tillaux fracture, which is an avulsion of the anterolateral distal tibial epiphysis. It is caused by the pull of the anterior inferior tibiofibular ligament (AITFL) during an external rotation mechanism, occurring uniquely when the central and medial physis have already closed.
Question 10
Topic: Ankle Trauma & Sports
A 45-year-old female sustains an ankle fracture. Radiographs demonstrate a transverse fracture of the medial malleolus and a comminuted fracture of the fibula at the level of the syndesmosis. According to the Lauge-Hansen classification, what is the mechanism of injury?
Correct Answer & Explanation
. Pronation-Abduction (PAB)
Explanation
A transverse medial malleolus fracture combined with a transverse or comminuted fibula fracture at the level of the joint line (syndesmosis) is characteristic of a Pronation-Abduction (PAB) injury pattern.
Question 11
Topic: Ankle Trauma & Sports
A 28-year-old patient had two cortical screws placed across the syndesmosis for a Maisonneuve fracture. At 10 weeks postoperatively, the patient is asymptomatic but asks about routine removal of the screws before initiating full weight-bearing. Based on current orthopedic literature, what is the recommended management regarding syndesmotic screw removal?
Correct Answer & Explanation
. Routine removal is not required, as retained or broken screws do not significantly worsen clinical outcomes
Explanation
Current evidence suggests that routine removal of syndesmotic screws is unnecessary. Clinical outcomes are similar whether the screws are removed, retained intact, or retained and broken. Removal is generally reserved for symptomatic hardware.
Question 12
Topic: Ankle Trauma & Sports
According to the Lauge-Hansen classification, what is the expected sequence of structural failure in a Supination-External Rotation (SER) type IV ankle injury?
Correct Answer & Explanation
. Anterior tibiofibular ligament -> short oblique fibula fracture -> posterior tibiofibular ligament -> deltoid ligament or medial malleolus
Explanation
An SER IV injury progresses sequentially in a circular fashion: 1) Anterior inferior tibiofibular ligament (AITFL) rupture, 2) short spiral/oblique lateral malleolus fracture, 3) Posterior inferior tibiofibular ligament (PITFL) rupture or posterior malleolus fracture, and 4) Deltoid ligament rupture or transverse medial malleolus fracture.
Question 13
Topic: Ankle Trauma & Sports
A 24-year-old gymnast sustains an ankle injury upon landing. Radiographs reveal a transverse fracture of the medial malleolus and a short oblique, comminuted fracture of the fibula exactly at the level of the tibial plafond. According to the Lauge-Hansen classification, what is the mechanism of this injury?
Correct Answer & Explanation
. Pronation-Abduction
Explanation
A Pronation-Abduction (PAB) injury pattern is characterized by a transverse fracture of the medial malleolus (or deltoid rupture) followed by a short oblique or transverse fibula fracture at or slightly above the level of the syndesmosis, often with lateral comminution.
Question 14
Topic: Ankle Trauma & Sports
A 29-year-old athlete presents with an isolated Weber B distal fibula fracture. A gravity stress radiograph is obtained to evaluate the integrity of the deltoid ligament and syndesmosis. At what threshold of medial clear space widening on the stress radiograph is the deep deltoid ligament considered incompetent, necessitating operative intervention?
Correct Answer & Explanation
. Greater than 4 mm
Explanation
On a gravity stress or manual stress radiograph, a medial clear space of greater than 4 mm (or >1 mm compared to the superior clear space) indicates deep deltoid ligament incompetence and syndesmotic instability, which is an indication for operative fixation.
Question 15
Topic: Ankle Trauma & Sports
A 35-year-old female sustains a twisting injury to her ankle. Radiographs demonstrate a short oblique fracture of the lateral malleolus at the level of the syndesmosis and a transverse fracture of the medial malleolus. According to the Lauge-Hansen classification, what is the initial structure injured in this sequence?
Correct Answer & Explanation
. Anterior inferior tibiofibular ligament
Explanation
This is a Supination-External Rotation (SER) stage IV injury. The predictable sequence of SER injuries begins with rupture of the anterior inferior tibiofibular ligament (AITFL) in Stage I.
Question 16
Topic: Ankle Trauma & Sports
A 30-year-old male undergoes open reduction and internal fixation for a Weber C ankle fracture with syndesmotic disruption. Postoperative CT evaluation is ordered to assess the syndesmosis. Which of the following technical errors during surgery most commonly leads to a malreduced syndesmosis?
Correct Answer & Explanation
. Placing the reduction clamp too anteriorly on the fibula
Explanation
Malreduction of the syndesmosis most frequently occurs due to improper reduction clamp placement. Placing the clamp too anteriorly on the fibula and too posteriorly on the tibia can cause the fibula to internally rotate and translate anteriorly.
Question 17
Topic: Ankle Trauma & Sports
Following fibular and medial malleolar fixation in the 32-year-old athlete, the surgeon proceeds to reduce the syndesmosis. A large Weber clamp is used to hold the reduction. According to current guidelines, at what approximate distance proximal to the joint line and at what angle relative to the coronal plane should the reduction clamp be applied to achieve optimal anatomical reduction?
Correct Answer & Explanation
. 2-3 cm proximal, 20-30 degrees anterior
Explanation
Correct Answer: BUnder 'Placement of the Reduction Clamp,' the case specifies: 'The clamp should be applied at the level of the planned fixation, typically 2 to 3 centimeters proximal to the joint line... The vector of compression must be parallel to the joint line and directed slightly anteriorly (approximately 20 to 30 degrees relative to the coronal plane) to match the anatomical axis of the syndesmosis.'Incorrect Options:A) 1 cm proximal, 0 degrees (parallel to coronal):This is too close to the joint line and lacks the correct anterior angulation.C) 4-5 cm proximal, 10 degrees posterior:This is too proximal and the posterior angulation is incorrect.D) At the joint line, 45 degrees anterior:Applying the clamp directly at the joint line is generally avoided to prevent articular damage, and 45 degrees anterior may be excessive.E) 2-3 cm proximal, 0 degrees (parallel to coronal):While the proximal distance is correct, the lack of anterior angulation (0 degrees) would not match the anatomical axis of the syndesmosis, potentially leading to malreduction.
Question 18
Topic: Ankle Trauma & Sports
In the context of the 32-year-old semi-professional soccer player, the surgeon is considering fixation options for the syndesmosis. Current literature and guidelines, as summarized in the case, suggest which of the following regarding suture button constructs compared to trans-syndesmotic screws?
Correct Answer: CUnder 'Syndesmotic Fixation Options' and 'Summary of Key Literature and Guidelines,' the case states: 'Suture Button Constructs: Increasingly preferred for high-energy athletic injuries. These dynamic devices... permit physiological micromotion, potentially accelerating rehabilitation and eliminating the need for routine hardware removal.' It further notes that 'dynamic fixation is associated with a lower incidence of syndesmotic malreduction' and 'yield equivalent or superior functional outcome scores.'Incorrect Options:A) Suture button constructs are associated with a higher incidence of syndesmotic malreduction:This is incorrect. The case states, 'dynamic fixation is associated with a lower incidence of syndesmotic malreduction.'B) Suture button constructs require routine removal at 8-12 weeks postoperatively:This is incorrect. The case states they 'eliminat[e] the need for routine hardware removal.'D) Trans-syndesmotic screws consistently yield superior functional outcome scores:This is incorrect. The case states, 'Studies consistently demonstrate that suture button constructs yield equivalent or superior functional outcome scores... compared to screw fixation.'E) Suture button constructs are contraindicated in high-demand athletic populations due to lower stability:This is incorrect. The case states they are 'increasingly preferred for high-energy athletic injuries' due to their dynamic nature and ability to accommodate physiological loading.
Question 19
Topic: Ankle Trauma & Sports
Biomechanical studies of the distal tibiofibular syndesmosis demonstrate that varying ligaments contribute to its stability. Which structure provides the greatest resistance to lateral displacement of the fibula?
Correct Answer & Explanation
. Posterior inferior tibiofibular ligament
Explanation
The posterior inferior tibiofibular ligament (PITFL) contributes approximately 42% of the resistance to lateral displacement, making it the strongest syndesmotic stabilizer. The AITFL contributes roughly 35%.
Question 20
Topic: Ankle Trauma & Sports
Which of the following ligamentous structures provides the greatest resistance to posterior translation and lateral displacement of the fibula relative to the tibia at the level of the syndesmosis?
The posterior inferior tibiofibular ligament (PITFL) is the strongest component of the syndesmosis, contributing approximately 42% of the resistance to diastasis. The AITFL contributes about 35%, and the interosseous ligament contributes 22%.
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