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8. Foot and Ankle MCQs

Practice Set 134 of 353

This practice set contains high-yield board review questions covering key concepts in 8. Foot and Ankle. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 2661

Topic: 8. Foot and Ankle

A 32-year-old construction worker reports a persistent burning, tingling sensation on the dorsum of his right foot and significant sensitivity on the plantar surface after a 500-lb steel beam dropped on it 8 weeks ago. Initial radiographs revealed no fractures, and the skin remained intact at the time of injury. Physical therapy, anti-inflammatory drugs, and a serotonin reuptake inhibitor have failed to provide relief. What is the next most appropriate step in management?

. Continued physical therapy
. Alteration of medication to include an anti-epileptic
. Tarsal tunnel release
. Sympathetic blocks
. Neurostimulation

Correct Answer & Explanation

. Sympathetic blocks

Explanation

Following failure of physical therapy and pharmacologic management in a patient with complex regional pain syndrome, the management of choice is sympathetic blocks. While continued physical therapy would be assistive, sympathetic blocks allow a more rapid relief of symptoms. Neurostimulation is not appropriate at this stage because of its invasive nature. Cepeda MS, Lau J, Carr DB: Defining the therapeutic role of local anesthetic sympathetic blockade in complex regional pain syndrome: A narrative and systematic review. Clin J Pain 2002;18:216-233. Perez RS, Kwakkel G, Zuurmond WW, et al: Treatment of reflex sympathetic dystrophy (CRPS type 1): A research synthesis of 21 randomized clinical trials. J Pain Symptom Manage 2001;21:511-526. Tran KM, Frank SM, Raja SN, et al: Lumbar sympathetic block for sympathetically maintained pain changes in cutaneous temperatures and pain perception. Anesth Analg 2000;90:1396-1401.

Question 2662

Topic: 8. Foot and Ankle

A 48-year-old man has had pain and swelling of the hallux metatarsophalangeal joint for the past 9 months. A rocker bottom stiff-soled shoe has failed to provide relief; however, two cortisone injections have temporarily alleviated his symptoms. The radiographs shown in Figures 20a and 20b reveal diffuse arthritis of the entire hallux metatarsophalangeal joint. What is the most definitive surgical treatment?

. Dorsal cheilectomy
. Keller resection arthroplasty
. Silastic joint replacement
. Hallux metatarsophalangeal arthrodesis
. Hallux valgus correction

Correct Answer & Explanation

. Hallux metatarsophalangeal arthrodesis

Explanation

Because the radiographs demonstrate severe arthritis, hallux metatarsophalangeal arthrodesis is the treatment of choice. Cheilectomy alone will not relieve pain because the entire joint is degenerative. Joint replacement has not been shown to be a long-term solution. Keller resection arthroplasty is not indicated in younger active patients. Hallux valgus correction will not address arthritis of the joint and could stiffen the joint further. Smith RW, Joanis TL, Maxwell PD: Great toe metatarsophalangeal joint arthrodesis: A user-friendly technique. Foot Ankle 1992;13:367-377.

Question 2663

Topic: 8. Foot and Ankle

An 18-year-old man sustains an injury to his lateral ankle after being kicked while playing soccer. He reports persistent pain on the lateral ankle as well as a popping sensation with attempted ankle dorsiflexion and eversion. Which of the following structures anatomically restrains the retracted structure shown in Figure 12?

Foot & Ankle Board Review 2006: High-Yield MCQs (Set 2) - Figure 4

. Posterior talofibular ligament
. Calcaneofibular ligament
. Superior peroneal retinaculum
. Inferior peroneal retinaculum
. Peroneal tubercle

Correct Answer & Explanation

. Superior peroneal retinaculum

Explanation

The peroneus brevis and peroneus longus muscles are the main evertors of the hindfoot. As they descend along the posterior fibula, they pass through the retromalleolar sulcus, formed by the concavity of the retromalleolar fibula. This sulcus is deepened by a fibrocartilaginous rim. The superior peroneal retinaculum covers the fibular groove and stabilizes the peroneal tendons within the retromalleolar sulcus. It originates from the posterolateral ridge of the fibula and inserts onto the lateral calcaneus. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 81-89.

Question 2664

Topic: 8. Foot and Ankle

Figures 5a and 5b show the radiographs of a 56-year-old man who was seen in the emergency department following a twisting injury to his left ankle. Examination in your office 3 days later reveals marked swelling and diffuse tenderness to palpation about the ankle and leg. What is the next most appropriate step in management?

. MRI of the ankle
. CT of the ankle
. Technetium bone scan
. Radiographs of the tibia and fibula
. Repeat radiographs of the ankle in 5 to 7 days

Correct Answer & Explanation

. Radiographs of the tibia and fibula

Explanation

The radiographs show an isolated posterior malleolus fracture which, given the injury mechanism, is highly suspicious for a Maisonneuve injury. As with any suspected extremity injury, radiographs including the joints above and below the level of injury are acutely indicated. Although MRI may reveal a ligamentous injury to the ankle and CT may show asymmetry of the ankle mortise or syndesmosis, both studies are considerably more costly and are not indicated in the absence of a complete radiographic work-up. Technetium bone scan is nonspecific and would be of limited value in this instance, as would repeat radiographs of the ankle. Walling AK, Sanders RW: Ankle fractures, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 2, pp 1973-2016.

Question 2665

Topic: 8. Foot and Ankle

A 24-year-old dancer sustains the injury shown in Figure 28. Management should consist of

Sports Medicine 2001 Practice Questions: Set 3 (Solved) - Figure 6

. closed reduction and application of a well-molded cast.
. open reduction and percutaneous pin fixation.
. open reduction and internal fixation with a mini fragment plate and screws.
. intramedullary screw fixation.
. brief immobilization and symptomatic treatment.

Correct Answer & Explanation

. brief immobilization and symptomatic treatment.

Explanation

The patient has a moderately displaced distal diaphyseal fracture of the fifth metatarsal, and the most appropriate treatment is brief immobilization and symptomatic management. Attempts at closed reduction are unlikely to appreciably alter the position of the fracture. Surgical techniques for either reduction of the fracture or fixation have not been shown to result in improved functional outcomes. O'Malley MJ, Hamilton WG, Munyak J: Fractures of the distal shaft of the fifth metatarsal: "Dancer's Fracture." Am J Sports Med 1996;24:240-243. DeLee JC: Fractures and dislocations of the foot, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, CV Mosby, 1993, pp 1465-1703.

Question 2666

Topic: 8. Foot and Ankle

A 35-year-old woman who is training for a triathlon has had a 2-month history of heel pain with weight bearing and is unable to run. History reveals that she is amenorrheic. Examination reveals that she is thin and has pain over the heel that is exacerbated with medial and lateral compression. Range of motion and motor and sensory function are normal. Radiographs are normal. What is the most likely diagnosis?

Foot & Ankle 2000 Practice Questions: Set 1 (Solved) - Figure 29

. Plantar fasciitis
. Seronegative inflammatory arthritis
. Stress fracture of the calcaneus
. Tarsal tunnel syndrome
. Peripheral neuropathy

Correct Answer & Explanation

. Stress fracture of the calcaneus

Explanation

The most likely diagnosis is a stress fracture of the calcaneus and is supported by the history of running, female gender, and amenorrhea. Reproducing pain with medial and lateral compression of the heel also supports the diagnosis. A bone scan or MRI would most likely confirm the diagnosis. Plantar fasciitis would result in pain on the bottom of the heel with point tenderness. The lack of other areas of involvement or other symptoms does not support a seronegative inflammatory arthritis. Tarsal tunnel syndrome and peripheral neuropathy are unlikely because of the normal neurologic examination. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 597-612.

Question 2667

Topic: 8. Foot and Ankle

A 14-year-old boy has medial ankle pain, progressive unilateral flatfoot deformity, and pain with most activities of daily living. He denies any recent injury. His parents recall that at age 7 years he sustained an injury that was treated as a sprain. Examination reveals valgus deformity with painless, unrestricted passive motion of the ankle. He has grossly equal limb lengths. A radiograph of the affected ankle is shown in Figure 48a, and the contralateral ankle is shown in Figure 48b. Management should consist of

. a University of California Biomechanics Laboratory (UCBL) orthosis.
. subtalar arthrodesis.
. physeal bar resection.
. tibial epiphysiodesis.
. closing wedge distal tibial osteotomy.

Correct Answer & Explanation

. closing wedge distal tibial osteotomy.

Explanation

Angular deformities of the ankle can occur following physeal injury. While an orthosis may be beneficial, the deformity is at the level of the ankle rather than the hindfoot. An epiphysiodesis or physeal bar resection would not be indicated as the growth plates are closed. Correction of the angular deformity should level the ankle joint and normalize the weight-bearing stresses on the ankle. This is most easily achieved with a closing wedge distal tibial osteotomy with or without concomitant osteotomy of the fibula. Thompson DM, Calhoun JH: Advanced techniques in foot and ankle reconstruction. Foot Ankle Clin 2000;5:417-442. Ting AJ, Tarr RR, Sarmiento A, Wagner K, Resnick C: The role of subtalar motion and ankle contact pressure changes from angular deformities of the tibia. Foot Ankle 1987;7:290-299.

Question 2668

Topic: Midfoot & Hindfoot

A 20-year-old man sustains the injury shown in Figures 1a and 1b in a motorcycle accident. In addition to a prompt closed reduction, his outcome might be optimized by

. a subtalar arthrodesis.
. screw fixation of the talar neck.
. repair of the medial subtalar capsule.
. temporary transarticular pin fixation.
. evaluation for and excision or fixation of osteochondral fractures.

Correct Answer & Explanation

. evaluation for and excision or fixation of osteochondral fractures.

Explanation

Lateral subtalar dislocations, which are less common than medial subtalar dislocations, are high-energy injuries that are frequently associated with small osteochondral fractures. It is generally recommended that large fragments be internally fixed, and small fragments entrapped within the joint be excised. Although arthrosis frequently occurs after this injury and is the most common long-term complication, primary subtalar arthrodesis is not indicated. A talar neck fracture is not evident on the radiographs, and lateral subtalar dislocation usually does not lead to instability.

Question 2669

Topic: 8. Foot and Ankle

A 52-year-old woman with diabetes mellitus has had a plantar foot ulcer under the second metatarsal head for the past week. The patient had a similar ulcer 2 months ago, and total contact casting resulted in healing. Examination reveals no signs of infection. What procedure will best prevent recurrence of the ulcer?

. Flexor hallucis longus transfer to the Achilles tendon
. Peripheral vascular bypass
. Jones procedure (extensor hallucis longus transfer to the first metatarsal with interphalangeal joint fusion)
. Posterior tibial tendon transfer to the anterior tibialis tendon
. Achilles tendon lengthening

Correct Answer & Explanation

. Achilles tendon lengthening

Explanation

The contracted Achilles tendon leads to increased forefoot pressure, thus increasing the risk for ulceration in neuropathic patients. Several studies have shown the benefit of Achilles tendon lengthening to heal and prevent forefoot ulceration in these patients. The flexor hallucis longus transfer is used for chronically torn/deficient Achilles tendons, not a contracted Achilles tendon. The Jones procedure works well for the first ray but does not help to alleviate pressure under the second ray. Peripheral bypass surgery is unnecessary because the ulcer healed during the initial treatment, indicating that the patient has adequate circulation. The posterior tibial tendon transfer is used for foot drop or other neuromuscular conditions to correct deformity and increase function. It is not used for forefoot ulcers in patients with diabetes mellitus. Armstrong DG, Stacpoole-Shea S, Nguyen H, et al: Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. J Bone Joint Surg Am 1999;81:535-538.

Question 2670

Topic: 8. Foot and Ankle

Figure 14 shows the clinical photographs and radiograph of an 8-year-old girl who has a progressive equinus deformity of the right ankle. There is no history of trauma or infection. What is the most likely diagnosis?

. Arthrogryposis
. Melorheostosis
. Focal scleroderma
. Calcaneal osteomyelitis
. Klippel-Trenaunay-Weber syndrome

Correct Answer & Explanation

. Focal scleroderma

Explanation

Focal scleroderma is characterized by the formation of patches of sclerotic skin, also known as morphea, or streaks of sclerosis (linear scleroderma). Systemic involvement in focal scleroderma is unusual; however, progression during childhood is common. Contracture of underlying tissues is common, often resulting in serious joint contractures. Bony changes similar to those seen in melorheostosis can be seen. This patient has characteristic skin changes, atrophy of the soft tissues, Achilles tendon contractures, and calcaneal deformities. There are no signs of arthrogryposis, which usually presents with bilateral congenital deformities, including equinovarus. Klippel-Trenaunay-Weber syndrome is characterized by venous malformation in association with focal overgrowth.

Question 2671

Topic: 8. Foot and Ankle

A patient with Charcot-Marie-Tooth disease has a progressively rigid cavovarus foot deformity. The patient states that the pain is restricted to the forefoot, where rigid claw toe deformities have developed. Which of the following structures is primarily involved in creation of a claw toe deformity?

Foot & Ankle 2000 Practice Questions: Set 1 (Solved) - Figure 18

. Laxity of the volar plate
. Intraosseous tendon
. Extensor digitorum longus tendon
. Extensor digitorum brevis tendon
. Flexor digitorum longus tendon

Correct Answer & Explanation

. Flexor digitorum longus tendon

Explanation

Diseases such as Charcot-Marie-Tooth result in spasticity to the extrinsic flexor tendons. This results in hyperflexion of the proximal and distal interphalangeal joints of the involved toe, as well as hyperextension at the metatarsophalangeal joint. The tendon often becomes contracted with progressive equinus of the ankle. Correction of ankle equinus exaggerates the claw toe deformity. The interosseous tendon plays no role in the etiology of a claw toe but may become contracted in later stages of the disease. Laxity of the volar plate may precipitate a claw toe deformity in a nonspastic situation. In patients with a head injury, claw toe deformities are generally the result of overactivity of the extensor tendons. Keenan MA, Gorai AP, Smith CW, Garland DE: Intrinsic toe flexion deformity following correction of spastic equinovarus deformity in adults. Foot Ankle 1987;7:333-337. Pichney GA, Derner R, Lauf E: Digital "V" arthrodesis. J Foot Ankle Surg 1993;32:473-479.

Question 2672

Topic: 8. Foot and Ankle

A 32-year-old runner has pain in the medial arch that radiates into the medial three toes. He reports the presence of pain only when running. Examination reveals normal hindfoot alignment. There is a weakly positive Tinel's sign over the posterior tibial nerve. Tenderness is noted with palpation over the plantar medial area in the vicinity of the navicular tuberosity. What is the most likely diagnosis?

. Plantar fasciitis
. Sinus tarsi syndrome
. Medial plantar nerve entrapment
. Entrapment of the nerve to the abductor digiti quinti
. Anterior tibial tendinitis

Correct Answer & Explanation

. Medial plantar nerve entrapment

Explanation

The examination findings reveal that there is specific involvement of the medial plantar nerve by the distribution of the pain medially. The symptoms exclude the possibility of plantar fasciitis and anterior tibial tendinitis. Sinus tarsi syndrome would produce anterolateral symptoms rather than medial symptoms. Rask MR: Medial plantar neurapraxia (jogger's foot): Report of three cases. Clin Orthop 1978;134:193-195. Murphy PC, Baxter DE: Nerve entrapment of the foot and ankle in runners. Clin Sports Med 1985;4:753-763.

Question 2673

Topic: 8. Foot and Ankle

A 7-month-old girl has had a severe flatfoot deformity since birth. The talar head is prominent in the medial plantar arch of the foot. No other deformities of the spine or extremities are present. Motor and sensory examinations of the extremities are normal. Figures 37a through 37c show simulated weight-bearing AP and lateral radiographs and a planter flexion lateral view. What is the most likely diagnosis?

. Pes calcaneovalgus
. Congenital vertical talus
. Flexible pes planus
. Peroneal spastic flatfoot
. Congenital short Achilles tendon

Correct Answer & Explanation

. Congenital vertical talus

Explanation

Congenital vertical talus is a fixed dorsal dislocation of the talonavicular joint with equinus of the ankle joint. The AP radiograph shows valgus of the midfoot and an increased talocalcaneal angle; the lateral radiograph shows a vertically positioned talus and equinus of the ankle joint, and the plantar flexion lateral view shows that the talonavicular joint does not reduce. A line drawn through the long axis of the talus passes below the long axis of the first metatarsal. Initial management should consist of serial casting to stretch the dorsal soft-tissue structures; surgery eventually will be required to reduce the talonavicular joint. The differential diagnosis of congenital vertical talus includes pes calcaneovalgus, flexible pes planus, and peroneal spastic flatfoot. Pes calcaneovalgus, flexible pes planus, congenital short Achilles tendon, and peroneal spastic flatfoot would not show resistent dorsal dislocation of the navicular on the plantar flexion view. Kodros SA, Dias LS: Single-stage surgical correction of congenital vertical talus. J Pediatr Orthop 1999;19:42-48.

Question 2674

Topic: 8. Foot and Ankle

A 24-year-old man reports the development of a foot drop following a knee dislocation 1 year ago. The common peroneal nerve was found to be in continuity at the time of surgical reconstruction of the posterolateral corner of the knee joint. He would like to eliminate the need for an ankle-foot orthosis. What is the best option to achieve elimination of the orthosis?

Foot & Ankle Board Review 2009: High-Yield MCQs (Set 2) - Figure 31

. Repeat neurolysis of the common peroneal nerve at the knee level
. Repeat neurolysis of the common peroneal nerve with cable grafting
. Extensor hallucis longus transfer to the distal first metatarsal
. Anterior transfer of the tibialis posterior tendon through the interosseous membrane
. Ankle fusion

Correct Answer & Explanation

. Anterior transfer of the tibialis posterior tendon through the interosseous membrane

Explanation

The ankle dorsiflexor muscles have been denervated for too long a period to expect reinnervation to be successful. Even if the extensor hallucis longus tendon was functional, it is unlikely to have sufficient strength to achieve dynamic ankle dorsiflexion. The tibialis posterior tendon transfer has been shown to predictably achieve these goals in a high percentage of patients. Successful ankle fusion is likely to fail with time due to the development of forefoot equinus. Pinzur MS, Kett N, Trilla M: Combined anteroposterior tibial tendon transfer in post-traumatic peroneal palsy. Foot Ankle 1988;8:27l-275.

Question 2675

Topic: 8. Foot and Ankle

A 35-year-old female runner reports progressive vague aching pain involving her midfoot. Her pain is most notable when running. She denies specific injury. Examination reveals minimal swelling and localized tenderness over the dorsal medial midfoot and navicular. Radiographs and an MRI scan are shown in Figures 37a through 37c. What is the most appropriate management?

. Non-weight-bearing immobilization and CT
. Walking boot and weight bearing as tolerated
. Activity restrictions (avoidance of running) and repeat radiographs in 2 to 4 weeks
. Activity restrictions and a bone scan
. Surgical fixation

Correct Answer & Explanation

. Non-weight-bearing immobilization and CT

Explanation

A high index of suspicion is required to identify a possible navicular stress fracture, especially in runners. High pain tolerance in the competitive athlete and often minimal swelling contribute to frequent delays in diagnosis. Localized tenderness over the dorsal navicular (so-called "N spot") in a running athlete should alert the treating physician. In this patient, the radiographs are negative and the MRI scan shows marrow edema within the navicular. This could represent a stress reaction, stress fracture, or osteonecrosis. Appropriate management should include non-weight-bearing immobilization and obtaining a CT scan to determine if a fracture is present. Early surgical treatment may be considered but only if a fracture is identified. Lee A, Anderson R: Stress fractures of the tarsal navicular. Foot Ankle Clin 2004;9:85-104.

Question 2676

Topic: 8. Foot and Ankle

A 47-year-old woman has a painful bunion of the right foot, and shoe wear modifications have failed to provide relief. Examination reveals a severe hallux valgus with dorsal subluxation of the second toe. Radiographs are shown in Figures 14a and 14b. The most appropriate management should include

. hallux metatarsophalangeal arthrodesis.
. custom orthotics.
. Chevron osteotomy with second toe correction.
. Keller resection arthroplasty with second toe correction.
. proximal metatarsal osteotomy with second toe correction.

Correct Answer & Explanation

. proximal metatarsal osteotomy with second toe correction.

Explanation

The radiographs do not show significant arthrosis of the hallux metatarsophalangeal joint; therefore, arthrodesis is unnecessary. Orthotics will not correct the deformity. A distally based osteotomy will not achieve sufficient correction of the incongruity of deformity, and a Keller resection is not indicated in the younger population. The treatment of choice is a proximal metatarsal osteotomy with second toe correction.

Question 2677

Topic: 8. Foot and Ankle

A 30-year-old woman injured her ankle playing soccer 3 months ago. She now reports popping and pain over the lateral side of her ankle. An MRI scan is shown in Figure 33. What structure needs to be repaired to alleviate the popping?

Foot & Ankle 2009 Practice Questions: Set 3 (Solved) - Figure 19

. Peroneal longus tendon
. Peroneal brevis tendon
. Superior peroneal retinaculum
. Anterior talofibular ligament
. Calcaneofibular ligament

Correct Answer & Explanation

. Superior peroneal retinaculum

Explanation

The symptoms and MRI scan indicate dislocated peroneal tendons. In this patient, the structure that needs to be repaired is the superior peroneal retinaculum. If the popping was coming from a torn peroneal tendon, repair would involve the peroneal longus or brevis tendon, but this is not shown in the MRI scan. The anterior talofibular ligament or the calcaneofibular ligament would need to be repaired if the patient had ankle instability due to an ankle sprain. Jones DC: Tendon disorders of the foot and ankle. J Am Acad Orthop Surg 1993;1:87-94.

Question 2678

Topic: 8. Foot and Ankle

The peroneus tertius is a commonly used landmark for arthroscopic portal placement. What is the function of this tendon?

Foot & Ankle 2009 Practice Questions: Set 1 (Solved) - Figure 36

. Dorsiflexion
. Eversion
. Dorsiflexion and eversion
. Fifth toe extension
. Lesser toe extension

Correct Answer & Explanation

. Dorsiflexion and eversion

Explanation

The peroneus tertius, although absent in 10% of the population, originates on the distal third of the extensor surface of the fibula and inserts onto the base of the fifth metatarsal, possibly extending to the fascia over the fourth interosseous space. The muscle is located in the anterior compartment of the leg and is innervated by the deep peroneal nerve. The tendon produces dorsiflexion and eversion when walking and can be used as an insertion point during tendon transfers to assist dorsiflexion. This tendon is peculiar to humans and is a proximally migrated deep extensor of the fifth toe. Joshi SD, Joshi SS, Athavale SA: Morphology of the peroneus tertius muscle. Clin Anat 2006;19:611-614. Williams PL, Bannister LH, Berry MM, et al (eds): Gray's Anatomy, ed 38. London, Churchill Livingston, 1995, p 883.

Question 2679

Topic: 8. Foot and Ankle

A 58-year-old man has had a 3-year history of recurrent ulcerations of the left ankle and instability despite multiple attempts at custom bracing, contact casting, and surgical debridement. He has an ankle-brachial index of 0.76. A clinical photograph and radiographs are shown in Figures 16a through 16c. Treatment should now consist of

. transtibial amputation.
. a double upright brace.
. dressing changes with platelet-derived growth factor.
. tibiocalcaneal arthrodesis.
. total ankle arthroplasty.

Correct Answer & Explanation

. tibiocalcaneal arthrodesis.

Explanation

Nonsurgical management has failed to provide relief; therefore, the treatment of choice is arthrodesis with an intramedullary nail. Amputation may be indicated if the arthrodesis fails. The patient does have adequate circulation for an attempt at salvage. Total ankle arthroplasty is not indicated in a neuropathic patient. Pinzur MS, Kelikian A: Charcot ankle fusion with a retrograde locked intramedullary nail. Foot Ankle Int 1997;18:699-704.

Question 2680

Topic: 8. Foot and Ankle

A 16-year-old boy has had a painful ingrown nail on his great toe for the past 3 months. When initial management consisting of soaking the foot in Epsom salts and trimming the nail failed to provide relief, his family physician recommended 2 weeks of oral antibiotics. His symptoms persist, and he is now seeking a second opinion. A clinical photograph is shown in Figure 18. Management should now consist of

Foot & Ankle Board Review 2000: High-Yield MCQs (Set 2) - Figure 6

. povidone-iodine soaks and oral antibiotics.
. povidone-iodine soaks and IV antibiotics.
. partial nail plate removal.
. phenol nail matrix ablation.
. surgical nail matrix ablation.

Correct Answer & Explanation

. partial nail plate removal.

Explanation

The patient has a chronic ingrown nail on his great toe, which is not an uncommon occurrence in teenagers because of improper nail care. There is local infection and a foreign body reaction because of the nail. Continued conservative management with soaks and antibiotics will not improve the clinical situation. In the presence of local chronic infection, nail matrix ablation is contraindicated. Additionally, in the absence of a history of an ingrown nail, a nail matrix ablation is not medically indicated. The appropriate treatment is partial removal of the nail plate. With nail plate removal, the inflammation and local infection will resolve rapidly. Pettine KA, Cofield RH, Johnson KA, Bussey RM: Ingrown toenail: Results of surgical treatment. Foot Ankle 1988;9:130-134.

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