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8. Foot and Ankle MCQs

Practice Set 137 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 2721

Topic: 8. Foot and Ankle

A 15-year-old boy has hindfoot pain and very limited subtalar motion. A CT scan reveals a talocalcaneal coalition involving 40% of the middle facet. He has no degeneration of the posterior subtalar facet. Following failure of nonsurgical management, treatment should consist of

. resection of the coalition with fat graft interposition.
. Grice extra-articular subtalar arthrodesis.
. subtalar arthroereisis.
. intra-articular subtalar fusion.
. medial sliding calcaneal osteotomy.

Correct Answer & Explanation

. resection of the coalition with fat graft interposition.

Explanation

The CT scan is an important test to help determine the extent of involvement of the talocalcaneal facet in a talocalcaneal coalition. In a young patient with no arthritis and joint involvement of less than 50%, resection of the coalition and fat pad interposition has been shown to be successful. A calcaneal osteotomy does not address the coalition. Subtalar arthroereisis has been used for treatment of a flexible flatfoot; tarsal coalition patients have a rigid-type flatfoot deformity. Sullivan JA: The child's foot, in Morrissy RT, Weinstein SL (eds): Lovell and Winter's Pediatric Orthopaedics, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 2, pp 1077-1135.

Question 2722

Topic: 8. Foot and Ankle

A 46-year-old woman reports pain and a shortened appearance of her toe after undergoing a Keller resection arthroplasty 2 years ago for hallux rigidus. Examination reveals mild swelling and motion limited to 25 degrees at the metatarsophalangeal joint. Radiographs show large dorsal osteophytes on the first metatarsal head, 50% resection of the proximal phalanx, and complete loss of the metatarsophalangeal joint space. Which of the following is considered the most reliable procedure to improve her pain and the appearance of her toe?

. Silastic arthroplasty
. Cheilectomy and soft-tissue interposition arthroplasty
. Moberg phalangeal dorsiflexion osteotomy
. Bone graft interposition arthrodesis
. Waterman first metatarsal dorsal osteotomy

Correct Answer & Explanation

. Bone graft interposition arthrodesis

Explanation

Because the patient has significant arthritis, arthrodesis is the treatment of choice. Adding a bone graft will prevent further shortening and add length to her toe, resulting in improved cosmesis. A cheilectomy will not alleviate her arthritis pain. The toe is too short for an effective Moberg phalangeal dorsiflexion osteotomy. A Waterman first metatarsal dorsal osteotomy will not address the degenerative joint disease or shortening. Silastic arthroplasty may help, but there is the risk of additional problems with foreign body reaction and a significant risk of failure known to occur with Silastic materials. Myerson MS, Schon LC, McGuigan FX, Oznur A:Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int 2000;21:297-306. Mann RA, Coughlin MJ: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 252-253.

Question 2723

Topic: 8. Foot and Ankle

In the nonsurgical management of posterior tibial tendon dysfunction with flexible deformity, a common strategy is to prescribe an ankle-foot orthosis or a University of California Biomechanics Laboratory (UCBL) orthosis with medial posting. A high patient satisfaction rating and favorable outcome with this nonsurgical management is most likely in which of the following situations?

. Relatively young, active patient
. Patient with an inflammatory systemic disorder
. Elderly patient with a sedentary lifestyle
. Patient with severe arthritis of the ipsilateral hip or knee
. Patient with Parkinson's disease

Correct Answer & Explanation

. Elderly patient with a sedentary lifestyle

Explanation

Most authors recommend an initial trial of nonsurgical management in the treatment of adult-acquired flatfoot deformity such as posterior tibial tendon dysfunction. Chao and associates found that there is high patient satisfaction with ankle-foot orthoses and UCBL-type inserts in elderly patients with a relatively sedentary lifestyle. Alternatively, there was a higher dissatisfaction rate in young active patients, those with balance and ambulation difficulties (Parkinson's, severe arthritis of the hip or knee), and patients with inflammatory systemic disorders. Chao W, Wapner KL, Lee TH, et al: Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int 1996;17:736-741.

Question 2724

Topic: Midfoot & Hindfoot

Figure 13 shows the clinical photograph of a 66-year-old man who has had an increasingly painful right foot deformity for the past 3 years. Examination reveals that the subtalar joint is fixed in 15 degrees of valgus, and forefoot supination can be corrected to 10 degrees from neutral. Nonsurgical management has failed to provide relief. Treatment should now consist of

Foot & Ankle Board Review 2006: High-Yield MCQs (Set 2) - Figure 6

. medial sliding calcaneal osteotomy with flexor digitorum longus (FDL) transfer.
. isolated subtalar arthrodesis.
. isolated talonavicular arthrodesis.
. triple arthrodesis.
. subtalar arthroereisis.

Correct Answer & Explanation

. triple arthrodesis.

Explanation

The most important determining factor for correction of an adult flatfoot without an arthrodesis is the flexibility of the subtalar and transverse tarsal joints. Rigid deformities cannot be corrected with a medial sliding calcaneal osteotomy with FDL transfer or a subtalar arthroereisis. Isolated subtalar or talonavicular arthrodesis does not correct the deformities entirely. If the patient has forefoot supination that can be corrected to less than 7 degrees, an isolated subtalar fusion is a possible alternative.

Question 2725

Topic: 8. Foot and Ankle

Figure 20 shows the clinical photograph of a man who has had diabetes mellitus controlled with oral medication for the past 10 years. He wears soft-soled shoes and only uses leather-soled shoes for important business meetings. Examination reveals palpable dorsalis pedis and posterior tibial pulses, although they are somewhat diminished. He is insensate to pressure with the Semmes-Weinstein 5.07 monofilament. The ulcer heals after treatment with a full contact cast. What is the best course of action at this time?

Foot & Ankle Board Review 2006: High-Yield MCQs (Set 2) - Figure 29

. Referral to his primary care physician
. Foot-specific patient education, depth-inlay shoes, custom accommodative foot orthoses, and follow-up observation
. Dorsiflexion osteotomy of the first and third metatarsals
. Excision of the second and third metatarsal heads
. Achilles tendon lengthening and dorsiflexion osteotomy of the first and third metatarsals

Correct Answer & Explanation

. Foot-specific patient education, depth-inlay shoes, custom accommodative foot orthoses, and follow-up observation

Explanation

The patient has not undergone a trial of foot-specific patient education and accommodative/therapeutic shoe wear. He must use therapeutic shoe wear at all times, as even the occasional use of pressure-concentrating shoe wear has a high likelihood of leading to the development of a diabetic foot ulcer. Pinzur MS, Kernan-Schroeder D, Emmanuele NV, et al: Development of a nurse-provided health system strategy for diabetic foot care. Foot Ank Int 2001;22:744-746. Pinzur MS, Shields N, Goelitz B, et al: American Orthopaedic Foot & Ankle Society shoe survey of diabetic patients. Foot & Ankle Int 1999;20:703-707.

Question 2726

Topic: 8. Foot and Ankle

A 57-year-old man has had right ankle pain for the past 10 months following an injury that went untreated. Radiographs are shown in Figures 30a through 30c. Management should consist of

. ankle arthrodesis.
. modified Brostrom ligament reconstruction.
. restoration of fibular length, alignment, and rotation.
. cast immobilization.
. tibial shortening osteotomy.

Correct Answer & Explanation

. restoration of fibular length, alignment, and rotation.

Explanation

The radiographs reveal a malunited distal fibular fracture with shortening. Because there appears to be an adequate cartilage space within the ankle joint, the role of reconstruction would be to prevent arthrosis and the need for ankle arthrodesis, as well as to decrease symptoms. The treatment of choice is restoration of fibular length, alignment, and rotation with osteotomy plating, and bone grafting as needed. There is no indication for ligament reconstruction of a mechanically stable ankle, and tibial shortening osteotomy will not assist in correcting the deformity. Cast immobilization may assist with improvement of symptoms but will not correct the overall process. Determination of fibular length is best done by comparing the talocrural angle of the injured side with the uninjured side. The goal is to perfectly reduce the talus in the ankle mortise. Marti RK, Raaymakers EL, Nolte PA: Malunited ankle fractures: The late results of reconstruction. J Bone Joint Surg Br 1990;72:709-713. Geissler W, Tsao A, Hughes J: Fractures and injuries of the ankle, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green's Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 2201-2206.

Question 2727

Topic: 8. Foot and Ankle

A 45-year-old man is seeking evaluation of an injury sustained in a motor vehicle accident 10 weeks ago. Current radiographs are shown in Figures 2a and 2b. Based on the radiographic findings, what is the most likely diagnosis?

. Varus malreduction of the talar neck
. Osteonecrosis of the talar body
. Subtalar traumatic arthropathy
. Nonunion of the talar neck
. Occult infection

Correct Answer & Explanation

. Osteonecrosis of the talar body

Explanation

An increased density of the talar body compared to the distal tibia following fracture of the talar neck is highly suggestive of vascular compromise of the talar body. Subchondral osteopenia of the talus at 6 to 8 weeks (Hawkins sign) is a favorable sign but does not eliminate the possibility of osteonecrosis. Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J: Fractures of the talus: Experience of two level 1 trauma centers. Foot Ankle Int 2000;21:1023-1029.

Question 2728

Topic: 8. Foot and Ankle

A 51-year-old plumber has a failed peroneus brevis tendon repair. He reports continued pain and swelling in the distal retrofibular area. MRI shows longitudinal tears of the peroneus longus and peroneus brevis. What is the surgical treatment of choice at this time?

Foot & Ankle Board Review 2009: High-Yield MCQs (Set 2) - Figure 37

. Subtalar fusion
. Posterior tibial tendon transfer to the cuboid
. Split posterior tibial tendon transfer to the lateral cuneiform
. Flexor digitorum longus transfer to the fifth metatarsal
. Excision of both the peroneus longus and brevis

Correct Answer & Explanation

. Flexor digitorum longus transfer to the fifth metatarsal

Explanation

A flexor digitorum longus transfer, while not as strong as the peroneals, improves the tendon balance and maintains hindfoot mobility. Subtalar fusion is a salvage procedure. Posterior tibial tendon transfer compromises inversion strength and arch height. Functional absence of the peroneals results in an imbalance that could lead to forefoot varus. Redfern D, Myerson M: The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int 2004;25:695-707.

Question 2729

Topic: 8. Foot and Ankle

A 21-year-old basketball player inverts his foot during practice. Examination reveals obvious deformity of the hindfoot with a prominence of the talar head dorsolaterally and medial displacement of the forefoot. A radiograph is shown in Figure 17. What is the most likely obstacle to closed reduction?

Trauma Board Review 2000: High-Yield MCQs (Set 2) - Figure 13

. Posterior tibial tendon
. Impaction fracture of the head of the talus
. Posterior tibial neurovascular bundle
. Achilles tendon
. Calcaneus fracture

Correct Answer & Explanation

. Posterior tibial tendon

Explanation

The patient has a medial subtalar dislocation. These injuries should be reduced as soon as possible to minimize risk to the skin. Most often, this can be done easily, and further radiographic evaluation then can be performed as necessary. On rare occasions, closed reduction is not possible because of fractures of the articular surface of the talus, navicular, interposed extensor digitorum brevis, or transverse fibers of the cruciate crural ligament. The posterior tibial tendon is the most common obstruction to closed reduction in lateral subtalar dislocations, which are less common than medial dislocations. The majority of both injuries can be managed by closed reduction and immobilization. Mulroy RD: The tibialis posterior tendon as an obstacle to reduction of a lateral anterior subtalar dislocation. J Bone Joint Surg Am 1953;37:859-863. Heckman JD: Fractures and dislocations of the foot, in Rockwood CA, Green DP, Bucholz RW (eds): Fractures in Adults. Philadelphia, PA, JB Lippincott, 1991, pp 2093-2100.

Question 2730

Topic: 8. Foot and Ankle

A 35-year-old man is seen for evaluation of his left ankle following multiple previous ankle sprains and frequent episodes of the ankle giving way. Examination reveals marked laxity about the lateral ankle with associated tenderness along the peroneal tendons. Physical therapy, anti-inflammatory drugs, and supportive bracing have failed to provide relief. An MRI scan shows peroneal tenosynovitis and a possible tear. He elects to undergo a peroneal tendon repair and lateral ligament reconstruction. Which of the following best describes the structure labeled "A" in Figure 45?

Foot & Ankle Board Review 2009: High-Yield MCQs (Set 4) - Figure 23

. Longitudinal split tear in the peroneus longus
. Longitudinal split tear in the peroneus brevis
. Plantaris
. Peroneus accessorius
. Peroneus quartus

Correct Answer & Explanation

. Peroneus quartus

Explanation

The structure labeled "A" is a peroneus quartus, a supernumary muscle arising most commonly from the peroneus brevis. The presence of peroneus quartus is not uncommon, with an incidence of up to 21%, and is associated with lateral ankle pain and peroneal tendon symptoms, theoretically as a result of mass effect within the peroneal tendon sheath. Zammit J, Singh D: The peroneus quartus muscle: Anatomy and clinical relevance. J Bone Joint Surg Br 2003;85:1134-1137.

Question 2731

Topic: 8. Foot and Ankle

A 61-year-old man has a symptomatic bunionette that is refractory to nonsurgical management. A radiograph is shown in Figure 6. What is the optimal surgical correction?

Foot & Ankle 2009 Practice Questions: Set 1 (Solved) - Figure 20

. Fifth metatarsal head lateral ostectomy
. Fifth metatarsal head excision
. Metatarsal osteotomy and fifth metatarsal head ostectomy
. Fifth metatarsal plantar condylectomy
. Fifth metatarsophalangeal Silastic implant arthroplasty

Correct Answer & Explanation

. Metatarsal osteotomy and fifth metatarsal head ostectomy

Explanation

The patient has a bunionette with a large 4-5 intermetatarsal angle. This requires not only ostectomy of the lateral prominence but metatarsal osteotomy to decrease the intermetatarsal angle. Excising the head results in a flail joint and creates the possibility of a transfer lesion. Condylectomy can reduce plantar pressures but does not address the bunionette. The joint surface is well maintained, thus there are no indications for resection. Coughlin MJ: Treatment of bunionette deformity with longitudinal diaphyseal osteotomy with distal soft tissue repair. Foot Ankle 1991;11:195-203.

Question 2732

Topic: 8. Foot and Ankle

A 13-year-old girl injures her ankle playing soccer. Radiographs reveal a displaced Tillaux fracture. CT scans are shown in Figure 25. What is the most important consideration for appropriate management?

Trauma Board Review 2006: High-Yield MCQs (Set 2) - Figure 32

. Joint congruity
. Torn anterior tibiofibular ligament
. Growth arrest leading to angular deformity
. Growth arrest leading to limb-length discrepancy
. Osteonecrosis of the talus

Correct Answer & Explanation

. Joint congruity

Explanation

Tillaux and triplane fractures occur in adolescents as the result of an external rotation injury of the ankle. As seen on the CT scan, the growth plate starts to close during adolescence; therefore, growth arrest resulting in limb-length discrepancy or angulation is less of a concern in this age group than achieving joint congruity. The joint should be surgically reduced if displacement is greater than 2 mm to minimize the chances of late arthrosis. Kay RM, Matthys GA: Pediatric ankle fractures: Evaluation and treatment. J Am Acad Orthop Surg 2001;9:268-278. Kling TF Jr: Operative treatment of ankle fractures in children. Orthop Clin North Am 1990;21:381-392.

Question 2733

Topic: 8. Foot and Ankle

A 47-year-old woman underwent a distal chevron bunionectomy 2 months ago. Her postoperative recovery had been uneventful until 1 week ago. She now has new onset pain and dorsal swelling in the area of the third metatarsal. A radiograph is shown in Figure 27. What is the most likely diagnosis?

Foot & Ankle 2000 Practice Questions: Set 3 (Solved) - Figure 1

. Transfer metatarsalgia
. Morton's neuroma
. Metatarsal stress fracture
. Freiberg's infraction
. Metatarsophalangeal synovitis

Correct Answer & Explanation

. Metatarsal stress fracture

Explanation

Based on findings of a sudden increase in pain with associated swelling, the most likely diagnosis is a stress fracture. The initial radiographic findings usually will be negative. Morton's neuroma and transfer metatarsalgia are not associated with swelling. Metatarsophalangeal synovitis usually involves the second metatarsophalangeal joint. Freiberg's infraction is seen clearly on a radiograph.

Question 2734

Topic: 8. Foot and Ankle

Figures 42a through 42c show the clinical photographs and radiograph of a patient with diabetes mellitus who lives independently. The patient was admitted to the hospital late yesterday afternoon with clinical signs of sepsis. Parenteral antibiotic therapy resolved the sepsis, and blood glucose levels are now well controlled. The patient has no palpable pulses. The ankle-brachial index is 0.70. Laboratory studies show a WBC count of 8,500/mm3, a serum albumin of 1.9 g/dL, and a total lymphocyte count of 1,500/mm3. What treatment has the best potential to optimize his survival and independence?

. Local wound care, parenteral antibiotic therapy, metabolic support, and reevaluation in 1 week
. Vascular consultation for a bypass operation
. Syme ankle disarticulation
. Guillotine transtibial amputation
. Closed transtibial amputation

Correct Answer & Explanation

. Syme ankle disarticulation

Explanation

The patient was admitted to the hospital with sepsis. The sepsis has resolved, leaving the patient with a negative nitrogen balance. Now that the patient is stable, metabolic support should be used to optimize his nutrition. If the serum albumin can be increased to 2.5 g/dL, he has an excellent potential to heal an amputation at the Syme ankle disarticulation level; a level that will optimize his functional independence. Pinzur MS, Stuck RR, Sage R, et al: Syme ankle disarticulation in patients with diabetes. J Bone Joint Surg Am 2003;85:1667-1672.

Question 2735

Topic: 8. Foot and Ankle

A 55-year-old woman with type I diabetes mellitus has a chronic ulcer over the dorsum of her right foot and reports forefoot pain. Examination reveals 1- x 2-cm nondraining ulcer over the dorsum of the foot. The patient has 1-2+ pain with compression of the foot and ankle. She has a weakly palpable posterior tibial pulse and an absent dorsalis pedis pulse. There is no erythema, cellulitis, or drainage. Radiographs are normal. Which of the following diagnostic studies should be obtained?

. MRI
. Doppler arterial study
. Arteriography
. Electromyography
. Triple phase bone scan (technetium Tc 99m)

Correct Answer & Explanation

. Doppler arterial study

Explanation

The presence of a dorsal ulcer in the presence of weak or absent pulses strongly suggests the possibility of arterial insufficiency. The best initial noninvasive study to assess for ischemia is the Doppler arterial study. A determination of the vascular status is of a greater priority than an assessment for infection or neuropathy because of the location and presentation of the ulcer. If ankle pressures are less than 45 mm Hg, there is a high risk that these lesions will not heal without revascularization. Wagner FW Jr: The dysvascular foot: A system for diagnosis and treatment. Foot Ankle 1981;2:64-122.

Question 2736

Topic: Forefoot

A 52-year-old woman who underwent cheilectomy 1 year ago for hallux rigidus now reports continued pain in the first metatarsophalangeal joint. She did not have any incision healing problems, and has not had any fevers, erythema, or drainage. Which of the following procedures will provide the best combination of pain relief and function?

Foot & Ankle Board Review 2009: High-Yield MCQs (Set 2) - Figure 25

. First metatarsophalangeal arthrodesis
. Soft-tissue interposition arthroplasty
. First metatarsophalangeal total joint arthroplasty
. First metatarsophalangeal resurfacing hemiarthroplasty
. Proximal phalanx dorsiflexion osteotomy (Moberg)

Correct Answer & Explanation

. First metatarsophalangeal arthrodesis

Explanation

All but the Moberg osteotomy are capable of providing pain relief; however, arthrodesis offers the best long-term results and restores weight bearing and propulsion function to the first ray. Machacek F Jr, Easley ME, Gruber F, et al: Salvage of a failed Keller resection arthroplasty. J Bone Joint Surg Am 2004;86:1131-1138.

Question 2737

Topic: 8. Foot and Ankle

A 45-year-old man has persistent hindfoot pain that is aggravated by weight-bearing activities. History reveals that he sustained a calcaneus fracture 2 years ago, and he underwent a subtalar fusion 1 year ago. Examination reveals tenderness in the sinus tarsi and across the transverse tarsal joint. A plain radiograph and a CT scan are shown in Figures 24a and 24b. A technetium Tc 99m bone scan reveals uptake at the subtalar joint and at the transverse tarsal joints. Management should now consist of

. casting with an external bone stimulator.
. ankle arthrodesis.
. revision subtalar arthrodesis.
. conversion to triple arthrodesis without revision of the subtalar arthrodesis.
. conversion to triple arthrodesis with revision of the subtalar arthrodesis.

Correct Answer & Explanation

. conversion to triple arthrodesis with revision of the subtalar arthrodesis.

Explanation

The patient has a nonunion at the subtalar joint because of poor preparation of the arthrodesis site with incomplete removal of the articular cartilage. Clinically, he has arthritis at the transverse tarsal joint. Casting with a bone stimulator is not expected to result in a union of the subtalar arthrodesis. To address both the subtalar nonunion and the transverse tarsal joint arthritis, revision of the subtalar arthrodesis and conversion to a triple arthrodesis is the preferred option. Graves SC, Mann RA, Graves KO: Triple arthrodesis in older adults: Results after long-term follow-up. J Bone Joint Surg Am 1993;75:355-362. Haddad SL, Myerson MS, Pell RF IV, Schon LC: Clinical and radiographic outcome of revision surgery for failed triple arthrodesis. Foot Ankle Int 1997;18:489-499. Sangeorzan BJ, Smith D, Veith R, Hansen ST Jr: Triple arthrodesis using internal fixation in treatment of adult foot disorders. Clin Orthop 1993;294:299-307. Sangeorzan BJ: Salvage procedures for calcaneus fractures. Instr Course Lect 1997;46:339-346.

Question 2738

Topic: 8. Foot and Ankle
A 43-year-old man reports a 3-year history of progressively worsening pain in the first metatarsophalangeal joint that is aggravated by activity. Larger shoes, intra-articular corticosteroid injections, and a Morton's extension pedorthic have failed to provide relief. Motion is limited to 10 degrees of dorsiflexion, and the "grind test" is positive. An AP radiograph is shown in Figure 39. What is the most appropriate surgical treatment?
. Cheilectomy
. Moberg osteotomy
. Keller resection arthroplasty
. Resurfacing implant hemiarthroplasty
. First metatarsophalangeal arthrodesis

Correct Answer & Explanation

. First metatarsophalangeal arthrodesis

Explanation

Stage III hallux rigidus comprises end-stage degenerative arthritis with loss of cartilage from the phalanx and metatarsal. Therefore, cheilectomy, osteotomy, and resection arthroplasty are inadequate. Resection arthroplasty results in diminished propulsion and transfer metatarsalgia. Resurfacing implant hemiarthroplasty remains unproven for earlier stages of hallux rigidus, but is not appropriate when there is cartilage loss from the base of the proximal phalanx. First metatarsophalangeal arthrodesis has proven to be a very reliable and functional treatment of end-stage hallux rigidus.

Question 2739

Topic: 8. Foot and Ankle

Figures 38a and 38b show the CT scans of a 64-year-old woman. What is the most likely diagnosis?

. Calcaneal fibular abutment
. Symmetrical narrowing of the subtalar joint consistent with an inflammatory arthropathy
. Cystic lesion of the tibia consistent with enchondroma
. Stress fracture of the talus
. A lateral malleolar fracture

Correct Answer & Explanation

. Calcaneal fibular abutment

Explanation

The CT scans show large cystic lesions in the talus and calcaneus with complete subluxation of the subtalar joint, allowing the calcaneus to slide laterally until it becomes blocked by the fibula. The cause of this subluxation is severe posterior tibial tendon dysfunction. Although no fibular fracture has yet appeared, it can occur with continued stress from the calcaneus. There is, however, a pathologic fracture in the medial calcaneus through a medial degenerative cyst. The joint space is irregular and not symmetrical as would be seen in an inflammatory arthropathy. Cystic lesions are not present in the tibia. No stress fracture is seen in the talus. Coughlin MJ: Sesamoids and accessory bones of the foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 437-499.

Question 2740

Topic: 8. Foot and Ankle

A 25-year-old woman has significant pain and swelling in her left ankle after falling off her bicycle. Examination reveals that she is neurovascularly intact. Radiographs are shown in Figures 33a through 33c. What is the next most appropriate step in management?

. Closed reduction and casting
. Open reduction and internal fixation of the ankle fracture
. Open reduction and internal fixation of the ankle fracture with syndesmosis fixation
. Percutaneous pinning of the ankle fracture
. Pins in plaster immobilization

Correct Answer & Explanation

. Open reduction and internal fixation of the ankle fracture with syndesmosis fixation

Explanation

The radiographs show a displaced ankle fracture with widening of the syndesmosis. Open reduction and internal fixation is indicated with fixation of the mortise with syndesmotic screws. Wuest TK: Injuries to the distal lower extremity syndesmosis. J Am Acad Orthop Surg 1997;5:172-181.

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