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8. Foot and Ankle MCQs

Practice Set 138 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 2741

Topic: 8. Foot and Ankle

A 47-year-old woman underwent a bunionectomy and hallux valgus correction a few years ago. She now has the complication shown in Figures 38a and 38b. She has no pain with motion of the metatarsophalangeal or interphalangeal joints. What is the best reconstructive option in this setting?

. Metatarsophalangeal joint arthrodesis
. Medial capsular release with lengthening of the abductor hallucis
. Medial capsular release with lateral sesamoid excision
. Proximal phalangeal lateral closing wedge osteotomy
. Medial capsular lengthening and split extensor hallucis longus tendon transfer

Correct Answer & Explanation

. Medial capsular lengthening and split extensor hallucis longus tendon transfer

Explanation

The patient has a flexible hallux varus that is a complication of the bunion surgery. With joints that are not arthritic and still flexible, a medial release is necessary to realign the joint. The extensor hallucis longus split transfer helps maintain position and still preserve motion at the interphalangeal joint level. Arthrodesis is a salvage procedure. Soft-tissue releases alone are most likely inadequate. Excision of the lateral sesamoid is contraindicated because that further compromises the forces resisting hallux varus. Phalangeal osteotomy would not address the medial subluxation at the metatarsophalangeal joint. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 27-32.

Question 2742

Topic: 8. Foot and Ankle

A 45-year-old woman with a long-standing history of diabetes mellitus has a large draining plantar ulcer of the right foot. Examination reveals some local cellulitis and erythema surrounding the ulcer. A clinical photograph is shown in Figure 7. Based on these findings, what is the most appropriate antibiotic?

Foot & Ankle 2000 Practice Questions: Set 1 (Solved) - Figure 15

. Penicillin G
. Cefazolin sodium
. Oxacillin
. Ampicillin sodium/sulbactam sodium
. Gentamicin

Correct Answer & Explanation

. Ampicillin sodium/sulbactam sodium

Explanation

Combination drugs with activity against both aerobic and anaerobic organisms have been determined to be the best approach. The first-generation cephalosporins do not provide adequate coverage for gram-negative and anaerobic organisms. Gentamicin alone would not provide adequate activity against anaerobes, and there is the risk of renal and auditory toxicity. Pinzur MS, Slovenkai MD, Trepman E: Guidelines for diabetic foot care. Foot Ankle Int 1999;20:695-702.

Question 2743

Topic: 8. Foot and Ankle

A 28-year-old man who sustained an ankle fracture in a motor vehicle accident underwent open reduction and internal fixation 3 months ago. He continues to report significant ankle pain with ambulation. Radiographs are shown in Figure 26. What is the next most appropriate step in management?

Foot & Ankle 2006 Practice Questions: Set 3 (Solved) - Figure 9

. Articulated ankle-foot orthosis
. Revision open reduction and internal fixation of the syndesmosis with debridement of the medial gutter
. Ankle arthrodesis
. Syndesmosis arthrodesis
. Ankle arthroscopy and debridement

Correct Answer & Explanation

. Revision open reduction and internal fixation of the syndesmosis with debridement of the medial gutter

Explanation

The patient sustained a bimalleolar ankle fracture with a syndesmosis disruption. The initial open reduction and internal fixation did not successfully reduce the distal tibiofibular joint. The patient may need a derotational distraction osteotomy of the fibula to reduce the syndesmosis. The other procedures do not address the primary problem of the fibular malunion and syndesmosis malreduction. There is no radiographic evidence of significant arthritis; therefore, ankle arthrodesis is not indicated.

Question 2744

Topic: 8. Foot and Ankle

You are asked to evaluate the patient whose current clinical photographs are shown in Figures 46a and 46b following aortic valve replacement 9 days ago. He is currently taking anticoagulation medication. He has no systemic signs of sepsis. What is the best management?

. Warming in a water or saline bath at 104 degrees F (40 degrees C) with no dressings
. Observation with possible late debridement
. Urgent arteriogram
. Reversal of anticoagulation, parenteral antibiotics, and debridement
. Reversal of anticoagulation, parenteral antibiotics, and open forefoot amputation

Correct Answer & Explanation

. Observation with possible late debridement

Explanation

These lesions are emboli related to the cardiac surgery, and the patient is already on anticoagulation medication. The foot reveals no signs consistent with gangrene or infection. Unless the patient shows local or systemic signs of sepsis, the best management is observation. It is unlikely that formal debridement will be necessary. Bowker JH, Pfeiffer MA (eds): The Diabetic Foot. St Louis, MO, Mosby, 2001, pp 219-260.

Question 2745

Topic: 8. Foot and Ankle

A 32-year-old man sustains a forceful inversion injury while playing soccer. Examination reveals tenderness in the lateral hindfoot and midfoot region with associated ecchymosis and swelling. Radiographs show proximal migration of the os peroneum. Active eversion is still present. These findings indicate disruption of the

. extensor digitorum brevis.
. plantar fascia.
. peroneus brevis.
. peroneus longus.
. syndesmosis.

Correct Answer & Explanation

. peroneus longus.

Explanation

The os peroneum is an accessory ossicle located within the peroneus longus tendon. It is typically located at the level of the cuboid groove in the lateral hindfoot and midfoot region. Proximal migration of the os peroneum indicates disruption of the peroneus longus tendon and is an important clue to diagnosis. This unusual condition can cause chronic lateral ankle pain, and surgical repair may be indicated. Active eversion indicates that the peroneus brevis is clinically intact. Disruption of the extensor digitorum brevis, plantar fascia, or syndesmosis would have no effect on the position of the os peroneum. Thompson FM, Patterson AH: Rupture of the peroneus longus tendon: Report of three cases. J Bone Joint Surg Am 1989;71:293-295.

Question 2746

Topic: 8. Foot and Ankle

Figures 50a and 50b show the standing clinical photographs of a 12-year-old boy who has had increasing pain in the left foot for the past 9 months. He reports that the pain is activity related, aching in nature, and localized to the medial aspect of the midfoot and hindfoot. History reveals that he sustained a puncture wound located superior and posterior to the medial malleolus from a plate glass window 18 months ago. Examination reveals no restriction of ankle or subtalar motion, normal neurovascular status, no masses, and a well-healed 1.5-cm laceration posterior to the superior aspect of the medial malleolus. Inversion strength of the foot is decreased to grade 3/5. Radiographs of the foot show no bony abnormalities. Treatment should consist of

. application of a UCBL orthoses.
. application of an ankle-foot orthosis.
. transfer of the flexor digitorum longus to the posterior tibialis tendon.
. a lengthening osteotomy of the calcaneus.
. talocalcaneal arthrodesis.

Correct Answer & Explanation

. transfer of the flexor digitorum longus to the posterior tibialis tendon.

Explanation

The photographs show a planovalgus posture of the foot. The foot deformity and decreased inversion strength are secondary to laceration of the posterior tibial tendon 18 months ago. If the injury had been recognized acutely, optimal treatment would have consisted of repair of the tendon; however, contracture now precludes that possibility. Therefore, transfer of the flexor digitorum longus or flexor hallucis longus is the preferred treatment. In adults with posterior tibial dysfunction, the entire tendon is typically degenerated and the transfer must be anchored through a drill hole in the navicular. In this patient, the distal end of the posterior tibial tendon is a satisfactory insertion site. Lengthening osteotomy of the calcaneus could be combined with the tendon transfer if the patient had a fixed deformity of the foot. UCBL orthoses and an ankle-foot orthosis are not considered good long-term solutions for a 12-year-old patient. Mosca VS: Flexible flatfoot and skewfoot, in Drennan JC (ed): The Child's Foot and Ankle. New York, NY, Raven Press, 1992, pp 355-376.

Question 2747

Topic: 8. Foot and Ankle

A 55-year-old patient is seeking a surgical consultation for a painful flatfoot deformity that has failed to respond to nonsteroidal anti-inflammatory drugs, shoe and activity modifications, and orthoses. The patient is of medium build, a nonsmoker, and has no history of diabetes mellitus. Radiographs are shown in Figures 43a through 43c. Based on these findings, treatment should consist of

. triple arthrodesis.
. lateral column lengthening with flexor digitorum longus tendon transfer.
. medial calcaneal displacement osteotomy, flexor digitorum longus transfer, and gastrocnemius recession.
. midfoot arthrodesis.
. subtalar arthroereisis with a Maxwell-Brancheau Arthroereisis titanium implant.

Correct Answer & Explanation

. midfoot arthrodesis.

Explanation

The patient has a degenerative collapse of the midfoot through the tarsometatarsal joints with significant forefoot abduction; therefore, a midfoot arthrodesis is required to address the arthritic joints and deformity at the tarsometatarsal articulation. All of the other procedures correct hindfoot deformities and therefore would not be appropriate treatment. Brage M: Degenerative joint disease of the midfoot. Foot Ankle Clin 1999;4:355-367.

Question 2748

Topic: 8. Foot and Ankle

A 48-year-old woman with a history of a spinal cord injury as a teenager, has unilateral weakness in the left lower extremity. She has used an ankle-foot orthosis for many years without difficulty but recently has had a recurrent painful callus beneath the great toe that has been recalcitrant to nonsurgical management. Examination reveals intact sensation with an intractable plantar keratosis (IPK) beneath the first metatarsal head. Motor examination reveals no active ankle or great toe dorsiflexion, and 4/5 plantar flexion strength at the ankle and great toe. Passive ankle dorsiflexion is 10 degrees, whereas passive plantar flexion is 40 degrees. Passive great toe dorsiflexion is 30 degrees and plantar flexion is 10 degrees. Foot alignment on standing is normal. Radiographs are shown in Figures 47a and 47b with a marker beneath the IPK. Based on her request for surgical treatment, what is the most appropriate procedure?

. Gastrocnemius recession
. Keller bunionectomy
. Flexor hallucis longus tendon transfer
. Planing/excising the superficial half of the medial sesamoid
. Dorsiflexion osteotomy of the first metatarsal

Correct Answer & Explanation

. Planing/excising the superficial half of the medial sesamoid

Explanation

Passive dorsiflexion is adequate to accommodate standing erect without excessive pressure, and a gastrocnemius recession may lead to more instability. Complete excision of the medial sesamoid could lead to an iatrogenic hallux valgus deformity. She does not have a cock-up toe deformity; therefore, a flexor hallucis longus tendon transfer is not warranted. There is no significant foot deformity; therefore, a dorsiflexion osteotomy is not warranted. The appropriate procedure is planing of the plantar half of the medial sesamoid, thereby preserving its function while diminishing the excessive pressure. Grace DL: Sesamoid problems. Foot Ankle Clin 2000;5:609-627. Mizel MS, Miller RA, Scioli MW (ed): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 135-150.

Question 2749

Topic: 8. Foot and Ankle

A 20-year-old woman has lateral foot and ankle pain after sustaining an inversion injury of the ankle while playing soccer 3 months ago. Activity modifications and physical therapy have failed to provide relief. She describes burning pain that extends from the anterior aspect of the ankle to the foot and lateral two toes. The pain is often worse at night. Plain radiographs, a bone scan, and an MRI scan are normal. Stress examination reveals no instability. What is the most likely diagnosis?

Foot & Ankle 2000 Practice Questions: Set 1 (Solved) - Figure 32

. Occult traumatic osteochondral lesion of the lateral talar dome
. Neurapraxia of the intermediate branch of the superficial peroneal nerve
. Incompetence of the superior peroneal retinaculum with peroneal subluxation
. Meniscoid lesion of the anterior talofibular ligament
. Syndesmotic injury (high ankle sprain)

Correct Answer & Explanation

. Neurapraxia of the intermediate branch of the superficial peroneal nerve

Explanation

Persistent pain following an ankle sprain can present a diagnostic dilemma. All of the injuries listed should be considered in the differential diagnosis. The superficial peroneal nerve courses in the lateral compartment and exits the crural fascia 12 to 15 cm above the level of the ankle. Muscle herniation through the fascial defect has been reported to be associated with entrapment of this nerve. The fascial hiatus also may serve as a potential tether in cases of inversion injuries causing injury to the superficial peroneal nerve. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 101-111.

Question 2750

Topic: 8. Foot and Ankle

A 50-year-old laborer sustained an isolated closed injury to his heel after falling 11 feet off a wall. A radiograph and a CT scan are shown in Figures 4a and 4b. To minimize the patient's temporary disability and allow him to return to work most rapidly, management should consist of

. cast immobilization for 6 weeks, followed by physical therapy.
. early range of motion with progressive weight bearing after 6 weeks.
. open reduction and internal fixation.
. open reduction and primary subtalar arthrodesis.
. closed reduction and percutaneous pinning.

Correct Answer & Explanation

. open reduction and primary subtalar arthrodesis.

Explanation

With a severe articular injury to the calcaneus, the ability to achieve satisfactory results with open reduction and internal fixation diminishes. An arthrodesis is often needed to allow a person who works as a laborer to return to work. Recent literature suggests that this can be successfully performed primarily, improving the odds of an earlier return to the labor force at 1 year. Huefner T, Thermann H, Geerling J, Pape HC, Pohlemann T: Primary subtalar arthrodesis of calcaneal fractures. Foot Ankle Int 2001;22:9-14. Coughlin MJ: Calcaneal fractures in the industrial patient. Foot Ankle Int 2000;21:896-905.

Question 2751

Topic: 8. Foot and Ankle

A 42-year-old woman has a history of nontraumatic ankle swelling with tenderness over the Achilles tendon and plantar fascia. She reports that while vacationing in Connecticut 2 months ago she noted the presence of a "red bull's eye" rash. Management should consist of

. physical therapy.
. doxycycline.
. ciprofloxacin.
. nonsteroidal anti-inflammatory drugs.
. gentamicin.

Correct Answer & Explanation

. doxycycline.

Explanation

The most likely diagnosis is Lyme disease because of the patient's recent vacation in an area with a high risk of exposure. The most effective treatment is doxycycline. Neu HC: A perspective on therapy of Lyme infection. Ann NY Acad Sci 1988;539:314-316.

Question 2752

Topic: 8. Foot and Ankle

Figures 11a and 11b show the clinical photograph and radiograph of a newborn. Based on these findings, what is the best course of action?

. Genetic testing
. Stretching exercises performed by the parents
. A series of corrective plaster casts
. A long leg orthosis to control the foot and leg
. Surgical lengthening of the anterior tibial tendon and a short leg cast

Correct Answer & Explanation

. Stretching exercises performed by the parents

Explanation

The newborn has posteromedial bowing of the tibia and calcaneal valgus deformity of the foot. Both are thought to be caused by abnormal intrauterine positioning. The foot deformity typically responds to stretching. The tibial bowing straightens with growth. The long-term problem is limb-length discrepancy. Heyman CH, Herndon CH, Heiple KG: Congenital posterior angulation of the tibia with talipes calcaneus. J Bone Joint Surg Am 1959;41:476-488.

Question 2753

Topic: 8. Foot and Ankle

Figure 11 shows the radiograph of an otherwise healthy 22-year-old man who sustained a midfoot injury in a motor vehicle accident 9 days ago. Treatment should consist of

Foot & Ankle 2006 Practice Questions: Set 1 (Solved) - Figure 34

. open reduction and internal fixation.
. a short leg weight-bearing cast.
. a short leg non-weight-bearing cast.
. first tarsometatarsal fusion.
. functional brace application and early range of motion.

Correct Answer & Explanation

. open reduction and internal fixation.

Explanation

The dislocation is between the medial and middle cuneiform. Although the first and second tarsometatarsal joints are aligned, there is a gap between the cuneiforms. The radiograph shows a Lisfranc dislocation variant. In a healthy active individual, open reduction and internal fixation yields the best results. The reestablishment of the normal arch and medial column support with anatomic reduction is critical to obtaining the best possible outcome from these injuries. Teng AL, Pinzur MS, Lomasney L, et al: Functional outcome following anatomic restoration of the tarsal-metatarsal fracture dislocation. Foot Ankle Int 2002;23:922-926.

Question 2754

Topic: 8. Foot and Ankle

A 27-year-old man was struck by a taxi cab and sustained comminuted right distal third tibia and fibula fractures; treatment consisted of placement of an intramedullary nail in the tibia the following morning. At his 6-month follow-up, he has clawing of all five toes. Examination reveals flexion deformities of the distal and proximal interphalangeal joints that are flexible with plantar flexion and rigid with dorsiflexion. Calluses are present on the dorsum and tip of the toes. Single heel rise is normal. He has a mild equinus contracture (relative to the left leg) that is not relieved with knee flexion. What is the most appropriate treatment option?

Foot & Ankle Board Review 2009: High-Yield MCQs (Set 2) - Figure 30

. Physical therapy and bracing
. Reassurance that the deformity will resolve with time
. Achilles tendon lengthening, and release or retromalleolar lengthening of the flexor digitorum longus (FDL) and flexor hallucis longus (FHL)
. FDL and FHL tenotomies at the individual digits with transfer of the posterior tibial tendon to the dorsum of the foot
. FDL and FHL tenotomies at the individual digits with midfoot capsular release and hallux interphalangeal fusion

Correct Answer & Explanation

. Achilles tendon lengthening, and release or retromalleolar lengthening of the flexor digitorum longus (FDL) and flexor hallucis longus (FHL)

Explanation

This is an example of tethering of the flexor hallucis longus/flexor digitorum longus (FHL/FDL) to the fracture site. Additional time and/or physical therapy and bracing would not be expected to be of benefit. Release of the FHL and FDL from the fracture site or retromalleolar lengthening will address the posttraumatic claw toe deformity and Achilles tendon lengthening will address the mild equinus. Posterior tibial tendon transfer is not appropriate as the patient demonstrates a normal heel rise. Midfoot releases and hallux fusion are also not indicated. Feeny MS, Williams RL, Stephens MM: Selective lengthening of the proximal flexor tendon in the management of acquired claw toes. J Bone Joint Surg Br 2001;83:335-338.

Question 2755

Topic: 8. Foot and Ankle

A 35-year-old woman reports worsening pain after undergoing a neurectomy in the third interspace for a Morton's neuroma 12 months ago. She states that the pain is sharp and electrical, worse than before her surgery, and prevents her from participating in her usual work and exercise activities. Use of wider shoes and pads used before her surgery have failed to provide relief. Examination does not reveal any deformity or inflammation. Tenderness along with neuritic pain occurs with compression of the plantar aspect of the foot between the third and fourth metatarsal head area. To most reliably alleviate her pain, management should consist of

Foot & Ankle Board Review 2000: High-Yield MCQs (Set 2) - Figure 17

. serial injection of steroids into the area of discomfort.
. custom orthotics with a second metatarsal pad.
. physical therapy for transcutaneous electrical nerve stimulation and desensitization.
. plantar condylectomy of the second and third metatarsal heads.
. plantar exploration and revision neurectomy to a more proximal level.

Correct Answer & Explanation

. plantar exploration and revision neurectomy to a more proximal level.

Explanation

Most patients with a significant recurrent neuroma will not obtain relief with conservative methods. Pain results from a stump neuroma at the weight-bearing area from too short of a resection of the nerve or from regrowth of the remaining nerve end. Although steroid injection may be helpful in localizing symptoms or providing temporary relief, it rarely cures a stump neuroma. Orthotics with a metatarsal pad will likely increase pressure and pain at the neuroma site. Physical therapy could temporize the symptoms but will not address the underlying problem. Similarly, bone decompression alone will not alter the location of the neuroma stump. Revision of the nerve to a more proximal level off of the weight-bearing area is the most likely method to succeed. A plantar approach facilitates identification and ability to revise the nerve to a more proximal level. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 101-111. Johnson JE, Johnson KA, Unni KK: Persistent pain after excision of an interdigital neuroma: Results of reoperation. J Bone Joint Surg Am 1988;70:651-657. Beskin JL, Baxter DE: Recurrent pain following interdigital neurectomy: A plantar approach. Foot Ankle 1988;9:34-39.

Question 2756

Topic: 8. Foot and Ankle

An 18-year-old football player reports acute pain and swelling after a direct injury to his plantar flexed foot. Examination reveals midfoot swelling and tenderness. Nonstanding radiographs are normal. What is the next most appropriate step in management?

Foot & Ankle Board Review 2009: High-Yield MCQs (Set 2) - Figure 12

. Gradual return to play
. Physical therapy program
. Custom orthosis
. Non-weight-bearing cast
. Weight-bearing AP radiograph

Correct Answer & Explanation

. Weight-bearing AP radiograph

Explanation

Differentiating between a midfoot sprain and Lisfranc diastasis is critical in the management of the athlete with an acute injury to the midfoot. Greater than 2 mm of displacement between the first and second metatarsals on a weight-bearing radiograph is an indication for anatomic reduction with internal fixation of the tarsometatarsal joints. If no subluxation is noted, treatment should consist of a non-weight-bearing cast for 6 weeks, followed by a gradual return to activity. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.

Question 2757

Topic: 8. Foot and Ankle

A 22-year-old professional ballet dancer reports a 3-month history of posterior ankle pain that occurs when she changes from a flat foot to pointe (hyperplantar flexed position). Examination does not elicit the pain with forced passive plantar flexion. A radiograph is shown in Figure 8. What is the most likely cause of the pain?

Sports Medicine 2001 Practice Questions: Set 1 (Solved) - Figure 23

. Mild subtalar arthritis
. Posterior tibialis tendinitis
. Os trigonum entrapment syndrome
. Flexor hallucis longus tenosynovitis
. Retrocalcaneal bursitis

Correct Answer & Explanation

. Flexor hallucis longus tenosynovitis

Explanation

The most common causes of posterior ankle pain in ballet dancers are flexor hallucis longus tenosynovitis and os trigonum syndrome. Flexor hallucis longus tenosynovitis differs from a symptomatic os trigonum by the absence of pain with forced plantar flexion and the presence of pain with resisted plantar flexion of the great toe. The pain is often felt in the posterior ankle and can be associated with a snapping or triggering sensation. Os trigonum syndrome commonly occurs in ballet dancers who perform in a position of extreme plantar flexion. The pain occurs from entrapment of the os trigonum between the posterior portion of the talus and calcaneus. Hamilton WG, Geppert MJ, Thompson FM: Pain in the posterior aspect of the ankle in dancers: Differential diagnosis and operative treatment. J Bone Joint Surg Am 1996;78:1491-1500.

Question 2758

Topic: 8. Foot and Ankle

Varus deformity after talar fractures is often seen due to collapse of the medial cortex. What artery supplies this portion of the talus?

. Artery of the tarsal sinus
. Artery of the tarsal canal
. Peroneal
. Perforating branch of the dorsalis pedis artery
. Lateral malleolar

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal is a branch of the posterior tibial artery. Among the branches of the artery of the tarsal canal is the deltoid artery. This arterial complex supplies the medial one third of the talar body. Disruption of this artery may lead to osteonecrosis of the medial body and subsequent collapse into varus. This is most commonly seen with talar body fractures but may be seen in Hawkins type 3 talar neck fractures. The artery of the tarsal sinus arises from the dorsalis pedis, lateral malleolar, and perforating peroneal arteries. The peroneal artery anastomoses with the calcaneal branches of the posterior tibial artery to form a plexus of vessels that supplies the posterior tubercle of the talus. Disruption of this artery would not result in collapse of the medial body, and thus would not lead to a varus deformity. Halibruton RA, Sullivan CR, Kelly PJ, et al: The extra-osseous and intra-osseous blood supply of the talus. J Bone Joint Surg Am 1958;40:1115.

Question 2759

Topic: 8. Foot and Ankle

A 63-year-old woman with a history of poliomyelitis has a fixed 30-degree equinus contracture of the ankle, rigid hindfoot valgus, and normal knee strength and stability. She reports persistent pain and has had several medial forefoot ulcerations despite a program of stretching, bracing, and custom footwear. What is the next most appropriate step in management?

Foot & Ankle 2006 Practice Questions: Set 1 (Solved) - Figure 19

. CROW walker
. Hyperbaric oxygen treatment
. Triple arthrodesis with Achilles tendon lengthening
. Transtibial amputation
. Ankle arthrodesis

Correct Answer & Explanation

. Triple arthrodesis with Achilles tendon lengthening

Explanation

The patient has a fixed deformity of the hindfoot and an Achilles tendon contracture; therefore, the treatment of choice is triple arthrodesis with Achilles tendon lengthening. Further bracing will not be helpful. Amputation is not indicated, and ankle arthrodesis will not address the hindfoot deformity. Palliative management would be more appropriate if the knee was unstable or the quadriceps were weak, because the equinus balances the ground reaction force across the knee. Perry J, Fontaine JD, Mulroy S: Findings in post-poliomyelitis syndrome: Weakness of muscles of the calf as a source of late pain and fatigue of muscles of the thigh after poliomyelitis. J Bone Joint Surg Am 1995;77:1148-1153.

Question 2760

Topic: 8. Foot and Ankle

An obese 56-year-old woman with hypertension has had posterior heel pain for the past 6 months. She also notes some enlargement over the posterior aspect of the heel. Examination reproduces pain with palpation at the insertion of the Achilles tendon. A lateral radiograph is shown in Figure 45. What is the most likely diagnosis?

Foot & Ankle Board Review 2000: High-Yield MCQs (Set 4) - Figure 13

. Stress fracture of the calcaneus
. Painful os trigonum
. Insertional Achilles tendinopathy
. Entrapment of the calcaneal branch of the posterior tibial nerve
. Rupture of the Achilles tendon

Correct Answer & Explanation

. Insertional Achilles tendinopathy

Explanation

The lateral radiograph shows a traction spur consistent with tendinopathy of the Achilles tendon. There is no displacement of the spur to suggest a rupture of the Achilles tendon, and os trigonum is not seen on the radiograph. The examination findings are not consistent with nerve entrapment. Schepsis AA, Wagner C, Leach RE: Surgical management of Achilles tendon overuse injuries: A long-term follow-up study. Am J Sports Med 1994;22:611-619.

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