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8. Foot and Ankle MCQs

Practice Set 140 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 2781

Topic: 8. Foot and Ankle

A 58-year-old woman with rheumatoid arthritis and a severe hindfoot valgus deformity now reports recurrent lateral ankle pain. Examination reveals pain over the fibula and sinus tarsi, with a valgus hindfoot that is passively correctable. Despite the use of an ankle-foot orthosis, this is the second time this problem has occurred. Radiographs and a clinical photograph are shown in Figures 28a through 28c. What is the next most appropriate step in treatment?

. Intramedullary screw fixation of the fibula
. Plating of the fibula with a one third tubular plate
. Subtalar arthrodesis with deformity correction
. Varus producing distal tibial osteotomy
. Ankle arthrodesis

Correct Answer & Explanation

. Subtalar arthrodesis with deformity correction

Explanation

Excessive hindfoot valgus can lead to abutment between the calcaneus and fibula. This valgus force can lead to a stress fracture of the distal fibula. Surgery may be required if an insufficiency fracture recurs despite orthotic management. Of the choices listed, a subtalar arthrodesis is most likely to achieve rebalancing of the foot at the level of the deformity. Stephens HM, Walling AK, Solmen JD, Tankson CJ: Subtalar repositional arthrodesis for adult acquired flatfoot. Clin Orthop 1999;365:69-73

Question 2782

Topic: 8. Foot and Ankle

Figure 26 shows the clinical photograph of a patient who has developed a residual limb ulcer following a traumatic transtibial amputation 2 years ago. What is the preferred treatment to resolve the ulcer?

Foot & Ankle 2009 Practice Questions: Set 3 (Solved) - Figure 4

. Avoid wearing the prosthesis until the ulcer is healed and perform local wound care.
. Obtain a new prosthesis with an energy-storing foot to dampen impact.
. Perform local wound care in conjunction with modification of the prosthetic socket and cushioned liner.
. Excise the wound and advance the soft-tissue envelope.
. Perform a distal tibiofibular bone bridge and advance the soft-tissue envelope.

Correct Answer & Explanation

. Perform local wound care in conjunction with modification of the prosthetic socket and cushioned liner.

Explanation

The first step in the treatment of an amputation residual limb (stump) ulcer is local wound care and adjustment of the residual limb-prosthetic interface, as well as adjusting prosthetic alignment. Surgical revision should be undertaken only when prosthetic modification is unsuccessful. Murnaghan JJ, Bowker JH: Musculoskeletal complications, in Smith DG, Michael JW, Bowker JH (eds): Atlas of Amputations and Limb Deficiencies, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 683-700.

Question 2783

Topic: 8. Foot and Ankle

Figures 12a and 12b show the radiographs of a 56-year-old man with diabetes mellitus who has had left foot swelling with no pain for the past several weeks. He denies any history of trauma. Examination reveals warmth, moderate swelling, no tenderness, and mild pes planus with standing. Pulses are palpable, and his sensory examination is grossly intact to light touch. Standing radiographs are shown in Figures 12c and 12d. What is the most likely diagnosis?

. Acute traumatic Lisfranc fracture-dislocation
. Acquired pes planus due to rupture of the posterior tibial tendon
. Neuropathic arthropathy
. Osteomyelitis
. Metatarsal stress fracture

Correct Answer & Explanation

. Neuropathic arthropathy

Explanation

The radiographs show tarsometatarsal joint subluxation without fragmentation. The clinical history and delay in presentation with the radiographic findings suggest a neuropathic or Charcot arthropathy involving the midfoot area. Intact sensory examination to light touch is not diagnostic for an intact peripheral neurologic system; monofilament testing is a more accurate office baseline examination for the presence of sensory peripheral neuropathy. With an acute traumatic Lisfranc fracture-dislocation, a history of a traumatic event is necessary, and radiographic abnormalities are expected, although nonstanding radiographs still may be misleading. Acquired pes planus due to posterior tibial tendon rupture may have negative nonstanding radiographs. Standing radiographs may reveal pes planus. However, intermetatarsal disruption is not expected as seen in a Lisfranc abnormality. Localized osteomyelitis of the foot without a penetrating injury or cutaneous ulceration is extremely unlikely and does not fit with the clinical picture described. An isolated metatarsal stress fracture would show osseous irregularity without the instability pattern pictured. Brodsky JW: The diabetic foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 895-969.

Question 2784

Topic: 8. Foot and Ankle

What type of brace is shown in Figures 22a and 22b?

. Charcot restraining orthotic walker (CROW)
. University of California Biomechanics Laboratory (UCBL) orthosis
. Double upright ankle-foot orthosis
. Chopart's prosthesis
. Below-knee prosthesis

Correct Answer & Explanation

. Charcot restraining orthotic walker (CROW)

Explanation

The figures show a Charcot restraining orthotic walker (CROW). This brace has been used as a customized total contact fit removable brace to maintain foot alignment as the patient evolves from Eichenholz stage 1 to Eichenholz stage 3 Charcot arthropathy. Mehta JA, Brown C, Sargeant N: Charcot restraint orthotic walker. Foot Ankle Int 1998;19:619-623.

Question 2785

Topic: 8. Foot and Ankle

A 65-year-old man has chronic Achilles insertional tendinitis that is refractory to nonsurgical management. A radiograph is shown in Figure 9. Preoperative counseling should include a discussion of the realistic duration of postoperative recovery. You should inform the patient that his expected recovery will last

Foot & Ankle 2009 Practice Questions: Set 1 (Solved) - Figure 27

. 6 weeks.
. 12 weeks.
. 3 to 6 months.
. 9 months.
. 12 months.

Correct Answer & Explanation

. 12 months.

Explanation

An older patient with calcaneal enthesopathy may take a year or more to recover after tendon debridement and calcaneal ostectomy. Young patients, and those with purely tendon pathology, may recover more quickly. McGarvey WC, Palumbo RC, Baxter DE, et al: Insertional Achilles tendinitis: Surgical treatment through a central tendon splitting approach. Foot Ankle Int 2002;23:19-25.

Question 2786

Topic: 8. Foot and Ankle

A soccer player who sustained a twisting injury to the right ankle while making a cut is unable to bear weight and has diffuse tenderness over the anterior and lateral aspects of the ankle. Examination also shows a positive squeeze test. Plain radiographs and a stress radiograph are shown in Figures 26a through 26c. Radiographs of the leg and knee are normal. What is the most appropriate management?

. Short leg non-weight-bearing cast for 6 weeks
. Air-stirrup splint and limited activity in 3 to 6 weeks
. Air-stirrup splint and resumption of activities as tolerated
. Immediate repair of the peroneal retinaculum
. Immediate reduction and placement of a syndesmotic screw

Correct Answer & Explanation

. Immediate reduction and placement of a syndesmotic screw

Explanation

The mechanism of injury, physical examination, and radiographs indicate a "high" ankle sprain with disruption of the distal tibiofibular ligaments and interosseous membrane. These injuries typically involve pronation and external rotation forces. In addition, recovery is significantly delayed, often requiring 6 to 8 weeks to heal. Radiographs obtained months after recovery often show calcification within the distal syndesmosis, which is not typically symptomatic. This patient has gross instability, resulting in a high incidence of chronic diastasis and subluxation leading to impaired function. Treatment should consist of reduction and stabilization with a transsyndesmotic screw because this injury demonstrates a widened syndesmosis. Boytim MJ, Fisher DA, Neumann L: Syndesmotic ankle sprains. Am J Sports Med 1991;19:294-298.

Question 2787

Topic: 8. Foot and Ankle

A 34-year-old man has had a 13-month history of an equinovarus deformity of the foot and ankle after a motorcycle accident. His foot and ankle are flexible, but bracing has become uncomfortable. Active dorsiflexion and eversion are absent. What is the most appropriate treatment?

Foot & Ankle Board Review 2009: High-Yield MCQs (Set 2) - Figure 18

. Ankle arthrodesis
. Subtalar arthrodesis
. Pantalar arthrodesis
. Posterior tibialis tendon transfer to the lateral midfoot with Achilles tendon lengthening
. Split anterior tibialis tendon transfer to the lateral midfoot with Achilles tendon lengthening

Correct Answer & Explanation

. Posterior tibialis tendon transfer to the lateral midfoot with Achilles tendon lengthening

Explanation

Arthrodesis of any of the ankle or hindfoot joints should be reserved for fixed deformities or end-stage degenerative arthritis. Achilles tendon lengthening is necessary to correct the equinus and to improve dorsiflexion-plantar flexion balance. Similarly, transfer of the posterior tibialis tendon reduces both plantar flexion and inversion torque. Hansen ST: Function Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 442-447.

Question 2788

Topic: 8. Foot and Ankle

A 35-year-old man has had a mass on the bottom of his foot for the past 6 months. He reports that initially the mass was exquisitely painful but now is minimally tender. Examination reveals a 2.5- x 2.0-cm firm, noncompressible, nonmobile mass contiguous with the plantar fascia in the distal arch. The mass is particularly prominent with passive dorsiflexion of the ankle and toes. What is the best course of action?

. Observation
. Incisional biopsy
. Excisional biopsy
. MRI
. Ultrasound

Correct Answer & Explanation

. Observation

Explanation

The history is most consistent with a plantar fibroma. The nodules typically are located within the substance of the plantar aponeurosis. The clinical appearance is usually diagnostic without the need for advanced imaging studies. While the lesion may be prominent and painful to direct palpation, the anatomic location is usually off of the weight-bearing surface. Observation with or without an accommodative orthotic is the treatment of choice. Recurrence is common following attempted excision. Sammarco GJ, Mangone PG: Classification and treatment of plantar fibromatosis. Foot Ankle Int 2000;21:563-569.

Question 2789

Topic: 8. Foot and Ankle

A 35-year-old woman who underwent open reduction and internal fixation of a calcaneal fracture 14 months ago reports pain that has failed to respond to nonsurgical management. Examination reveals limited painful subtalar motion but no hindfoot deformity. A lateral radiograph is shown in Figure 6. Surgical reconstruction is best accomplished with

Trauma 2000 Practice Questions: Set 1 (Solved) - Figure 12

. calcaneal osteotomy.
. subtalar joint arthrodesis.
. triple arthrodesis.
. pantalar arthrodesis.
. distraction bone block arthrodesis.

Correct Answer & Explanation

. subtalar joint arthrodesis.

Explanation

The patient has posttraumatic subtalar joint arthrosis that developed following a calcaneal fracture. Because there is no hindfoot deformity, in situ subtalar joint arthrodesis is the treatment of choice. Calcaneal osteotomy or distraction bone block arthrodesis is beneficial in patients with severe talar dorsiflexion or malunion of the calcaneal body. Triple arthrodesis is not warranted without changes at the transverse tarsal joint, and typically even with injury into the calcaneocuboid joint, this joint is often asymptomatic. Pantalar arthrodesis is not indicated as the pathology is occurring at the subtalar joint and not in the ankle joint. Sanders R: Fractures and fracture-dislocations of the calcaneus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1422-1464. Juliano TJ, Myerson MS: Fractures of the hindfoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1297-1340.

Question 2790

Topic: 8. Foot and Ankle

Figures 34a and 34b show the clinical photographs of a 46-year-old woman who has a painful deformity of the second toe. Surgical treatment consisting of metatarsophalangeal capsulotomy and proximal interphalangeal joint resection arthroplasty resulted in satisfactory correction, but the toe remains unstable at the metatarsophalangeal joint. What is the next most appropriate step?

. Flexor digitorum longus tenotomy
. Resection of the metatarsal head and pin fixation
. Transfer of the flexor digitorum longus to the extensor tendon
. Excision at the base of the proximal phalanx and syndactyly with the third toe
. Arthrodesis of the second metatarsophalangeal joint

Correct Answer & Explanation

. Transfer of the flexor digitorum longus to the extensor tendon

Explanation

Crossover second toes are attributed to attenuation or rupture of the plantar plate and lateral collateral ligament and are associated with varying degrees of instability. Flexor-to-extensor transfer (Girdlestone/Taylor procedure) can provide intrinsic stability to the toe. Although plantar metatarsal head condylectomy can increase stability by resulting in scarring of the plantar plate, excision of the entire second metatarsal head carries a high risk of transfer metatarsalgia. Removal of the base of the proximal phalanx destabilizes the toe and should be reserved as a salvage procedure. Simple flexor tenotomy alone will not improve stability, and arthrodesis of the second metatarsophalangeal joint will limit motion and impair function. Coughlin MJ: Crossover second toe deformity. Foot Ankle 1987;8:29-39.

Question 2791

Topic: 8. Foot and Ankle

A 15-year-old girl who plays high school basketball has had worsening forefoot pain and swelling that is aggravated by activity for the past 5 weeks. She denies any history of an injury. Examination reveals no deformities. A radiograph is shown in Figure 38. Initial management should consist of

Foot & Ankle Board Review 2006: High-Yield MCQs (Set 4) - Figure 9

. no weight bearing.
. weight bearing as tolerated in a hard-soled shoe.
. a short leg walking cast.
. second metatarsophalangeal joint debridement and metatarsal osteotomy.
. a longitudinal arch support with metatarsal head relief.

Correct Answer & Explanation

. a short leg walking cast.

Explanation

Freiberg's infraction is believed to be an osteochondrosis of the second metatarsal head. It is the only osteochondrosis that has a predilection for females. The typical patient is an athletically active adolescent female. The radiograph shows stage II disease wherein reossification is occurring; it is at this time that the second metatarsal head is most susceptible to deformation. Therefore, initial management should consist of a short leg walking cast.

Question 2792

Topic: 8. Foot and Ankle

Figures 21a and 21b show the clinical photograph and radiograph of a 15-year-old girl who has a deformity of her feet. Her parents are concerned because there is a family history of Charcot-Marie-Tooth disease. The patient reports some mild instability of the ankle and has noticed mild early callosities; however, she is not having any significant pain. Coleman block testing reveals a forefoot valgus and supple hindfoot. She has weakness to eversion and dorsiflexion. Initial management should consist of

. dorsiflexion osteotomy of the first metatarsal with peroneus longus to brevis transfer.
. plantar fasciotomy with dorsiflexion osteotomy of the first metatarsal and calcaneal osteotomy.
. a stretching and strengthening physical therapy program and accommodative inserts.
. observation.
. calcaneal osteotomy, dorsiflexion osteotomy of the first metatarsal, peroneus longus to brevis transfer, plantar fascia release, Achilles tendon lengthening, and midfoot osteotomy.

Correct Answer & Explanation

. a stretching and strengthening physical therapy program and accommodative inserts.

Explanation

Initial management of a young patient with a cavovarus deformity of the foot and a family history of Charcot-Marie-Tooth disease should focus on mobilization and strengthening of the weakening muscular units and an accommodative insert. Surgical intervention should be delayed until progression of the deformity begins to cause symptoms and/or weakness of the muscular units, resulting in contractures of the antagonistic muscle units. Pinzur MS: Charcot's foot. Foot Ankle Clin 2000;5:897-912. Holmes JR, Hansen ST Jr: Foot and ankle manifestations of Charcot-Marie-Tooth disease. Foot Ankle 1993;14:476-486.

Question 2793

Topic: 8. Foot and Ankle

Following application of a short leg cast, a patient reports a complete foot drop. A compression injury of the peroneal nerve at the fibular neck is confirmed by electrical studies. Which of the following muscles is expected to be the last to recover function during the ensuing months?

. Extensor digitorum longus
. Flexor digitorum longus
. Peroneus longus
. Extensor hallucis longus
. Tibialis anterior

Correct Answer & Explanation

. Extensor hallucis longus

Explanation

The recovery process from peroneal nerve palsy may take many months as axonal regrowth occurs. Of the muscles listed, the extensor hallucis is innervated most distally by the peroneal nerve. The flexor digitorum longus is innervated by the tibial nerve.

Question 2794

Topic: 8. Foot and Ankle

A 40-year-old man fell 10 feet from a tree and sustained the closed isolated injury shown in Figures 35a and 35b. Management consists of splinting. At his 2-week follow-up visit, he clinically passes the wrinkle test. He agrees to open reduction and internal fixation. What is the best surgical approach to obtain anatomic reduction and limit wound dehiscence?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with a lateral approach, extensile right-angled lateral incision, vertical limb 0.5 cm anterior to the Achilles tendon, and horizontal limb at the junction of the lateral skin and the plantar glabrous skin
. Open reduction and internal fixation with a lateral approach, extensile right-angled lateral incision, vertical limb 2.0 cm anterior to the Achilles tendon, and horizontal limb 2.0 cm proximal to the line marking the plantar glabrous skin
. Sinus tarsi approach
. Ollier approach

Correct Answer & Explanation

. Open reduction and internal fixation with a lateral approach, extensile right-angled lateral incision, vertical limb 0.5 cm anterior to the Achilles tendon, and horizontal limb at the junction of the lateral skin and the plantar glabrous skin

Explanation

The approach to the calcaneus has evolved from several different patterns, driven by a high wound complication rate of 10%. The current extensile lateral approach was described by Zwipp and associates in 1988. The surgical exposure uses an L-shaped incision, with the vertical component positioned one half a finger's breath anterior to the Achilles tendon and extending distally to the junction of the lateral skin and the plantar skin. Borrelli and Lashgari mapped the angiosome of the lateral calcaneal flap and found that the major arterial blood supply to this flap consisted of three arteries: the lateral calcaneal artery, the lateral malleolar artery, and the lateral tarsal artery. The lateral calcaneal artery appeared to be responsible for most of the blood supply to the corner of the flap. This was found 1.5 cm anterior to the Achilles tendon. Division of this artery with inaccurate placement of the vertical limb of the incision can cause ischemia of the lateral skin flap. Borrelli J Jr, Lashgari C: Vascularity of the lateral calcaneal flap: A cadaveric injection study. J Orthop Trauma 1999;13:73-77. Freeman BJC, Duff S, Allen PE, et al: The extended lateral approach to the hindfoot: An anatomical basis and surgical implications. J Bone Joint Surg Br 1998;80:139-142.

Question 2795

Topic: 8. Foot and Ankle
The arthroscopic views shown in Figures 31a and 31b reveal extensive synovitis in the anterolateral corner of the ankle overlying a band of tissue sometimes implicated in soft-tissue impingement of the ankle following a chronic sprain injury. This band is a portion of the
. anteroinferior tibiofibular ligament.
. anterior talofibular ligament.
. calcaneofibular ligament.
. deltoid ligament.
. extensor retinaculum.

Correct Answer & Explanation

. anteroinferior tibiofibular ligament.

Explanation

The arthroscopic views show the lateral side of the ankle as demonstrated by the presence of the tibiofibular articulation. As is typical in chronic anterolateral impingement, synovitis overlies the anteroinferior band of the tibiofibular ligament, the most distal portion of the anterior syndesmosis. Hypertrophic scar formed on or in this ligament can impinge on the lateral margin of the talar dome and has been associated with chronic anterolateral ankle pain. Bassett FH III, Gates HS III, Billys JB, et al: Talar impingement by the anteroinferior tibiofibular ligament: A cause of chronic pain in the ankle after inversion sprain. J Bone Joint Surg Am 1990;72:55-59.

Question 2796

Topic: 8. Foot and Ankle

A 45-year-old woman has had intense pain in her foot for the last 3 days. She also reports a mild fever and difficulty with shoe wear. Examination reveals a swollen, slightly erythematous warm foot with tenderness at the great toe metatarsophalangeal joint and pain with passive motion of the joint. An AP radiograph is shown in Figure 13. Which of the following will best aid in determining a definitive diagnosis?

Foot & Ankle 2009 Practice Questions: Set 1 (Solved) - Figure 33

. Gadolinium-enhanced MRI of the great toe
. Serum uric acid level, C-reactive protein, and erythrocyte sedimentation rate
. Serum rheumatoid factor
. Aspiration of the first metatarsophalangeal joint
. Fasting serum glucose level

Correct Answer & Explanation

. Aspiration of the first metatarsophalangeal joint

Explanation

The patient has gouty arthropathy of the first metatarsophalangeal joint. This definitive diagnosis is achieved with aspiration of the joint and polarized light microscopy that shows needle-shaped negatively birefringent monosodium urate crystals. Differential diagnoses of infectious arthritis and pseudogout are also definitively made through joint aspiration. Although rheumatoid arthritis is a possibility, a serum rheumatoid factor is not always diagnostic and a patient with rheumatoid arthritis may have concomitant gouty arthritis. The radiographic findings are not typical of diabetes mellitus or of a patient with Charcot arthropathy. Wise CM, Agudelo CA: Diagnosis and management of complicated gout. Bull Rheum Dis 1998;47:2-5.

Question 2797

Topic: 8. Foot and Ankle

A 5-year-old boy has had pain in the right foot for the past month. Examination reveals tenderness and mild swelling in the region of the tarsal navicular. Radiographs are shown in Figure 30. Management should consist of

Pediatrics 2007 Practice Questions: Set 3 (Solved) - Figure 13

. biopsy of the tarsal navicular.
. curettage and bone grafting of the tarsal navicular.
. CBC count, C-reactive protein level, erythrocyte sedimentation rate, blood cultures, and IV antibiotics.
. symptomatic treatment with restriction of weight bearing or application of short leg cast.
. medial column lengthening of the foot through the tarsal navicular.

Correct Answer & Explanation

. symptomatic treatment with restriction of weight bearing or application of short leg cast.

Explanation

The child has the classic findings of Kohler's disease or osteochondrosis of the tarsal navicular. The cause of this condition is not known, but osteonecrosis and mechanical compression have been proposed. Children generally report midfoot pain over the tarsal navicular and limping. Physical findings include tenderness, swelling, and occasionally redness in the region of the tarsal navicular. Radiographs show sclerosis and narrowing of the tarsal navicular. The natural history of the condition is spontaneous resolution and reconstitution of the navicular. Symptomatic treatment with restriction of weight bearing or casting is recommended. Karp M: Kohler's disease of the tarsal scaphoid. J Bone Joint Surg 1937;19:84-96.

Question 2798

Topic: 8. Foot and Ankle

A 20-year-old football player sustains a dorsiflexion external rotation injury to his right ankle. During sideline evaluation, which of the following findings best indicates a syndesmosis ankle sprain without diastasis?

. Tenderness over the anterior talofibular and calcaneofibular ligaments
. A positive dorsiflexion external rotation test
. Loss of passive range of motion
. Positive squeeze test
. Inability to single leg hop

Correct Answer & Explanation

. Inability to single leg hop

Explanation

The inability to single leg hop is considered the best indicator of a syndesmosis ankle sprain without diastasis. Tenderness along the syndesmosis, the deltoid, or over the anterior talofibular ligament or anterior distal tibia/fibula may present later, following the initial injury. The squeeze test and tenderness with dorsiflexion and external rotation may be positive but often are not present initially. The best determinant for prediction of return to play is the amount of tenderness along the syndesmosis, measured from the distal fibula up the syndesmosis. Nussbaum ED, Hosea TM, et al: Prospective evaluation of syndesmosis ankle sprains without diastasis. Am J Sports Med 2001;29:31-35. Miller CD, Shelton WR, Barrett GR, et al: Deltoid and syndesmosis ligament injury of the ankle without fracture. Am J Sports Med 1985;23:746-750.

Question 2799

Topic: 8. Foot and Ankle

A 17-year-old patient sustained a closed calcaneal fracture when he jumped off of a roof 2 years ago, and he underwent nonsurgical management at the time of injury. The patient now reports lateral hindfoot pain that is worse with weight-bearing activities. Anti-inflammatory drugs and orthoses have failed to provide relief. Coronal and sagittal CT scans are shown in Figures 36a and 36b. What is the best course of action?

. In situ subtalar arthrodesis
. Cortisone injection in the subtalar joint followed by casting for 4 to 6 weeks
. UCBL insert
. Lateral wall exostectomy
. Bone block arthrodesis of the subtalar joint

Correct Answer & Explanation

. Lateral wall exostectomy

Explanation

The CT scans show evidence of a lateral wall blowout and malunion without significant arthrosis of the subtalar joint. In a young patient, it is preferable to avoid a fusion and allow residual motion by performing an exostectomy that decompresses the lateral subtalar joint and peroneal tendons. Chandler JT, Bonar SK, Anderson RB, et al: Results of in situ subtalar arthrodesis for late sequelae of calcaneus fractures. Foot Ankle Int 1999;20:18-24.

Question 2800

Topic: 8. Foot and Ankle

A 26-year-old rugby player injured his foot when tackled from behind. Radiographs are seen in Figures 35a through 35c. What is the most appropriate treatment?

. Closed reduction and percutaneous pin fixation
. Application of a short leg non-weight-bearing cast
. Application of a walking boot with weight bearing as tolerated
. Open reduction and internal fixation
. Elastic bandage wrap and activity as tolerated

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

The patient has a ligamentous Lisfranc injury. Diastasis seen between the bases of the second metatarsal and medial cuneiform is pathognomonic for a rupture of the Lisfranc's ligament. This injury is best treated surgically with either open reduction and internal fixation or possibly closed manipulation and percutaneous screw fixation if anatomic alignment can be achieved closed. Pin fixation has been shown to be inferior to screw fixation due to the length of time that fixation is required for adequate ligament healing. Chiodo CP, Myerson MS: Developments and advances in the diagnosis and treatment of injuries of the tarsometatarsal joint. Orthop Clin North Am 2001;32:11-20.

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