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 2801
Topic: 8. Foot and Ankle
An 83-year-old woman with a long history of her foot slowly and progressively "turning out" now reports significant ankle pain. History reveals that she has significant cardiac disease and exercise-induced angina. Examination reveals a deficiency in the posterior tibial tendon; however, the hindfoot remains moderately supple. Radiographs reveal a valgus tilt of the tibiotalar joint and early arthrosis. What is the most appropriate orthotic management?
Correct Answer & Explanation
. Molded ankle gauntlet (Arizona brace)
Explanation
The patient will continue to have pain secondary to the ankle arthrosis with both the UCBL and the molded articulated ankle-foot orthosis. The total contact orthotic does not provide enough hindfoot control to support the progressive collapse of the ankle into valgus positioning. A molded leather gauntlet will not only control tibiotalar motion but also control hindfoot motion and allow support of the longitudinal arch.
Question 2802
Topic: 8. Foot and Ankle
A 25-year-old man sustained a head injury after being ejected from his car. Examination reveals a Glasgow Coma Scale score of 7 and a swollen right knee. Clinical examination shows that the knee is very unstable, suggesting tears of the medial collateral and anterior and posterior cruciate ligaments, as well as the posterior lateral corner. What is the most appropriate first step to rule out a vascular injury?
Correct Answer & Explanation
. Examination of the pedal pulses
Explanation
A knee dislocation carries the potential for an arterial injury and has always brought up the question of need for arteriography to rule out this limb-threatening injury. However, arteriography has an inherent complication rate that may compromise the general care of the patient. In over 240 published cases with documented knee dislocations that were evaluated for vascular injury by physical examination (without imaging studies), not a single missed injury was reported, for a 100% negative predictive value (0% false-negative rate). This degree of accuracy at excluding major vascular injury is unsurpassed by the results obtained with arteriography but with no risk involved and a marked savings in time, equipment, and costs. Therefore, the most appropriate first step to rule out vascular injury is examination of the pedal pulses. If there is any doubt about an arterial injury, another option is the ankle-brachial index (ABI). If the ABI is greater than 0.9, the chance of arterial injury is again nonexistent. However, a positive physical examination or an ABI of less than 0.9 is not 100% predictive of an arterial injury; therefore, arteriography is recommended. Miranda FE, Dennis JW, Veldenz HC, et al: Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: A prospective study. J Trauma 2002;52:247-252.
Question 2803
Topic: 8. Foot and Ankle
A 10-year-old soccer player has bilateral heel pain and reports that the pain is worse during and immediately after sports. Examination reveals that the calcaneal tuberosities are painful to palpation bilaterally. What is the most likely diagnosis?
Correct Answer & Explanation
. Calcaneal apophysitis
Explanation
Calcaneal apophysitis (Sever's disease) is a common cause of heel pain in children who are active in sports. The symptoms are most commonly bilateral and will often respond to a gastrocnemius-soleus complex stretching program. In addition, rest, anti-inflammatory drugs, and heel pads for the shoe may be prescribed. There is no effect on the long-term growth of the calcaneus. Micheli LJ, Ireland ML: Prevention and management of calcaneal apophysitis in children: An overuse syndrome. J Pediatr Orthop 1987;7:34-38.
Question 2804
Topic: 8. Foot and Ankle
A 45-year-old man who sustains a medial subtalar dislocation while playing basketball undergoes immediate closed reduction. No fractures or osteochondral defects are noted on postreduction radiographs. The next most appropriate step in management should consist of
Correct Answer & Explanation
. a short leg cast for 4 weeks.
Explanation
Most subtalar dislocations can be easily reduced by closed methods. If no fractures or defects are seen on the postreduction radiographs, then the success rate with cast immobilization is good. Medial dislocations have a better prognosis than lateral dislocations. Late instability is rare; therefore, the duration of immobilization should not be excessive. Most subtalar dislocations result in some stiffening of the hindfoot, and painful degenerative arthrosis is the most common serious complication.
Question 2805
Topic: Forefoot
A 28-year-old woman has a moderate hallux valgus deformity and a prominence of the medial eminence. She can participate in all activities and reports that she could wear 3-inch heels in the past, but she now notes medial eminence pain even while wearing a soft leather flat shoe with a cushioned sole. She requests recommendations regarding surgical correction. Examination reveals a 1-2 intermetatarsal angle of 10 degrees. A clinical photograph and radiograph are shown in Figures 13a and 13b. What is the best course of action?
Correct Answer & Explanation
. Chevron osteotomy to correct hallux valgus
Explanation
Based on her symptoms and prior shoe wear modifications, the treatment of choice is surgical correction of the hallux valgus with a chevron osteotomy. There are no data to support the use of a custom orthosis to delay the progression of a hallux valgus deformity. Steroid injection would only risk infection, as well as joint and capsule damage. Extra-depth shoes are an option; however, the patient is interested in surgical options. Chou LB, Mann RA, Casillas MM: Biplanar chevron osteotomy. Foot Ankle Int 1998;19:579-584. Coughlin MJ: Roger A. Mann Award: Juvenile hallux valgus. Etiology and treatment. Foot Ankle Int 1995;16:682-697.
Question 2806
Topic: 8. Foot and Ankle
A 45-year-old woman with stage II posterior tibial tendinitis has failed to respond to nonsurgical management. Recommended treatment now includes posterior tibial tendon debridement and medial calcaneal displacement osteotomy along with transfer of what tendon?
Correct Answer & Explanation
. Flexor digitorum longus
Explanation
The flexor digitorium longus is the commonly accepted tendon transfer for posterior tibial tendon insufficiency. The flexor hallucis longus has to be carefully rerouted to avoid crossing the neurovascular bundle and has not been shown clinically to provide superior results to flexor digitorum longus transfer. Use of the peroneus longus results in loss of plantar flexion strength of the first metatarsal, contributing to the flatfoot deformity. The anterior tibial tendon is in the anterior compartment and fires out of phase with the posterior tibial tendon. Sitler DF, Bell SJ: Soft tissue procedures. Foot Ankle Clin 2003;8:503-520.
Question 2807
Topic: 8. Foot and Ankle
In Charcot-Marie-Tooth disease a progressive deformity develops in the foot. Which functional muscles predominate in deformity formation?
Correct Answer & Explanation
. Posterior tibialis and peroneus longus
Explanation
In Charcot-Marie-Tooth disease, the posterior tibialis and peroneus longus tendons remain strong, serving to invert the hindfoot and depress the first metatarsal head thus causing the cavovarus foot associated with this disease. In contrast, the tibialis anterior and peroneus brevis are less functional and therefore cannot dorsiflex the ankle, elevate the first metatarsal, or evert the foot, contributing to the deformity.
Question 2808
Topic: 8. Foot and Ankle
A 57-year-old man with type II diabetes mellitus was successfully treated for a first occurrence forefoot full-thickness (Wagner II) diabetic foot ulcer underlying the third metatarsal head with associated hammertoe with a series of weight-bearing total contact casts. There was no evidence of osteomyelitis. The ulcer is now fully healed. He is insensate to the Semmes-Weinstein 5.07 (10 gm) monofilament. What is the next most appropriate step in management?
Correct Answer & Explanation
. Depth-inlay shoes with a custom accommodative foot orthosis
Explanation
This is the first occurrence of diabetic foot-specific morbidity. The patient has a foot deformity, a history of a diabetic foot ulcer, and is insensate to the monofilament. He is at moderate risk for the development of a recurrent ulcer. This is best avoided with therapeutic footwear. Commercially available depth-inlay shoes should be combined with a custom accommodative foot orthosis to accommodative the deformity. Pinzur MS, Slovenkai MP, Trepman E, et al: Guidelines for diabetic foot care: Recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society. Foot Ankle Int 2005;26:113-119.
Question 2809
Topic: 8. Foot and Ankle
The patient shown in Figure 44 reports that her toes hurt when she walks. Management should consist of
Correct Answer & Explanation
. shoe modifications for comfort.
Explanation
Brachymetatarsia is a congenital hypoplasia of one or more metatarsals. Shortening of the fourth metatarsal is the most common form of brachymetatarsia and is often bilateral. Taping and manipulative reduction attempts are ineffective, and extensor tenotomy and capsulotomy are not likely to sufficiently correct the deformity. Fusion or metatarsal lengthening result in complications and generally are not indicated. Shoe modifications, such as extra-depth or extra-wide shoes, generally will improve symptoms. If pressure and trauma persist in the older child, metatarsal lengthening or amputation may be indicated. Stevens PM: Toe deformities, in Drennan JC (ed): The Child's Foot and Ankle. New York, NY, Raven Press, 1992, p 195.
Question 2810
Topic: 8. Foot and Ankle
A 45-year-old man is seen in the emergency department after returning from a 2-hour airplane flight. He is reporting severe pain in his right leg but has no trouble moving his ankle, leg, or knee. Venous doppler testing reveals no evidence of deep venous thrombosis. He is placed on IV cephazolin but continues to worsen. On the third day in the hospital he has increased pain, some respiratory distress, and trouble maintaining his blood pressure. His leg takes on the appearance seen in Figure 15. An urgent MRI scan shows thickening of the subcutaneous tissues and superficial swelling in the leg but no evidence of an abscess. What is the next most appropriate step in management?
Correct Answer & Explanation
. Urgent aggressive debridement of skin, subcutaneous fat, and fascia
Explanation
The patient has necrotizing fasciitis, a rare and sometimes fatal disease that has many different etiologies. Signs that this is not a normal infection are the worsening clinical symptoms despite IV antibiotics and the systemic symptoms. He needs urgent surgical care before he becomes completely septic and unstable. He needs very aggressive debridement of his tissues. Hyperbaric oxygen and immunoglobulins are only anecdotally helpful, and would only be used after surgery. Fontes RA, Ogilvie CM, Miclau T: Necrotizing soft-tissue infections. J Am Acad Orthop Surg 2000;8:151-158.
Question 2811
Topic: 8. Foot and Ankle
Figure 12 shows the radiograph of a 15-year-old boy with cerebral palsy who has pain at the first metatarsophalangeal joints. He is a community ambulator. Management consisting of accommodative shoes has failed to provide relief. What is the treatment of choice?
Correct Answer & Explanation
. First metatarsophalangeal joint arthrodeses
Explanation
While other surgeries have provided some success, first metatarsophalangeal joint arthrodesis has the highest overall success rate compared to other surgeries in ambulatory and nonambulatory children with cerebral palsy. The recurrence rate is unacceptably high with the other procedures listed above. In contrast, neurologically normal children are amenable to osteotomies and soft-tissue procedures. Davids JR, Mason TA, Danko A, et al: Surgical management of hallux valgus deformity in children with cerebral palsy. J Pediatr Orthop 2001;21:89-94.
Question 2812
Topic: 8. Foot and Ankle
A 58-year-old man with type 1 diabetes mellitus is seen in the emergency department and he reports a 3-day history of a red swollen foot but no history of trauma. Examination reveals that the skin is intact, and the patient has discomfort with passive range of motion at the ankle, hindfoot, and midfoot joints. He denies any fever. Laboratory studies show a WBC count of 7,800/mm3, an erythrocyte sedimentation rate of 40 mm/h, a C-reactive protein level of 23, and a serum glucose of 100. A radiograph and MRI scans are shown in Figures 16a through 16c. What is the next most appropriate step in management?
Correct Answer & Explanation
. Total contact casting, no weight bearing, and weekly cast changes until erythema and swelling is decreased
Explanation
Whereas it is difficult to distinguish between cellulitis, septic joint, osteomyelitis, and early Eichenholtz stage 1 Charcot, the presence of a fracture in the absence of ulcerations with a normal WBC count and serum glucose strongly indicates that the described symptoms are due to an early Charcot process alone. A technetium Tc 99m scan alone would not be helpful; however, the addition of a sulfur colloid marrow scan or indium In 111 scan may be more specific to rule out infection, though it is not warranted here. Total contact casting with non-weight-bearing or limited weight bearing during Eichenholtz stage 1 when the foot is warm, erythematous, and swollen is advised to help prevent deformity. Alternatively, stabilization with pneumatic bracing may also be considered. While some authors have proposed early fixation or arthrodesis for Eichenholtz stage 1, the gold standard is still total contact casting with no to limited weight bearing until the swelling resolves and evidence of consolidation is seen on radiographs. Trepman E, Nihal A, Pinzur MS: Current topics review: Charcot neuropathy of the foot and ankle. Foot Ankle Int 2005;26:46-63. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 123-134.
Question 2813
Topic: 8. Foot and Ankle
A 14-year-old boy with a history of cerebral palsy has a clawed hallux, cavus foot deformity, and associated pain. Examination reveals pain under the first metatarsal head and a rigid first tarsometatarsal joint. Treatment should consist of
Correct Answer & Explanation
. transfer of the extensor hallucis longus to the neck of the first metatarsal with first metatarsal osteotomy.
Explanation
In a retrospective study for clawing of the hallux with associated cavus foot deformities, the modified Robert Jones tendon transfer was shown to be effective in relieving symptoms related to clawing of the hallux in 90% of patients but was not reliable in relieving pain under the first metatarsal head, with success in only 43% of patients. In three patients, pain under the metatarsal head was relieved initially but recurred by 18 months. The return of symptoms in these cases is the result of stretching of the muscle and tendon of the extensor hallucis longus by the more powerful peroneus longus. Basal dorsal wedge osteotomy at the time of the modified Robert Jones procedure is recommended. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 79-100.
Question 2814
Topic: 8. Foot and Ankle
Figure 33 shows the oblique radiograph of an 11-year-old boy who has a mild left flatfoot deformity. Examination reveals that subtalar motion is limited and painful. Despite casting for 6 weeks, the patient reports foot pain that limits participation in sport activities. A CT scan shows no subtalar joint abnormalities. Management should now include
Correct Answer & Explanation
. coalition resection with interposition of fat or muscle.
Explanation
The radiograph shows an incompletely ossified calcaneonavicular coalition. When symptomatic, a trial of cast immobilization is reasonable. If this fails to provide relief, the preferred treatment is resection of the coalition. Before attempting surgery, a CT scan should be obtained to rule out ipsilateral subtalar coalition. Recurrence of the coalition is usually prevented with interposition of autogenous fat graft or with local interposition of the extensor digitorum brevis muscle. Approximately 80% of patients treated in this manner have decreased pain and improved subtalar motion. When the flatfoot deformity is mild, calcaneal lengthening or medial translation osteotomy is unnecessary. Primary triple arthrodesis may be indicated if degenerative changes are present in the subtalar or midfoot joints. Peroneal lengthening has been described for treatment of the peroneal spastic flatfoot without demonstrable tarsal coalition. Gonzalez P, Kumar SJ: Calcaneonavicular coalition treated by resection and interposition of the extensor digitorum brevis muscle. J Bone Joint Surg Am 1990;72:71-77. Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.
Question 2815
Topic: 8. Foot and Ankle
A 42-year-old man reports a 12-month history of a painful fusiform swelling of the Achilles tendon. Physical therapy, heel lifts, and anti-inflammatory drugs have failed to provide relief. MRI scans are shown in Figures 44a and 44b. What is the treatment of choice?
Correct Answer & Explanation
. Debridement and flexor hallucis longus tendon transfer
Explanation
The area of the tendon degeneration is greater than 50% of the width so a supplemental tendon transfer is needed. Debridement and repair alone do not provide adequate strength. Injection risks tendon rupture. Brisement is indicated for peritendinitis, not tendinosis. Nonsurgical management is unlikely to be of benefit after 12 months. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 94-95.
Question 2816
Topic: 8. Foot and Ankle
A 35-year-old man sustained an injury to his lower extremity after falling 10 feet from a ladder; initial management was nonsurgical. He now reports chronic hindfoot and anterior ankle pain. Radiographs are shown in Figures 22a and 22b. Surgical reconstruction of this painful process should consist of
Correct Answer & Explanation
. distraction bone block subtalar joint arthrodesis.
Explanation
The radiographs reveal a hindfoot deformity that developed following a severe, comminuted, intra-articular fracture of the calcaneus. There is deformity of the calcaneal body and collapse of the talus into the calcaneus, leading to dorsiflexion of the talus and anterior ankle joint impingement. Distraction bone block subtalar joint arthrodesis will assist with correction of the calcaneal height and will allow for an improved talar declination angle. With this procedure, care must be taken to avoid placing the hindfoot into further varus. A similar reconstruction option not listed would be a calcaneal osteotomy and arthrodesis as described by Romash. Talectomy and tibiocalcaneal arthrodesis are not warranted because the primary structure of the talus and ankle joint is well preserved. In situ subtalar joint arthrodesis will not correct the deformity, and symptoms about the ankle and hindfoot would most likely persist. Lateral wall calcaneal exostectomy may decrease pain from subfibular impingement but will not deal directly with subtalar joint arthrosis and deformity. Carr JB, Hansen ST , Benirschke SK: Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle 1988;9:81-86. 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 2817
Topic: 8. Foot and Ankle
A patient with rheumatoid arthritis with both ankle and subtalar involvement was treated as shown in Figures 11a and 11b. What complication is unique to this type of fixation?
Correct Answer & Explanation
. Tibial stress fracture
Explanation
The interlocking screws at the proximal end of the rod can act as a stress riser and lead to fracture. Postoperative pain at this level should prompt inclusion of this diagnosis in the differential. Removing the screws following bone union can decrease the chances of this occurring. A short rod that avoids the diaphyseal area may also be beneficial. Rotatory deformity is controlled by the perpendicularly oriented distal transfixion screws. Talar osteonecrosis would be unusual since the dissection can be minimized with an intramedullary rod. Any type of hardware can fail if the construct does not lead to a solid arthrodesis. Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 236-237. Thordarson DB, Chang D: Stress fractures and tibial cortical hypertrophy after tibiotalocalcaneal arthrodesis with an intramedullary nail. Foot Ankle Int 1999;20:497-500.
Question 2818
Topic: 8. Foot and Ankle
An active 36-year-old woman with rheumatoid arthritis has continued forefoot discomfort despite the use of orthotics and shoe wear modifications. A radiograph and a clinical photograph are shown in Figures 26a and 26b. Treatment at this point should consist of
Correct Answer & Explanation
. first metatarsophalangeal joint fusion and lesser metatarsal head resections.
Explanation
In a patient with inflammatory arthritis, advanced hallux valgus deformity in conjunction with lesser metatarsophalangeal joint destruction and subluxation warrants fusion of the first metatarsophalangeal joint and lesser metatarsal head resections. Hallux valgus correction will fail because of incompetent soft tissues. A Keller resection arthroplasty is not indicated in this age group. Synovectomy is contraindicated because of evidence of erosive changes of the lesser metatarsophalangeal joints. Ouzounian T: Rheumatoid arthritis of the foot & ankle, in Myerson MS (ed): Foot & Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, vol 2, pp 1189-1204. Mann RA, Thompson FM: Arthrodesis of the first metatarsophalangeal joint for hallux valgus in rheumatoid arthritis. J Bone Joint Surg Am 1984;66:687-692.
Question 2819
Topic: 8. Foot and Ankle
A 40-year-old man underwent an ankle arthroscopy 6 months ago for a talus osteochondral defect. He continues to have pain and burning on the lateral portal but states that the pain is now more superficial than his original pain. Examination reveals that he has shooting pain to his medial foot and ankle when his lateral portal is tapped. A previous injection around the lateral portal gave him relief for about 2 weeks. What treatment will best eliminate his pain?
Correct Answer & Explanation
. Neuroplasty or excision and burial of the medial branch of the superficial peroneal nerve
Explanation
The patient clearly has entrapment of the superficial peroneal nerve in the lateral portal. It is most likely only the medial branch by examination. If the nerve is in good condition, it can simply be released. If the nerve is cut or severely thinned, it is better excised and buried. The sural nerve most likely would be caught in a posterior-lateral portal. Jobe MT, Wright PE: Peripheral nerve injuries, in Canale ST (ed): Campbell's Operative Orthopaedics. St Louis, MO, Mosby, 1998, pp 3839-3844.
Question 2820
Topic: 8. Foot and Ankle
A 21-year-old college student reports hearing a pop and has acute pain laterally over the ankle after twisting it during a recreational basketball game. Examination 1 hour after the injury reveals minimal swelling and ecchymosis. The anterior drawer sign is positive. Radiographs reveal no evidence of a fracture. What is the best course of action?
Correct Answer & Explanation
. Functional brace treatment
Explanation
Even though the patient has a grade 3 ankle ligament injury, studies have shown that 95% of patients with a grade 3 injury that may include a complete tear of the ligaments will heal successfully with conservative functional management. Extensive diagnostic evaluation with stress radiographs, CT, and MRI is not indicated. Surgical reconstruction is not indicated because of the overwhelming success of conservative management; however, in the few patients where late instability develops, surgical reconstruction offers an excellent outcome. Carne P: Nonsurgical treatment of ankle sprains using the modified Sarmiento brace. Am J Sports Med 1989;17:253-257.
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