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8. Foot and Ankle MCQs

Practice Set 149 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 2961

Topic: 8. Foot and Ankle

A construction worker sustained a comminuted calcaneus fracture 2 years ago. He now reports progressive hindfoot pain with the recent onset of anterior ankle pain. A lateral hindfoot radiograph is shown in Figure 31. Treatment should consist of

General Orthopedics 2026 Practice Questions: Set 11 (Solved) - Figure 1

. in situ subtalar fusion.
. tibiotalocalcaneal arthrodesis using an intramedullary rod.
. ankle arthroscopy with debridement of osteophytes.
. subtalar distraction bone block arthrodesis.
. lateral wall ostectomy of the calcaneus.

Correct Answer & Explanation

. subtalar distraction bone block arthrodesis.

Explanation

The patient has subtalar arthrosis, a loss of heel height with anterior ankle impingement. The mechanics of the ankle are impaired, and dorsiflexion is painful and limited. The talar declination angle is measured by drawing a line through the longitudinal axis of the talus and the plane of support of the foot on a weight-bearing lateral radiograph. Anterior impingement is suggested with any value below 20°. By performing a distraction arthrodesis through the subtalar joint, the normal declination of the talus is reestablished, eliminating the anterior ankle impingement. Tibiotalocalaneal fusion would be inappropriate because the patient does not have arthritic symptoms in the ankle. Ankle arthroscopy or in situ arthrodesis would not reestablish appropriate ankle mechanics, and the osteophytes would be prone to redevelop. Lateral wall ostectomy may help with impingement at the level of the fibula or the lateral ankle but would provide no benefit to anterior ankle impingement. Carr JB, Hansen ST, Benirschke SK: Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle 1988;9:81-86.

Question 2962

Topic: 8. Foot and Ankle

The Coleman block test is used to evaluate the cavovarus foot. What is the most important information obtained from this test?

. Determines the patient's ability to balance
. Determines hindfoot flexibility
. Determines forefoot flexibility
. Assesses the patient for Achilles tendon contractures
. Evaluates peroneus longus strength

Correct Answer & Explanation

. Determines forefoot flexibility

Explanation

Coleman block testing, performed by placing an elevation under the lateral border of the foot, is used to determine if the forefoot and/or plantar flexed first ray is causing a compensatory varus in the hindfoot. The block is placed under the lateral border of the foot, and therefore does not have any relation to the Achilles tendon and suppleness of the hindfoot. Holmes JR, Hansen ST Jr: Foot and ankle manifestations of Charcot-Marie-Tooth disease. Foot Ankle 1993;14:476-486.

Question 2963

Topic: 8. Foot and Ankle

A 58-year-old diabetic male presents with an acutely swollen, red, and warm left foot, without an open wound. Radiographs, shown here, reveal disorganized joint architecture, subluxation, and fragmentation of the midfoot bones, consistent with Charcot neuroarthropathy (Eichenholtz Stage 1). ESR and CRP are mildly elevated, and WBC count is normal. He reports numbness in both feet.

What is the cornerstone of initial non-surgical management for this condition?

. Broad-spectrum oral antibiotics.
. Rigid foot orthoses and gradual weight-bearing.
. Total contact casting (TCC).
. Immediate surgical stabilization.
. Non-steroidal anti-inflammatory drugs (NSAIDs) and elevation.

Correct Answer & Explanation

. Total contact casting (TCC).

Explanation

The patient presents with an acute Charcot foot (Eichenholtz Stage 1), characterized by an acutely swollen, red, and warm foot with radiographic evidence of bony fragmentation and joint disorganization. The absence of an open wound, normal WBC, and only mildly elevated inflammatory markers make acute infection less likely, distinguishing it from osteomyelitis. The cornerstone of initial non-surgical management for acute Charcot neuroarthropathy is strict non-weight-bearing and immobilization to protect the fragile foot, allow the inflammatory process to subside, and prevent further destruction and deformity.Total contact casting (TCC) (Option C) is considered the gold standard for offloading and immobilizing the acute Charcot foot. It distributes pressure evenly across the plantar surface, reduces stress on compromised areas, and accommodates swelling. This is a much more effective and crucial method of immobilization and offloading compared to rigid foot orthoses (Option B), which might be used in later, quiescent stages or for maintenance but are insufficient for the acute phase.Option A (broad-spectrum oral antibiotics) is incorrect as there is no strong evidence of infection. While differentiation from infection can be challenging, the absence of an open wound and normal WBC count make it less likely to be the primary management.Option D (immediate surgical stabilization) is generally reserved for severe instability, gross deformity that prevents bracing, or failed conservative management, and is typically not the first-line treatment for an acute Charcot foot.Option E (NSAIDs and elevation) may help with swelling and pain but does not address the fundamental need for strict offloading and immobilization to protect the bone and joint architecture.

Question 2964

Topic: 8. Foot and Ankle

A 48-year-old male with end-stage post-traumatic ankle arthritis, severe subtalar arthritis, and a mild equinus contracture presents for surgical management. He is a non-smoker, has no diabetes, and desires to maintain some motion. Clinical examination reveals significant tibiotalar and subtalar stiffness with pain. Radiographs

confirm advanced arthritis in both joints. What is the most appropriate surgical recommendation?

. Isolated total ankle arthroplasty (TAA).
. Isolated ankle arthrodesis.
. Pantalar arthrodesis.
. Total ankle arthroplasty combined with subtalar arthrodesis.
. Distraction arthroplasty of the ankle.

Correct Answer & Explanation

. Total ankle arthroplasty combined with subtalar arthrodesis.

Explanation

This patient has end-stage arthritis affecting both the tibiotalar (ankle) joint and the subtalar joint, along with an equinus contracture. The patient desires to maintain some motion, making arthroplasty an attractive option if appropriate.Option A (Isolated total ankle arthroplasty - TAA) would address the ankle arthritis but not the subtalar arthritis, which is also described as 'severe.' A TAA in the presence of severe subtalar arthritis can lead to persistent pain from the subtalar joint, and the altered biomechanics might accelerate subtalar degeneration.Option B (Isolated ankle arthrodesis) would fuse the ankle but not the subtalar joint, again leaving a source of pain. Also, it contradicts the patient's desire to maintain motion.Option C (Pantalar arthrodesis) involves fusing the tibiotalar, subtalar, talonavicular, and calcaneocuboid joints. While it provides a pain-free, stable foot, it results in a completely rigid foot, eliminating all ankle and foot motion. This is a salvage procedure typically reserved for pan-articular arthritis, severe deformity, or failed previous surgeries, and it goes against the patient's desire to maintain some motion.Option D (Total ankle arthroplasty combined with subtalar arthrodesis) is the most appropriate recommendation. This approach allows for motion preservation at the tibiotalar joint via TAA while simultaneously addressing the painful, arthritic subtalar joint with an arthrodesis. The equinus contracture can also be addressed during the surgical procedure (e.g., gastrocnemius recession or Achilles lengthening), which is critical for successful TAA outcomes. This combined procedure allows for pain relief, corrects deformity, and maintains a degree of ankle motion, which aligns with the patient's goals and addresses the extent of his disease.Option E (Distraction arthroplasty of the ankle) is a joint-sparing procedure used for early to moderate ankle arthritis, aiming to regenerate cartilage or reduce pain. It is generally not indicated for end-stage arthritis with severe destruction and existing subtalar disease.

Question 2965

Topic: 8. Foot and Ankle
A 58-year-old diabetic male with peripheral neuropathy presents with a rapidly progressing, painful, and deformed right foot. Physical examination reveals a warm, swollen, erythematous foot with a rocker-bottom deformity and collapse of the midfoot arch. Radiographs show fragmentation and dislocation of the tarsometatarsal joints, with evidence of osteolysis and new bone formation. What is the primary goal of acute treatment for this condition?
. Surgical arthrodesis of the tarsometatarsal joints to restore arch.
. Systemic antibiotics to address possible infection.
. Non-weight bearing with total contact casting (TCC).
. Corticosteroid injections to reduce inflammation.
. Amputation due to severe deformity and infection risk.

Correct Answer & Explanation

. Non-weight bearing with total contact casting (TCC).

Explanation

This clinical scenario is highly suggestive of acute Charcot neuroarthropathy of the foot, often seen in diabetic patients with neuropathy. The primary goal of acute treatment for active Charcot foot (Eichenholtz stage I) is to prevent further collapse and deformity. This is achieved through strict non-weight bearing and immobilization using a total contact cast (TCC) or a removable walking boot (Charcot Restraint Orthotic Walker - CROW). TCC helps distribute pressure, reduce swelling, and stabilize the joints. Surgical arthrodesis is typically reserved for reconstructive purposes after the acute inflammatory phase has settled (Eichenholtz stage III). While infection can coexist, the primary process described is neuroarthropathy, and systemic antibiotics are not the primary treatment for Charcot itself. Corticosteroids are contraindicated. Amputation is a last resort for uncontrolled infection or non-salvageable limbs.

Question 2966

Topic: 8. Foot and Ankle

A 50-year-old female presents with burning pain, numbness, and tingling in the third and fourth toes of her left foot, worsened by wearing tight shoes and prolonged standing. Physical examination reveals tenderness in the third intermetatarsal space with a positive Mulder's sign. Radiographs are unremarkable. What is the MOST appropriate initial non-surgical management?

. Surgical excision of the neuroma.
. Steroid injection into the intermetatarsal space.
. Custom orthotics with a metatarsal pad and wide toe box shoes.
. Oral non-steroidal anti-inflammatory drugs (NSAIDs) and rest.
. Ultrasound-guided radiofrequency ablation.

Correct Answer & Explanation

. Custom orthotics with a metatarsal pad and wide toe box shoes.

Explanation

The patient's symptoms and positive Mulder's sign are classic for Morton's neuroma (interdigital neuroma), which is a benign enlargement of the common plantar digital nerve, typically between the third and fourth metatarsal heads. The MOST appropriate initial non-surgical management focuses on alleviating pressure on the nerve. This includes custom orthotics with a metatarsal pad to splay the metatarsal heads, and wearing wide-toe box shoes to reduce compression. Steroid injections can be effective but are typically considered after shoe wear modifications. Oral NSAIDs and rest may offer temporary relief but do not address the underlying mechanical cause. Surgical excision and radiofrequency ablation are surgical or minimally invasive treatments considered after failed conservative management.

Question 2967

Topic: Ankle Trauma & Sports

A 45-year-old male with a history of recurrent ankle sprains develops chronic lateral ankle instability. Clinical examination reveals a positive anterior drawer test and talar tilt test. Imaging shows chronic attenuation of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). He fails a trial of bracing and physical therapy. What is the MOST appropriate surgical procedure for definitive stabilization?

. Arthroscopic debridement of impingement.
. Lateral ankle arthrodesis.
. Modified Brostrom-Gould procedure.
. Peroneal tendon transfer.
. Ankle replacement.

Correct Answer & Explanation

. Modified Brostrom-Gould procedure.

Explanation

For chronic lateral ankle instability due to attenuation of the ATFL and CFL that has failed conservative management, the Modified Brostrom-Gould procedure is considered the 'gold standard' and most appropriate surgical intervention. This procedure involves direct repair of the attenuated ATFL and CFL by shortening and reattaching them, often reinforced with the inferior extensor retinaculum (Gould modification). Arthroscopic debridement is for impingement, not instability. Lateral ankle arthrodesis is a salvage procedure for end-stage arthritis. Peroneal tendon transfer is a reconstructive procedure usually reserved for failed Brostroms, highly ligamentous lax patients, or poor tissue quality. Ankle replacement is for end-stage arthritis.

Question 2968

Topic: 8. Foot and Ankle

A 58-year-old male with a 20-year history of Type 2 Diabetes Mellitus presents with sudden onset of warmth, redness, and swelling in his left midfoot, without a clear history of trauma. He reports mild discomfort but no severe pain. Radiographs are obtained and are shown below.

The imaging shows early fragmentation and joint disorganization of the tarsometatarsal joints, consistent with Eichenholtz Stage I Charcot neuroarthropathy. What is the MOST critical initial management step?

. Immediate open reduction and internal fixation to stabilize the joints.
. Broad-spectrum intravenous antibiotics.
. Non-weight-bearing with total contact cast (TCC) application.
. Corticosteroid injection into the affected joints to reduce inflammation.
. Referral for amputation consultation due to severe deformity risk.

Correct Answer & Explanation

. Non-weight-bearing with total contact cast (TCC) application.

Explanation

The MOST critical initial management step for acute Charcot neuroarthropathy (Eichenholtz Stage I) is aggressive offloading of the affected foot to prevent further joint destruction and deformity progression. This is most effectively achieved with a Total Contact Cast (TCC) or a removable cast walker (RCW) with strict adherence to non-weight-bearing. While infection can mimic Charcot, the lack of a clear entry point, minimal pain despite significant inflammation, and typical radiographic findings of fragmentation favor Charcot. Antibiotics would be indicated if infection were confirmed. Surgical intervention is typically reserved for severe deformities that cannot be accommodated with bracing or in cases of instability or ulceration. Corticosteroids are contraindicated. Amputation is a last resort.

Question 2969

Topic: 8. Foot and Ankle

A pediatrician refers a 3-week-old infant due to a rigid 'rocker-bottom' deformity of the left foot. Physical examination reveals a dorsiflexed ankle, a prominent talar head on the plantar aspect, and a non-reducible midfoot and forefoot abduction. Lateral radiographs confirm congenital vertical talus (CVT) with dorsal dislocation of the navicular on the talar head. What is the MOST accepted initial primary treatment approach for congenital vertical talus?

. Serial manipulation and casting using the Ponseti method.
. Immediate extensive surgical release and reduction.
. Observation with passive stretching exercises.
. Bracing with ankle-foot orthoses (AFOs).
. Percutaneous lengthening of the Achilles tendon only.

Correct Answer & Explanation

. Serial manipulation and casting using the Ponseti method.

Explanation

Congenital vertical talus (CVT) is a rigid 'rocker-bottom' foot deformity that traditionally required extensive surgical release. However, a modified serial manipulation and casting technique, sometimes referred to as the 'reverse Ponseti' method, has gained acceptance as the initial primary treatment approach. This method involves serial casting with specific manipulations to reduce the talonavicular joint and achieve progressive correction of the foot deformity, often followed by a limited surgical release (e.g., Achilles tenotomy, talonavicular pin) if full correction is not achieved non-surgically. Extensive surgical release is still commonly performed, especially if casting fails, but initial non-operative treatment is increasingly preferred.

Question 2970

Topic: 8. Foot and Ankle

A 35-year-old male sustains a high-energy injury to his right ankle after falling from a significant height. Clinical examination reveals severe swelling and deformity, with palpable crepitus. Radiographs, shown below, demonstrate a comminuted fracture of the distal tibia articular surface with metaphyseal extension, but no significant fibular fracture. There is also disruption of the tibiofibular syndesmosis.

What is the most appropriate initial management strategy for this type of injury, specifically considering the soft tissue condition?

. Immediate open reduction and internal fixation (ORIF) with anatomical plating to restore articular congruity.
. Application of a spanning external fixator with a definitive ORIF performed within 24 hours.
. Emergent reduction and splinting, followed by serial examinations and delayed definitive fixation once soft tissue swelling subsides.
. Closed reduction and casting for 6 weeks, followed by progressive weight-bearing.
. Placement of an ankle arthrodesis in cases of severe articular comminution.

Correct Answer & Explanation

. Application of a spanning external fixator with a definitive ORIF performed within 24 hours.

Explanation

The image depicts a severe comminuted pilon fracture (distal tibial articular fracture). Pilon fractures, especially high-energy ones, are notorious for significant soft tissue swelling, blistering, and potential compromise due to the limited soft tissue envelope around the ankle. Immediate definitive ORIF in the presence of severe soft tissue swelling carries a high risk of wound complications, infection, and flap necrosis.The standard initial management for these high-energy pilon fractures is to stabilize the injury and protect the soft tissues. This typically involves emergent reduction (to minimize tension on skin) and application of a spanning external fixator from the tibia to the foot or calcaneus. This provides temporary stability, allows for soft tissue rest, reduces swelling, and facilitates serial wound checks. Definitive ORIF is then delayed until the 'wrinkle sign' appears, indicating resolution of significant soft tissue swelling, which often takes 7-14 days.Rationale for options:A. Immediate ORIF is contraindicated due to severe soft tissue swelling and high risk of complications.B. Emergent reduction and application of a spanning external fixator, followed by serial examinations and delayed definitive fixation (typically after 7-14 days), is the cornerstone of management for high-energy pilon fractures with significant soft tissue injury. This is the correct answer.C. While emergent reduction and splinting is a good initial step, a spanning external fixator provides superior stability and soft tissue protection for these severe fractures, making it more appropriate than just splinting.D. Closed reduction and casting is generally insufficient for comminuted articular fractures and syndesmotic disruption, leading to poor anatomical reduction and high rates of post-traumatic arthritis.E. Ankle arthrodesis is a salvage procedure considered for severe, unreconstructable articular comminution or failed prior attempts, not as the primary initial management for a reconstructable fracture.

Question 2971

Topic: 8. Foot and Ankle
A 65-year-old male with a history of diabetes, peripheral neuropathy, and end-stage renal disease presents with a warm, swollen, and deformed right midfoot that developed acutely after a minor twist. Radiographs reveal diffuse osteopenia, joint subluxation, and fragmentation of the navicular and cuneiform bones, consistent with a Charcot neuroarthropathy flare. He is currently non-ambulatory due to pain and instability. What is the most critical immediate management step for this patient?
. Immediate surgical stabilization with internal fixation and arthrodesis.
. Prescription of custom orthotics and gradual return to weight-bearing.
. Total contact casting (TCC) and strict non-weight-bearing.
. Administration of high-dose systemic corticosteroids to reduce inflammation.
. Amputation due to severe deformity and risk of infection.

Correct Answer & Explanation

. Total contact casting (TCC) and strict non-weight-bearing.

Explanation

The patient presents with an acute Charcot neuroarthropathy flare, characterized by warmth, swelling, deformity, pain, and radiographic changes (fragmentation, subluxation, osteopenia). The most critical immediate management step for acute Charcot foot is to protect the limb from further damage by immobilization and strict non-weight-bearing. This aims to halt the destructive process and prevent further deformity progression. The gold standard for this is total contact casting (TCC).

Question 2972

Topic: 8. Foot and Ankle

A 4-year-old male is brought to the clinic for evaluation of an insensate, swollen, and progressively deforming right foot. His parents report a history of spina bifida and hydrocephalus requiring a shunt. Clinical examination reveals a rigid, rocker-bottom foot deformity with plantar ulceration and claw toes. Radiographs show significant midfoot collapse, fragmentation, and dislocation of the talonavicular and calcaneocuboid joints.

This presentation is most consistent with a neglected Charcot arthropathy of the foot, secondary to his underlying neurological condition. What is the MOST appropriate surgical management for this severe, rigid, and ulcerated deformity in a young, neuropathic patient?

. Serial casting and orthotic management.
. Talectomy (astragalectomy).
. Triple arthrodesis.
. Pantalus arthrodesis.
. Supramalleolar osteotomy to correct deformity.

Correct Answer & Explanation

. Triple arthrodesis.

Explanation

The image provided shows a severely deformed foot, consistent with Charcot neuroarthropathy. The patient has severe, rigid, rocker-bottom foot deformity with plantar ulceration and significant midfoot collapse due to Charcot arthropathy secondary to spina bifida. This represents a complex and challenging foot deformity in a neuropathic child.Conservative management (serial casting, orthotics) is generally ineffective for rigid, severe deformities, especially with ulceration, as it cannot correct the underlying bony instability and malalignment. Amputation is a salvage procedure, typically reserved for uncontrolled infection or unbraceable deformities failing all other attempts. Talectomy is primarily used for severe equinus deformity in resistant clubfoot or vertical talus, or for severe hindfoot deformity.For severe, rigid, and unstable Charcot deformities in children, surgical reconstruction and arthrodesis are often necessary to achieve a plantigrade, stable foot that can be braced and protected from ulceration. Triple arthrodesis (fusion of talocalcaneal, talonavicular, and calcaneocuboid joints) is a common reconstructive procedure for such severe hindfoot and midfoot deformities. In cases of significant midfoot collapse (rocker-bottom), the surgical approach may involve a midfoot osteotomy and fusion (e.g., modified midfoot fusion or 'super-reconstruction') to correct the sag and stabilize the arch, often incorporating principles similar to a triple arthrodesis.Rationale for options:A. Serial casting and orthotics are useful for flexible deformities or as an adjunct, but insufficient for a rigid, ulcerated, severe Charcot foot.B. Talectomy is used for severe equinus or fixed vertical talus, but not typically for a comprehensive reconstruction of a collapsed midfoot Charcot deformity.C. Triple arthrodesis (fusion of subtalar, talonavicular, and calcaneocuboid joints) is a workhorse procedure for correcting rigid hindfoot and midfoot deformities, providing stability and a plantigrade foot suitable for bracing. Given the severe collapse and instability, a comprehensive fusion is often required. This is the correct answer.D. Pantalus arthrodesis refers to an ankle and subtalar joint fusion. While relevant for ankle Charcot, the primary deformity described is midfoot collapse, which a triple arthrodesis addresses more directly.E. Supramalleolar osteotomy is for correction of angular deformities of the distal tibia, not the primary treatment for a rigid, multi-joint foot collapse.

Question 2973

Topic: 8. Foot and Ankle
A 35-year-old construction worker presents with chronic, debilitating pain and stiffness in his left ankle following a pilon fracture sustained 5 years ago, treated with ORIF. Radiographs demonstrate severe post-traumatic ankle osteoarthritis with significant joint space narrowing, osteophytes, and subchondral sclerosis. He has failed extensive conservative management, including bracing, NSAIDs, and intra-articular injections. Given his age, activity level, and the severity of his ankle arthritis, what is the most appropriate definitive surgical management?
. Arthroscopic debridement and microfracture.
. Ankle distraction arthroplasty.
. Total ankle arthroplasty (TAA).
. Ankle arthrodesis.
. Supramalleolar osteotomy.

Correct Answer & Explanation

. Total ankle arthroplasty (TAA).

Explanation

For end-stage post-traumatic ankle arthritis in a young, active patient, the choice is between arthrodesis and TAA. While arthrodesis is the traditional gold standard for durability, modern TAA designs have improved, making it an increasingly appropriate option for patients who desire motion preservation. Among the choices provided, TAA is the most appropriate definitive surgical management for motion preservation.

Question 2974

Topic: Midfoot & Hindfoot

A 55-year-old female presents with severe, progressive right foot pain and deformity for 2 years. She has a history of systemic lupus erythematosus (SLE) and chronic steroid use. Clinical examination reveals a fixed, planovalgus foot deformity with a prominence medially. Radiographs demonstrate collapse of the midfoot arch, marked talonavicular subluxation, and degenerative changes, consistent with a severe pes planovalgus deformity with secondary arthritis. What is the MOST appropriate surgical treatment for this rigid, symptomatic deformity in a patient with SLE and chronic steroid use?

. Isolated subtalar arthrodesis.
. Medializing calcaneal osteotomy and flexor digitorum longus (FDL) transfer.
. Triple arthrodesis.
. Lateral column lengthening with a calcaneocuboid fusion.
. Custom orthotics and shoe modifications.

Correct Answer & Explanation

. Triple arthrodesis.

Explanation

The patient presents with severe, rigid, symptomatic pes planovalgus deformity with secondary arthritis, complicated by a history of SLE and chronic steroid use (which can affect bone healing and soft tissue integrity). This is a complex, acquired flatfoot deformity.Conservative measures (orthotics) are typically ineffective for rigid deformities with established arthritis. Isolated subtalar arthrodesis or medializing calcaneal osteotomy with FDL transfer are reconstructive procedures often used for flexible flatfoot or early stages of rigid flatfoot, but they are unlikely to be sufficient for a severe, rigid deformity with talonavicular subluxation and arthritis.For severe, rigid pes planovalgus deformity with significant talonavicular subluxation and secondary arthritis, a triple arthrodesis (fusion of the subtalar, talonavicular, and calcaneocuboid joints) is often the most appropriate and reliable surgical option. It corrects the deformity, provides a stable, pain-free plantigrade foot, and addresses the multi-joint arthritis. The history of SLE and steroid use means attention to wound healing and bone fusion potential is critical, but triple arthrodesis is a proven salvage.Rationale for options:A. Isolated subtalar arthrodesis is for flexible flatfoot or less severe rigid flatfoot primarily affecting the subtalar joint. It would not correct the severe midfoot collapse and talonavicular subluxation.B. Medializing calcaneal osteotomy and FDL transfer are common procedures for flexible flatfoot reconstruction (adult acquired flatfoot deformity) and are insufficient for a rigid deformity with advanced arthritis.C. Triple arthrodesis (fusion of subtalar, talonavicular, and calcaneocuboid joints) is the definitive treatment for severe, rigid pes planovalgus deformity with secondary arthritis. It provides correction, stability, and pain relief. This is the correct answer.D. Lateral column lengthening with a calcaneocuboid fusion is a component of some flatfoot reconstructions but is not a comprehensive solution for a severe, rigid, multi-joint arthritic deformity.E. Custom orthotics and shoe modifications are conservative measures, which have already failed given the chronic and worsening nature of the rigid deformity.

Question 2975

Topic: 8. Foot and Ankle

A 24-year-old equestrian falls from a horse, trapping her foot in the stirrup.

A Lisfranc injury is suspected based on midfoot swelling and plantar ecchymosis. The primary Lisfranc ligament anatomically connects which two osseous structures?

. Medial cuneiform to the base of the second metatarsal
. Lateral cuneiform to the base of the second metatarsal
. Medial cuneiform to the base of the first metatarsal
. Navicular to the base of the second metatarsal

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is an intra-articular ligament that provides vital stability to the midfoot. It courses from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. There is notably no direct ligamentous connection between the first and second metatarsal bases.

Question 2976

Topic: 8. Foot and Ankle

A 35-year-old construction worker falls from a ladder, sustaining an intra-articular calcaneus fracture.

If an extensile lateral approach is utilized for open reduction and internal fixation, which anatomical structure is at highest risk of injury during the elevation of the inferior aspect of the full-thickness flap?

. Sural nerve
. Deep peroneal nerve
. Medial plantar nerve
. Posterior tibial artery

Correct Answer & Explanation

. Sural nerve

Explanation

The extensile lateral approach to the calcaneus involves creating a full-thickness subperiosteal flap. The vertical limb is placed just anterior to the Achilles tendon, and the horizontal limb is roughly at the transition between the glabrous and non-glabrous skin. The sural nerve is at significant risk of being transected or stretched, particularly at the corner and during the inferior horizontal incision.

Question 2977

Topic: 8. Foot and Ankle

A 40-year-old weekend warrior feels a distinct 'pop' in his heel while playing basketball.

A Thompson test is positive, confirming an acute Achilles tendon rupture. If the patient and surgeon agree on nonoperative management, which of the following describes the most appropriate and modern evidence-based protocol?

. Immobilization in strict dorsiflexion for 6 weeks
. Functional rehabilitation with early protected weight-bearing in an equinus cast or boot
. Strict non-weight-bearing in a neutral cast for 8 weeks
. Immediate unrestricted weight-bearing and full range of motion

Correct Answer & Explanation

. Functional rehabilitation with early protected weight-bearing in an equinus cast or boot

Explanation

Modern evidence for nonoperative management of acute Achilles tendon ruptures emphasizes early functional rehabilitation. Protocols involving early protected weight-bearing in an equinus boot/brace have been shown to drastically reduce the risk of deep vein thrombosis and result in re-rupture rates comparable to operative management, without the risks of surgical complications.

Question 2978

Topic: 8. Foot and Ankle

The Lisfranc ligament is a critical structure for midfoot stability. Between which two bones does the primary, most substantial band (interosseous portion) of the Lisfranc ligament course?

. Medial cuneiform and the base of the first metatarsal.
. Medial cuneiform and the base of the second metatarsal.
. Middle cuneiform and the base of the second metatarsal.
. Lateral cuneiform and the cuboid.
. Navicular and the medial cuneiform.

Correct Answer & Explanation

. Medial cuneiform and the base of the second metatarsal.

Explanation

The Lisfranc ligament is an interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. There is no direct intermetatarsal ligament between the first and second metatarsal bases, making the Lisfranc ligament the critical stabilizer linking the medial and central columns of the foot.

Question 2979

Topic: 8. Foot and Ankle

A 45-year-old poorly controlled diabetic patient presents with an acutely swollen, erythematous, and warm right foot. There are no open ulcers. Radiographs demonstrate periarticular debris, fragmentation, and subluxation at the tarsometatarsal joints. What is the most appropriate initial management?

. Immediate operative debridement and arthrodesis
. Intravenous antibiotics and MRI of the foot
. Strict non-weight bearing in a total contact cast
. Prescription of custom orthotics with a rigid sole
. Corticosteroid injection into the affected joints

Correct Answer & Explanation

. Strict non-weight bearing in a total contact cast

Explanation

The patient is presenting with acute Eichenholtz Stage 1 (developmental) Charcot arthropathy. The gold standard for initial management is immobilization and offloading, typically achieved with a total contact cast, to prevent further deformity while the acute inflammation subsides.

Question 2980

Topic: 8. Foot and Ankle

A 24-year-old football player sustains a hyperplantarflexion injury to his midfoot. Radiographs show a 3 mm diastasis between the base of the first and second metatarsals. He is diagnosed with a purely ligamentous Lisfranc injury. What is the currently recommended surgical treatment for this specific type of injury?

. Closed reduction and percutaneous pinning.
. Open reduction and internal fixation (ORIF) with transarticular screws.
. Open reduction and internal fixation (ORIF) with dorsal bridge plating.
. Primary arthrodesis of the first, second, and third tarsometatarsal joints.
. Non-weight bearing cast immobilization for 6 weeks.

Correct Answer & Explanation

. Primary arthrodesis of the first, second, and third tarsometatarsal joints.

Explanation

For purely ligamentous Lisfranc injuries, level I evidence suggests that primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) results in better functional outcomes and a lower rate of hardware removal or reoperation compared to ORIF. Bony Lisfranc injuries, however, are typically treated with ORIF.

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