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 3781
Topic: 8. Foot and Ankle
A 30-year-old male presents to the trauma bay following a high-speed motorcycle crash with a grossly deformed left knee. The joint is urgently reduced. Post-reduction, the distal pulses are palpable but symmetric, and the Ankle-Brachial Index (ABI) is calculated to be 0.8. What is the most appropriate next step in management?
Correct Answer & Explanation
. Discharge with urgent outpatient orthopedic follow-up
Explanation
An ABI less than 0.9 in the setting of a knee dislocation is highly suspicious for a popliteal artery injury. A CT angiogram is indicated to evaluate the vascular status comprehensively before proceeding with surgical intervention or observation.
Question 3782
Topic: 8. Foot and Ankle
A 30-year-old unrestrained driver is brought to the trauma bay after a motor vehicle collision. He has a grossly deformed knee which is quickly reduced. Post-reduction, distal pulses are palpable, but the Ankle-Brachial Index (ABI) is calculated to be 0.8. What is the most appropriate next step in management?
Correct Answer & Explanation
. Immediate discharge with a hinged knee brace
Explanation
Following a knee dislocation, an ABI less than 0.9 is highly concerning for a popliteal artery injury, even if palpable pulses return. A CT angiogram is urgently indicated to evaluate for an intimal flap, occlusion, or active extravasation.
Question 3783
Topic: 8. Foot and Ankle
Figures 28a through 28d show the radiographs and MRI scans of a 20-year-old basketball player who sustained an inversion injury to his right ankle. Management should consist of
Correct Answer & Explanation
. open reduction and internal fixation.
Explanation
Osteochondral fractures involving the talar dome have been classified based on radiographic and MRI findings. A nondisplaced and incomplete fracture may be treated effectively with a short leg cast and no weight bearing for 6 weeks. This patient has a complete, separated, and displaced osteochondral fragment involving the midlateral talar dome that will most likely cause pain, mechanical symptoms, and effusion if treated nonsurgically. In addition, there is very little bone remaining on the fragment, making the likelihood of healing with open reduction and internal fixation problematic. The treatment of choice includes arthroscopy, removal of the loose fragment, curettage or drilling of the base, and a rehabilitation program that emphasizes peroneal strengthening, range of motion, and proprioceptive training. Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 205-226.
Question 3784
Topic: 8. Foot and Ankle
A 28-year-old professional hockey player sustains an inversion ankle injury. He has tenderness over the anterior inferior tibiofibular ligament (AITFL) and proximal fibula. Which test is most specific for diagnosing a syndesmotic injury in this patient?
Correct Answer & Explanation
. External rotation stress test
Explanation
The external rotation stress test is considered the most reliable and specific clinical test for evaluating the integrity of the distal tibiofibular syndesmosis. The squeeze test has high specificity but lower sensitivity.
Question 3785
Topic: 8. Foot and Ankle
A 34-year-old recreational basketball player sustains an acute Achilles tendon rupture. He opts for nonoperative management with a functional rehabilitation protocol. Compared to operative repair, which of the following is true regarding his clinical outcomes?
Correct Answer & Explanation
. Higher risk of deep vein thrombosis
Explanation
Historically, nonoperative management of Achilles tendon ruptures has a slightly higher re-rupture rate compared to operative repair, though functional rehab protocols have narrowed this gap. Operative management has a higher risk of wound complications.
Question 3786
Topic: 8. Foot and Ankle
A 20-year-old gymnast complains of persistent deep ankle pain following an injury 6 months ago. MRI reveals a 1.5 cm osteochondral lesion on the posteromedial aspect of the talar dome. What is the classic mechanism of injury associated with this specific lesion location?
Correct Answer & Explanation
. Inversion and plantarflexion
Explanation
Osteochondral lesions of the talus follow the "DIAL a PIMP" mnemonic: Dorsiflexion Inversion causes Anterior Lateral lesions, whereas Plantarflexion Inversion causes Medial Posterior lesions. Medial lesions are typically larger, deeper, and more commonly non-traumatic or insidious.
Question 3787
Topic: 8. Foot and Ankle
A 26-year-old downhill skier sustains a forceful dorsiflexion and eversion injury to the right ankle. He now complains of a painful popping sensation over the lateral malleolus when circumducting the foot. Injury to which of the following structures is responsible for his symptoms?
Correct Answer & Explanation
. Anterior talofibular ligament (ATFL)
Explanation
The superior peroneal retinaculum (SPR) is the primary restraint against peroneal tendon subluxation. Injury to the SPR, typically via forced dorsiflexion and eversion with reflex peroneal contraction, allows the tendons to snap over the lateral malleolus.
Question 3788
Topic: 8. Foot and Ankle
A 30-year-old male recreational hockey player is evaluated for an ankle injury. Exam shows tenderness over the anterior inferior tibiofibular ligament (AITFL) and a positive external rotation stress test. Radiographs show a widened medial clear space. What is the most appropriate next step?
Correct Answer & Explanation
. Functional bracing and early weight-bearing
Explanation
A syndesmotic injury with a widened medial clear space indicates dynamic or static instability of the ankle mortise. Operative reduction and stabilization (e.g., screw or suture button fixation) are required to prevent rapid post-traumatic arthritis.
Question 3789
Topic: 8. Foot and Ankle
A 45-year-old weekend warrior sustains an acute Achilles tendon rupture. He elects for non-operative management. What is the most critical component of his rehabilitation to ensure outcomes comparable to surgical repair?
Correct Answer & Explanation
. Strict immobilization in a cast for 8 weeks
Explanation
Recent studies show that non-operative management with early functional rehabilitation yields re-rupture rates and functional outcomes similar to operative repair. This protocol avoids surgical complications like wound necrosis and nerve injury.
Question 3790
Topic: 8. Foot and Ankle
A 22-year-old gymnast complains of deep, aching posteromedial ankle pain. MRI shows an osteochondral lesion of the talus (OLT) on the posteromedial dome. Which mechanism of injury is most classically associated with this specific lesion location?
Correct Answer & Explanation
. Inversion and dorsiflexion
Explanation
Posteromedial osteochondral lesions of the talus are classically caused by an inversion and plantarflexion injury. They are typically deeper and cup-shaped compared to anterolateral lesions, which are often shallow and caused by inversion and dorsiflexion.
Question 3791
Topic: 8. Foot and Ankle
A 32-year-old runner has chronic heel pain localized to the insertion of the Achilles tendon. Conservative treatment has failed. MRI shows a Haglund's deformity and insertional Achilles tendinopathy with calcification. If surgery is performed involving detachment and reattachment of the Achilles, what structure is most at risk during the lateral exposure?
Correct Answer & Explanation
. Tibial nerve
Explanation
The sural nerve courses distally along the posterolateral aspect of the calf and ankle. It is at significant risk of iatrogenic injury during lateral surgical approaches to the Achilles tendon and calcaneal tuberosity.
Question 3792
Topic: 8. Foot and Ankle
A 26-year-old female dancer has chronic lateral ankle instability despite 6 months of physical therapy. She undergoes a modified Broström-Gould procedure. Which anatomic structure is advanced and attached to the fibula to augment the repair in the Gould modification?
Correct Answer & Explanation
. Inferior extensor retinaculum
Explanation
The Broström-Gould modification involves mobilizing and advancing the inferior extensor retinaculum to the distal fibula. This reinforces the primary anatomic repair of the anterior talofibular and calcaneofibular ligaments, improving overall stability.
Question 3793
Topic: 8. Foot and Ankle
A 21-year-old collegiate football player sustains a rotational ankle injury. Examination reveals tenderness over the anterior inferior tibiofibular ligament and a positive squeeze test. Gravity stress radiographs demonstrate 6 mm of medial clear space widening. What is the best management?
Correct Answer & Explanation
. Syndesmotic screw fixation or flexible suture-button construct
Explanation
Medial clear space widening on stress radiographs indicates a dynamically unstable syndesmosis injury. Operative fixation with syndesmotic screws or a flexible suture-button construct is required to restore and maintain the syndesmosis.
Question 3794
Topic: 8. Foot and Ankle
A 32-year-old male sustains an acute Achilles tendon rupture. When comparing nonoperative management utilizing early functional rehabilitation to operative repair, which of the following statements is true?
Correct Answer & Explanation
. Nonoperative management has a significantly higher re-rupture rate with modern protocols
Explanation
Recent high-quality literature demonstrates that with early functional rehabilitation, re-rupture rates are similar between operative and nonoperative management. However, operative repair carries a significantly higher risk of soft-tissue and wound complications.
Question 3795
Topic: 8. Foot and Ankle
A 30-year-old skier sustains a traumatic knee dislocation.
The knee is urgently reduced in the emergency department. The ankle-brachial index (ABI) is subsequently measured at 0.8. What is the most appropriate next step in management?
Correct Answer & Explanation
. Observation with serial examinations
Explanation
An ABI less than 0.9 following a knee dislocation is highly suggestive of a vascular injury. CT angiography is the standard of care to accurately diagnose and localize popliteal artery injuries before potential surgical intervention.
Question 3796
Topic: 8. Foot and Ankle
A 42-year-old recreational tennis player feels a sharp "pop" in his posterior heel.
The Thompson test is positive. He elects for nonoperative management of his acute Achilles tendon rupture. Which rehabilitation protocol yields re-rupture rates most comparable to surgical repair?
Correct Answer & Explanation
. Cast immobilization in equinus for 8 weeks
Explanation
Recent studies demonstrate that early functional rehabilitation protocols (including early protected weight-bearing and range of motion) for nonoperatively managed Achilles ruptures result in re-rupture rates comparable to surgical repair. Traditional prolonged immobilization carries higher re-rupture and complication rates.
Question 3797
Topic: 8. Foot and Ankle
An obese 35-year-old male sustains a low-velocity knee dislocation following a fall. After successful closed reduction, vascular evaluation reveals an Ankle-Brachial Index (ABI) of 0.8. What is the most appropriate next step in management?
Correct Answer & Explanation
. Immediate application of a spanning external fixator
Explanation
An ABI less than 0.9 following a knee dislocation is highly suspicious for a vascular injury and mandates advanced imaging, typically CT angiography, to evaluate the popliteal artery.
Question 3798
Topic: 8. Foot and Ankle
A 28-year-old male is evaluated following a traumatic posterior knee dislocation that was immediately reduced in the emergency department. His foot is warm and well-perfused, but the Ankle-Brachial Index (ABI) of the injured extremity is 0.82. What is the most appropriate next step in management?
Correct Answer & Explanation
. Serial physical examinations every 4 hours
Explanation
An ABI < 0.90 after a knee dislocation signifies a high risk for an intimal tear or vascular injury requiring intervention. CT angiography (or traditional arteriography) is urgently indicated to confirm and localize the popliteal artery lesion.
Question 3799
Topic: 8. Foot and Ankle
A 25-year-old male is evaluated in the trauma bay following a high-velocity anterior knee dislocation. The knee is reduced, but the ankle-brachial index (ABI) is 0.8. What is the most appropriate next step in management?
Correct Answer & Explanation
. Observation and repeat ABI in 4 hours
Explanation
An ABI of less than 0.9 following a knee dislocation is highly suspicious for a popliteal artery injury. This mandates immediate advanced imaging, typically a CT angiogram, to accurately delineate the vascular injury before potential surgical intervention.
Question 3800
Topic: 8. Foot and Ankle
A 30-year-old motorcyclist sustains a traumatic high-velocity knee dislocation. Following emergent closed reduction in the trauma bay, ankle-brachial indices (ABI) are measured at 0.8. What is the next most appropriate step in management?
Correct Answer & Explanation
. Discharge with close outpatient clinical follow-up
Explanation
An ABI less than 0.9 following a knee dislocation is highly suspicious for a popliteal artery injury. Emergent CT angiography or immediate vascular surgery consultation is required to evaluate for an intimal flap or complete occlusion.
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