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8. Foot and Ankle MCQs

Practice Set 262 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 5221

Topic: 8. Foot and Ankle

When performing a syndesmotic fixation, which statement regarding screw removal is generally accepted as standard practice?

. Syndesmotic screws should never be removed.
. Syndesmotic screws are always removed after 6-8 weeks, regardless of healing.
. Syndesmotic screws are removed only if symptomatic or before full weight-bearing on the ankle.
. Syndesmotic screws are removed after bony union of the fracture and before full weight-bearing on the ankle, typically 8-12 weeks.
. Syndesmotic screws are left in place if they are bioabsorbable.

Correct Answer & Explanation

. Syndesmotic screws are removed after bony union of the fracture and before full weight-bearing on the ankle, typically 8-12 weeks.

Explanation

Syndesmotic screws are typically removed once the primary fracture has healed and the syndesmosis has had time to stabilize, usually around 8-12 weeks post-operatively. This is done to prevent screw breakage (due to cyclical loading as the bone heals and moves) and to allow for normal physiological motion of the ankle mortise during full weight-bearing, which can be restricted by the rigid position screw. While removal can be considered if symptomatic earlier, routine removal is preferred prior to full, unprotected weight-bearing. Bioabsorbable screws, if used, would obviate the need for removal.

Question 5222

Topic: 8. Foot and Ankle

In the evaluation of a suspected Lisfranc injury, the 'fleck sign' on a standard AP radiograph of the foot represents an avulsion fracture originating from which anatomical structure?

. Plantar aspect of the first cuneiform
. Base of the second metatarsal
. Base of the first metatarsal
. Dorsal aspect of the navicular
. Cuboid

Correct Answer & Explanation

. Base of the second metatarsal

Explanation

The 'fleck sign' is a pathognomonic avulsion fracture occurring at the attachment of the Lisfranc ligament at the medial base of the second metatarsal. The ligament courses from the medial cuneiform to the base of the second metatarsal.

Question 5223

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a warm, swollen, erythematous foot without ulceration. Radiographs show extensive fragmentation, periarticular debris, and subluxation of the midfoot joints. According to the Eichenholtz classification, what stage of Charcot arthropathy does this represent?

. Stage 0 (High risk)
. Stage 1 (Development/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Reconstruction/Consolidation)
. Stage 4 (Ulceration)

Correct Answer & Explanation

. Stage 1 (Development/Fragmentation)

Explanation

Eichenholtz Stage 1 (Development/Fragmentation) is characterized clinically by a warm, red, swollen foot and radiographically by joint subluxation/dislocation, bone fragmentation, and debris. Stage 2 (Coalescence) shows absorption of fine debris and early fusion. Stage 3 (Reconstruction) shows rounding of bone ends and solid arthrodesis.

Question 5224

Topic: 8. Foot and Ankle

A patient with an ankle fracture treated with a syndesmotic screw complains of persistent pain and stiffness 6 months post-operatively, after full weight-bearing. Radiographs show no loss of reduction. What is the most likely cause of their symptoms?

. Failure of the syndesmotic screw due to corrosion.
. Loosening of the syndesmotic screw requiring re-tightening.
. Over-compression of the syndesmosis, limiting normal ankle motion.
. Non-union of the associated fibular fracture.
. Development of heterotopic ossification around the screw.

Correct Answer & Explanation

. Over-compression of the syndesmosis, limiting normal ankle motion.

Explanation

Syndesmotic screws are often removed between 6-12 weeks or before full weight-bearing, particularly if they are bicortical and non-locking. Persistent pain and stiffness 6 months after full weight-bearing, with no loss of reduction, strongly suggests that the syndesmotic screw is restricting the normal physiological motion (slight widening during dorsiflexion) of the ankle mortise. This over-compression can lead to pain and stiffness. While loosening (B) can occur, it's typically associated with instability. Corrosion (A) is rare. Non-union (D) would usually be evident on imaging or clinical instability. Heterotopic ossification (E) can occur but is less common as a primary cause ofallsymptoms here.

Question 5225

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male with severe peripheral neuropathy presents with a rapidly developing, painless swelling and erythema of his left midfoot. Radiographs show disorganization, fragmentation, and subluxation of the tarsometatarsal joints, with significant bone destruction but no overt signs of infection. ESR and CRP are mildly elevated. What is the most crucial initial management strategy?

. Urgent surgical fusion of the midfoot joints.
. Non-weight-bearing in a total contact cast (TCC) or removable walker boot.
. Aggressive antibiotic therapy.
. Biopsy of the affected joints to rule out osteomyelitis.
. Physical therapy to maintain range of motion.

Correct Answer & Explanation

. Non-weight-bearing in a total contact cast (TCC) or removable walker boot.

Explanation

The patient's presentation (diabetic neuropathy, painless swelling, erythema, rapid onset, radiographic changes of disorganization/fragmentation without infection) is classic for acute Charcot arthropathy (Eichenholtz Stage 1). The paramount initial management is strict non-weight-bearing and immobilization in a total contact cast (TCC) or a custom removable walker boot (CROW boot) to protect the collapsing foot and prevent further destruction. Urgent surgical fusion (A) is typically reserved for stable, chronic deformities or acute unstable fractures that cannot be controlled non-operatively. Aggressive antibiotics (C) are not indicated unless infection is proven. While ruling out osteomyelitis (D) can be important, it's usually secondary to clinical suspicion and imaging, and the primary management for acute Charcot remains immobilization. Physical therapy (E) is contraindicated in the acute phase due to the risk of exacerbating joint destruction.

Question 5226

Topic: 8. Foot and Ankle

A 58-year-old diabetic male presents with a warm, swollen, erythematous right foot and ankle, which he attributes to a minor twist several weeks ago. Radiographs show disorganization of the midfoot joints, fragmentation, and new bone formation. He has a history of peripheral neuropathy. His ESR is 45 mm/hr and CRP is 2.5 mg/L. Which of the following is the most appropriate initial management strategy?

. Emergent surgical debridement and fusion to rule out infection.
. Total contact cast (TCC) and strict non-weight bearing.
. Oral antibiotics (e.g., ciprofloxacin) for 6 weeks.
. Corticosteroid injections into the affected joints.
. Amputation due to severe joint destruction.

Correct Answer & Explanation

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

Explanation

This clinical scenario describes acute Charcot neuroarthropathy (often correlating with Eichenholtz Stage I-II). The key features are a diabetic patient with peripheral neuropathy, an acute inflammatory presentation (warm, swollen, erythematous), and specific radiographic changes (joint disorganization, fragmentation, new bone formation). While infection can mimic Charcot, the ESR and CRP, while mildly elevated, are not typically as high as in acute osteomyelitis, and there are no other overt signs of infection. The cornerstone of acute Charcot management is immediate immobilization and strict non-weight bearing to protect the foot from further destruction and promote healing. This is most effectively achieved with a total contact cast (TCC), which provides offloading and protection. Emergent surgery (Option A) is typically reserved for severe deformity in the reconstructive phase or definitive infection. Antibiotics (Option C) are inappropriate without confirmed infection. Corticosteroids (Option D) are contraindicated. Amputation (Option E) is a salvage procedure for severe, uncorrectable deformity or uncontrolled infection, not initial management.

Question 5227

Topic: 8. Foot and Ankle

A neonate is diagnosed with arthrogryposis multiplex congenita (AMC) involving all four extremities. Clinical examination reveals bilateral clubfeet, fixed knee flexion contractures, hip dislocations, and severe wrist and elbow contractures. After initial conservative management for the clubfeet and passive stretching, what is generally considered the most crucial initial surgical priority in a patient with diffuse AMC to maximize functional independence in the early years?

. Bilateral hip reduction
. Serial casting and Achilles tenotomy for clubfeet
. Release of severe elbow flexion contractures to facilitate self-feeding
. Correction of severe knee flexion contractures to achieve plantigrade foot placement
. Surgical correction of wrist deformities for improved grasp

Correct Answer & Explanation

. Release of severe elbow flexion contractures to facilitate self-feeding

Explanation

In patients with diffuse arthrogryposis multiplex congenita, surgical priorities often focus on enabling crucial activities of daily living. While all listed interventions are important, improving elbow function (specifically achieving sufficient extension to facilitate self-feeding and hygiene) is frequently prioritized in the early stages as it significantly impacts a child's ability to achieve independence in basic self-care. Hip and knee surgeries are often delayed or considered after upper limb function is addressed, and clubfoot management, though initiated early, is often non-surgical initially.

Question 5228

Topic: 8. Foot and Ankle

A 55-year-old diabetic patient presents with a severely deformed midfoot, warmth, erythema, and swelling, but no open wounds or signs of systemic infection. Radiographs show extensive osteolysis, fragmentation, and dislocation of the tarsometatarsal joints, consistent with Charcot neuroarthropathy (Eichenholtz Stage II - Coalescence). Despite immobilization in a total contact cast for 3 months, the deformity progresses. What is the most appropriate next step in management?

. Immediate surgical correction and internal fixation
. Transition to a custom ankle-foot orthosis (AFO) and weight-bearing
. Continue total contact casting with closer monitoring
. Non-weight-bearing in a CAM walker
. Bisphosphonate therapy to reduce osteoclast activity

Correct Answer & Explanation

. Immediate surgical correction and internal fixation

Explanation

In Charcot neuroarthropathy, Eichenholtz Stage II (coalescence) is characterized by resorption of acute inflammation and early bone healing, but progressive deformity can still occur, especially if instability is severe. If conservative management with total contact casting fails to stabilize the deformity and it continues to progress, particularly when the deformity threatens skin integrity or future ambulation, surgical correction and stable internal or external fixation become necessary. Surgical goals include correcting deformity, achieving stability, and creating a plantigrade foot. Transitioning to an AFO or CAM walker is appropriateafterthe acute phase and stabilization, not if the deformity is actively progressing. Bisphosphonates may have a role in the acute inflammatory phase (Stage 0/I) but are not the primary treatment for progressive mechanical deformity.

Question 5229

Topic: 8. Foot and Ankle

A 60-year-old female presents with severe forefoot pain, multiple plantar ulcerations under the metatarsal heads, and a 'rocker-bottom' deformity of the forefoot. She has severe hallux valgus, lesser toe deformities (hammer/claw toes), and metatarsalgia with subluxation of the MTP joints. Plain radiographs show a positive Tomeno-Langerhans sign (MTP joint subluxation with relative sparing of the joint space in early stages). What is the most likely diagnosis, and what surgical principle should guide correction?

. Rheumatoid arthritis; MTP joint resections/arthroplasties and 1st MTP fusion
. Diabetic neuropathic arthropathy; non-weight bearing and custom orthotics
. Freiberg's infraction; isolated metatarsal head resection
. Hallux rigidus; cheilectomy
. Chronic Lisfranc injury; midfoot fusion

Correct Answer & Explanation

. Rheumatoid arthritis; MTP joint resections/arthroplasties and 1st MTP fusion

Explanation

The constellation of symptoms and signs (severe forefoot pain, multiple plantar ulcerations, 'rocker-bottom' deformity, severe hallux valgus, lesser toe deformities, MTP subluxation, and the Tomeno-Langerhans sign) is characteristic of advanced rheumatoid forefoot disease. Surgical management typically involves correcting the deformities, often through metatarsal head resections, MTP arthroplasties (for lesser toes), and fusion of the first MTP joint (e.g., Lapidus procedure or MTP fusion) to stabilize the medial column and prevent recurrence of the hallux valgus and address the forefoot splay. Diabetic neuropathic arthropathy (Charcot) usually involves the midfoot or hindfoot more severely, and while it can cause ulcers, the specific pattern points more to RA. Freiberg's is osteonecrosis of a single metatarsal head.

Question 5230

Topic: 8. Foot and Ankle
A 60-year-old diabetic patient with peripheral neuropathy presents with a chronic, non-healing plantar ulcer over a rocker-bottom deformity of the midfoot due to Charcot neuroarthropathy (Eichenholtz stage II/III). Conservative management with offloading has failed to heal the ulcer. Which of the following is the most appropriate surgical intervention?
. Custom accommodative orthosis with further offloading.
. Local debridement of the ulcer and antibiotic therapy.
. Midfoot arthrodesis with internal fixation for deformity correction and stability.
. Exostectomy of prominent bone to reduce pressure.
. Transmetatarsal amputation.

Correct Answer & Explanation

. Midfoot arthrodesis with internal fixation for deformity correction and stability.

Explanation

For Charcot neuroarthropathy with a significant rocker-bottom deformity and chronic ulceration that has failed conservative management, surgical reconstruction via midfoot arthrodesis is the most appropriate definitive treatment. This aims to correct the deformity, achieve a stable, plantigrade foot, and allow for ulcer healing, thereby preventing limb loss. Exostectomy alone may reduce pressure points but typically does not address the underlying instability and progressive deformity. Offloading has already proven insufficient. Amputation is a salvage procedure for uncontrolled infection or unsalvageable limbs.

Question 5231

Topic: 8. Foot and Ankle

A 60-year-old female presents with progressive forefoot pain and deformity. Clinical examination reveals a 'rocker-bottom' deformity of the foot, severe hallux valgus, hammer toes, and a prominent plantar aspect of the midfoot. Sensation is decreased in a stocking-glove distribution, and vibratory perception is absent. Radiographs confirm midfoot collapse with significant disorganization and fragmentation of the tarsometatarsal joints. There is no evidence of infection. What is the most critical initial management step for this condition?

. Prescribe broad-spectrum antibiotics and elevate the limb.
. Surgical correction with arthrodesis of the tarsometatarsal joints.
. Initiate aggressive vascular assessment and revascularization if needed.
. Strict non-weight-bearing in a total contact cast or specialized offloading boot.
. Prescribe custom orthotics and physical therapy for gait training.

Correct Answer & Explanation

. Strict non-weight-bearing in a total contact cast or specialized offloading boot.

Explanation

This patient presents with classic signs and symptoms of Charcot neuroarthropathy of the foot (midfoot collapse, 'rocker-bottom' deformity, neuropathy, history of diabetes suggested by sensory loss). The most critical initial management step for an acute or subacute Charcot foot (even without active infection or ulceration, as in this case) is strict non-weight-bearing and immobilization in a total contact cast (TCC) or specialized offloading boot. This is essential to prevent further bony collapse and deformity, reduce inflammation, and allow for bone healing (the 'C' phase of Eichenholtz). Antibiotics (Option A) are only indicated for infection. Surgical correction (Option B) is generally reserved for stable, severe deformities that cannot be accommodated by bracing, or for failed conservative treatment, and is contraindicated in the acute inflammatory phase. Vascular assessment (Option C) is important but offloading takes precedence for joint preservation in Charcot. Custom orthotics (Option E) are for chronic, stable deformities and are insufficient in the acute phase.

Question 5232

Topic: 8. Foot and Ankle

A 22-year-old male sustains a severe ankle injury during a fall, leading to an open fracture-dislocation. Radiographs show a talar body fracture with significant comminution and displacement, and extrusion of the talus. The foot is pulseless, and the skin is severely devitalized. What is the most appropriate management in this acute setting?

. Emergency open reduction and internal fixation of the talus followed by vascular repair.
. Immediate closed reduction and immobilization, followed by revascularization.
. Urgent debridement, administration of broad-spectrum antibiotics, and exploration for vascular injury, with consideration for primary talectomy and ankle arthrodesis or primary amputation.
. Long-term intravenous antibiotics with external fixation to preserve the talus.
. Observation and delayed management after the soft tissues improve.

Correct Answer & Explanation

. Urgent debridement, administration of broad-spectrum antibiotics, and exploration for vascular injury, with consideration for primary talectomy and ankle arthrodesis or primary amputation.

Explanation

This is a devastating ankle injury involving an extruded talar body fracture, vascular compromise (pulseless foot), and severe soft tissue devitalization. These are critical factors that often contraindicate attempts at talar salvage. The priority is limb viability and infection control. Urgent surgical debridement of contaminated tissues, broad-spectrum antibiotics, and aggressive exploration for vascular injury (Option C) are paramount. Given the severe nature, particularly the extrusion, comminution, and vascular compromise, the talus is often non-viable or too severely damaged for successful reconstruction. In such cases, options like primary talectomy with tibiocalcaneal arthrodesis (a form of ankle fusion) or even primary amputation must be considered to save the limb or life, especially if revascularization is not feasible or the talus is too damaged to be reimplanted. Options A and B are not appropriate given the severe open nature, extrusion, and vascular compromise. Options D and E are inadequate for an acute, limb-threatening injury.

Question 5233

Topic: 8. Foot and Ankle

A 55-year-old male with long-standing poorly controlled Type 2 diabetes presents with a chronically painful, deformed right foot characterized by a 'rocker-bottom' deformity, prominent plantar ulceration beneath the midfoot, and radiographic evidence of fragmentation, sclerosis, and bony proliferation of the tarsometatarsal joints (Lisfranc region) consistent with Charcot neuroarthropathy. He has failed conservative management including total contact casting. Which surgical intervention is most appropriate at this stage?

. Percutaneous plantar fascia release.
. Exostectomy of the prominent plantar bone.
. Midfoot arthrodesis with internal fixation.
. Below-knee amputation.
. Open reduction and internal fixation of individual fragmented bones.

Correct Answer & Explanation

. Midfoot arthrodesis with internal fixation.

Explanation

The patient presents with advanced Charcot neuroarthropathy (rocker-bottom deformity, chronic plantar ulceration, radiographic changes) in the midfoot, refractory to conservative management. Percutaneous plantar fascia release (A) is for plantar fasciitis, not Charcot. Exostectomy of the prominent plantar bone (B) might relieve pressure and heal the ulcer temporarily, but it does not address the underlying instability and progressive deformity, often leading to recurrence of the ulcer or new ulcers. Below-knee amputation (D) is a last resort, usually reserved for unmanageable infection, severe intractable pain, or uncontrollable deformity despite reconstructive efforts, which is not indicated as themost appropriate initial surgical interventionhere. Open reduction and internal fixation of individual fragmented bones (E) is generally not feasible or effective in Charcot foot due to severe osteopenia, bone fragmentation, and underlying neuropathy, which compromise fixation and healing.Midfoot arthrodesis with internal fixation(C) is the most appropriate surgical intervention for a stable, plantigrade foot in Charcot neuroarthropathy with rocker-bottom deformity and recurrent ulceration that has failed conservative care. This procedure aims to correct the deformity, stabilize the joints, and create a stable, fusable platform to redistribute plantar pressure and facilitate ulcer healing, thereby preserving the limb.

Question 5234

Topic: Midfoot & Hindfoot

A 58-year-old female presents with recurrent right foot and ankle pain, progressively worsening over 5 years. She has a history of type 2 diabetes with peripheral neuropathy. Clinical examination reveals a fixed, rigid planovalgus deformity with a 'rocker-bottom' foot, severe midfoot collapse, and significant hindfoot abduction. Radiographs show extensive disorganization of the midfoot joints, fragmentation, and new bone formation. This presentation is most consistent with what stage of Charcot arthropathy and what is the primary surgical goal?

. Eichenholtz Stage 0; pain relief.
. Eichenholtz Stage 1 (Acute/Development); immobilization.
. Eichenholtz Stage 2 (Coalescence); offloading.
. Eichenholtz Stage 3 (Reconstruction/Consolidation); correction of deformity and stabilization.
. Eichenholtz Stage 4 (Reactivation); antibiotic therapy.

Correct Answer & Explanation

. Eichenholtz Stage 3 (Reconstruction/Consolidation); correction of deformity and stabilization.

Explanation

The clinical and radiographic findings of a fixed, rigid rocker-bottom foot with severe midfoot collapse and extensive joint disorganization, fragmentation, and new bone formation are characteristic of Eichenholtz Stage 3 (Reconstruction/Consolidation) Charcot arthropathy. At this stage, the primary surgical goal is to correct the severe deformity and achieve stable bony union, which often requires complex reconstructive procedures such as osteotomy, arthrodesis, and robust internal fixation. Stage 0 is preclinical. Stage 1 is acute, characterized by inflammation and joint effusion, requiring immobilization. Stage 2 is coalescence, where fragments begin to heal, still primarily requiring offloading. Stage 4 is not a standard Eichenholtz stage but refers to reactivation of disease, requiring re-evaluation. While offloading is always important for Charcot, the fixed deformity and chronic nature points to Stage 3 and the need for stabilization.

Question 5235

Topic: 8. Foot and Ankle

A 60-year-old male with a history of Type 2 diabetes and chronic renal failure develops left foot pain and swelling. Radiographs show significant bone resorption in the forefoot, with a 'pencil-in-cup' deformity of the MTP joints. Blood tests reveal elevated parathyroid hormone levels and normal calcium. What is the most likely diagnosis?

. Diabetic osteoarthropathy.
. Gout.
. Rheumatoid arthritis.
. Secondary hyperparathyroidism with osteitis fibrosa cystica.
. Psoriatic arthritis.

Correct Answer & Explanation

. Secondary hyperparathyroidism with osteitis fibrosa cystica.

Explanation

The combination of chronic renal failure, elevated parathyroid hormone, and specific radiographic findings of bone resorption (e.g., 'pencil-in-cup' deformity, subperiosteal resorption in phalanges, tuft resorption), particularly in the forefoot, is highly suggestive of secondary hyperparathyroidism with osteitis fibrosa cystica. While diabetic osteoarthropathy (Charcot foot) can cause foot deformity, the 'pencil-in-cup' and elevated PTH point specifically to hyperparathyroidism. Gout and rheumatoid arthritis have different radiographic features and underlying pathophysiology. Psoriatic arthritis can have 'pencil-in-cup' but PTH is not typically elevated. Therefore, secondary hyperparathyroidism is the most fitting diagnosis.

Question 5236

Topic: Midfoot & Hindfoot
A 68-year-old female presents with severe, progressive adult acquired flatfoot deformity (AAFD) of her left foot. Clinical examination reveals a rigid hindfoot valgus, abduction of the forefoot, and inability to perform a single-limb heel rise. Radiographs confirm severe talonavicular collapse and midfoot break. This presentation corresponds to what stage of Johnson & Strom classification, and what is the generally accepted surgical management?
. Stage I; Tenosynovectomy of posterior tibial tendon.
. Stage II; FDL transfer to navicular + calcaneal osteotomy.
. Stage III; Triple arthrodesis.
. Stage IV; Isolated subtalar arthrodesis.
. Stage II; Lateral column lengthening.

Correct Answer & Explanation

. Stage III; Triple arthrodesis.

Explanation

The description of rigid hindfoot valgus, forefoot abduction, inability to perform a single-limb heel rise (indicating posterior tibial tendon dysfunction), and talonavicular collapse with midfoot break in an elderly patient is consistent with Stage III AAFD (flexible deformity with fixed hindfoot valgus, severe forefoot abduction, and rigid changes in the talonavicular joint). For Stage III AAFD, the deformity is rigid, and reconstructive procedures like tendon transfers and osteotomies alone are often insufficient. Triple arthrodesis (fusion of the talonavicular, subtalar, and calcaneocuboid joints) is the generally accepted surgical management to correct the deformity and provide stable fusion, allowing the patient to bear weight on a corrected, stable foot. Stage I and II are flexible, managed with more conservative or joint-preserving surgeries. Stage IV involves ankle involvement. Lateral column lengthening is usually part of a Stage II reconstruction.

Question 5237

Topic: 8. Foot and Ankle

A 55-year-old diabetic male presents with an acutely swollen, red, warm, and painful left foot, but denies any recent trauma. Radiographs show early fragmentation and disorganization of the midfoot joints. He has peripheral neuropathy. Which of the following is the most critical initial management step for this suspected Charcot neuroarthropathy?

. Immediate surgical fusion
. Aggressive intravenous antibiotics
. Non-weight bearing and total contact casting
. Corticosteroid injection into the affected joints
. Amputation of the affected limb

Correct Answer & Explanation

. Non-weight bearing and total contact casting

Explanation

The most critical initial management for acute Charcot neuroarthropathy is strict offloading and immobilization of the affected limb to protect the fragile and unstable joints from further destruction. This is most effectively achieved with a total contact cast (TCC) or a controlled ankle motion (CAM) walker, ensuring complete non-weight bearing. Surgical fusion is typically reserved for later stages after the acute inflammatory phase has subsided and a stable deformity needs correction. Antibiotics are only indicated if a superimposed infection is present. Corticosteroid injections are contraindicated. Amputation is a salvage procedure for severe, uncontrollable deformity or infection.

Question 5238

Topic: 8. Foot and Ankle
A 50-year-old obese female presents with progressive flattening of her left foot, pain along the medial ankle, and inability to perform a single-leg heel raise. Clinical examination shows a flexible hindfoot valgus and forefoot abduction. What stage of adult acquired flatfoot deformity (AAFD) does this presentation most likely represent, and what is the typical surgical management strategy?
. Stage I, tenosynovectomy
. Stage II, combined tendon transfer and osteotomies
. Stage III, triple arthrodesis
. Stage IV, pantalar arthrodesis
. Early Charcot arthropathy, total contact casting

Correct Answer & Explanation

. Stage II, combined tendon transfer and osteotomies

Explanation

This patient's presentation with a progressive, flexible flatfoot deformity, medial ankle pain, hindfoot valgus, forefoot abduction, and inability to perform a single-leg heel raise is classic for Adult Acquired Flatfoot Deformity (AAFD) Stage II. Stage II is characterized by a flexible deformity with posterior tibial tendon (PTT) dysfunction. Surgical management for Stage II typically involves a combination of PTT debridement, flexor digitorum longus (FDL) tendon transfer to the navicular, and corrective osteotomies such as a medial displacement calcaneal osteotomy and/or lateral column lengthening (e.g., Evans calcaneal osteotomy) to restore the arch and alignment. Stage I involves PTT inflammation without deformity. Stage III involves a rigid deformity with associated arthritis, often requiring triple arthrodesis. Stage IV includes deltoid ligament failure and ankle valgus, often requiring more extensive fusions.

Question 5239

Topic: 8. Foot and Ankle

A 60-year-old diabetic male presents with a painful, deformed right foot, characterized by a 'rocker-bottom' deformity, collapse of the midfoot arch, and a plantar ulceration beneath the prominence. Radiographs show extensive disorganization of the midfoot joints, fragmentation, and new bone formation, consistent with active Charcot neuroarthropathy (Eichenholtz Stage II). He has good peripheral pulses. What is the primary surgical goal for this condition?

. Immediate amputation to prevent further progression.
. Arthrodesis with correction of the deformity and stabilization.
. Long-term non-weight-bearing in a total contact cast.
. Debridement of the ulceration and local wound care only.
. Prophylactic internal fixation before deformity develops.

Correct Answer & Explanation

. Arthrodesis with correction of the deformity and stabilization.

Explanation

This patient has an active Charcot neuroarthropathy with a significant deformity and plantar ulceration, placing him at high risk for infection and limb loss. While conservative management (total contact casting) is initially pursued for acute Charcot, surgical intervention is indicated for unstable deformities that lead to ulceration and risk of infection. The primary surgical goal is arthrodesis (fusion) with correction of the deformity and rigid internal fixation. This aims to stabilize the foot, eliminate the rocker-bottom prominence, and prevent recurrent ulceration, ultimately preserving the limb. Amputation is a salvage procedure. Long-term non-weight-bearing in a cast is appropriate for acute Charcot without severe deformity or for a non-surgical candidate but does not correct fixed deformity. Debridement alone won't address the underlying bony prominence. Prophylactic fixation is not applicable once deformity is established.

Question 5240

Topic: 8. Foot and Ankle

A 22-year-old male sustains a high-energy knee dislocation following a skiing accident. Physical examination reveals gross instability in both valgus and varus stress, a positive posterior drawer, and hyperextension. Distal pulses are palpable but weak, and the foot is cool to touch. Which of the following is the most critical immediate concern and first step in management?

. Emergent surgical stabilization of all torn ligaments.
. Application of a hinged knee brace and non-weight bearing.
. Immediate formal angiography to assess for popliteal artery injury.
. Reduction of the knee dislocation and reassessment of vascular status.
. Administration of high-dose corticosteroids to reduce swelling.

Correct Answer & Explanation

. Immediate formal angiography to assess for popliteal artery injury.

Explanation

Knee dislocations carry a significant risk of popliteal artery injury, which can lead to limb loss if not promptly identified and treated. Any sign of vascular compromise (weak pulse, coolness, pallor, paresthesias) dictates immediate action. While reduction of the dislocation should be performed promptly to relieve tension on the neurovascular structures, themost critical immediate concernand first step when pulses are weak and the foot is cool is to formally assess vascular integrity, typically with angiography (CT angiography is often preferred acutely). Delay in diagnosing and treating arterial injury can result in irreversible ischemia and amputation. Surgical stabilization of ligaments is typically delayed until vascular integrity is ensured and stabilized.

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