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8. Foot and Ankle MCQs

Practice Set 269 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 5361

Topic: 8. Foot and Ankle

A 35-year-old male sustains a Lisfranc injury to his midfoot. Which of the following is the most critical anatomical structure to assess for stability and guide treatment?

. Navicular-cuneiform joint
. Cuboid-metatarsal joints
. First metatarsal-medial cuneiform joint
. Second metatarsal-middle cuneiform articulation
. Talonavicular joint

Correct Answer & Explanation

. Second metatarsal-middle cuneiform articulation

Explanation

The Lisfranc ligament complex primarily connects the medial cuneiform to the base of the second metatarsal. The keystone of the Lisfranc joint is the second metatarsal, which is recessed into the middle cuneiform. Injury to this area, particularly the articulation between the second metatarsal and the middle cuneiform, and the Lisfranc ligament itself, is paramount for stability and dictates the diagnosis and treatment of Lisfranc injuries. Disruption of this articulation signifies an unstable injury requiring surgical stabilization. While other joints may be involved, the second metatarsal-middle cuneiform articulation is the critical nexus.

Question 5362

Topic: Ankle Trauma & Sports

Which of the following ligaments is most critical for maintaining stability of the distal tibiofibular syndesmosis?

. Anterior talofibular ligament (ATFL)
. Calcaneofibular ligament (CFL)
. Posterior talofibular ligament (PTFL)
. Anterior inferior tibiofibular ligament (AITFL)
. Deltoid ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

The anterior inferior tibiofibular ligament (AITFL) is a key component of the distal tibiofibular syndesmosis, along with the posterior inferior tibiofibular ligament (PITFL) and the interosseous ligament. The syndesmosis maintains the integrity of the 'mortise' and prevents diastasis between the tibia and fibula. Injuries to the syndesmosis often involve the AITFL. The ATFL, CFL, and PTFL are lateral collateral ligaments of the ankle, primarily stabilizing the talus.

Question 5363

Topic: Ankle Trauma & Sports
A 13-year-old girl sustains an isolated avulsion fracture of the anterolateral distal tibial epiphysis. The injury was caused by an external rotation force. Which ligament is directly responsible for pulling off this epiphyseal fragment?
. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Calcaneofibular ligament (CFL)
. Anterior talofibular ligament (ATFL)
. Deltoid ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

The described injury is a juvenile Tillaux fracture (a Salter-Harris III fracture of the anterolateral distal tibia). It occurs in adolescents when the medial and central portions of the distal tibial physis have closed, but the lateral aspect remains open. The mechanism is external rotation, and the bony avulsion is mediated via tension on the anterior inferior tibiofibular ligament (AITFL).

Question 5364

Topic: 8. Foot and Ankle

A 13-year-old boy presents with vague, deep midfoot pain and frequent ankle sprains. Examination shows a rigid, flat foot with lack of subtalar motion and peroneal spasticity. Lateral radiographs of the foot reveal a continuous bony bridge forming a 'C-sign' encompassing the medial talar dome and sustentaculum tali. What is the diagnosis?

. Calcaneonavicular coalition
. Accessory navicular syndrome
. Talocalcaneal coalition
. Osteochondritis dissecans of the talus
. Sever's disease

Correct Answer & Explanation

. Talocalcaneal coalition

Explanation

The 'C-sign' on a lateral radiograph is formed by the medial outline of the talar dome and the posteroinferior outline of the sustentaculum tali, representing a continuous bony bridge. It is highly specific for a talocalcaneal (subtalar) coalition. Calcaneonavicular coalitions often show the 'anteater nose' sign on oblique views.

Question 5365

Topic: 8. Foot and Ankle

A 2-week-old infant presents with severe, rigid congenital talipes equinovarus (clubfoot). The treating orthopedic surgeon initiates the Ponseti casting technique. After initial correction of the cavus deformity by elevating the first ray, the subsequent casts aim to correct the forefoot adduction and heel varus. Where should the examiner apply counterpressure (the fulcrum) during the manipulation phase?

. The medial malleolus
. The calcaneocuboid joint
. The lateral aspect of the head of the talus
. The base of the fifth metatarsal
. The navicular tuberosity

Correct Answer & Explanation

. The lateral aspect of the head of the talus

Explanation

In the Ponseti technique, after correcting the cavus by elevating the first ray, forefoot adduction and heel varus are corrected by abducting the forefoot in supination while applying counterpressure over the lateral aspect of the head of the talus. Pressure should NEVER be applied to the calcaneocuboid joint, as this will block the calcaneus from abducting and create a spurious correction (bean-shaped foot).

Question 5366

Topic: 8. Foot and Ankle

An 11-year-old boy presents with frequent ankle sprains and a rigid, painful flatfoot. On physical examination, there is marked spasm of the peroneal muscles. A lateral radiograph demonstrates a continuous C-shaped bony arc formed by the medial outline of the talar dome and the posteroinferior aspect of the sustentaculum tali. This radiographic sign is highly specific for which of the following conditions?

. Calcaneonavicular coalition
. Talonavicular coalition
. Talocalcaneal coalition
. Accessory navicular syndrome
. Congenital vertical talus

Correct Answer & Explanation

. Talocalcaneal coalition

Explanation

The 'C-sign' on a lateral radiograph is formed by the continuous bony bridge between the talar dome and the sustentaculum tali and is a classic radiographic sign of a talocalcaneal (subtalar) coalition. Calcaneonavicular coalitions often present with the 'anteater sign' on the lateral view and are best visualized on a 45-degree internal oblique radiograph.

Question 5367

Topic: 8. Foot and Ankle

A 12-year-old boy presents with a history of recurrent ankle sprains and a rigid flatfoot. Clinical examination demonstrates peroneal spasticity. Radiographs demonstrate an 'anteater nose' sign. Which of the following radiographic views is most appropriate to best visualize the pathology in question?

. Harris axial view
. Anteroposterior view of the foot
. Lateral view of the foot
. Canale view
. 45-degree internal oblique view of the foot

Correct Answer & Explanation

. 45-degree internal oblique view of the foot

Explanation

The 'anteater nose' sign is a radiographic finding representing a calcaneonavicular coalition. It is characterized by an elongated anterior process of the calcaneus extending toward the navicular. This specific coalition is best visualized on a 45-degree internal oblique radiograph of the foot. Talocalcaneal coalitions, on the other hand, often present with a 'C-sign' on the lateral view and are best evaluated with a Harris axial view or CT scan.

Question 5368

Topic: 8. Foot and Ankle

A 2-month-old infant is evaluated for bilateral rigid rocker-bottom feet. To reliably differentiate Congenital Vertical Talus (CVT) from an oblique talus, which of the following imaging modalities or specific views is most diagnostic?

. AP foot with weight-bearing
. Lateral foot in maximum dorsiflexion
. Lateral foot in maximum plantarflexion
. Harris axial view
. Hindfoot alignment view

Correct Answer & Explanation

. Lateral foot in maximum plantarflexion

Explanation

In Congenital Vertical Talus (CVT), the talonavicular joint is rigidly and irreducibly dislocated dorsally. The definitive radiographic diagnostic test is a lateral radiograph of the foot in maximum plantarflexion. If the navicular (or the first metatarsal axis if the navicular is unossified) fails to align with the talar axis and remains dorsally displaced, CVT is confirmed. In an oblique talus, it will reduce.

Question 5369

Topic: 8. Foot and Ankle

A 14-year-old with spastic diplegic cerebral palsy presents with worsening 'crouch gait'. Kinematic analysis shows excessive knee flexion throughout the stance phase. Which of the following prior surgical interventions most commonly precipitates or significantly worsens an iatrogenic crouch gait?

. Bilateral hamstring lengthening
. Adductor longus tenotomy
. Isolated Achilles tendon overlengthening
. Rectus femoris transfer
. Psoas lengthening

Correct Answer & Explanation

. Isolated Achilles tendon overlengthening

Explanation

Crouch gait involves excessive hip and knee flexion with excessive ankle dorsiflexion during stance. A frequent iatrogenic cause is isolated overlengthening of the Achilles tendon. This abolishes the critical plantarflexion-knee extension couple; without strong plantarflexors to control the forward progression of the tibia over the foot, the knee inevitably buckles into excessive flexion (crouch).

Question 5370

Topic: 8. Foot and Ankle

A 30-year-old male sustains a twisting injury to his foot during a soccer game. He complains of midfoot pain and difficulty weight-bearing. On examination, there is subtle swelling and tenderness over the dorsal midfoot, and a plantar ecchymosis is noted. Radiographs taken in the emergency department are initially interpreted as normal, but weight-bearing AP and lateral views show slight widening between the medial cuneiform and the base of the second metatarsal. What is the most appropriate next step in management?

. Non-weight-bearing in a walking boot for 4-6 weeks.
. MRI of the foot to assess ligamentous injury.
. CT scan of the foot to further characterize the bony injury.
. Referral for immediate surgical fixation.
. Continue weight-bearing as tolerated with an arch support.

Correct Answer & Explanation

. Referral for immediate surgical fixation.

Explanation

This scenario describes a subtle but unstable Lisfranc (tarsometatarsal) injury. The key findings are midfoot pain after a twisting injury, plantar ecchymosis (a highly suspicious sign for Lisfranc injury), and subtle widening between the medial cuneiform and the second metatarsal base on weight-bearing radiographs. This widening indicates disruption of the Lisfranc ligament complex, which is a critical stabilizer of the midfoot. Even subtle instability requires surgical fixation (Option D) to restore anatomical alignment and prevent progressive deformity, chronic pain, and post-traumatic arthritis. Non-weight-bearing in a boot (Option A) is inadequate for an unstable Lisfranc injury. While MRI (Option B) or CT (Option C) can confirm the extent of injury, they are not strictly necessary before fixation if instability is clearly demonstrated on weight-bearing X-rays. Continuing weight-bearing (Option E) would worsen the injury.

Question 5371

Topic: 8. Foot and Ankle

A 58-year-old diabetic male with peripheral neuropathy presents with a warm, swollen, erythematous, and insensate right foot. Radiographs reveal diffuse osteopenia, joint subluxation, and fragmentation of the tarsometatarsal joints. He denies acute trauma. What is the MOST appropriate initial management strategy?

. Immediate surgical fusion of the tarsometatarsal joints to prevent further collapse.
. Aggressive non-weight-bearing in a total contact cast or Charcot Restraint Orthotic Walker (CROW) boot.
. Systemic broad-spectrum antibiotics for presumed osteomyelitis.
. Below-knee amputation due to progressive destructive changes.
. Corticosteroid injections into the affected joints to reduce inflammation.

Correct Answer & Explanation

. Aggressive non-weight-bearing in a total contact cast or Charcot Restraint Orthotic Walker (CROW) boot.

Explanation

The clinical presentation (warm, swollen, erythematous, insensate foot in a diabetic with neuropathy, without acute trauma) and radiographic findings (osteopenia, joint subluxation, fragmentation of tarsometatarsal joints) are classic for an acute Charcot neuroarthropathy (Eichenholtz Stage 1, development/fragmentation phase).Option A (Immediate surgical fusion) is generally not indicated in the acute, inflammatory phase of Charcot (Eichenholtz Stage 1). Surgical intervention is typically reserved for reconstructive purposes in the quiescent phase (Stage 2 or 3) after inflammation has subsided, or for severe instability/ulceration that cannot be managed conservatively.Option B (Aggressive non-weight-bearing in a total contact cast or CROW boot) is the cornerstone of initial management for acute Charcot neuroarthropathy. The goal is to offload the foot to prevent further fragmentation and collapse of the joints during the active inflammatory phase. A total contact cast (TCC) or a Charcot Restraint Orthotic Walker (CROW) boot are excellent choices for this purpose.Option C (Systemic broad-spectrum antibiotics) would be appropriate if there was clear evidence of infection (e.g., open wound, purulent drainage, high WBC, positive cultures). While infection can coexist with Charcot, the described scenario primarily points to acute Charcot, not necessarily osteomyelitis as the primary diagnosis, and antibiotics are not the initial treatment for Charcot itself.Option D (Below-knee amputation) is an extreme measure reserved for unsalvageable feet with severe infection, unmanageable deformity, or uncontrollable ulcers. It is not an initial management strategy for acute Charcot.Option E (Corticosteroid injections) are contraindicated in Charcot neuroarthropathy as they can further weaken bone and cartilage, potentially accelerating the destructive process.

Question 5372

Topic: Midfoot & Hindfoot
A 55-year-old obese female with a history of hypertension and osteoarthritis presents with progressive, severe planovalgus foot deformity. Examination reveals a painful, collapsed medial arch, hindfoot valgus, forefoot abduction, and the 'too many toes' sign. She has intact posterior tibial tendon strength (5/5). Which stage of adult acquired flatfoot deformity (AAFD) according to Johnson & Strom classification does this represent, and what is the typical surgical approach?
. Stage I; non-operative management with orthotics.
. Stage II; flexor digitorum longus (FDL) transfer and calcaneal osteotomy.
. Stage III; triple arthrodesis.
. Stage IV; pantalar fusion.
. Stage II; subtalar fusion.

Correct Answer & Explanation

. Stage II; flexor digitorum longus (FDL) transfer and calcaneal osteotomy.

Explanation

The Johnson & Strom classification for Adult Acquired Flatfoot Deformity (AAFD) due to Posterior Tibial Tendon Dysfunction (PTTD) is: Stage I: Tenosynovitis, normal alignment. Stage II: Flexible flatfoot deformity, PTT elongated/attenuated. Stage III: Fixed flatfoot deformity. Stage IV: Involvement of the ankle joint. The patient's clinical picture (collapsed arch, hindfoot valgus, forefoot abduction, 'too many toes' sign) is consistent with a Stage II flexible deformity. Despite the 'intact' strength on manual testing, the tendon is functionally insufficient to maintain the arch, leading to the deformity. The standard surgical treatment for Stage II AAFD is FDL transfer and calcaneal osteotomy (Option 1).

Question 5373

Topic: Midfoot & Hindfoot
A 35-year-old female presents with bilateral, painful pes planus. She has a history of rheumatoid arthritis (RA) and reports increasing difficulty with ambulation due to pain and stiffness in her feet. Examination reveals a rigid hindfoot valgus and forefoot abduction, with collapse of the longitudinal arch that is not correctable manually. Radiographs confirm severe hindfoot arthritis and talonavicular joint collapse. Which stage of adult acquired flatfoot deformity (AAFD) does this represent, and what is the most appropriate surgical intervention?
. Stage II RA-associated AAFD; FDL transfer and calcaneal osteotomy.
. Stage III RA-associated AAFD; triple arthrodesis.
. Stage I RA-associated AAFD; orthotics and anti-inflammatory medication.
. Stage IV RA-associated AAFD; pantalar fusion.
. Subtalar arthroereisis.

Correct Answer & Explanation

. Stage III RA-associated AAFD; triple arthrodesis.

Explanation

This patient's presentation (bilateral painful pes planus, rigid hindfoot valgus, forefoot abduction, uncorrectable arch collapse, severe hindfoot arthritis, and talonavicular joint collapse) in the context of rheumatoid arthritis indicates an advanced, fixed flatfoot deformity. This aligns with Stage III of the RA-associated AAFD classification. Option A (Stage II RA-associated AAFD; FDL transfer and calcaneal osteotomy) describes treatment for a flexible deformity, typically Stage II. The patient's deformity is described as 'rigid' and 'not correctable manually', ruling out Stage II. Option B (Stage III RA-associated AAFD; triple arthrodesis) is the most appropriate diagnosis and surgical intervention. Stage III in RA-associated flatfoot typically involves fixed deformity and significant hindfoot arthritis, often with talonavicular collapse. A triple arthrodesis (fusion of the talonavicular, subtalar, and calcaneocuboid joints) is the gold standard for correcting and stabilizing a rigid, arthritic flatfoot, providing pain relief and improved function by creating a stable platform for ambulation. Option C (Stage I RA-associated AAFD; orthotics and anti-inflammatory medication) is for early stages with synovitis and mild or no deformity. Option D (Stage IV RA-associated AAFD; pantalar fusion) involves ankle joint involvement (valgus tibiotalar tilt), necessitating fusion of the ankle in addition to the hindfoot. Option E (Subtalar arthroereisis) is a less invasive procedure used to limit subtalar joint eversion, mainly in pediatric flexible flatfoot, and is inappropriate for a rigid, arthritic adult flatfoot.

Question 5374

Topic: 8. Foot and Ankle

A 55-year-old male with a 20-year history of type 2 diabetes mellitus presents with progressive deformity, swelling, and instability of his left foot, resulting in a 'rocker-bottom' appearance. Radiographs demonstrate severe disorganization, subluxation, fragmentation, and osteolysis involving the midfoot (tarsometatarsal joints) and hindfoot, with a large bony prominence on the plantar aspect. The foot is warm but not acutely infected. This presentation is consistent with Charcot neuroarthropathy, Eichenholtz Stage II (Coalescence). What is the most appropriate management for this patient?

. Total contact casting (TCC) to promote healing and offloading.
. Serial casting for correction of the deformity, followed by custom orthotics.
. Custom accommodative orthotics and diabetic shoes for life.
. Open reduction and internal fixation with arthrodesis of the affected joints.
. Amputation due to severe deformity and high risk of ulceration.

Correct Answer & Explanation

. Custom accommodative orthotics and diabetic shoes for life.

Explanation

This patient presents with Charcot neuroarthropathy Eichenholtz Stage II (Coalescence), characterized by decreasing inflammation, absorption of fine debris, and remodeling of bone. The foot has a fixed 'rocker-bottom' deformity with bony prominence. While initial management of acute Charcot (Stage I) focuses on immobilization and offloading with total contact casting (TCC) (Option A), in Stage II with a fixed deformity, the goal shifts to accommodating the deformity and protecting the foot from ulceration and further injury. Surgical correction (Option D) might be considered for a severe, unstable deformity that is recalcitrant to bracing, but in Stage II with a 'rocker-bottom' and a large prominence, the priority is often accommodation. Amputation (Option E) is typically reserved for irreducible deformities with recurrent ulceration and uncontrolled infection. Serial casting (Option B) is usually for early, more reducible deformities, or for initial immobilization. Therefore, custom accommodative orthotics and diabetic shoes (Option C) are essential to distribute pressure, reduce friction, and prevent skin breakdown over the bony prominences, making it the most appropriate ongoing management for a fixed deformity in Stage II, alongside regular foot inspections.

Question 5375

Topic: Midfoot & Hindfoot
A 50-year-old obese female presents with a progressive, painful flatfoot deformity of her right foot. Clinical examination reveals a prominent navicular, 'too many toes' sign, hindfoot valgus, and forefoot abduction. She is unable to perform a single-limb heel rise, but the deformity is passively correctable. MRI shows tendinopathy and attenuation of the posterior tibial tendon (PTT). This presentation is consistent with Adult Acquired Flatfoot Deformity (AAFD) Stage IIB. What is the most appropriate surgical management?
. Isolated flexor digitorum longus (FDL) tendon transfer to the navicular.
. Medializing calcaneal osteotomy, FDL tendon transfer, and lateral column lengthening.
. Triple arthrodesis.
. Subtalar fusion and deltoid ligament repair.
. Isolated lateral column lengthening with calcaneocuboid fusion.

Correct Answer & Explanation

. Medializing calcaneal osteotomy, FDL tendon transfer, and lateral column lengthening.

Explanation

This patient has Adult Acquired Flatfoot Deformity (AAFD) Stage IIB, characterized by a flexible deformity, inability to perform a single-limb heel rise, and PTT dysfunction with significant forefoot abduction. Surgical management for Stage II AAFD aims to correct the deformity, offload the PTT, and provide stability. A combination of procedures is typically required. Medializing calcaneal osteotomy (MCO) corrects hindfoot valgus. Flexor digitorum longus (FDL) tendon transfer to the navicular augments or replaces the failing PTT. Lateral column lengthening (LCL), usually via a calcaneal osteotomy (e.g., Evans osteotomy), corrects forefoot abduction. Therefore, medializing calcaneal osteotomy, FDL tendon transfer, and lateral column lengthening (Option B) represent the comprehensive surgical approach for Stage IIB AAFD. Isolated FDL transfer (Option A) would not adequately correct the bony deformity. Triple arthrodesis (Option C) is reserved for rigid (Stage III or IV) deformities. Subtalar fusion (Option D) is often part of a triple arthrodesis but not comprehensive enough for Stage IIB. Isolated lateral column lengthening (Option E) does not address the hindfoot valgus or PTT insufficiency.

Question 5376

Topic: Midfoot & Hindfoot

A 22-year-old female presents with a 6-month history of right foot pain and a progressive flatfoot deformity. She has failed conservative management including orthotics and physical therapy. Physical exam reveals a rigid valgus hindfoot, abduction of the forefoot, and tenderness over the sinus tarsi. Radiographs show talonavicular coalition. What is the most appropriate surgical management?

. Isolated excision of the talonavicular coalition with interposition material.
. Triple arthrodesis (talonavicular, calcaneocuboid, subtalar fusions).
. Subtalar arthroereisis with an implant.
. Isolated subtalar fusion.
. Medializing calcaneal osteotomy with FDL transfer.

Correct Answer & Explanation

. Triple arthrodesis (talonavicular, calcaneocuboid, subtalar fusions).

Explanation

The patient's rigid flatfoot deformity and talonavicular coalition, with failure of conservative treatment, point towards surgical intervention. For symptomatic rigid flatfoot due to talonavicular coalition, the most appropriate initial surgical management in a young adult is often a triple arthrodesis (Option B). This procedure corrects the multi-planar deformity and provides stability for a rigid flatfoot. Isolated excision of the coalition (Option A) is typically reserved for asymptomatic or minimally symptomatic coalitions, or for calcaneonavicular coalitions, and is less effective for a rigid talonavicular coalition. Subtalar arthroereisis (Option C) is generally for flexible flatfoot in younger patients. Isolated subtalar fusion (Option D) would not address the talonavicular pathology or the overall rigidity. Medializing calcaneal osteotomy with FDL transfer (Option E) is used for flexible flatfoot caused by posterior tibial tendon dysfunction, not for rigid flatfoot from a coalition.

Question 5377

Topic: 8. Foot and Ankle

A 35-year-old male presents with persistent pain, stiffness, and crepitus in his right ankle 2 years after sustaining a pilon fracture that was treated with open reduction and internal fixation. Radiographs demonstrate significant post-traumatic ankle arthritis with joint space narrowing, subchondral sclerosis, and osteophytes. He has failed extensive non-operative management. He is otherwise healthy and active. What is the most appropriate definitive surgical management?

. Ankle arthroscopy with debridement and osteophyte resection.
. Supramalleolar osteotomy.
. Total ankle arthroplasty (TAA).
. Ankle arthrodesis (fusion).
. Distraction arthroplasty.

Correct Answer & Explanation

. Total ankle arthroplasty (TAA).

Explanation

The patient has advanced post-traumatic ankle arthritis causing significant pain and functional impairment. Ankle arthroscopy (Option A) might offer temporary relief for mild symptoms but is insufficient for advanced arthritis with structural changes. Supramalleolar osteotomy (Option B) is indicated for early to moderate arthritis with malalignment but not for advanced arthritis. For advanced, symptomatic ankle arthritis, the definitive surgical options are total ankle arthroplasty (TAA) or ankle arthrodesis (fusion). In a 35-year-old active and otherwise healthy individual, total ankle arthroplasty (TAA) (Option C) is increasingly preferred over fusion to preserve motion, especially in younger, active patients without significant deformity or bone loss, if the anatomy allows. Ankle arthrodesis (Option D) is a reliable pain-relieving procedure but sacrifices motion and can lead to increased stress on adjacent joints. Distraction arthroplasty (Option E) is a salvage procedure for some specific cases but not a primary definitive solution for advanced post-traumatic arthritis. Given the patient's age and activity level, TAA is the most appropriate definitive option to preserve function while relieving pain.

Question 5378

Topic: 8. Foot and Ankle
A 55-year-old female presents with a progressive, painful adult acquired flatfoot deformity (AAFD) classified as Stage IIB. She exhibits a flexible hindfoot valgus, midfoot abduction, and evidence of posterior tibial tendon (PTT) dysfunction with an associated Achilles tendon contracture. What is the most comprehensive and appropriate surgical approach for this specific stage and presentation?
. Flexor digitorum longus (FDL) tendon transfer to the navicular and calcaneal osteotomy
. FDL transfer to the navicular, calcaneal osteotomy, and lateral column lengthening
. Isolated subtalar arthrodesis
. Triple arthrodesis (subtalar, talonavicular, calcaneocuboid fusions)
. Isolated Achilles tendon lengthening

Correct Answer & Explanation

. FDL transfer to the navicular, calcaneal osteotomy, and lateral column lengthening

Explanation

Stage IIB AAFD is characterized by a flexible deformity, PTT dysfunction, and forefoot abduction requiring a bony correction. The presence of an Achilles contracture also needs to be addressed. The most comprehensive surgical approach for Stage IIB AAFD includes an FDL tendon transfer to augment the weakened PTT, a medializing calcaneal osteotomy to correct hindfoot valgus, lateral column lengthening (e.g., Evans osteotomy) to correct forefoot abduction, and Achilles tendon lengthening (or gastrocnemius recession) to address the equinus contracture. Option 1 is missing the lateral column lengthening, which is crucial for Stage IIB. Isolated subtalar fusion would not address the PTT dysfunction or forefoot abduction. Triple arthrodesis is reserved for rigid (Stage III or IV) deformities. Isolated Achilles lengthening would not address the primary deformity or PTT pathology.

Question 5379

Topic: 8. Foot and Ankle

A 50-year-old diabetic patient presents with acute onset redness, swelling, and warmth in the left midfoot, accompanied by severe pain and loss of arch height. Radiographs show early bone fragmentation and joint dislocation without evidence of infection. Laboratory markers for inflammation are elevated. This presentation is consistent with Eichenholtz Stage I Charcot neuroarthropathy. Which of the following statements regarding the management of this condition is most accurate?

. Surgical intervention is indicated immediately to reduce dislocations and fuse joints.
. Non-weight-bearing in a total contact cast (TCC) is the cornerstone of initial management.
. High-dose systemic antibiotics are required to prevent osteomyelitis.
. The use of bisphosphonates is contraindicated due to potential for atypical fractures.
. Physical therapy for strengthening and range of motion should begin immediately.

Correct Answer & Explanation

. Non-weight-bearing in a total contact cast (TCC) is the cornerstone of initial management.

Explanation

For acute (Eichenholtz Stage I) Charcot neuroarthropathy, the cornerstone of initial management is strict non-weight-bearing and immobilization in a total contact cast (TCC) or removable cast walker (RCW) to protect the collapsing foot, reduce inflammation, and prevent further deformity. Surgical intervention is generally not indicated in the acute inflammatory stage unless there is gross instability that cannot be contained or if there are ulcerations/infections. High-dose antibiotics are not indicated unless there is confirmed infection. Bisphosphonates can be considered in some cases to slow bone resorption, but their role is still debated and they are not contraindicated due to atypical fractures in this context. Physical therapy for ROM and strengthening is contraindicated in the acute inflammatory stage due to the risk of exacerbating the collapse.

Question 5380

Topic: 8. Foot and Ankle

A patient with Charcot-Marie-Tooth disease presents with progressive foot deformities. From a basic science perspective, which component of the peripheral nervous system is primarily affected in this condition, leading to the observed muscle weakness and atrophy?

. Sensory neurons in the dorsal root ganglia
. Motor neurons in the anterior horn of the spinal cord
. Myelin sheath of peripheral nerves
. Schwann cells responsible for nerve regeneration
. Axonal transport mechanisms within motor neurons

Correct Answer & Explanation

. Myelin sheath of peripheral nerves

Explanation

Charcot-Marie-Tooth (CMT) disease is a group of inherited disorders characterized by progressive peripheral neuropathy. The most common forms (CMT1 and CMT2) involve defects in either the myelin sheath (CMT1, demyelinating neuropathy) or the axon itself (CMT2, axonal neuropathy). However, the fundamental defect leading to the clinical manifestations of muscle weakness and atrophy is typically related to the myelin sheath or the axon of peripheral nerves, impairing nerve conduction. While Schwann cells are involved in myelin production, the primary affectedcomponentis the myelin sheath itself (or the axon), leading to impaired function. Sensory and motor neurons are the cell types affected, but the question asks for thecomponentprimarily affected, and the myelin sheath is a key structural component whose integrity is compromised.

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