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 581
Topic: 8. Foot and Ankle
A 45-year-old man presents with post-traumatic ankle osteoarthritis following a malreduced lateral malleolus fracture. Biomechanical studies have shown that a lateral shift of the talus by 1 mm decreases the tibiotalar contact area by approximately what percentage?
Correct Answer & Explanation
. 42%
Explanation
Ramsey and Hamilton demonstrated that a 1 mm lateral shift of the talus reduces the tibiotalar contact area by 42%. This drastically increases peak contact stresses across the joint, leading to rapid post-traumatic osteoarthritis.
Question 582
Topic: 8. Foot and Ankle
A 55-year-old male with end-stage post-traumatic ankle osteoarthritis is undergoing an ankle arthrodesis. To optimize his postoperative gait, what is the ideal position for fusing the tibiotalar joint?
Correct Answer & Explanation
. Neutral dorsiflexion, 0 to 5 degrees valgus, 5 to 10 degrees external rotation
Explanation
The ideal position for ankle arthrodesis is neutral dorsiflexion (0 degrees), 0 to 5 degrees of hindfoot valgus, and 5 to 10 degrees of external rotation. This matches normal opposite side rotation and provides the best mechanics for ambulation.
Question 583
Topic: 8. Foot and Ankle
A 40-year-old female experiences an inversion injury to her ankle. Radiographs show a transverse fracture of the lateral malleolus at the level of the joint line, and a vertical fracture of the medial malleolus. According to the Lauge-Hansen classification, what is the mechanism of injury?
Correct Answer & Explanation
. Supination-Adduction (SAD)
Explanation
The Supination-Adduction (SAD) pattern is characterized by a transverse fracture of the fibula below or at the level of the joint line (tension failure), followed by a vertical fracture of the medial malleolus (shear failure).
Question 584
Topic: 8. Foot and Ankle
During surgical repair of an acute ankle syndesmotic disruption, the surgeon identifies the most important ligamentous stabilizer of the distal tibiofibular joint, which contributes to over 40% of its ultimate strength. Which ligament is this?
The posterior inferior tibiofibular ligament (PITFL) is the strongest component of the syndesmotic complex, providing approximately 42% of its strength. The AITFL is the most commonly injured but provides less total strength.
Question 585
Topic: Ankle Trauma & Sports
A 45-year-old male sustains an ankle injury during a fall. Radiographs show widening of the medial clear space and a proximal fibular fracture, but no lateral malleolus fracture at the ankle level. According to the Lauge-Hansen Pronation-External Rotation (PER) classification, which of the following structures is injured last in the sequence?
Correct Answer & Explanation
. Posterior inferior tibiofibular ligament (PITFL) or posterior malleolus
Explanation
In a Lauge-Hansen Pronation-External Rotation (PER) mechanism, the sequence of injury is: 1) Deltoid/Medial malleolus, 2) AITFL/Syndesmosis, 3) High fibular fracture, and 4) PITFL or posterior malleolus fracture. Therefore, the posterior structures are the final to fail in this high-energy pattern.
Question 586
Topic: Ankle Trauma & Sports
A 14-year-old female presents after an acute ankle twisting injury. Radiographs show a Salter-Harris III fracture of the anterolateral aspect of the distal tibial epiphysis, with 3 mm of displacement. Which of the following ligaments is primarily responsible for avulsing this fracture fragment?
Correct Answer & Explanation
. Anterior inferior tibiofibular ligament (AITFL)
Explanation
This describes a juvenile Tillaux fracture, which is an avulsion of the anterolateral distal tibial epiphysis. It is caused by the pull of the anterior inferior tibiofibular ligament (AITFL) during an external rotation mechanism, occurring uniquely when the central and medial physis have already closed.
Question 587
Topic: 8. Foot and Ankle
A 58-year-old male with end-stage post-traumatic ankle osteoarthritis complains of daily, severe pain that limits his ambulation. He elects to undergo an open ankle arthrodesis. To ensure the most energy-efficient gait and to limit the breakdown of adjacent hindfoot joints, what is the optimal position for the tibiotalar fusion?
Correct Answer & Explanation
. Neutral dorsiflexion, 5 degrees of valgus, 5 degrees of external rotation, and slight posterior translation of the talus
Explanation
The optimal position for ankle arthrodesis is neutral dorsiflexion (0 degrees), 0 to 5 degrees of hindfoot valgus, 5 to 10 degrees of external rotation (approximating the contralateral limb), and slight posterior translation of the talus. This positioning maximizes the lever arm for toe-off and protects the subtalar and transverse tarsal joints.
Question 588
Topic: 8. Foot and Ankle
A 38-year-old male presents with a displaced posterior malleolus fracture involving 35% of the distal tibial articular surface, as confirmed by pre-operative CT scan. The fracture is associated with a fibula fracture and suspected syndesmotic instability. The orthopedic surgeon plans a posterolateral approach for direct reduction and internal fixation. During the initial dissection, which of the following neurovascular structures is most vulnerable and requires meticulous identification and protection?
Correct Answer & Explanation
. Sural Nerve
Explanation
Correct Answer: C - Sural NerveThe case explicitly states under 'Surgical Anatomy & Biomechanics' that theSural Nerveruns superficially along the posterolateral aspect of the lower leg, typically coursing with the small saphenous vein. It is vulnerable during the skin incision and initial dissection, especially at the level of the ankle joint, and should be identified and protected, usually retracted anteriorly with the peroneal tendons.Option A (Posterior Tibial Nerve):This nerve is located more medially and deep, within the tarsal tunnel. It is generally not at direct risk with a strictly posterolateral approach.Option B (Peroneal Artery):This artery is located deep in the posterior compartment, more medially, and is not typically at risk with the posterolateral approach.Option D (Flexor Hallucis Longus Tendon):While the FHL tendon is in the surgical field, it is a muscular/tendinous structure, not a neurovascular structure, and is retracted medially with the Achilles tendon. It is not considered 'most vulnerable' in the same sense as a superficial nerve during initial dissection.Option E (Small Saphenous Artery):The case mentions the Small Saphenous Vein, which accompanies the sural nerve and is vulnerable. There is no mention of a 'Small Saphenous Artery' in the context of vulnerability during this approach.
Question 589
Topic: 8. Foot and Ankle
A 62-year-old female undergoes a posterolateral approach for a complex pilon fracture. Post-operatively, she complains of numbness and tingling along the lateral aspect of her foot and ankle, extending to her little toe. On examination, she has diminished sensation in the distribution of the sural nerve. Which of the following is the most appropriate initial management strategy for this complication?
Correct Answer & Explanation
. Observation, NSAIDs, and reassurance, as most neurapraxias resolve spontaneously.
Explanation
Correct Answer: C - Observation, NSAIDs, and reassurance, as most neurapraxias resolve spontaneously.The case discusses 'Sural Nerve Injury' under 'Complications & Management,' stating that it can range from temporary neurapraxia to permanent transection. For 'Post-operative' management, it advises 'Conservative management for neurapraxia (observation, NSAIDs).' The symptoms described are consistent with a neurapraxia (stretch or contusion injury) rather than a complete transection, which typically presents with immediate and complete loss of sensation. Most neurapraxias improve over weeks to months.Option A (Immediate surgical exploration and nerve repair):This is too aggressive for an initial presentation of sensory deficit, which is likely neurapraxia. Surgical exploration is reserved for persistent symptoms or clear evidence of transection.Option B (Referral for EMG and NCS within 48 hours):While EMG/NCS can be useful, they are typically not performed acutely (within 48 hours) as nerve degeneration takes time to manifest on these studies. They are more useful for assessing nerve recovery or persistent deficits after several weeks to months.Option D (Application of a nerve block):A nerve block might temporarily alleviate symptoms but does not address the underlying issue or aid in recovery. It's not an initial management strategy for the nerve injury itself.Option E (Initiation of high-dose oral corticosteroids):There is no evidence presented in the case, nor is it standard practice, to use high-dose oral corticosteroids for sural nerve neurapraxia following ankle surgery.
Question 590
Topic: 8. Foot and Ankle
A surgeon is preparing for a posterolateral approach to fix a posterior malleolus fracture. The patient has a history of severe obesity and sleep apnea, making prone positioning challenging for anesthetic access. Which alternative patient positioning, as described in the case, offers easier anesthetic access while still allowing for the posterolateral approach?
Correct Answer & Explanation
. Lateral decubitus position on the contralateral side of the injured ankle.
Explanation
Correct Answer: B - Lateral decubitus position on the contralateral side of the injured ankle.Under 'Pre-Operative Planning & Patient Positioning,' the case discusses 'Patient Positioning.' For the 'Lateral Decubitus Position,' it lists 'Advantages' including 'Easier anesthetic access to the airway.' It specifies the setup: 'Patient is placed in a lateral decubitus position on the contralateral side of the injured ankle (e.g., right ankle injury, left lateral decubitus). 'Option A (Supine position):A supine position does not provide adequate direct access to the posterolateral aspect of the ankle for this approach.Option C (Beach chair position):The beach chair position is typically used for shoulder or elbow surgery and is not suitable for a posterolateral ankle approach.Option D (Lithotomy position):The lithotomy position is used for perineal or lower extremity procedures but does not provide optimal exposure for a posterolateral ankle approach.Option E (Prone position with the patient's head turned to the side):While the head is turned in prone, the case explicitly states 'More challenging for anesthetic access to the airway if intubated' as a disadvantage of the prone position, making it less ideal for a patient with sleep apnea.
Question 591
Topic: 8. Foot and Ankle
The patient's mechanism of injury involved a direct axial load. According to the biomechanics described in the case, what is the primary event that initiates the typical intra-articular calcaneal fracture pattern?
Correct Answer & Explanation
. The lateral process of the talus acting as a wedge driving into the angle of Gissane
Explanation
Correct Answer: BExplanation:The case explicitly states, 'The biomechanics of this injury pattern involve a high-energy axial load where the body weight is driven downward while the ground reaction force is transmitted upward through the heel. In this scenario, the lateral process of the talus acts as a wedge, driving into the crucial angle of Gissane of the calcaneus. This sheer force typically creates a primary fracture line extending from the proximal-medial aspect to the distal-lateral aspect of the calcaneus...' This describes the classic mechanism for intra-articular calcaneal fractures.Incorrect Options:A. Hyperplantarflexion causing avulsion of the anterior process:While anterior process fractures can occur, they are typically extra-articular and often result from hyperplantarflexion with inversion, not the primary mechanism for a complex intra-articular fracture.C. Direct impact of the calcaneal tuberosity on the ground causing a crush injury:While the tuberosity is impacted, the critical internal mechanism involves the talus acting as a wedge, not just a direct crush. The comminution is a secondary effect of the energy dissipation.D. Eversion injury leading to disruption of the calcaneocuboid joint:Eversion injuries are less common for calcaneal fractures and typically involve different ligamentous or bony structures. While the calcaneocuboid joint can be involved, it's not the primary initiating event for the intra-articular pattern.E. Inversion injury causing a stress fracture of the sustentaculum tali:Inversion injuries are more associated with lateral ankle sprains or talar dome injuries. The sustentaculum tali is a robust structure, and its fracture is usually part of a larger intra-articular pattern, not an isolated stress fracture from inversion.
Question 592
Topic: 8. Foot and Ankle
Initial radiographs of the left calcaneus revealed a Bohler's angle of 5 degrees (normal 20-40 degrees) and a Gissane's angle of 140 degrees (normal 100-120 degrees). What do these specific radiographic findings collectively indicate?
Correct Answer & Explanation
. Significant collapse of the posterior facet and loss of calcaneal height, with disruption of the lateral process of the talus.
Explanation
Correct Answer: BExplanation:The case states, 'X-ray Findings (Left Calcaneus): Lateral View: Demonstrated a significant decrease in Bohler's angle (measured at 5 degrees, normal 20-40 degrees), indicative of substantial collapse of the posterior facet and loss of calcaneal height. Gissane's angle (Crucial angle) was increased to 140 degrees (normal 100-120 degrees), reflecting the disruption of the lateral process of the talus and the primary fracture line.' These two angles are critical for assessing the severity and intra-articular nature of calcaneal fractures.Incorrect Options:A. An isolated anterior process fracture with minimal displacement:Anterior process fractures typically do not significantly alter Bohler's or Gissane's angles.C. A non-displaced extra-articular fracture of the calcaneal tuberosity:While a tuberosity fracture can affect calcaneal height, a non-displaced extra-articular fracture would not typically cause such a drastic reduction in Bohler's angle or increase in Gissane's angle, which are hallmarks of intra-articular collapse.D. A subtalar dislocation with intact calcaneal morphology:Subtalar dislocations involve disruption of the talocalcaneal and talonavicular joints, but the calcaneal bone itself may be intact. The described angle changes are specific to calcaneal bone collapse.E. A talar neck fracture with secondary involvement of the calcaneus:Talar neck fractures primarily affect the talus and its relationship with the tibia and navicular, not directly the calcaneal angles in this manner.
Question 593
Topic: 8. Foot and Ankle
During the extensile lateral approach for this calcaneal fracture, the case describes a specific technique for retracting the full-thickness soft tissue flap to minimize microvascular compromise. What is this technique?
Correct Answer & Explanation
. Driving three 1.6 mm Kirschner wires into the lateral talus, talar neck, and cuboid, then bending them over the flap for gentle retraction.
Explanation
Correct Answer: CExplanation:The case details the specific, meticulous technique for flap retraction: 'To retract the flap without causing crush injury to the microvasculature, self-retaining retractors are strictly avoided. Instead, three 1.6 mm Kirschner wires (K-wires) are driven into the lateral talus, the talar neck, and the cuboid. The full-thickness flap is then gently retracted superiorly and held in place by bending the K-wires over the soft tissue. This technique eliminates continuous point pressure on the flap edges, significantly reducing the risk of postoperative marginal necrosis.'Incorrect Options:A. Using self-retaining retractors to maintain constant tension on the flap:The case explicitly states that self-retaining retractors are 'strictly avoided' due to the risk of crush injury to the microvasculature.B. Employing multiple blunt Hohmann retractors placed directly on the bone:While Hohmanns are used in orthopedic surgery, using them for continuous flap retraction in this context can still cause pressure necrosis, and the K-wire technique is specifically highlighted for its gentleness.D. Utilizing skin hooks to apply continuous traction to the flap edges:Skin hooks, especially with continuous traction, can cause localized pressure and compromise the delicate flap edges, increasing the risk of necrosis.E. Performing a separate medial incision for counter-traction and flap elevation:A separate medial incision is not part of the extensile lateral approach for flap retraction; it would be a different surgical approach entirely, typically used for medial column fractures or specific medial fragment reduction.
Question 594
Topic: 8. Foot and Ankle
For this Sanders IIIBC tongue-type calcaneal fracture, the surgical technique outlines a specific sequence for reduction. What is the initial step in reconstructing the calcaneus?
Correct Answer & Explanation
. Insertion of a Schanz pin into the tuberosity for axial traction and correction of varus deformity.
Explanation
The case describes the fracture reduction sequence: '1. Tuberosity Reduction: A 5.0 mm Schanz pin is inserted percutaneously from posterior to anterior into the dense bone of the calcaneal tuberosity fragment. Using this pin as a joystick, axial traction is applied to restore calcaneal length. The tuberosity is then translated medially and rotated out of varus to restore the mechanical axis of the hindfoot.' This establishes the overall length and alignment before addressing the articular surface.
Question 595
Topic: 8. Foot and Ankle
Following provisional reduction of this Sanders IIIBC fracture, a low-profile, anatomically contoured calcaneal perimeter plate is applied. What is the primary biomechanical goal of this plate in the fixation construct?
Correct Answer & Explanation
. To act as a lateral buttress, maintaining restored calcaneal height, length, and neutral alignment.
Explanation
The case states, 'The primary biomechanical goal of the plate is to act as a lateral buttress, maintaining the restored calcaneal height, length, and neutral alignment of the tuberosity, while supporting the elevated posterior facet.' This buttress function is critical for preventing collapse of the reconstructed calcaneus.
Question 596
Topic: Midfoot & Hindfoot
The patient's smoking history is a significant comorbidity. According to the landmark Buckley trial (JBJS 2002) referenced in the case, how does smoking status impact outcomes following operative intervention for displaced intra-articular calcaneal fractures?
Correct Answer & Explanation
. Smokers have outcomes that are not significantly different from, or are worse than, those managed non-operatively, with a drastically higher rate of wound complications.
Explanation
Correct Answer: BExplanation:The case directly references the Buckley trial: 'The Buckley trial (JBJS 2002), a landmark prospective randomized controlled trial comparing operative versus non-operative management of calcaneal fractures, demonstrated that while young, healthy, non-workers' compensation patients had significantly better outcomes with surgery, patients who smoked or were receiving workers' compensation had outcomes that were not significantly different from, or were worse than, those managed non-operatively. Furthermore, smokers had a drastically higher rate of wound complications.' This highlights the critical impact of smoking on surgical outcomes and complication rates.Incorrect Options:A. Smokers consistently have significantly better outcomes with surgery due to enhanced bone healing:This is incorrect. Smoking is detrimental to bone healing and significantly increases complication rates.C. Smoking primarily affects long-term subtalar joint arthritis rates but not acute wound complications:This is incorrect. Smoking significantly increases the risk of acute wound complications, including marginal flap necrosis and deep infection, as stated in the case.D. The Buckley trial found no significant correlation between smoking and surgical outcomes:This is incorrect. The trial found a strong negative correlation, indicating worse outcomes and higher complication rates for smokers.E. Smokers require a shorter period of non-weight-bearing post-surgery due to faster soft tissue healing:This is incorrect. Smoking impairs soft tissue healing, necessitating careful postoperative management and often a longer recovery period, not shorter.
Question 597
Topic: 8. Foot and Ankle
During an extensile lateral approach to the calcaneus, a full-thickness fasciocutaneous flap is developed. To minimize the risk of flap necrosis, the surgeon must preserve the primary blood supply to this flap. Which of the following vessels provides the primary arterial supply to the lateral calcaneal flap?
Correct Answer & Explanation
. Lateral calcaneal artery branch of the peroneal artery
Explanation
The lateral calcaneal artery, a terminal branch of the peroneal artery, is the primary blood supply to the lateral fasciocutaneous flap. Dissection must remain subperiosteal to protect this vessel and minimize the risk of corner necrosis.
Question 598
Topic: 8. Foot and Ankle
A 50-year-old female presents with a closed tongue-type calcaneus fracture. On examination, the skin over the posterior heel is blanched and non-blanching on pressure, though intact. What is the most appropriate initial management?
Correct Answer & Explanation
. Emergent percutaneous reduction and screw fixation
Explanation
Tongue-type calcaneus fractures can cause pressure necrosis of the posterior heel skin due to superior displacement of the tuberosity fragment. Emergent percutaneous reduction and fixation are indicated to relieve tension and prevent full-thickness skin loss.
Question 599
Topic: 8. Foot and Ankle
A 35-year-old male presents with chronic lateral hindfoot pain 18 months after non-operative management of an intra-articular calcaneus fracture. Clinical exam reveals pain localized inferior to the lateral malleolus. Radiographs show a healed calcaneus fracture with loss of Bohler's angle and a widened hindfoot. What is the most likely cause of his pain?
Correct Answer & Explanation
. Subfibular impingement with peroneal tendon entrapment
Explanation
Malunion of a calcaneus fracture typically results in lateral wall 'blowout,' leading to subfibular impingement and potential peroneal tendon stenosis or subluxation. This classic presentation requires a lateral wall exostectomy, often combined with a subtalar arthrodesis if subtalar arthritis is present.
Question 600
Topic: 8. Foot and Ankle
A 62-year-old male with long-standing, poorly controlled diabetes mellitus type 2 sustains a displaced bimalleolar equivalent ankle fracture. He undergoes ORIF. Compared to a non-diabetic patient, which modification in postoperative management is most appropriate?
Correct Answer & Explanation
. Prolongation of non-weight-bearing status for double the standard duration
Explanation
Diabetic patients with ankle fractures have a significantly higher risk of complications, including Charcot arthropathy, nonunion, and hardware failure. Prolonging the non-weight-bearing period (often double the usual time) and using augmented fixation are recommended to mitigate these risks.
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