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8. Foot and Ankle MCQs

Practice Set 54 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 1061

Topic: 8. Foot and Ankle

A 49-year-old female presents to the emergency department after falling down stairs, complaining of severe left foot pain, bruising, and swelling, with an inability to bear weight. Initial AP and oblique radiographs are obtained.

Based on the provided image, which of the following findings is MOST indicative of a Lisfranc injury?

. Diastasis of 1 mm between the base of the first and second metatarsals.
. A small avulsed fragment of bone lateral to the third metatarsal base.
. Diastasis greater than 2 mm between the base of the first and second metatarsals.
. Fracture of the cuboid bone with minimal displacement.
. Subluxation of the navicular-cuneiform joint.

Correct Answer & Explanation

. Diastasis greater than 2 mm between the base of the first and second metatarsals.

Explanation

Correct Answer: CExplanation:The case explicitly states that the candidate identifies "diastasis of > 2 mm between the base of the first and second metatarsals" as a key feature suggestive of Lisfranc tarsometatarsal fracture dislocation. This finding, along with the presence of a 'fleck sign' (an avulsed fragment from the Lisfranc ligament insertion), is pathognomonic for a Lisfranc injury. The Lisfranc ligament connects the medial cuneiform to the base of the second metatarsal, and its disruption leads to instability and widening of the interval between the first and second metatarsal bases.Option A (Diastasis of 1 mm):While diastasis is a key sign, a 1 mm widening is often considered within normal limits or equivocal. A threshold of 2 mm or more is generally accepted as significant for Lisfranc injury, especially when compared to the contralateral foot or with stress views.Option B (Avulsed fragment lateral to the third metatarsal base):The 'fleck sign' specifically refers to an avulsion fracture from the insertion of the Lisfranc ligament, which is typically at the base of the second metatarsal, not the third.Option D (Fracture of the cuboid bone):While cuboid fractures can occur in foot trauma, they are not the primary diagnostic feature of a Lisfranc injury, which involves the tarsometatarsal joint complex.Option E (Subluxation of the navicular-cuneiform joint):This describes a Chopart joint injury, which is distinct from a Lisfranc injury involving the tarsometatarsal joints.

Question 1062

Topic: Midfoot & Hindfoot

Following initial radiographs, the emergency department physician is still uncertain about the diagnosis of a Lisfranc injury. The patient continues to experience severe pain and swelling. According to the case discussion, what would be the MOST appropriate next step in imaging to confirm or rule out a Lisfranc injury?

. Immediate MRI of the foot.
. Repeat AP and oblique radiographs with increased exposure.
. Obtain lateral view, stress views, and a CT scan.
. Order a bone scan to assess for occult fractures.
. Discharge the patient with a walking boot and follow-up in 1 week.

Correct Answer & Explanation

. Obtain lateral view, stress views, and a CT scan.

Explanation

Correct Answer: CExplanation:The case explicitly states the candidate's response to inconclusive radiographs: "I would consider further radiographic imaging, oblique and lateral view, stress views and a CT scan or may opt for an MRI scan." This indicates a clear progression of imaging modalities to definitively diagnose a Lisfranc injury when initial views are insufficient.Option A (Immediate MRI of the foot):While MRI is excellent for soft tissue and ligamentous injuries, it is often reserved for cases where CT is inconclusive or for assessing ligamentous integrity more precisely. The immediate next step typically involves further plain radiographs and CT.Option B (Repeat AP and oblique radiographs with increased exposure):Simply repeating the same views with different exposure is unlikely to provide new diagnostic information if the initial views were inconclusive for a structural injury like a Lisfranc dislocation. Additional views and advanced imaging are needed.Option C (Obtain lateral view, stress views, and a CT scan):This aligns perfectly with the candidate's recommended approach. A lateral view is crucial for assessing dorsal/plantar displacement, stress views can reveal instability not apparent on static films, and a CT scan provides detailed bony anatomy, crucial for identifying subtle fractures, displacement, and comminution within the complex tarsometatarsal joint.Option D (Order a bone scan):A bone scan is highly sensitive but non-specific for fractures and can take hours to days for results, making it unsuitable for acute diagnosis in the emergency setting for a potentially unstable injury.Option E (Discharge with a walking boot):Discharging a patient with a suspected Lisfranc injury, especially if radiographs are inconclusive, is inappropriate and carries a high risk of missed diagnosis and poor outcome, as up to 20% of these injuries are initially missed.

Question 1063

Topic: 8. Foot and Ankle

A 49-year-old female with a Lisfranc injury is being counseled regarding her prognosis. Based on the information provided in the case, which of the following statements should the orthopedic surgeon include in the discussion with the patient?

. The injury typically heals without long-term complications, and a full return to pre-injury activity is expected within 3 months.
. Post-traumatic osteoarthritis is a rare complication, occurring in less than 10% of cases.
. Residual pain and a stiff foot are uncommon, especially with successful surgical intervention.
. This is a serious injury with a potentially poor outcome, and post-traumatic osteoarthritis may occur in more than 50% of cases despite surgery.
. The recovery period is generally short, and patients can expect to resume full weight-bearing within 6 weeks.

Correct Answer & Explanation

. This is a serious injury with a potentially poor outcome, and post-traumatic osteoarthritis may occur in more than 50% of cases despite surgery.

Explanation

Correct Answer: DExplanation:The case explicitly addresses the prognosis for Lisfranc injuries, stating, "This is a serious injury with potentially a poor outcome. Post-traumatic osteoarthritis may occur in more than 50% of cases despite surgical intervention. Residual pain and stiff foot are not uncommon complications of this injury." This information is crucial for informed consent and realistic patient expectations.Option A (Full return to pre-injury activity within 3 months):This is overly optimistic for a serious injury like a Lisfranc fracture-dislocation, which often requires a prolonged recovery period, sometimes up to a year or more, and may not result in a full return to pre-injury activity.Option B (Post-traumatic osteoarthritis is a rare complication, occurring in less than 10% of cases):This contradicts the case, which states it may occur in "more than 50% of cases."Option C (Residual pain and a stiff foot are uncommon):This also contradicts the case, which states they "are not uncommon complications."Option D (This is a serious injury with a potentially poor outcome, and post-traumatic osteoarthritis may occur in more than 50% of cases despite surgery):This statement directly reflects the prognosis provided in the case, emphasizing the severity and potential long-term complications.Option E (Recovery period is generally short, and patients can expect to resume full weight-bearing within 6 weeks):This is incorrect. Even for stable injuries, non-weightbearing is typically for 6 weeks, and for surgical cases, the recovery and return to full weight-bearing are much longer.

Question 1064

Topic: Midfoot & Hindfoot

A 49-year-old female sustains a Lisfranc injury. The candidate in the case mentions the importance of the 'fleck sign'. What does the 'fleck sign' specifically represent in the context of a Lisfranc injury?

. A small avulsion fracture from the insertion of the Lisfranc ligament into the base of the second metatarsal.
. A small intra-articular fracture within the talonavicular joint.
. A displaced fracture of the cuboid bone.
. A comminuted fracture of the medial cuneiform.
. A small osteochondral defect on the talar dome.

Correct Answer & Explanation

. A small avulsion fracture from the insertion of the Lisfranc ligament into the base of the second metatarsal.

Explanation

Correct Answer: AExplanation:The case explicitly defines the 'fleck sign': "There is a small avulsed fragment of bone in that interval. This avulsion fracture could be from the insertion of the Lisfranc ligament into the base of the second metatarsal, called a โ€˜fleck signโ€™." This is a classic radiographic indicator of a Lisfranc ligament injury.Option A (A small avulsion fracture from the insertion of the Lisfranc ligament into the base of the second metatarsal):This is the correct definition of the 'fleck sign' as described in the case and in orthopedic literature. It signifies disruption of the Lisfranc ligament complex.Option B (A small intra-articular fracture within the talonavicular joint):This describes an injury to the Chopart joint, not the Lisfranc joint.Option C (A displaced fracture of the cuboid bone):While cuboid fractures can occur, they are not referred to as a 'fleck sign' in the context of Lisfranc injuries.Option D (A comminuted fracture of the medial cuneiform):Fractures of the cuneiforms can be part of a Lisfranc injury, but the 'fleck sign' specifically refers to the avulsion from the second metatarsal base.Option E (A small osteochondral defect on the talar dome):This is an ankle injury, unrelated to the Lisfranc joint.

Question 1065

Topic: 8. Foot and Ankle

A 49-year-old female with a Lisfranc injury is being prepared for surgical intervention due to significant displacement. The surgeon plans to perform open reduction and internal fixation. Which of the following is a critical step that must be completed prior to taking the patient to the operating theatre, as emphasized in the case?

. Obtain a second opinion from a foot and ankle specialist.
. Administer prophylactic antibiotics 24 hours prior to surgery.
. Discuss management options, postoperative rehabilitation, outcome, and potential complications with the patient and obtain informed consent.
. Ensure the patient has been non-weightbearing for at least 72 hours.
. Perform a diagnostic arthroscopy of the tarsometatarsal joints.

Correct Answer & Explanation

. Discuss management options, postoperative rehabilitation, outcome, and potential complications with the patient and obtain informed consent.

Explanation

Correct Answer: CExplanation:The case explicitly states, "Informed consent should be taken. The management options, postoperative rehabilitation, outcome and potential complications should be discussed in detail with the patient and documented in medical records." This is a fundamental ethical and legal requirement before any surgical procedure.Option A (Obtain a second opinion):While sometimes helpful, a second opinion is not a mandatory critical step before every surgical case, especially when the diagnosis and treatment plan are clear.Option B (Administer prophylactic antibiotics 24 hours prior):Prophylactic antibiotics are typically given within 60 minutes prior to incision, not 24 hours prior, to be most effective.Option C (Discuss management options, postoperative rehabilitation, outcome, and potential complications with the patient and obtain informed consent):This is a crucial step for patient autonomy and shared decision-making, as highlighted in the case.Option D (Ensure the patient has been non-weightbearing for at least 72 hours):While non-weightbearing is part of initial management, a specific 72-hour non-weightbearing period is not a universal prerequisite for surgery, especially if the soft tissue envelope is acceptable.Option E (Perform a diagnostic arthroscopy):Diagnostic arthroscopy of the tarsometatarsal joints is not a standard or necessary step prior to ORIF for a Lisfranc injury. The diagnosis is typically made with radiographs and CT.

Question 1066

Topic: 8. Foot and Ankle

A 49-year-old female presents with a Lisfranc injury. The provided radiographs show the characteristic findings.

Considering the anatomy of the Lisfranc joint complex, which of the following statements accurately describes the primary stabilizing structure that is typically disrupted in this type of injury?

. The plantar fascia, connecting the calcaneus to the metatarsal heads.
. The spring ligament, supporting the talonavicular joint.
. The Lisfranc ligament, connecting the medial cuneiform to the base of the second metatarsal.
. The deltoid ligament, stabilizing the medial ankle.
. The calcaneocuboid ligament, stabilizing the midtarsal joint.

Correct Answer & Explanation

. The Lisfranc ligament, connecting the medial cuneiform to the base of the second metatarsal.

Explanation

Correct Answer: CExplanation:The case explicitly mentions the Lisfranc ligament and its insertion. The Lisfranc joint complex is stabilized by a network of ligaments, but the Lisfranc ligament itself is the key structure connecting the medial cuneiform to the base of the second metatarsal. Its disruption is central to the instability seen in Lisfranc injuries.Option A (The plantar fascia):The plantar fascia is a strong aponeurosis on the sole of the foot, crucial for arch support, but not the primary stabilizer of the tarsometatarsal joints.Option B (The spring ligament):The spring ligament (plantar calcaneonavicular ligament) supports the talar head and the medial longitudinal arch, primarily stabilizing the talonavicular joint, which is part of the Chopart joint, not the Lisfranc joint.Option C (The Lisfranc ligament, connecting the medial cuneiform to the base of the second metatarsal):This is the correct anatomical description of the Lisfranc ligament, which is the primary stabilizer preventing dorsal and lateral displacement of the metatarsals relative to the tarsus. Its disruption is the hallmark of a Lisfranc injury.Option D (The deltoid ligament):The deltoid ligament is a strong ligament on the medial side of the ankle, stabilizing the tibiotalar joint, not the midfoot.Option E (The calcaneocuboid ligament):This ligament stabilizes the calcaneocuboid joint, part of the Chopart joint, and is not the primary stabilizer of the Lisfranc joint complex.

Question 1067

Topic: 8. Foot and Ankle

A 22-year-old collegiate football player presents with midfoot pain after a severe axial load was applied to his plantarflexed foot. Non-weight-bearing radiographs appear largely unremarkable, but he has severe pain with passive pronation of the forefoot. What is the most appropriate next step in imaging to evaluate for a subtle Lisfranc injury?

. Non-weight-bearing oblique radiographs of the foot
. Weight-bearing anteroposterior, lateral, and oblique radiographs of the foot
. Bone scintigraphy (Tc-99m bone scan)
. Diagnostic ultrasound of the dorsal foot
. Fluoroscopic stress views under general anesthesia immediately

Correct Answer & Explanation

. Weight-bearing anteroposterior, lateral, and oblique radiographs of the foot

Explanation

Weight-bearing radiographs are critical for detecting subtle Lisfranc injuries, as the axial load stresses the tarsometatarsal joints. This stress can reveal widening (diastasis) between the first and second metatarsal bases that is not apparent on resting views.

Question 1068

Topic: 8. Foot and Ankle

A 55-year-old male with poorly controlled type 2 diabetes presents with a unilaterally swollen, red, and warm left foot. He denies trauma. Pedal pulses are bounding, and he has profound peripheral neuropathy. Radiographs reveal fragmentation and subluxation at the tarsometatarsal joints without soft tissue gas. What is the most appropriate initial management?

. Immediate incision and drainage with deep tissue cultures
. Emergent midfoot arthrodesis
. Immobilization in a total contact cast and strict non-weight-bearing
. Intravenous antibiotics and observation
. Application of a Charcot Restraint Orthotic Walker (CROW) boot and immediate weight-bearing

Correct Answer & Explanation

. Immobilization in a total contact cast and strict non-weight-bearing

Explanation

The patient is presenting with acute stage 0/1 Charcot neuroarthropathy. The gold standard for initial management of the acute, active Charcot foot is offloading and immobilization, most effectively achieved with a total contact cast (TCC).

Question 1069

Topic: 8. Foot and Ankle

A 38-year-old male undergoes open repair of an acute Achilles tendon rupture using a posteromedial approach. During the dissection, the surgeon must be cautious to protect the sural nerve. What is the classic anatomic course of the sural nerve relative to the Achilles tendon?

. It courses medial to the Achilles tendon throughout the posterior calf
. It crosses from medial to lateral across the Achilles tendon roughly 10 cm proximal to its insertion
. It runs within the deep posterior compartment alongside the posterior tibial artery
. It courses superficial to the crural fascia and does not cross the Achilles tendon
. It crosses the lateral border of the Achilles tendon approximately 2 cm proximal to its insertion

Correct Answer & Explanation

. It crosses from medial to lateral across the Achilles tendon roughly 10 cm proximal to its insertion

Explanation

The sural nerve classically crosses the lateral border of the Achilles tendon roughly 10 cm (range 9-12 cm) proximal to the calcaneal insertion. Knowledge of this anatomy is vital to prevent iatrogenic nerve injury during Achilles tendon repairs.

Question 1070

Topic: 8. Foot and Ankle
A 26-year-old female sustains a Hawkins Type III talar neck fracture following a fall from height. Which of the following best describes the disruption of the blood supply and the associated risk of avascular necrosis (AVN) of the talar body?
. Disruption of the artery of the tarsal canal only; AVN risk is 10-20%
. Disruption of the artery of the tarsal sinus only; AVN risk is 30-40%
. Disruption of two of three blood supplies; AVN risk is 40-50%
. Disruption of all three major blood supplies; AVN risk is nearly 100%
. Disruption of the anterior tibial artery branches; AVN risk is 0-10%

Correct Answer & Explanation

. Disruption of all three major blood supplies; AVN risk is nearly 100%

Explanation

A Hawkins Type III fracture involves a talar neck fracture with dislocation of both the subtalar and tibiotalar joints. This completely disrupts all three primary blood supplies to the talar body (artery of tarsal canal, deltoid branches, and sinus tarsi vessels), leading to a nearly 100% risk of AVN.

Question 1071

Topic: 8. Foot and Ankle
A 42-year-old roofer falls 15 feet and sustains a displaced intra-articular calcaneus fracture (Sanders Type III). During operative reconstruction via an extensile lateral approach, the surgeon must reduce the tuberosity to the 'constant fragment'. Which anatomic structure defines the constant fragment in a calcaneus fracture?
. The anterior process of the calcaneus
. The posterior facet of the calcaneus
. The sustentacular (superomedial) fragment
. The lateral wall fragment
. The calcaneal tuberosity

Correct Answer & Explanation

. The sustentacular (superomedial) fragment

Explanation

In intra-articular calcaneus fractures, the superomedial (sustentacular) fragment is termed the 'constant fragment'. It remains securely attached to the talus by the strong interosseous talocalcaneal and deltoid ligaments, serving as the foundation for anatomic reduction.

Question 1072

Topic: 8. Foot and Ankle

A 52-year-old female presents with a progressive flatfoot deformity. On exam, she has a positive 'too many toes' sign and is entirely unable to perform a single-leg heel rise on the affected side. She has pain along the medial ankle. Dysfunction of which of the following tendons is the primary etiology of this condition?

. Flexor hallucis longus
. Tibialis anterior
. Posterior tibial tendon
. Peroneus brevis
. Achilles tendon

Correct Answer & Explanation

. Posterior tibial tendon

Explanation

The patient has Stage II adult-acquired flatfoot deformity, primarily driven by posterior tibial tendon dysfunction (PTTD). The posterior tibial tendon is the primary dynamic stabilizer of the medial longitudinal arch, and its failure results in hindfoot valgus and forefoot abduction.

Question 1073

Topic: 8. Foot and Ankle

A 22-year-old collegiate football player sustains an axial load to a plantarflexed foot. Weight-bearing radiographs reveal widening of the interval between the first and second metatarsal bases. The primary ligament disrupted in this injury originates from and inserts into which of the following structures?

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

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is an interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is critical for the stability of the tarsometatarsal joint complex.

Question 1074

Topic: Midfoot & Hindfoot

A 58-year-old female presents with a progressive, flexible flatfoot deformity and inability to perform a single-leg heel rise. Examination reveals a 'too many toes' sign and tenderness over the medial ankle. Which of the following surgical interventions is most appropriate for a Stage IIb posterior tibial tendon dysfunction?

. Isolated posterior tibial tendon debridement
. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis
. Subtalar arthrodesis

Correct Answer & Explanation

. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction denotes a flexible flatfoot with significant forefoot abduction (>40% talonavicular uncoverage). Appropriate treatment includes FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening to correct the abduction.

Question 1075

Topic: Midfoot & Hindfoot

A 40-year-old laborer sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial and middle cuneiforms. Based on current high-level evidence, what is the primary advantage of primary arthrodesis over open reduction and internal fixation (ORIF) for this specific injury pattern?

. Lower rate of hardware removal and higher functional scores
. Decreased risk of deep vein thrombosis
. Shorter time to full weight-bearing
. Higher rate of return to heavy labor within 3 months
. Preserved physiologic motion of the medial column

Correct Answer & Explanation

. Lower rate of hardware removal and higher functional scores

Explanation

Purely ligamentous Lisfranc injuries have a significantly higher rate of failure with ORIF compared to primary arthrodesis. Primary arthrodesis of the medial columns (1st-3rd TMT joints) typically yields higher long-term functional scores and avoids the morbidity of planned hardware removal.

Question 1076

Topic: 8. Foot and Ankle

A 45-year-old male sustains an acute Achilles tendon rupture. He is counseled on nonoperative versus operative management. Based on current high-level evidence, which of the following is true regarding nonoperative management with early functional rehabilitation compared to operative repair?

. It has a significantly higher re-rupture rate
. It has equivalent re-rupture rates but lower functional scores
. It has equivalent re-rupture rates and functional outcomes with fewer soft tissue complications
. It requires an additional 6 weeks of strict non-weight-bearing
. It leads to a significantly greater loss of plantarflexion strength

Correct Answer & Explanation

. It has equivalent re-rupture rates and functional outcomes with fewer soft tissue complications

Explanation

Current high-level prospective evidence (e.g., Willits et al.) demonstrates that nonoperative management combined with an early functional rehabilitation protocol yields equivalent re-rupture rates and functional outcomes to operative repair. However, operative repair carries a significantly higher risk of soft-tissue complications, including infection.

Question 1077

Topic: 8. Foot and Ankle

A 10-year-old boy with Duchenne Muscular Dystrophy is undergoing preoperative evaluation for a planned Achilles tendon lengthening procedure to address a severe equinus contracture. His medical history includes chronic corticosteroid use. Which of the following is an absolute contraindication to proceeding with this elective orthopedic surgery?

. Preoperative ejection fraction (EF) of 40%
. History of multiple low-energy long bone fractures
. Baseline FVC of 25% predicted with significant CO2 retention
. Ongoing physical therapy and bracing for the contracture
. Mild hip flexion contractures

Correct Answer & Explanation

. Baseline FVC of 25% predicted with significant CO2 retention

Explanation

Correct Answer: CThe case explicitly lists severe cardiorespiratory compromise as the most significant absolute contraindication to orthopedic surgery in DMD patients. Specifically, a severely impaired pulmonary function (e.g., FVC < 20% predicted, or significant CO2 retention) often precludes major surgery unless life-sustaining benefits clearly outweigh risks. A baseline FVC of 25% predicted with significant CO2 retention falls into this category, indicating severe respiratory compromise that would make elective surgery prohibitively risky.Option A (Preoperative ejection fraction (EF) of 40%):While cardiac function is critical, an EF of 40% is generally considered moderate impairment. The case specifies an EF < 30-35% as a more definitive contraindication. An EF of 40% would require careful cardiac optimization but might not be an absolute contraindication on its own for an elective procedure like Achilles lengthening, which is less invasive than spinal fusion.Option B (History of multiple low-energy long bone fractures):This indicates significant osteopenia, a common complication of DMD and corticosteroid use. While it increases surgical risk (e.g., for spinal instrumentation or fracture fixation), it is not an absolute contraindication for a soft tissue procedure like Achilles lengthening. Bone fragility is a relative contraindication, and management strategies exist.Option D (Ongoing physical therapy and bracing for the contracture):Non-operative management is the cornerstone of DMD care. Ongoing PT and bracing indicate that conservative measures are being pursued, but if the contracture is severe and interfering with function (as implied by the need for surgery), this is not a contraindication but rather a preceding step to surgery.Option E (Mild hip flexion contractures):Mild contractures are common in DMD and are often managed non-operatively or addressed in conjunction with other procedures. They do not represent an absolute contraindication to an Achilles lengthening.

Question 1078

Topic: 8. Foot and Ankle

A 6-year-old boy with Duchenne Muscular Dystrophy presents with a progressive equinus contracture of the ankle, making it difficult to wear his Ankle-Foot Orthoses (AFOs) and affecting his balance during ambulation. Non-operative management with stretching and bracing has failed to improve the contracture. The orthopedic surgeon plans a surgical release. Which of the following is a key principle to adhere to during the surgical technique for Achilles tendon lengthening in this patient?

. Aggressive overcorrection to prevent recurrence of the contracture.
. Complete tenotomy of the Achilles tendon without repair to maximize lengthening.
. Meticulous technique to avoid overcorrection and damage to neurovascular structures.
. Exclusive use of open Z-lengthening for all equinus contractures.
. Ignoring the sural nerve as it is not typically in close proximity to the Achilles tendon.

Correct Answer & Explanation

. Meticulous technique to avoid overcorrection and damage to neurovascular structures.

Explanation

Correct Answer: CThe case emphasizes that for Achilles tendon lengthening, meticulous technique is required to avoid overcorrection or damage to neurovascular structures. Overcorrection leading to a calcaneus deformity must be avoided, as this can create new functional deficits. The image provided shows a lower limb, consistent with a procedure like Achilles tendon lengthening, where careful technique is paramount.Option A (Aggressive overcorrection to prevent recurrence of the contracture):This is incorrect. The case specifically warns against overcorrection, stating it must be avoided as it can lead to new functional deficits (e.g., calcaneus deformity).Option B (Complete tenotomy of the Achilles tendon without repair to maximize lengthening):This is incorrect. Achilles tendon lengthening is typically performed via sequential tenotomies (e.g., three-portal percutaneous technique for a Z-lengthening effect) or a formal open Z-plasty, which involves controlled lengthening, not a complete, unrepaired tenotomy.Option D (Exclusive use of open Z-lengthening for all equinus contractures):This is incorrect. The case mentions both percutaneous Achilles tenotomy/lengthening (for its minimally invasive approach) and open Z-lengthening (for more severe or resistant contractures), indicating that the choice depends on the severity and specific situation.Option E (Ignoring the sural nerve as it is not typically in close proximity to the Achilles tendon):This is incorrect. The case specifically mentions that during open Z-lengthening of the Achilles tendon, the sural nerve must be carefully mobilized and protected, indicating its proximity and vulnerability.

Question 1079

Topic: 8. Foot and Ankle

The patient reported transient numbness and tingling along the dorsum of both feet and a foot drop sensation, particularly on the right side, which resolved completely within 15 to 20 minutes of resting. Post-exertion examination confirmed 4-/5 weakness in right ankle dorsiflexion and great toe extension, and diminished sensation over the dorsum of the right foot. These specific neurological deficits are most consistent with transient ischemic neuropraxia of which nerves?

. Sural nerve and saphenous nerve
. Tibial nerve and medial plantar nerve
. Deep peroneal nerve and superficial peroneal nerve
. Common peroneal nerve and posterior tibial nerve
. Femoral nerve and obturator nerve

Correct Answer & Explanation

. Deep peroneal nerve and superficial peroneal nerve

Explanation

Correct Answer: CThe correct answer is C. The deep peroneal nerve innervates the muscles of the anterior compartment, including the tibialis anterior and extensor hallucis longus, which are responsible for ankle dorsiflexion and great toe extension, respectively. Ischemic neuropraxia of the deep peroneal nerve would therefore cause transient weakness (foot drop sensation) in these movements. The deep peroneal nerve also provides sensation to the first dorsal web space.The superficial peroneal nerve provides sensation to the dorsum of the foot (excluding the first web space). Compression or ischemia of the superficial peroneal nerve would lead to the reported numbness and tingling along the dorsum of the foot. Both of these nerves are particularly vulnerable to compression in the anterior and lateral compartments, respectively, during episodes of elevated intracompartmental pressure.The other options involve nerves with different motor and sensory distributions (e.g., sural nerve for lateral foot sensation, tibial nerve for plantarflexion and plantar foot sensation, femoral nerve for hip flexion and knee extension).

Question 1080

Topic: 8. Foot and Ankle

In the immediate post-operative period (Weeks 0-2) following bilateral anterolateral fasciectomy, the patient was allowed to weight-bear as tolerated and encouraged to perform active and passive range of motion exercises for the ankle and toes. What is the primary goal of initiating early active dorsiflexion and plantarflexion exercises in this phase?

. To rapidly restore full muscle strength in the affected compartments.
. To prevent the muscles from scarring down to the overlying subcutaneous tissues and skin.
. To assess the integrity of the fascial repair and prevent dehiscence.
. To stretch the newly released fascia and prevent re-tightening.
. To reduce the risk of deep vein thrombosis by promoting venous return.

Correct Answer & Explanation

. To prevent the muscles from scarring down to the overlying subcutaneous tissues and skin.

Explanation

Correct Answer: BThe correct answer is B. In the immediate post-operative period (Phase 1), early active and passive range of motion exercises for the ankle and toes, particularly active dorsiflexion and plantarflexion, are critical to prevent the muscles from scarring down to the overlying subcutaneous tissues and skin. This helps maintain the mobility of the muscle bellies within the newly released compartment, preventing restrictive scar tissue formation that could lead to recurrent symptoms.Option A is incorrect; rapid restoration of full muscle strength is a later goal. Option C is incorrect; the deep fascia is explicitly left open, so there is no fascial repair to assess for dehiscence. Option D is incorrect; the goal is to prevent scarring, not to stretch the fascia, which has been excised. Option E is a secondary benefit of early weight-bearing and movement, but the primary goal for specific muscle exercises is to prevent adhesions.

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