Menu

8. Foot and Ankle MCQs

Practice Set 82 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 1621

Topic: 8. Foot and Ankle

A 23-year-old man sustained an injury to his left foot when a forklift rolled over it at work. Examination reveals marked swelling of the midfoot and forefoot, with tenderness to palpation over the medial hindfoot and dorsomedial forefoot. The distal dorsalis pedis pulse is audible on Doppler examination, and his sensation is intact to touch. Radiographs are shown in Figures 33a and 33b. Management should consist of

. closed reduction and cast immobilization for 6 weeks.
. closed reduction and percutaneous pin fixation.
. open reduction of the tarsal navicular and closed management of the Lisfranc joint.
. open reduction and internal fixation of the Lisfranc joint, the tarsal navicula, and second metatarsal neck fractures.
. open reduction and primary arthrodesis of the Lisfranc joint and internal fixation of the tarsal navicula and second metatarsal neck fractures.

Correct Answer & Explanation

. open reduction and internal fixation of the Lisfranc joint, the tarsal navicula, and second metatarsal neck fractures.

Explanation

DISCUSSION: The best results after dislocations of the tarsometatarsal joints are seen with anatomic reduction; this is best achieved by open reduction and maintained with internal fixation with either pins or screws.  Open reduction provides a means of debriding small bony fragments from the joint and allowing direct inspection of the reduction.  Associated crush or shearing fractures of the cuboid or tarsal navicula are signs that suggest a Lisfranc injury.  Because patients can function quite well despite the development of arthrosis in the Lisfranc joint, primary arthrodesis is not indicated in the management of this injury.REFERENCES: Resch S, Stenstrom A: The treatment of tarsometatarsal injuries.  Foot Ankle 1990;11:117-123.Schenck RC Jr, Heckman JD: Fractures and dislocations of the forefoot: Operative and nonoperative treatment.  J Am Acad Orthop Surg 1995;3:70-78.Kuo RS, Tejwani NC, Digiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries.  J Bone Joint Surg Am 2000;82:1609-1618.

Question 1622

Topic: Forefoot

What is the preferred treatment of a symptomatic curly toe deformity in a 6-year-old child?

. Observation
. Tape the toe to the adjacent toes for 8 weeks
. Tenotomy of the flexor tendons
. Transfer of the flexor tendons to the extensor mechanism
. Arthrodesis of the proximal interphalangeal joint

Correct Answer & Explanation

. Tenotomy of the flexor tendons

Explanation

DISCUSSION: While some curly toe deformities spontaneously improve in younger children, the deformity is likely to persist in a 6-year-old child.  Taping techniques result in no change or only a temporary decrease in deformity.  Studies have shown that simple flexor tenotomy is as effective as flexor tendon transfer.  Arthrodesis is rarely indicated.REFERENCES: Hamer A, Stanley D, Smith TW: Surgery for curly toe deformity: Adouble-blind, randomized, prospective trial.  J Bone Joint Surg Br 1993;75:662-663.Ross ER, Menelaus MB: Open flexor tenotomy for hammer toes and curly toes in childhood.J Bone Joint Surg Br 1984;66:770-771.

Question 1623

Topic: 8. Foot and Ankle

A 10-year-old soccer player has bilateral heel pain and reports that the pain is worse during and immediately after sports. Examination reveals that the calcaneal tuberosities are painful to palpation bilaterally. What is the most likely diagnosis?

. Plantar fasciitis
. Calcaneal apophysitis
. Achilles tendinitis
. Calcaneal bursitis
. Stress fractures of the calcanei

Correct Answer & Explanation

. Calcaneal apophysitis

Explanation

DISCUSSION: Calcaneal apophysitis (Sever’s disease) is a common cause of heel pain in children who are active in sports.  The symptoms are most commonly bilateral and will often respond to a gastrocnemius-soleus complex stretching program.  In addition, rest, anti-inflammatory drugs, and heel pads for the shoe may be prescribed.  There is no effect on the long-term growth of the calcaneus.REFERENCES: Micheli LJ, Ireland ML: Prevention and management of calcaneal apophysitis in children: An overuse syndrome.  J Pediatr Orthop 1987;7:34-38. 500.FOR ALL MCQS CLICK THE LINK ORTHOMCQ BANK

Question 1624

Topic: 8. Foot and Ankle

Which lower extremity muscle is first weakened in Charcot-Marie-Tooth (CMT) disease?

. Peroneus brevis
. Peroneus longus
. Foot intrinsics
. Tibialis anterior

Correct Answer & Explanation

. Foot intrinsics

Explanation

DISCUSSIONAlthough many of the lower extremity muscles may be affected in CMT, those innervated by the longest axons have been shown to be affected first. In the lower extremity the muscles innervated by the longest axons are the intrinsic foot muscles. The tibialis anterior and the peroneus brevis may be severely affected but not before the foot intrinsics. The peroneus longus typically is spared, resulting in the cavus.RECOMMENDED READINGSPareyson D, Marchesi C. Diagnosis, natural history, and management of Charcot-Marie-Tooth disease. Lancet Neurol. 2009 Jul;8(7):654-67. Review. PubMed PMID: 19539237.ViewAbstract at PubMedWenz W, Dreher T. Charcot-Marie-Tooth disease and the cavovarus foot. In: Pinzur MS, ed. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:291-306.CLINICAL SITUATION FOR QUESTIONS 60 THROUGH 63Figure 60 is the standing radiograph of a 27-year-old man who played football throughout his teen years. During those years, he noted that he had less mobility of his left foot and ankle. He twisted his left foot and ankle 8 months ago and has tried over-the-counter nonsteroidal anti-inflammatory drugs and a brace. He now has pain and edema in the left sinus tarsi area.|MotionRight (degrees)Left (degrees)Ankle dorsiflexion55Ankle plantar flexion3030Foot inversion105Foot eversion105

Question 1625

Topic: 8. Foot and Ankle

A toddler is brought in by his parents for evaluation of gait problems. Birth history and neurologic examination are unremarkable. After evaluating femoral torsion, tibial torsion, and foot contour, the diagnosis is excessive internal tibial torsion. The parents should be advised to expect which of the following outcomes? Review Topic

. Resolution by age 3 or 4 years without active treatment in most patients
. Resolution by age 8 or 9 years without active treatment in most patients
. Resolution with casting as the most effective treatment
. Resolution with bracing and shoe modification as the most effective treatment
. Resolution with surgery as the most effective treatment

Correct Answer & Explanation

. Resolution by age 3 or 4 years without active treatment in most patients

Explanation

Excessive internal tibial torsion is a common cause of intoeing in toddlers. In most children, this resolves spontaneously by 3 to 4 years of age. Intoeing in elementary age children is usually the result of excessive femoral anteversion. Studies have shown that active intervention (casting, splinting, and shoe modifications) has no demonstrable effect on the natural history or resolution of tibial torsion. Surgery is rarely indicated in adolescents with severe internal tibial torsion that has not resolved and is resulting in cosmetic and functional problems.

Question 1626

Topic: 8. Foot and Ankle

Figure 1 shows the radiograph of a 60-year-old woman who underwent a previous operation for great toe pain 20 years ago. She has had increasing pain over the past 5 years and now reports pain with any motion, swelling, and clicking. She also reports pain under the ball of foot. What is the most appropriate management to alleviate her metatarsalgia and great toe pain?

. Orthotic with Morton’s extension
. In situ great toe fusion with implant removal
. Keller resection arthroplasty
. Implant removal with structural bone grafting and metatarsophalangeal (MTP) fusion
. Implant removal, bone grafting, and titanium total toe implants

Correct Answer & Explanation

. Orthotic with Morton’s extension

Explanation

DISCUSSION: The patient has a failed Silastic implant.  Nonsurgical management will not work at this point.  A Keller resection will only exacerbate her metatarsalgia.  Implant removal with structural bone grafting and MTP fusion is the most appropriate choice because restoration of length is needed to alleviate the forefoot pain and bone grafting is required to fuse the MTP joint because there is an abundance of osteolysis.  Total toe implants do not offer good long-term outcomes and are very difficult to fit into the large exploded-out cavity of the proximal phalanx.REFERENCES: Hecht PJ, Gibbons MJ, Wapner KL, et al: Arthrodesis of the first metatarsophalangeal joint to salvage failed silicone implant arthroplasty.  Foot Ankle Int 1997;18:383-390.Myerson MS, Schon LC, McGuigan FX, et al: Results of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length.  Foot Ankle Int2000;21:297-306.

Question 1627

Topic: 8. Foot and Ankle

Which of the following patients is considered the most appropriate candidate for an isolated split posterior tendon transfer?

. A 2-year-old with spastic diplegia and a flexible equinovarus foot
. A 5-year-old with spastic quadriplegia and athetosis
. A 6-year-old with spastic hemiplegia, a flexible equinovarus foot, and out-of-phase posterior tendon activity on electromyography
. A 6-year-old with spastic hemiplegia, a flexible equinovarus foot, and continuous posterior tibial tendon activity on electromyography
. A 10-year-old with spastic quadriplegia and a rigid equinovarus foot

Correct Answer & Explanation

. A 6-year-old with spastic hemiplegia, a flexible equinovarus foot, and continuous posterior tibial tendon activity on electromyography

Explanation

DISCUSSION: Isolated split posterior tendon transfer alone is best performed in a patient with cerebral palsy who is between the ages of 4 and 7 years and has a flexible equinovarus foot.  Rigid deformities often must be managed with a combination of soft-tissue and bony procedures.  Patients with out-of-phase activity may be best managed with a transfer of the posterior tibialis to the dorsum of the foot, while those with continuous activity are better candidates for an isolated split posterior tendon transfer.REFERENCES: Drennan JC (ed): The Child’s Foot and Ankle.  New York, NY, Raven Press, 1992, pp 291-294.Green NE, Griffin PP, Shiavi R: Split posterior tibial-tendon transfer in cerebral palsy.  J Bone Joint Surg Am 1983;65:748-754.Kling TF Jr, Kaufer H, Hensinger RN: Split posterior tibial-tendon transfers in children with cerebral spastic paralysis and equinovarus deformity.  J Bone Joint Surg Am 1985;67:186-194.

Question 1628

Topic: 8. Foot and Ankle

When considering a flexor digitorum longus tendon transfer as part of the surgical treatment in patients with symptomatic flatfoot deformity caused by posterior tibial tendon insufficiency, which of the following patients is the most appropriate candidate?

. A 45-year-old woman with a hypermobile foot
. A 45-year-old man with a rigid hindfoot valgus deformity
. A thin 55-year-old woman with mild hemiparesis affecting the symptomatic foot from a previous stroke
. An active 55-year-old woman with a progressively worsening supple hindfoot valgus
. A moderately obese 70-year-old woman with a supple hindfoot

Correct Answer & Explanation

. An active 55-year-old woman with a progressively worsening supple hindfoot valgus

Explanation

DISCUSSION: Transfer of the flexor digitorum longus tendon is a common technique combined with other procedures to treat patients with posterior tibial tendon insufficiency.  However, it is contraindicated in patients with a fixed hindfoot deformity, hypermobility, or neuromuscular compromise.  It is relatively contraindicated in patients who are obese, and those older than age 60 to 70 years.REFERENCES: Pedowitz WJ, Kovatis P: Flatfoot in the adult.  J Am Acad Orthop Surg 1995;3:293-302.Mann RA: Surgery of the Foot and Ankle, ed 6.  St Louis, MO, Mosby-Year Book, 1993, pp 167-296.

Question 1629

Topic: 8. Foot and Ankle

After full healing from this injury, which option most likely will help to optimize this patient's activities?

. Extra-depth shoes
. Rocker-bottom soles
. Figure-of-8 soft-ankle brace
. A patellar-tendon-bearing brace

Correct Answer & Explanation

. Rocker-bottom soles

Explanation

DISCUSSIONMidfoot fracture dislocations typically occur after a fall from a height or a motor vehicle collision involving severe dorsiflexion loading of the foot from a brake pedal or the floorboards. The deformity that results may be subtle because the subluxation may be a valgus or varus rotation around the midfoot rather than pure dorsiflexion. Early recognition and reduction is indicated to minimize secondary complications such as nerve injury or vascular compromise. Closed reduction usually necessitates formal anesthesia in an operating room to permit adequate relaxation and reduction. In many cases, satisfactory reduction can be accomplished closed, but the surgeon must be prepared to perform an open reduction if needed. The most common reason for failed closed reduction is that the talar head is caught by the tibialis posterior tendon (under which the talar head has protruded). This acts as a Chinese finger trap, preventing relocation by the usual distraction followed bya plantar flexion maneuver. In these cases, open reduction is performed through a dorsomedial incision through which the tibialis posterior is retracted medially, allowing reduction of the talonavicular joint. The joints usually require pinning to maintain stability during healing. The long-term prognosis for these injuries is guarded because many patients develop degenerative changes in the Chopart joint. If symptomatic arthritis develops, helpful external supports are designed to limit sagittal motion at the joint (for example, carbon fiber inserts or rocker-bottom soles).RECOMMENDED READINGSSwords MP, Schramski M, Switzer K, Nemec S. Chopart fractures and dislocations. Foot Ankle Clin. 2008 Dec;13(4):679-93, viii. Doi: 10.1016/j.fcl.2008.08.004. Review. PubMed PMID: 19013402.View Abstract at PubMedRichter M, Thermann H, Huefner T, Schmidt U, Goesling T, Krettek C. Chopart joint fracture-dislocation: initial open reduction provides better outcome than closed reduction. Foot Ankle Int. 2004 May;25(5):340-8. PubMed PMID: 15134617.View Abstract at PubMed

Question 1630

Topic: 8. Foot and Ankle

A 55-year-old man who runs on the weekends reports a 1-year history of continued pain directly posteriorly in the heel. Management consisting of anti-inflammatory drugs, icing techniques, a heel-counter in his shoe split, and physical therapy consisting of stretching, contrast baths, custom orthotics, and iontophoresis has failed to provide relief. Not only is his lifestyle disrupted with respect to running, but he now has pain with normal ambulation with all forms of shoe wear. He is not necessarily concerned with returning to running; he is primarily seeking pain relief. A lateral radiograph and clinical photograph are shown in Figures 32a and 32b. Treatment should now consist of

. injection directly into the tendon with triamcinolone or methylprednisolone.
. shock wave treatment to the posterior heel to break up calcific deposits.
. brisement.
. a simple lateral surgical approach to the posterior heel, with resection of the Haglund’s exostosis.
. a central-splitting surgical approach through the tendon, excision of the Haglund’s exostosis and the insertional calcifications, bursectomy, flexor hallucis longus tendon transfer to the posterior tuberosity, and attachment of the tendon to the calcaneus.

Correct Answer & Explanation

. injection directly into the tendon with triamcinolone or methylprednisolone.

Explanation

DISCUSSION: The patient has severe calcifications at the insertion of the Achilles tendon.  Failure to address the Haglund’s exostosis and the calcifications will leave the patient with persistent pain.  Steroids should not be injected directly into the tendon because of the increased risk of tendon rupture.  Shock wave treatment may have some value in treating plantar fasciitis, but its efficacy has not been documented with insertional calcifications and Haglund’s exostosis treatment.  Brisement is injection of saline solution around the Achilles tendon in an attempt to decompress the peritenon.  This may be valuable in intrasubstance Achilles tendinosis or peritendinitis but has no value with insertional disease.  Symptoms persisting beyond 6 months are difficult to treat nonsurgically; therefore, the appropriate treatment protocol is aggressive and must address all pathology.  The patient may not be able to run at the level achieved prior to surgery, but the goal of the surgery is pain relief.REFERENCES: Clain M, Baxter D: Achilles tendinitis.  Foot Ankle 1992;13:482-487.Schepsis A, Wagner C, Leach R: Surgical management of Achilles tendon overuse injuries: A long-term follow-up study.  Am J Sports Med 1994;22:611-619.Schepsis A, Leach R: Surgical management of Achilles tendinitis.  Am J Sports Med 1987;15:308-315.Keck S, Kelly P: Bursitis of the posterior part of the heel: Evaluation of surgical treatment of eighteen patients.  J Bone Joint Surg Am 1965;47:267-273.

Question 1631

Topic: 8. Foot and Ankle

An active 55-year-old man who felt a sudden pop in the left heel while playing tennis 6 months ago was diagnosed with an ankle sprain around the time of injury. He now reports calf atrophy and severe weakness with running. Examination reveals a palpable defect in the Achilles tendon and only trace passive ankle flexion when the calf is squeezed. At the time of surgery, an Achilles tendon defect of 6 cm cannot be approximated. Surgical management of the Achilles tendon should include

. a local fascia turndown flap, followed by immobilization in a plantar flexed short leg cast for 12 weeks.
. multiple nonabsorbable sutures to bridge the gap and immobilization in a plantar flexed short leg cast for 12 weeks.
. a pull out wire and strict immobilization for 12 weeks.
. closure of the paratenon with a tight running suture, followed by rehabilitation.
. release of the flexor hallucis longus tendon at the Knot of Henry, followed by transfer through the calcaneus either alone or in combination with a V-Y advancement of the gastrocnemius.

Correct Answer & Explanation

. a local fascia turndown flap, followed by immobilization in a plantar flexed short leg cast for 12 weeks.

Explanation

DISCUSSION: Chronic or neglected Achilles tendon ruptures can present a surgical problem.  Ideally, end-to-end apposition of tendon should be attempted, but this should be accomplished without placing the foot in marked equinus.  A defect of greater than 5 cm requires the use of a tendon transfer either alone or in combination with a V-Y advancement of the gastrocnemius.  Because of its proximity to the Achilles tendon and its strength as a plantar flexor, the flexor hallucis longus is an ideal choice for this task.  Studies have shown that early active range-of-motion exercises after an Achilles tendon repair is beneficial for tendon healing and improved clinical outcomes.REFERENCES: Myerson M: Achilles tendon ruptures.  Instr Course Lect 1999;48:219-230.Mandelbaum BR, Myerson MS, Forster R: Achilles tendon ruptures: A new method of repair, early range of motion, and functional rehabilitation.  Am J Sports Med 1995;23:392-395.

Question 1632

Topic: 8. Foot and Ankle

An 18-year-old football player reports acute pain and swelling after a direct injury to his plantar flexed foot. Examination reveals midfoot swelling and tenderness. Nonstanding radiographs are normal. What is the next most appropriate step in management?

. Gradual return to play
. Physical therapy program
. Custom orthosis
. Non-weight-bearing cast
. Weight-bearing AP radiograph

Correct Answer & Explanation

. Gradual return to play

Explanation

DISCUSSION: Differentiating between a midfoot sprain and Lisfranc diastasis is critical in the management of the athlete with an acute injury to the midfoot.  Greater than 2 mm of displacement between the first and second metatarsals on a weight-bearing radiograph is an indication for anatomic reduction with internal fixation of the tarsometatarsal joints.  If no subluxation is noted, treatment should consist of a non-weight-bearing cast for 6 weeks, followed by a gradual returnto activity.REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.Chiodo CP, Myerson MS: Developments and advances in the diagnosis and treatment of injuries with the transmetatarsal joint.  Orthop Clin North Am 2001;32:11-20.

Question 1633

Topic: 8. Foot and Ankle

A B C Figures 63a through 63c are the radiographs of a 19-year-old woman who sustained injuries in a motorcycle collision. Which initial treatment will result in the best functional outcome and lowest pain scores at 2 years?

. - Open reduction and internal fixation (ORIF)
. - Closed reduction and percutaneous pinning
. - Nonsurgical management with closed reduction and casting
. - Primary arthrodesis of the first and second tarsometatarsal joints

Correct Answer & Explanation

. - Primary arthrodesis of the first and second tarsometatarsal joints

Explanation

DISCUSSIONLigamentous injuries to the tarsometatarsal and intermetatarsal joints are commonly a result of high-energy mechanisms. These injuries have resulted in worse outcomes following ORIF than Lisfranc injuries, which involve fractures. Multiple injury patterns may occur, with some injuries involving mostly the ligamentous structures. Ligamentous Lisfranc injuries treated with primary arthrodesis have been shown to result in improved American Orthopaedic Foot & Ankle Society scores and lower Visual Analog Scale pain scores at 2-year follow-up than injuries treated with ORIF. ORIF with either plate or screw fixation has resulted in higher rates of secondary surgeries and lower functional scores. Nonsurgical management is not recommended for displaced injuries. Cast placement is recommended for patients with midfoot sprains with displacement of less than 2 mm. Nonanatomic reductions have been associated with poor results. Closed reduction and percutaneous pinning is unlikely to achieve an anatomic reduction and stable fixation.RECOMMENDED READINGSHenning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009 Oct;30(10):913-22. doi: 10.3113/FAI.2009.0913. PubMed PMID: 19796583.ViewAbstract at PubMedLy TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006 Mar;88(3):514-20. PubMed PMID: 16510816.ViewAbstract at PubMedKuo RS, Tejwani NC, Digiovanni CW, Holt SK, Benirschke SK, Hansen ST Jr, Sangeorzan BJ. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000 Nov;82-A(11):1609-18. PubMed PMID: 11097452.View Abstract at PubMedNunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. 2002 Nov-Dec;30(6):871-8. PubMed PMID: 12435655.ViewAbstract at PubMed

Question 1634

Topic: 8. Foot and Ankle

Figures 15a through 15c show the radiographs of a 23-year-old football player who was injured when another player fell on his flexed and planted foot. He reports severe pain in the midfoot with a feeling of numbness on the dorsum of the foot, and he is unable to bear weight on the limb. Examination reveals mild swelling. Management should consist of

. casting.
. closed reduction, casting, and no weight bearing for 6 weeks.
. open reduction and internal fixation.
. closed reduction and percutaneous Kirschner wire fixation.
. closed reduction and percutaneous screw fixation.

Correct Answer & Explanation

. open reduction and internal fixation.

Explanation

DISCUSSION: Myerson and associates studied the outcomes of 19 patients with tarsometatarsal joint injuries during athletic activity.  Injuries were classified as first- or second-degree sprains of the tarsometatarsal joint or a third-degree sprain with diastasis between the metatarsals or cuneiforms.  Poor functional results were seen in those with a delay in diagnosis and with inadequate treatment.  For patients with third-degree sprains, poor results were obtained with nonsurgical management.  These patients required open reduction and internal fixation for optimal return to function.  The anatomic reduction is critical to the outcome; therefore, open reduction is preferred.REFERENCES: Baxter DE: The Foot and Ankle in Sport, ed 1.  St Louis, MO, Mosby, 1995,pp 107-123.Curtis MJ, Myerson M, Szura B: Tarsometatarsal joint injuries in the athlete.  Am J Sports Med 1993;21:497-502.Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries.  J Bone Joint Surg Am 2000;82:1609-1618.Thompson MC, Mormino MA: Injury to the tarsometatarsal joint complex.  J Am Acad Orthop Surg 2003;11:260-267.

Question 1635

Topic: 8. Foot and Ankle
  • A 40-year-old woman has had pain in the metatarsophal joint of the second toe for the past 6 months despite nonsurgical treatment. A dorsalplantar stress test reproduces the pain, and there is 10 mm of dorsal subluxation of the toe. Radiographs show a normal second metatarsophalangeal joint. Surgical treatment should consist of synovectomy and
. Advancement of the plantar plate
. Resection of the second metatarsal head
. Dorsiflexion osteotomy of the second metatarsal neck
. Transfer of the flexor digitorum longus tendon to the dorsum of the toe
. Transfer of the extensor digitorum comminus tendon to the metatarsal neck

Correct Answer & Explanation

. Transfer of the flexor digitorum longus tendon to the dorsum of the toe

Explanation

Number four is the correct answer because the flexor digitorum longus tendon will give excellent plantar support when transferred to the dorsum of the toe and this removes the main dynamic deforming force. Number one is incorrect because the planter plate will stretch in time and be insufficient. Number two is incorrect because the radiographs show a normal second metatarsophalangeal joint surface and it is not a fixed/dislocated joint and it is in a young patient. Number three is incorrect because it is not a frank dislocation. Number five is incorrect as this is reserved for mild deformity and would not be sufficient correction in this case.

Question 1636

Topic: 8. Foot and Ankle

A 32-year-old man sustains a forceful inversion injury while playing soccer. Examination reveals tenderness in the lateral hindfoot and midfoot region with associated ecchymosis and swelling. Radiographs show proximal migration of the os peroneum. Active eversion is still present. These findings indicate disruption of the

. extensor digitorum brevis.
. plantar fascia.
. peroneus brevis.
. peroneus longus.
. syndesmosis.

Correct Answer & Explanation

. extensor digitorum brevis.

Explanation

DISCUSSION: The os peroneum is an accessory ossicle located within the peroneus longus tendon.  It is typically located at the level of the cuboid groove in the lateral hindfoot and midfoot region.  Proximal migration of the os peroneum indicates disruption of the peroneus longus tendon and is an important clue to diagnosis.  This unusual condition can cause chronic lateral ankle pain, and surgical repair may be indicated.  Active eversion indicates that the peroneus brevis is clinically intact.  Disruption of the extensor digitorum brevis, plantar fascia, or syndesmosis would have no effect on the position of the os peroneum.REFERENCES: Thompson FM, Patterson AH: Rupture of the peroneus longus tendon: Report of three cases.  J Bone Joint Surg Am 1989;71:293-295.Clanton TO: Athletic injuries to the soft tissues of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7.  St Louis, MO, Mosby, 1999, pp 1090-1209.

Question 1637

Topic: 8. Foot and Ankle

When performing a gastrocnemius recession, what structure should be protected?

. Tibial nerve
. Sural artery
. Plantaris
. Posterior tibial artery
. Sural nerve

Correct Answer & Explanation

. Tibial nerve

Explanation

DISCUSSION: When performing a gastrocnemius slide at the tendinous portion of the gastrocnemius insertion, the sural nerve and saphenous vein, which tend to run midline posterior at this level, must be protected and retracted laterally.  An anatomic study of the sural nerve at this level localized the nerve superficial to the deep fascia overlying the gastrocnemius in 42.5% of the cases; deep to the superficial fascia in 57.5% of the cases, and directly applied to the gastrocnemius tendon in 12.5% of cases.REFERENCES: Pinney SJ, Sangeorzan BJ, Hanen ST Jr: Surgical anatomy of the gastrocnemius resection (Strayer procedure).  Foot Ankle Int 2004;25:247-250.Hansen ST Jr: Functional Reconstruction of the Foot and Ankle.  Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 415-417.

Question 1638

Topic: 8. Foot and Ankle

Figure 70 is the radiograph of a 14-year-old girl with increasing posterior ankle pain, especially during pointe technique exercises. Nonsurgical measures such as modification, stretching, and injection have been unsuccessful. Which nerve is most vulnerable to injury during endoscopic excision of this lesion?

. Sural
. Deep peroneal
. Medial plantar
. Posterior tibial

Correct Answer & Explanation

. Sural

Explanation

DISCUSSIONThe pathology is that of posterior ankle impingement, which is secondary to a symptomatic os trigonum. Endoscopic excision necessitates posteromedial and posterolateral ankle portals. Although plantar numbness has been described as a relatively common postsurgical complication, the neurovascular structure most commonly injured is the sural nerve.

Question 1639

Topic: 8. Foot and Ankle

What is the most frequent location of entrapment of the deep peroneal nerve?

. Tendon of the extensor hallucis brevis
. Inferior extensor retinaculum
. Osteophytes of the talonavicular joint
. Os intermetatarseum
. Base of the fifth metatarsal

Correct Answer & Explanation

. Tendon of the extensor hallucis brevis

Explanation

DISCUSSION: The most frequently described entrapment of the deep peroneal nerve is the anterior tarsal tunnel syndrome.  This syndrome refers to entrapment of the deep peroneal nerve under the inferior extensor retinaculum.  Entrapment can also occur as the nerve passes under the tendon of the extensor hallucis brevis.  Compression by underlying dorsal osteophytes of the talonavicular joint and an os intermetatarseum (between the bases of the first and second metatarsals) have previously been described in runners.REFERENCES: Kopell HP, Thompson WA: Peripheral entrapment neuropathies of the lower extremity.  N Engl J Med 1960;262:56-60.Schon LC, Mann RA: Diseases of the nerves, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8.  Philadelphia, PA, Mosby-Elsevier, 2007, vol 1, pp 675-677.

Question 1640

Topic: 8. Foot and Ankle

Which stress fracture location is reported most frequently among ballet dancers?

. Base of the second metatarsal
. Base of the fifth metatarsal
. Tibial sesamoid
. Central third of the tarsal navicular

Correct Answer & Explanation

. Base of the second metatarsal

Explanation

DISCUSSIONStress fractures are a frequent overuse injury among professional ballet dancers. The most common location is at the proximal metaphyseal-diaphyseal junction of the second metatarsal. Repetitive stress injuries and fractures of the tibial sesamoid, tarsal navicular, and base of the fifth metatarsal occur among other athletes.RECOMMENDED READINGSO'Malley MJ, Hamilton WG, Munyak J, DeFranco MJ. Stress fractures at the base of the second metatarsal in ballet dancers. Foot Ankle Int. 1996 Feb;17(2):89-94. PubMed PMID: 8919407.View Abstract at PubMedMicheli LJ, Sohn RS, Solomon R. Stress fractures of the second metatarsal involving Lisfranc's joint in ballet dancers. A new overuse injury of the foot. J Bone Joint Surg Am. 1985 Dec;67(9):1372-5. PubMed PMID: 4077907.View Abstract at PubMedGehrmann RM, Renard RL. Current concepts review: Stress fractures of the foot. Foot Ankle Int. 2006 Sep;27(9):750-7. Review. PubMed PMID: 17038292.View Abstract at PubMed

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page