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 1821
Topic: 8. Foot and Ankle
When utilizing the extensile lateral approach for open reduction internal fixation of a calcaneus fracture, a full-thickness subperiosteal flap must be elevated off the lateral wall. Which nerve is most at risk if the flap is elevated too thinly or sharply dissected?
Correct Answer & Explanation
. Sural nerve
Explanation
The sural nerve courses superficially over the lateral aspect of the hindfoot. A full-thickness subperiosteal flap must be elevated off the calcaneus to protect this nerve and the lateral calcaneal artery to prevent wound sloughing.
Question 1822
Topic: 8. Foot and Ankle
Recent high-quality randomized controlled trials comparing early functional rehabilitation (non-operative) versus surgical repair for acute Achilles tendon ruptures demonstrate which of the following outcomes?
Correct Answer & Explanation
. Surgical repair has a significantly higher re-rupture rate.
Explanation
Level I evidence indicates that when utilizing early functional weight-bearing rehabilitation protocols, the re-rupture rates between operative and non-operative management are statistically similar. However, operative repair carries a higher risk of soft-tissue and nerve complications.
Question 1823
Topic: 8. Foot and Ankle
Which of the following foot deformities is commonly seen in patients with Charcot-Marie-Tooth disease? Review Topic
Correct Answer & Explanation
. Plantar flexed first metatarsal and hindfoot valgus
Explanation
Charcot-Marie-Tooth disease is an inherited progressive motor and sensory peripheral neuropathy. Patients commonly present with bilateral pes cavovarus deformities characterized by plantar flexed metatarsals and a varus hindfoot.
Question 1824
Topic: 8. Foot and Ankle
A 24-year-old woman was struck by a mini van in a parking lot and sustained a closed segmental tibia fracture that was treated with an intramedullary nail the following morning. Follow-up examinations reveal a slowly progressive clawing of all five toes, a progressive equinocavovarus contracture, and the patient is unable to perform a single heel rise on the affected limb. At 1 year after surgery, the patient now has a 10-degree equinus contracture that is not relieved with knee flexion. Treatment should now consist of
Correct Answer & Explanation
. posterior capsule release, Achilles tendon lengthening, and excision of the scarred muscle and tendon in the leg and foot.
Explanation
This is an example of a missed deep posterior compartment syndrome that typically presents 6 months after the injury with progressive clawing due to necrosis, scarring, and contracture of the posterior tibial tendon, flexor digitorum longus, and flexor hallucis longus. Treatment consists of debridement of necrotic muscle and scar tissue with corresponding tendon excision. After debridement and posterior capsule release, if the equinus is relieved with knee flexion, a gastrocnemius slide may be performed. Otherwise, the lengthening should be at the level of the Achilles tendon. Bracing will not address the claw toes.
Question 1825
Topic: 8. Foot and Ankle
-What is the most appropriate course of action for this patient’s condition?
Correct Answer & Explanation
. Early mobilization and a guided proprioceptive and strengthening rehabilitation program
Explanation
DISCUSSION FOR QUESTIONS 7 THROUGH 9The anterior drawer test is performed with the ankle in 10 degrees of plantar flexion, which results in the greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed over the edge of a table or bench, the physician or examiner uses one hand to stabilize the distal leg and with the other applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the tibia. The anterior talofibular ligament and calcaneofibular ligament are both compromised based on the examination findings. The anterior drawer test result reflects injury to the anterior talofibular ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement greater than 15 degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments.The diagnosis is a severe lateral ligament complex sprain. Considering the involvement of the anterior talofibular ligament and calcaneofibular ligaments, early mobilization with a cast or controlled ankle movement walker boot has been documented to result in better patient outcomes than compression or air casting.
Question 1826
Topic: 8. Foot and Ankle
A 25-year-old woman with a healed proximal tibiofibular fracture treated with an intramedullary nail 2 years ago is currently wearing an ankle-foot orthosis (AFO) and reports a persistent foot drop. She is unhappy with the AFO and has not seen any functional improvement despite months of physical therapy. Serial electromyograms (EMG) show no recent change over the past year. Examination and EMG findings are consistent with a tibialis anterior 1/5, extensor hallucis longus 2/5, extensor digitorum longus 2/5, posterior tibial tendon (PTT) 5/5, peroneals 3/5, flexor hallucis longus 5/5, and gastrocsoleus 5/5. No discrete nerve lesion was identified. The patient has a flexible equinovarus contracture. What is the most appropriate management?
Correct Answer & Explanation
. Continued AFO bracing and therapy
Explanation
DISCUSSION: This pattern of injury is consistent with an unrecognized compartment syndrome of the anterior and lateral compartments. Transfer of the PTT through a long incision in the interosseous membrane corrects the foot drop deformity, and allows adequate dorsiflexion provided that the tendon to be transferred has a strength of 5/5. Muscles/tendons typically lose one grade of strength after transfer. Transfer into the tendons at the level of the ankle prevents overtensioning or pullout of a PTT tendon that is not long enough. Debridement of the scarred muscle in the anterior compartment decreases the risk of scarring down to the tendon transfer. Transfer of the peroneus longus is not preferred given its relative lack of strength and line of pull. Continued therapy and bracing are unlikely to lead to further improvement at 2 years after injury. An ankle fusion would correct the foot drop but would not address the tendon imbalances between the tibialis anterior and the peroneus longus, and the PTT and the peroneus brevis.REFERENCES: Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, p 192.Atesalp AS, Yildiz C, Komurcu M, et al: Posterior tibial tendon transfer and tendo-Achilles lengthening for equinovarus foot deformity due to severe crush injury. Foot Ankle Int 2002;23:1103-1106.Scott AC, Scarborough N: The use of dynamic EMG in predicting the outcome of split posterior tibial tendon transfers in spastic hemiplegia. J Pediatr Orthop 2006;26:777-780.Williams PF: Restoration of muscle balance of the foot by transfer of the tibialis posterior. J Bone Joint Surg Br 1976;58:217-219.
Question 1827
Topic: 8. Foot and Ankle
A 42-year-old woman sustained a closed, displaced talar neck fracture in a motor vehicle accident. Which of the following is an avoidable complication of surgical treatment?
Correct Answer & Explanation
. Malunion of the talus
Explanation
DISCUSSION: Malunion of the talus is a devastating complication that leads to malpositioning of the foot and subsequent arthrosis of the subtalar joint complex. This is considered an avoidable complication in that accurate surgical reduction will minimize its development. Posttraumatic arthritis of the subtalar joint, osteonecrosis of the talus, posttraumatic arthritis of the ankle joint, and complex regional pain syndrome all may develop as a result of the initial traumatic event and may not be avoidable despite anatomic reduction.
Question 1828
Topic: 8. Foot and Ankle
Figures 56a through 56c are the lateral radiograph and MRI scans of a 32-year-old woman who reports a 3-week history of heel pain, tenderness, swelling, and onset following an increase in running activity. What is the most likely diagnosis?
Correct Answer & Explanation
. Plantar fasciitis
Explanation
The sagittal T1-weighted MRI scan reveals a linear streak of low signal intensity consistent with a stress fracture of the posterior calcaneal tuberosity. The surrounding area of hypointensity on the T1 MRI scan and the hyperintensity on the T2 MRI scan represent bone contusion, hemorrhage, and edema within the calcaneus, with an unremarkable radiograph. The plantar fascia, Achilles tendon, retrocalcaneal bursa, and heel pad all display normal signal in the accompanying MRI scans.
Question 1829
Topic: 8. Foot and Ankle
What is the most likely long-term sequela of the injury shown in Figures 47a and 47b?
Correct Answer & Explanation
. Subtalar joint arthrosis
Explanation
The imaging studies show a comminuted lateral talar process fracture. This injury is often missed on plain radiographs; therefore, CT provides the best method of diagnostic evaluation. The most likely long-term sequela of this injury is subtalar joint arthrosis. Although this injury involves the fibular gutter region, progression to true ankle arthritis is unlikely. There does not appear to be any association with this injury and chronic mechanical instability of the ankle or disruption of the superior peroneal retinaculum and subsequent peroneal tendon instability. Entrapment of the flexor hallucis longus tendon may occur with fractures of the sustentaculum tali but not with injuries of the lateral talar process.
Question 1830
Topic: 8. Foot and Ankle
Figures 38a and 38b
Correct Answer & Explanation
. Open reduction and internal fixation (ORIF)
Explanation
DISCUSSIONInversion of the ankle can cause various injuries about the foot and ankle, all via the same mechanism. Fifth metatarsal base avulsion (Figure 35) fractures can be treated with use of a walking boot until pain subsides. Jones fractures (Figure 36) can be treated with surgical or nonsurgical treatment, although young, active patients are perhaps better treated with ORIF, which can decrease disability time. Treatment of an anterior process calcaneus fracture (Figure 37) is similar to that for a fifth metatarsal base avulsion fracture. Figures 38a and 38b show a calcaneal fracture-dislocation, which necessitates ORIF.RECOMMENDED READINGSSchepers T, Backes M, Schep NW, Carel Goslings J, Luitse JS. Functional outcome following a locked fracture-dislocation of the calcaneus. Int Orthop. 2013 Sep;37(9):1833-8. PubMed PMID: 23959223.View Abstract at PubMedPolzer H, Polzer S, Mutschler W, Prall WC. Acute fractures to the proximal fifth metatarsal bone: development of classification and treatment recommendations based on the current evidence. Injury. 2012 Oct;43(10):1626-32. doi: 10.1016/j.injury.2012.03.010. Epub 2012 Mar 30. Review. PubMed PMID: 22465516.View Abstract at PubMedRoche AJ, Calder JD. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013 Jun;21(6):1307-15. doi: 10.1007/s00167-012-2138-8. Epub 2012 Sep 6. Review. PubMed PMID: 22956165.View Abstract atPubMedBerkowitz MJ, Kim DH. Process and tubercle fractures of the hindfoot. J Am Acad Orthop Surg. 2005 Dec;13(8):492-502. Review. PubMed PMID: 16330511.View Abstract at PubMed
Question 1831
Topic: 8. Foot and Ankle
When performing a Weil osteotomy of a lesser metatarsal, the desired angle of the saw cut should be approximately
Correct Answer & Explanation
. parallel with the plantar surface of the foot.
Explanation
DISCUSSION: Appropriate orientation of the saw cut when performing a Weil osteotomy is approximately parallel with the plantar surface of the foot. This is done in an effort to minimize plantar displacement of the capital fragment. The removal of additional bone from the osteotomy site either by removing a separate wafer of bone or using a thicker saw blade has also been described to minimize plantar displacement of the distal fragment. REFERENCES: Trnka H, Nyska M, Parks BG, et al: Dorsiflexion contracture after the Weil osteotomy: Results of cadaver study and three-dimensional analysis. Foot Ankle Int 2001;22:47-50. Grimes J, Coughlin M: Geometric analysis of the Weil osteotomy. Foot Ankle Int 2006;27:985-992.
Question 1832
Topic: 8. Foot and Ankle
A Canale view best visualizes which of the following structures?
Correct Answer & Explanation
. Talar neck
Explanation
DISCUSSION: The Canale view, which visualizes the talar neck, is taken with the ankle in maximum plantar flexion and the foot pronated 15°. The radiograph is directed at a 75° angle from the horizontal plane in the anteroposterior plane. The Broden view, which is different from the Canale view, is best for imaging the posterior facet of the subtalar joint. REFERENCES: Canale ST, Kelly FB Jr: Fractures of the neck of the talus: Long-term evaluation of seventy-one cases. J Bone Joint Surg Am 1978;60:143-156. Bruden B: Roentgen examination of the subtaloid joint in fractures of the calcaneus. Acta Radiol 1949;31:85-91.
Question 1833
Topic: 8. Foot and Ankle
During a posterior approach to the right Achilles tendon, the surgeon encounters a nerve running with the small saphenous vein as shown in Figure 22. This nerve innervates what part of the foot?
Correct Answer & Explanation
. Dorso-lateral foot
Explanation
DISCUSSION: The sural nerve runs with the small saphenous vein on the posterior leg just lateral to the Achilles tendon. It is formed by contributions from both the tibial and common peroneal nerves and provides sensation on the dorso-lateral aspect of the foot. REFERENCES: Aktan Ikiz ZA, Ucerler H, Bilge O: The anatomic features of the sural nerve with an emphasis on its clinical importance. Foot Ankle Int 2005;26:560-567. Lawrence SJ, Botte MJ: The sural nerve in the foot and ankle: An anatomic study with clinical and surgical implications. Foot Ankle Int 1994;15:490-494.
Question 1834
Topic: 8. Foot and Ankle
Figures 34a and 34b show the clinical photograph and a weight-bearing radiograph of a patient with diabetes mellitus who has had recurrent ulcers under the head of the talus that have previously resolved with a series of non-weight-bearing total contact casts. The deformity does not correct passively. Dorsalis pedis and posterior tibial pulses are palpable. The patient is insensate to the Semmes-Weinstein 5.07 (10 gm) monofilament. The ulcer is currently healed. What is the best option to prevent recurrent ulceration and infection?
Correct Answer & Explanation
. Surgical correction of the deformity, Achilles tendon lengthening, and therapeutic footwear
Explanation
DISCUSSION: This is a nonplantigrade deformity in a patient with a Charcot foot deformity. Longitudinal studies have shown that recurrent ulceration/infection is likely unless the deformity is corrected. Achilles tendon lengthening is advised for simple forefoot ulcers. The current approach to this problem is best managed with surgical correction of the deformity, Achilles tendon lengthening, and therapeutic footwear. REFERENCES: Bevan WP, Tomlinson MP: Radiographic measures as a predictor of ulcer formation in diabetic charcot midfoot. Foot Ank Int 2008;29:568-573. Simon SR, Tejwani SG, Wilson DL, et al: Arthrodesis as an early alternative to nonoperative management of Charcot arthropathy of the diabetic foot. J Bone Joint Surg Am 2000;82:939-950. Pinzur M: Surgical versus accommodative treatment for Charcot arthropathy of the midfoot. Foot Ankle Int 2004;25:545-549.
Question 1835
Topic: 8. Foot and Ankle
Contracture of which structure causes hammertoe deformity?
Correct Answer & Explanation
. Flexor digitorum longus tendon
Explanation
DISCUSSION: A patient with a flexible hammertoe deformity has the deformity while standing, but practically no deformity when seated with the foot in equinus. The metatarsophalangeal joint is not involved. The deformity is created by contracture of the flexor digitorum longus tendon.
Question 1836
Topic: 8. Foot and Ankle
A 45-year-old man is seeking evaluation of an injury sustained in a motor vehicle accident 10 weeks ago. Current radiographs are shown in Figures 2a and 2b. Based on the radiographic findings, what is the most likely diagnosis?
Correct Answer & Explanation
. Osteonecrosis of the talar body
Explanation
DISCUSSION: An increased density of the talar body compared to the distal tibia following fracture of the talar neck is highly suggestive of vascular compromise of the talar body. Subchondral osteopenia of the talus at 6 to 8 weeks (Hawkins sign) is a favorable sign but does not eliminate the possibility of osteonecrosis.
Question 1837
Topic: 8. Foot and Ankle
Which of the following is considered the most appropriate shoe modification following transmetatarsal amputation?
Correct Answer & Explanation
. Cushioned molded insole and toe filler over a carbon fiber footplate
Explanation
DISCUSSION: Most patients who undergo transmetatarsal amputation do not require custom shoe wear or an orthosis above the ankle. A molded toe filler is used to prevent excessive shear that can lead to ulceration. Use of a soft toe filler without stiffening of the sole results in excessive flexibility from the shortened lever arm, which reduces the efficiency of gait. A firm footplate or carbon fiber base adds rigidity to aid in push-off. A rocker bottom also may be added to the shoe.
Question 1838
Topic: 8. Foot and Ankle
A soccer player who sustained a twisting injury to the right ankle while making a cut is unable to bear weight and has diffuse tenderness over the anterior and lateral aspects of the ankle. Examination also shows a positive squeeze test. Plain radiographs and a stress radiograph are shown in Figures 26a through 26c. Radiographs of the leg and knee are normal. What is the most appropriate management?
Correct Answer & Explanation
. Immediate reduction and placement of a syndesmotic screw
Explanation
The mechanism of injury, physical examination, and radiographs indicate a “high” ankle sprain with disruption of the distal tibiofibular ligaments and interosseous membrane. This patient has gross instability, resulting in a high incidence of chronic diastasis and subluxation leading to impaired function. Treatment should consist of reduction and stabilization with a transsyndesmotic screw because this injury demonstrates a widened syndesmosis.
Question 1839
Topic: 8. Foot and Ankle
What type of brace is shown in Figures 22a and 22b?
Correct Answer & Explanation
. Charcot restraining orthotic walker (CROW)
Explanation
DISCUSSION: The figures show a Charcot restraining orthotic walker (CROW). This brace has been used as a customized total contact fit removable brace to maintain foot alignment as the patient evolves from Eichenholz stage 1 to Eichenholz stage 3 Charcot arthropathy. REFERENCES: Mehta JA, Brown C, Sargeant N: Charcot restraint orthotic walker. Foot Ankle Int 1998;19:619-623. Morgan JM, Biehl WC III, Wagner FW Jr: Management of neuropathic arthropathy with the Charcot restraint orthotic walker. Clin Orthop 1993;296:58-63.
Question 1840
Topic: 8. Foot and Ankle
A 12-year-old girl is seen for left ankle pain. Radiographs reveal osteochondritis dissecans (OCD) involving the talus. What should the parents be told regarding management? Review Topic
Correct Answer & Explanation
. No treatment is required because spontaneous healing is common.
Explanation
Nonsurgical management of OCD of the talus in skeletally immature individuals frequently results in a fairly rapid decrease in symptoms, but radiographic abnormalities can frequently be found even 6 months after treatment. Spontaneous resolution of this condition is rare. Hyperbaric oxygen treatment has not been shown to be beneficial for this condition. Progression of the condition to the point of requiring ankle fusion is rare.
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