A 9-year-old girl has pain over the fifth toe that is aggravated by shoe wear. Clinical photographs are shown in Figures 28a and 28b. Treatment of this deformity should consist of

a dorsal and plantar racquet-shaped incision around the fifth toe, combined with extensor digitorum longus tenotomy and circumferential fifth MTP joint release (Butler procedure).

A biopsy of the involved physis in a patient with slipped capital femoral epiphysis (SCFE) would most likely reveal

granulation tissue between the columns in the zone of hypertrophy.

Nonsurgical management of pectoralis major tears is likely to result in weakness of glenohumeral Review Topic

adduction and internal rotation.

A 17-year-old pitcher reports pain over the medial aspect of the elbow that occurs during the acceleration phase of throwing, and it prevents him from throwing at the velocity needed to be competitive. What structure is most likely injured in this pa

Anterior bundle of the ulnar collateral ligament

Free Foot & Ankle Orthopedics Review Quiz | Dr Hutaif

Question 1

A 35-year-old male sustains a Hawkins Type III talus neck fracture. Which of the following best describes the blood supply to the talar body that is disrupted in this injury?

Explanation

A Hawkins Type III talus neck fracture involves displacement at both the subtalar and tibiotalar joints, thereby disrupting the three main sources of blood supply to the talar body: the artery of the tarsal canal (from posterior tibial), the artery of the tarsal sinus (from perforating peroneal and dorsalis pedis), and the deltoid branches. This results in a nearly 100% risk of avascular necrosis.

Question 2

The Lisfranc ligament is essential for midfoot stability. Which of the following accurately describes its precise anatomic attachments?

Explanation

The Lisfranc ligament is a strong interosseous ligament that originates from the lateral aspect of the medial cuneiform and inserts onto the medial aspect of the base of the second metatarsal. It is the strongest of the tarsometatarsal ligaments and its disruption is the hallmark of a Lisfranc injury.

Question 3

A 45-year-old female presents with a painful bunion. Radiographs reveal a hallux valgus angle (HVA) of 42 degrees, an intermetatarsal angle (IMA) of 18 degrees, and clinical examination demonstrates significant hypermobility of the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention?

Explanation

A first TMT arthrodesis (Lapidus procedure) is indicated for patients with moderate to severe hallux valgus (IMA > 15 degrees) accompanied by hypermobility of the first TMT joint. Distal osteotomies do not correct large IMA angles or address TMT hypermobility, leading to high recurrence rates in these specific patients.

Question 4

A 55-year-old female presents with a flexible acquired flatfoot deformity. Standing radiographs reveal 45% talonavicular uncoverage. She is diagnosed with Stage IIB posterior tibial tendon dysfunction. Which of the following surgical strategies is most appropriate?

Explanation

Stage IIB posterior tibial tendon dysfunction is characterized by a flexible deformity with significant forefoot abduction (typically >40% talonavicular uncoverage on AP radiograph). Treatment requires addressing both the valgus hindfoot and the forefoot abduction. Therefore, a lateral column lengthening (e.g., Evans osteotomy) is required in addition to an MDCO and FDL transfer to adequately correct the severe abduction deformity.

Question 5

A 28-year-old male with Charcot-Marie-Tooth disease presents with a cavovarus foot deformity. A Coleman block test is performed, and the hindfoot varus corrects to neutral. This finding dictates which of the following regarding surgical management?

Explanation

The Coleman block test evaluates the flexibility of the hindfoot in a cavovarus foot. By dropping the first ray off the block, a flexible hindfoot will correct to neutral or valgus. This indicates that the hindfoot varus is compensatory and driven by a rigidly plantarflexed first ray. Surgical treatment should therefore target the forefoot (e.g., first metatarsal dorsiflexion osteotomy) rather than relying primarily on hindfoot arthrodesis.

Question 6

A 35-year-old roofer falls and sustains a displaced intra-articular calcaneus fracture. He undergoes open reduction and internal fixation via an extensile lateral approach. Postoperatively, he complains of numbness and neuropathic pain along the lateral aspect of his foot. Which nerve is most likely injured, and what is its typical anatomical location at risk during this approach?

Explanation

The sural nerve is at high risk during the extensile lateral approach to the calcaneus. It courses posterior to the lateral malleolus and runs superficially over the peroneal tendons and lateral calcaneal wall. Retraction, excessive tension, or direct injury during flap elevation can lead to lateral foot numbness and neuropathic pain.

Question 7

Which of the following statements most accurately reflects current evidence regarding the comparison of operative versus non-operative management of acute Achilles tendon ruptures when modern early functional rehabilitation protocols are utilized?

Explanation

Modern high-quality randomized controlled trials (e.g., Willits et al.) have demonstrated that when early functional rehabilitation (early weight-bearing and active ROM) is employed, the re-rupture rates between operative and non-operative groups are statistically similar. However, operative management carries a higher risk of soft-tissue and wound complications.

Question 8

During fixation of a pronation-external rotation ankle fracture with syndesmotic instability, you elect to place a syndesmotic screw. Based on anatomical and biomechanical studies, what is the optimal trajectory for this screw?

Explanation

The fibula sits slightly posterior to the midline of the tibia in the incisura fibularis. To accurately capture the center of the tibia and avoid eccentrically pushing the fibula, a syndesmotic screw should be directed approximately 20 to 30 degrees anteriorly from the lateral fibula toward the tibia.

Question 9

A professional football player sustains a severe hyperextension injury to his first metatarsophalangeal (MTP) joint (Turf toe). MRI confirms a complete tear of the plantar plate from the base of the proximal phalanx with proximal migration of the sesamoids (Grade 3). What is the most appropriate management?

Explanation

Grade 3 turf toe involves a complete tear of the plantar plate and capsuloligamentous complex, often accompanied by proximal sesamoid migration. In high-demand athletes, non-operative management leads to chronic instability, weakness in push-off, and progressive deformity. Primary surgical repair of the plantar plate is indicated to restore joint stability and function.

Question 10

A 22-year-old basketball player sustains a fracture of the fifth metatarsal. Radiographs show a transverse fracture at the metaphyseal-diaphyseal junction, extending into the 4th-5th intermetatarsal articulation. What is the blood supply to this specific region, and what is the corresponding diagnosis?

Explanation

A classic Jones fracture occurs in Zone 2, which is the metaphyseal-diaphyseal junction of the fifth metatarsal extending into the 4th-5th intermetatarsal articulation. This is a recognized vascular watershed area, which makes these fractures prone to delayed union or nonunion. Zone 1 is the tuberosity (good cancellous blood supply), and Zone 3 is the proximal diaphysis distal to the 4th-5th articulation.

Question 11

A 58-year-old diabetic male presents with a red, hot, swollen right foot mimicking cellulitis, but without open wounds. Radiographs reveal periarticular debris, fragmentation, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what is the stage and the most appropriate initial treatment?

Explanation

The clinical and radiographic picture (erythema, swelling, bony fragmentation, debris, joint subluxation) describes Eichenholtz Stage I (developmental/fragmentation stage) of Charcot neuroarthropathy. The gold standard initial treatment in the acute, active stage is strict offloading, typically achieved with a total contact cast, until the inflammation subsides. Surgery is generally contraindicated in the acute phase due to severe bone softening and high complication rates.

Question 12

A 25-year-old female presents with chronic ankle pain after multiple sprains. MRI demonstrates a 2.0 cm squared osteochondral lesion of the medial talar dome with significant subchondral cystic changes. She has failed 6 months of conservative management. What is the most appropriate next step in surgical management?

Explanation

For larger osteochondral lesions of the talus (typically those >1.5 cm squared) or those associated with significant subchondral cystic changes, isolated microfracture (bone marrow stimulation) has a high failure rate. Structural restoration of the subchondral bone and articular cartilage with an osteochondral autograft transfer (OATS) or fresh osteochondral allograft is the recommended surgical treatment.

Question 13

A 30-year-old skier experiences a snapping sensation at the lateral aspect of her ankle during a forceful dorsiflexion and eversion injury. Examination reveals active subluxation of the peroneal tendons over the lateral malleolus. This injury pattern most commonly involves pathology of which anatomic structure?

Explanation

Peroneal tendon subluxation is most commonly caused by stripping or avulsion of the superior peroneal retinaculum (SPR) from its insertion on the posterolateral aspect of the fibula. This typically occurs during a sudden, forceful dorsiflexion and eversion of the foot, which violently contracts the peroneal muscles against the retinaculum.

Question 14

A 42-year-old construction worker falls from a height, sustaining a high-energy displaced intra-articular tibial plafond (pilon) fracture. The soft tissues are tense with massive swelling and fracture blisters. What is the standard of care regarding the timing and strategy of fixation?

Explanation

High-energy pilon fractures with severe soft tissue compromise (Tscherne grade 2 or 3) are managed with a staged protocol to minimize catastrophic soft tissue complications (infection, wound breakdown). The standard of care is temporary spanning external fixation (often with fibular fixation to restore length) followed by delayed definitive open reduction and internal fixation (ORIF) of the tibia once the soft tissue envelope has healed (appearance of skin wrinkles, resolution of blisters), usually 10-21 days later.

Question 15

A 20-year-old competitive track athlete presents with an insidious onset of vague dorsal midfoot pain. Plain radiographs are normal, but an MRI confirms a non-displaced stress fracture of the central third of the tarsal navicular. What is the recommended initial management?

Explanation

Navicular stress fractures are high-risk fractures due to the watershed blood supply in the central third of the bone. For non-displaced fractures, strict non-weight bearing (NWB) in a cast for 6 to 8 weeks is the gold standard initial treatment to ensure healing and prevent progression to nonunion. Allowing weight-bearing in a boot has unacceptably high failure rates.

Question 16

Total ankle arthroplasty (TAA) is increasingly utilized for end-stage ankle osteoarthritis. Which of the following is considered an absolute contraindication to performing a primary TAA?

Explanation

Absolute contraindications to total ankle arthroplasty (TAA) include active or recent deep infection, severe avascular necrosis of the talus, Charcot arthropathy, absent motor function, and severe uncorrectable malalignment (coronal plane deformities >15 degrees that cannot be surgically balanced). Concomitant subtalar arthritis is actually a relative indication for TAA rather than arthrodesis, as TAA preserves adjacent joint motion.

Question 17

A 15-year-old female gymnast presents with chronic pain and swelling over the dorsal aspect of the forefoot. Radiographs demonstrate sclerosis, fragmentation, and flattening of the second metatarsal head. Which of the following is the most likely diagnosis?

Explanation

Freiberg's infarction is an avascular necrosis of the metatarsal head, most commonly affecting the second metatarsal. It typically presents in adolescent females who participate in activities involving repetitive microtrauma or mechanical overload to the forefoot, such as gymnastics or ballet.

Question 18

The calcaneonavicular (spring) ligament complex is a critical static stabilizer of the longitudinal arch and is often attenuated in adult acquired flatfoot deformity. Which of the following describes its most robust and clinically critical fascicle for supporting the talonavicular joint?

Explanation

The spring ligament complex consists of three main fascicles. The superomedial calcaneonavicular ligament is the most robust, widest, and most clinically important fascicle. It acts as a sling under the talar head, and its failure is a hallmark of progressive adult acquired flatfoot deformity associated with posterior tibial tendon dysfunction.

Question 19

A 45-year-old runner with refractory insertional Achilles tendinopathy and a prominent Haglund's deformity undergoes surgical debridement. During the procedure, the surgeon notes that greater than 50% of the Achilles tendon insertion must be detached to adequately resect the calcaneal exostosis and debride the diseased tendon. What is the most appropriate next step?

Explanation

When debridement of insertional Achilles tendinopathy requires detachment of greater than 50% of the tendon insertion, the residual construct is significantly weakened. Augmentation is recommended to prevent postoperative rupture and restore plantarflexion power. The flexor hallucis longus (FHL) tendon transfer is the procedure of choice due to its proximity, strength, and in-phase firing with the gastrocnemius-soleus complex.

Question 20

During a severe external rotation injury to the ankle, a bony avulsion of the anterior inferior tibiofibular ligament (AITFL) from its tibial attachment is identified on a CT scan. What is the eponymous name of this specific fracture fragment?

Explanation

The Tillaux-Chaput fragment is the anterolateral tibial avulsion of the anterior inferior tibiofibular ligament (AITFL). The Wagstaffe (or Le Fort-Wagstaffe) fragment is the fibular avulsion of the AITFL. The Volkmann fragment is the posterolateral tibial avulsion of the posterior inferior tibiofibular ligament (PITFL).

Question 21

A 55-year-old female presents with medial ankle pain and an inability to perform a single-leg heel rise. Clinical examination reveals a flexible hindfoot valgus, with no significant forefoot abduction (too-many-toes sign is negative). Radiographs show a preserved subtalar joint without arthritis. Which of the following is the most appropriate surgical management for this patient?

Explanation

This patient presents with Stage IIA Adult Acquired Flatfoot Deformity (Posterior Tibial Tendon Dysfunction). Stage II denotes a flexible deformity. Stage IIA involves hindfoot valgus without significant forefoot abduction. The gold standard surgical management for Stage IIA is a Flexor Digitorum Longus (FDL) tendon transfer to the navicular combined with a Medial Displacement Calcaneal Osteotomy (MDCO) to correct the hindfoot valgus axis. Lateral column lengthening (Evans osteotomy) is typically added for Stage IIB, where clinically significant forefoot abduction is present. Triple arthrodesis is reserved for Stage III (rigid deformity).

Question 22

A 60-year-old male with a 15-year history of poorly controlled type 2 diabetes mellitus presents with a red, hot, and swollen right foot. He denies any trauma. His pedal pulses are bounding. Initial radiographs were interpreted as normal, but repeat radiographs 3 weeks later reveal periarticular fragmentation and dorsal subluxation at the tarsometatarsal joints. What is the most appropriate initial management?

Explanation

This clinical scenario is classic for an acute Charcot arthropathy (Eichenholtz Stage I: Developmental/Fragmentation stage), characterized by a red, hot, swollen foot mimicking infection, but with bounding pulses and characteristic radiographic progression (fragmentation, debris, subluxation). The mainstay of treatment in the acute fragmentation phase is immobilization and strict offloading, ideally with non-weight bearing in a total contact cast (TCC) to prevent further deformity until the foot reaches the coalescence and consolidation phases (Stages II and III). Surgery during the acute inflammatory phase is generally contraindicated due to poor bone quality and high failure rates.

Question 23

A 35-year-old male undergoes a percutaneous minimally invasive repair of an acute Achilles tendon rupture. Postoperatively, he complains of numbness and paresthesias along the lateral aspect of his foot. Which of the following anatomic structures was most likely injured during the procedure?

Explanation

The sural nerve is at highest risk during percutaneous or minimally invasive Achilles tendon repair, particularly when placing sutures in the proximal stump. The sural nerve crosses the lateral border of the Achilles tendon approximately 9 to 12 cm proximal to its insertion on the calcaneus. Injury to the sural nerve results in sensory deficits along the lateral hindfoot and lateral border of the foot.

Question 24

A 25-year-old professional athlete sustains a rotational ankle injury. Intra-operative stress testing confirms syndesmotic instability requiring fixation. Which of the following ligamentous structures provides the greatest biomechanical resistance to lateral translation of the fibula relative to the tibia?

Explanation

The ankle syndesmosis consists of the AITFL, PITFL, interosseous ligament, and the transverse tibiofibular ligament. Biomechanical studies have demonstrated that the Posterior Inferior Tibiofibular Ligament (PITFL) is the strongest of the syndesmotic ligaments and provides the greatest resistance (approximately 42%) to lateral displacement of the fibula, followed by the AITFL (35%) and the interosseous ligament (22%).

Question 25

A 22-year-old professional soccer player presents with acute lateral foot pain after a cutting maneuver. Radiographs demonstrate a transverse fracture of the fifth metatarsal extending into the fourth-fifth intermetatarsal articulation. What is the most appropriate management for this athlete?

Explanation

The radiograph describes a Zone II fracture of the proximal fifth metatarsal (Jones fracture), which occurs at the metaphyseal-diaphyseal junction and extends into the 4th-5th intermetatarsal facet. Due to a vascular watershed area in this region, these fractures are prone to delayed union or nonunion. In elite or professional athletes, early operative intervention with an intramedullary screw is the gold standard. It significantly decreases the rate of nonunion and reduces the time to return to play compared to conservative management.

Question 26

A 62-year-old male complains of worsening pain and stiffness in his right great toe, particularly during the toe-off phase of gait. Radiographs demonstrate severe joint space narrowing (>50%), extensive dorsal osteophytosis, and subchondral sclerosis at the first metatarsophalangeal (MTP) joint. On examination, dorsiflexion is limited to 10 degrees and elicits significant pain. According to the Coughlin and Shurnas classification, what is the most definitive and reliable surgical treatment for this condition?

Explanation

The patient has Grade 3 hallux rigidus (Coughlin and Shurnas classification), characterized by significant pain at the extremes of motion, >50% joint space narrowing, and extensive osteophytes. While a dorsal cheilectomy is highly successful for Grade 1 and 2 hallux rigidus, Grade 3 and 4 disease is best treated with a first MTP joint arthrodesis, which is the gold standard and provides the most reliable long-term pain relief and functional restoration.

Question 27

A 40-year-old male sustains a Sanders Type III intra-articular calcaneus fracture and undergoes Open Reduction and Internal Fixation (ORIF) via a standard extensile lateral approach. Which of the following is the most frequent early postoperative complication associated with this surgical approach?

Explanation

The standard extensile lateral approach to the calcaneus involves creating a full-thickness fasciocutaneous flap. The blood supply to the apex of this flap relies critically on the lateral calcaneal artery, a branch of the peroneal artery. Compromise of this vascular supply, compounded by postoperative swelling, makes wound edge necrosis and dehiscence the most common early postoperative complication, occurring in 10% to 25% of cases.

Question 28

A 28-year-old professional football player sustains an acute hyperextension injury to his first MTP joint. He exhibits significant ecchymosis, swelling, and an inability to bear weight. MRI confirms a complete tear of the plantar plate from the base of the proximal phalanx, with 5 mm of proximal retraction of the sesamoids compared to the contralateral side. What is the diagnosis and recommended management?

Explanation

The scenario describes a Grade III turf toe injury, which is a complete rupture of the plantar plate complex. Indications for surgical repair in turf toe injuries include a Grade III sprain with significant proximal retraction of the sesamoids (indicating complete disruption of the intrinsic stabilizing structures), intra-articular loose bodies, a displaced sesamoid fracture, or vertical instability of the joint. Surgical repair ensures the restoration of the anatomy and maximizes the athlete's chance of returning to elite-level sports.

Question 29

A 12-year-old boy presents with a painful, rigid flatfoot and a history of recurrent ankle sprains. Subtalar motion is markedly decreased. A lateral radiograph of the foot reveals a continuous, solid bony bridge forming a 'C-sign' outline around the posterior talus and the sustentaculum tali. Which anatomical location is most commonly involved in this specific type of coalition?

Explanation

The 'C-sign' on a lateral radiograph of the foot is highly indicative of a talocalcaneal coalition. Talocalcaneal coalitions most frequently involve the middle facet of the subtalar joint (between the medial talus and the sustentaculum tali). Conversely, the 'anteater nose' sign on a lateral oblique radiograph is pathognomonic for a calcaneonavicular coalition.

Question 30

A 45-year-old avid distance runner presents with chronic, intractable medial plantar heel pain that radiates laterally. The pain has failed to improve after 6 months of physical therapy, orthotics, and corticosteroid injections. MRI of the hindfoot demonstrates isolated fatty atrophy of the abductor digiti minimi muscle. Entrapment of which of the following nerves is the most likely cause of this patient's symptoms?

Explanation

The first branch of the lateral plantar nerve, also known as Baxter's nerve, provides sensory innervation to the calcaneal periosteum and motor innervation to the abductor digiti minimi (ADM) muscle. Entrapment commonly occurs between the deep fascia of the abductor hallucis and the medial margin of the quadratus plantae. Chronic compression leads to denervation and subsequent fatty atrophy of the ADM on MRI, a pathognomonic finding for Baxter's nerve entrapment.

Question 31

A 42-year-old roofer falls from a height and sustains a Sanders Type III calcaneus fracture. He undergoes open reduction and internal fixation via an extensile lateral approach. Which of the following neurovascular structures is at greatest risk of iatrogenic injury during the full-thickness flap elevation?

Explanation

The sural nerve is at significant risk during the extensile lateral approach to the calcaneus. Retraction of the full-thickness flap must be done carefully using "no-touch" techniques with K-wires to minimize tension on the skin edge and protect the nerve.

Question 32

A 14-year-old male presents with recurrent ankle sprains and a rigid, painful flatfoot. Radiographs demonstrate an elongated anterior process of the calcaneus. A "C-sign" is absent. What is the most appropriate initial surgical management if non-operative measures fail?

Explanation

The patient has a calcaneonavicular coalition, suggested by the "anteater sign" (elongated anterior calcaneal process). If conservative treatment fails, resection of the bar with fat or muscle (EDB) interposition is the standard initial surgical treatment.

Question 33

A 55-year-old woman presents with progressive flattening of her left foot. She has pain along the medial ankle and is unable to perform a single-leg heel raise. Hindfoot valgus is passively correctable. Which of the following is the most appropriate surgical treatment?

Explanation

This is a Stage II Adult Acquired Flatfoot Deformity (correctable hindfoot, posterior tibial tendon insufficiency). Joint-sparing procedures, such as FDL transfer combined with a calcaneal osteotomy (and often a gastrocnemius recession), are indicated.

Question 34

A 38-year-old male undergoes percutaneous repair of an acute Achilles tendon rupture. Post-operatively, he complains of numbness along the lateral aspect of his foot. Which of the following structures was most likely injured during the procedure?

Explanation

The sural nerve crosses from medial to lateral across the Achilles tendon, typically 9-12 cm proximal to its insertion. It is at particularly high risk during percutaneous or minimally invasive Achilles repairs.

Question 35

A 22-year-old professional soccer player sustains a Zone 2 fracture of the proximal fifth metatarsal. He wishes to return to play as soon as possible. What is the most appropriate management?

Explanation

Zone 2 fractures (Jones fractures) involve the vascular watershed area and have a higher risk of nonunion. Intramedullary screw fixation is recommended for high-level athletes to ensure reliable union and an expedited return to sport.

Question 36

A 45-year-old marathon runner complains of chronic medial heel pain that radiates to the plantar aspect of the foot. Examination reveals a positive Tinel's sign over the tarsal tunnel and maximum tenderness over the first branch of the lateral plantar nerve. What muscle's atrophy is most commonly associated with this nerve entrapment?

Explanation

Entrapment of the first branch of the lateral plantar nerve (Baxter's nerve) often causes chronic heel pain mimicking plantar fasciitis. Chronic compression leads to denervation and atrophy of the abductor digiti minimi muscle.

Question 37

A 60-year-old male presents with dorsal foot pain and restricted toe dorsiflexion. Radiographs show severe joint space narrowing, large dorsal osteophytes, and subchondral sclerosis at the first metatarsophalangeal joint (Coughlin and Shurnas Grade 3). What is the gold standard surgical treatment?

Explanation

For advanced hallux rigidus (Grade 3 or 4) with diffuse joint space loss and significant pain, first MTP joint arthrodesis is the gold standard procedure. It provides reliable pain relief and functional improvement.

Question 38

Which of the following is considered an absolute contraindication for a total ankle arthroplasty (TAA) in a patient with end-stage ankle osteoarthritis?

Explanation

Significant avascular necrosis of the talus (more than 50%) precludes adequate component fixation and is an absolute contraindication for TAA. These patients are better served with an ankle or tibiotalocalcaneal arthrodesis.

Question 39

During an open reduction and internal fixation of a pronation-external rotation ankle fracture, the syndesmosis is evaluated. The "Cotton test" is performed. Which of the following intraoperative findings best confirms a syndesmotic injury requiring fixation?

Explanation

The Cotton test involves applying lateral traction to the fibula using a bone hook. Widening of the syndesmosis or a medial clear space greater than 4-5 mm on fluoroscopy confirms syndesmotic instability requiring stabilization.

Question 40

A 40-year-old male sustains a high-energy closed OTA/AO 43-C3 pilon fracture with severe soft tissue swelling and fracture blisters. What is the most appropriate initial management?

Explanation

High-energy pilon fractures with severe soft tissue compromise should be managed with damage-control orthopedics. A spanning external fixation allows for soft tissue recovery, followed by delayed definitive ORIF, significantly reducing the risk of wound complications.

Question 41

A 24-year-old football player sustains a severe hyperextension injury to his great toe. MRI reveals a complete rupture of the plantar plate with proximal retraction of the sesamoids. What is the most appropriate management?

Explanation

Grade 3 turf toe injuries (complete disruption of the plantar plate complex) with sesamoid retraction, severe instability, or intra-articular loose bodies typically require surgical repair. This is necessary to restore the push-off strength required in high-level athletes.

Question 42

A 20-year-old track athlete complains of vague, aching midfoot pain that worsens with sprinting. CT scan reveals an incomplete, non-displaced stress fracture in the central third of the tarsal navicular. What is the most appropriate initial treatment?

Explanation

The central third of the navicular is a hypovascular zone prone to delayed union. Non-displaced stress fractures are initially treated with strict non-weight-bearing in a cast for 6-8 weeks to optimize healing.

Question 43

A 55-year-old diabetic patient presents with a swollen, erythematous, and warm painless right foot. Radiographs show fragmentation, debris, and subluxation at the tarsometatarsal joints. Which Eichenholtz stage does this represent, and what is the optimal initial management?

Explanation

Eichenholtz Stage I (Development/Fragmentation) is characterized by acute inflammation, joint debris, and subluxation. The mainstay of treatment is immobilization and offloading, typically utilizing a total contact cast until the acute phase resolves.

Question 44

A 28-year-old female presents with chronic deep ankle pain following an inversion injury 2 years ago. MRI demonstrates an 8 mm osteochondral lesion of the talus. Based on typical injury patterns, where is this trauma-induced lesion most likely located and what is its morphologic characteristic?

Explanation

Anterolateral osteochondral lesions of the talus are typically traumatic in origin, shallow, and wafer-shaped. Posteromedial lesions are often deeper, cup-shaped, and usually have an insidious or non-traumatic etiology.

Question 45

A 42-year-old male sustains a displaced intra-articular calcaneus fracture and undergoes Open Reduction Internal Fixation (ORIF) via an extensile lateral approach. Postoperatively, he develops altered sensation along the lateral aspect of his foot. Which nerve is most likely at risk during the distal extension of this surgical approach?

Explanation

The sural nerve is highly vulnerable during the extensile lateral approach to the calcaneus, particularly at the distal limb of the incision. Injury results in numbness along the lateral foot.

Question 46

A 38-year-old weekend warrior sustains an acute Achilles tendon rupture. When comparing nonoperative management utilizing early functional rehabilitation to operative repair, which of the following statements regarding outcomes is most accurate?

Explanation

Recent high-level evidence shows that nonoperative treatment with early functional rehabilitation offers similar rerupture rates to surgical repair while avoiding surgical complications like wound necrosis or infection.

Question 47

A 55-year-old female presents with Stage IIb Adult Acquired Flatfoot Deformity (posterior tibial tendon dysfunction). Clinical examination reveals a flexible hindfoot valgus and significant forefoot abduction (>30%). Which surgical reconstruction is most appropriate?

Explanation

Stage IIb features forefoot abduction (uncovering of the talonavicular joint). It requires an FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening (e.g., Evans osteotomy) to correct the abduction.

Question 48

A 22-year-old elite track athlete complains of vague, aching midfoot pain that worsens with sprinting. Imaging reveals a stress fracture of the tarsal navicular. Why is this specific fracture prone to nonunion or delayed union?

Explanation

The central third of the tarsal navicular is a vascular watershed area supplied by branches of the dorsalis pedis and medial plantar arteries. This limited blood supply predisposes stress fractures in this region to nonunion.

Question 49

A 60-year-old diabetic patient presents with a swollen, erythematous, and warm left foot. Radiographs show soft tissue swelling but no osseous destruction. Which clinical test is most helpful in differentiating acute Charcot arthropathy from a deep soft-tissue infection?

Explanation

Elevating the leg for 5 to 10 minutes will typically cause the erythema and swelling to resolve or significantly improve in acute Charcot arthropathy, whereas cellulitis or infection will remain erythematous.

Question 50

A 65-year-old male with severe hallux rigidus (Coughlin and Shurnas Grade 3) complains of persistent pain and inability to wear normal shoes despite conservative management. He desires a definitive surgical procedure with the lowest risk of recurrence. What is the gold standard treatment?

Explanation

First MTP joint arthrodesis is the gold standard for advanced (Grade 3 or 4) hallux rigidus, providing reliable pain relief, durable functional outcomes, and the lowest recurrence rate.

Question 51

Total ankle arthroplasty (TAA) has become an increasingly popular option for end-stage ankle arthritis. Which of the following is considered an absolute contraindication to this procedure?

Explanation

Active or neuropathic joint destruction (Charcot arthropathy) is an absolute contraindication to total ankle arthroplasty due to the extremely high risk of premature catastrophic failure.

Question 52

A 24-year-old professional football player sustains an acute Zone 2 fracture of the proximal fifth metatarsal (Jones fracture). Given his desire for a rapid return to play, intramedullary screw fixation is planned. Which anatomical factor must be strictly respected to avoid complication during screw placement?

Explanation

The fifth metatarsal has a lateral and plantar bow. The starting point must be high and medial on the tuberosity to safely pass down the straight medullary canal and avoid medial cortical perforation.

Question 53

A 28-year-old female skier presents with acute ankle pain after forced dorsiflexion and eversion. Radiographs reveal a small bony avulsion flake arising from the lateral ridge of the distal fibula. What pathology does this 'fleck sign' typically represent?

Explanation

A fleck of bone off the lateral ridge of the distal fibula represents an avulsion of the superior peroneal retinaculum (SPR), which is pathognomonic for acute peroneal tendon subluxation or dislocation.

Question 54

A 30-year-old construction worker falls from a ladder and sustains an injury to his midfoot. Radiographs show a purely ligamentous Lisfranc injury with widening of the first intermetatarsal space. According to recent literature, what is the preferred surgical treatment to maximize long-term functional outcome?

Explanation

Recent studies, including classic prospective trials, demonstrate that purely ligamentous Lisfranc injuries treated with primary arthrodesis of the first three TMT joints have better functional outcomes and lower reoperation rates compared to ORIF.

Question 55

A 35-year-old male sustains a severe ankle injury. Radiographs show a posterior fracture-dislocation of the ankle that is irreducible in the emergency department. The fibula appears displaced behind the posterior tubercle of the tibia. What is this specific injury pattern called?

Explanation

A Bosworth fracture-dislocation involves the proximal fibular fragment becoming locked behind the posterior tubercle of the tibia, making closed reduction impossible and necessitating emergent open reduction.

Question 56

A 14-year-old boy presents with an ankle injury after an external rotation force. Radiographs show a Salter-Harris III fracture of the anterolateral aspect of the distal tibia. Which ligament is responsible for the avulsion of this bony fragment?

Explanation

A juvenile Tillaux fracture is an SH III fracture of the anterolateral distal tibia. The fragment is avulsed by the intact anterior inferior tibiofibular ligament (AITFL) during an external rotation injury.

Question 57

A 25-year-old snowboarder is diagnosed with a 'snowboarder's fracture' after reporting persistent lateral ankle pain following a crash. Which anatomic structure is fractured in this injury?

Explanation

A 'snowboarder's fracture' refers to a fracture of the lateral process of the talus. It is caused by an axial load on a dorsiflexed, everted foot and is often misdiagnosed as a lateral ankle sprain.

Question 58

A patient with Charcot-Marie-Tooth (CMT) disease presents with a progressive cavovarus foot deformity. A Coleman block test is performed, and the hindfoot varus corrects to neutral when the first ray drops off the block. What does this indicate regarding the primary deforming force and hindfoot flexibility?

Explanation

Correction of hindfoot varus during a Coleman block test indicates a flexible hindfoot. The deformity is primarily forefoot-driven by a rigid plantarflexed first ray, typically due to peroneus longus overpull.

Question 59

During surgical release for Tarsal Tunnel Syndrome, the flexor retinaculum is divided to decompress the posterior tibial nerve. In the region of the medial malleolus, what is the anatomical relationship of the nerve to the adjacent tendons and vessels (from anterior/medial to posterior/lateral)?

Explanation

The order of structures passing behind the medial malleolus is Tom, Dick, AND Harry: Tibialis posterior, flexor digitorum longus, Artery (posterior tibial), Nerve (posterior tibial), and flexor hallucis longus.

Question 60

A 40-year-old female presents with severe pain in the forefoot and a sensation of 'walking on a marble.' She is diagnosed with a Morton's neuroma in the third web space. Histological examination of the excised tissue would most likely reveal which of the following?

Explanation

Morton's neuroma is not a true neuroma (neoplasm). It is an entrapment neuropathy characterized by perineural fibrosis, local vascular changes, and endoneurial edema.

Question 61

In assessing a patient with a suspected syndesmotic injury, radiographs are obtained. Which radiographic parameter is considered the most reliable indicator of syndesmotic widening on a standard AP or Mortise view?

Explanation

A tibiofibular clear space greater than 5-6 mm on either the AP or Mortise view is the most reliable and reproducible radiographic parameter indicating syndesmotic widening.

Question 62

A 50-year-old obese male presents with non-insertional Achilles tendinosis. Conservative management has failed. MRI shows mucoid degeneration involving 60% of the cross-sectional area of the tendon. If surgical debridement is performed, what additional procedure is highly recommended?

Explanation

When debridement of the Achilles tendon requires resection of >50% of the diseased tendon, an FHL transfer is indicated to provide vascularity and adequate plantarflexion strength.

Question 63

The Sanders classification is utilized for preoperative planning of intra-articular calcaneus fractures. Which imaging modality and anatomical plane is the basis for this classification system?

Explanation

The Sanders classification relies on coronal CT imaging at the widest point of the posterior facet of the calcaneus, categorizing fractures based on the number and location of articular fracture lines.

Question 64

A 26-year-old professional dancer presents with focal pain over the plantar aspect of the first metatarsophalangeal (MTP) joint after forceful hyperextension ('Turf Toe'). MRI reveals a complete tear of the plantar plate with proximal retraction of the sesamoids. What is the most appropriate management?

Explanation

Grade 3 turf toe injuries (complete tear of the plantar complex) with proximal migration of the sesamoids, clinical instability, or functional demands of an elite athlete typically warrant primary surgical repair.

Question 65

A 42-year-old roofer falls from a height and sustains a displaced intra-articular calcaneus fracture. An extensile lateral approach is planned. Which of the following nerves is at greatest risk of iatrogenic injury during the inferior and posterior aspects of the incision?

Explanation

The sural nerve is at significant risk during the extensile lateral approach to the calcaneus, particularly at the posterior and inferior limbs of the incision. It courses posterior to the lateral malleolus and provides sensation to the lateral foot.

Question 66

A 24-year-old male presents with a progressive unilateral cavovarus foot deformity. A Coleman block test is performed, which corrects the hindfoot varus to a neutral alignment. What does this physical examination finding indicate?

Explanation

The Coleman block test evaluates hindfoot flexibility in cavovarus deformities. If the hindfoot varus corrects when the first metatarsal is allowed to drop off the block, the deformity is forefoot-driven (plantarflexed first ray) and the hindfoot remains flexible.

Question 67

A 55-year-old overweight female presents with acquired flatfoot deformity. Examination shows a flexible hindfoot, but radiographs reveal greater than 40% talonavicular uncoverage indicating significant forefoot abduction. What is the most appropriate surgical management for this Stage IIb posterior tibial tendon dysfunction?

Explanation

Stage IIb PTTD is characterized by a flexible hindfoot with significant forefoot abduction (talonavicular uncoverage >40%). Optimal treatment includes an FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening (e.g., Evans osteotomy) to correct the abduction.

Question 68

A 20-year-old track athlete presents with insidious onset, vague midfoot pain. MRI confirms a stress fracture of the tarsal navicular. Which region of the navicular is most susceptible to this injury due to its watershed blood supply?

Explanation

The central third of the navicular is a relative watershed area, receiving precarious blood supply from the medial and lateral capsular vessels. This lack of vascularity makes it highly susceptible to stress fractures and nonunion.

Question 69

Following an ankle sprain, a 28-year-old male has persistent ankle pain. MRI reveals an osteochondral lesion of the talus. Based on classic morphologic principles, what is the typical mechanism and shape of a posteromedial talar dome lesion?

Explanation

Posteromedial talar lesions classically result from Plantarflexion and Inversion, and are morphologically deep and cup-shaped. Anterolateral lesions result from Dorsiflexion and Inversion, and are anterior, shallow, and wafer-shaped.

Question 70

A 58-year-old male with poorly controlled diabetes mellitus and severe peripheral neuropathy presents with a red, hot, swollen foot without skin ulceration. Radiographs show periarticular debris, fragmentation, and subluxation at the tarsometatarsal joints. What is the most appropriate initial management?

Explanation

The patient is in Eichenholtz Stage I (fragmentation/development) of Charcot arthropathy. The gold standard initial treatment to prevent further deformity is strict offloading, typically achieved with total contact casting (TCC).

Question 71

A 65-year-old male with end-stage post-traumatic ankle osteoarthritis is considering a total ankle arthroplasty (TAA). Which of the following conditions represents an absolute contraindication to performing a TAA?

Explanation

Charcot neuroarthropathy and absent protective sensation are absolute contraindications to total ankle arthroplasty due to the extremely high risk of implant failure, collapse, and severe complications. Ankle arthrodesis is the preferred surgical option in neuropathic patients.

Question 72

A 22-year-old elite collegiate basketball player sustains a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal base (Zone 2). Given his desire for a rapid and reliable return to sport, what is the gold standard treatment?

Explanation

Zone 2 fractures (Jones fractures) have a high risk of delayed union or nonunion due to watershed vascularity. In high-performance athletes, intramedullary screw fixation is the gold standard to decrease nonunion rates and accelerate return to play.

Question 73

A professional American football player sustains a "turf toe" injury after a tackle. Which of the following best describes the pathoanatomy and mechanism of this injury?

Explanation

Turf toe is characterized by a severe hyperextension injury to the first metatarsophalangeal (MTP) joint. This mechanism stretches or tears the plantar plate and the sesamoid complex, leading to instability and pain.

Question 74

A 55-year-old female presents with progressive flattening of her left foot, medial ankle pain, and difficulty performing a single-leg heel rise. Radiographs demonstrate >50% uncovering of the talonavicular joint on the AP view and a significant decrease in the calcaneal pitch. Which of the following is the most appropriate surgical management for this flexible deformity?

Explanation

This patient has Stage IIb Adult Acquired Flatfoot Deformity (AAFD), characterized by a flexible deformity with significant forefoot abduction (>50% talonavicular uncoverage). Treatment requires addressing both the hindfoot valgus and the severe forefoot abduction with a lateral column lengthening, in addition to an MDCO and FDL transfer.

Question 75

A 40-year-old male undergoes open reduction and internal fixation of a displaced intra-articular calcaneus fracture via an extensile lateral approach. Postoperatively, he develops full-thickness wound necrosis at the apex of the L-shaped incision. The blood supply to this specific vulnerable angiosome is predominantly provided by which of the following arteries?

Explanation

The extensile lateral approach to the calcaneus relies on the lateral calcaneal artery, which is a terminal branch of the peroneal artery. Compromise of this angiosome is responsible for the high rate of apical wound necrosis seen in this approach.

Question 76

A 25-year-old athlete sustains a pronation-external rotation ankle fracture. Following rigid fixation of the malleoli, the intraoperative Cotton test reveals widening of the syndesmosis. A syndesmotic screw is planned. According to recent orthopedic literature, what is the optimal position of the ankle during screw placement to prevent postoperative loss of dorsiflexion?

Explanation

Recent high-level evidence demonstrates that the position of the ankle (dorsiflexion vs. plantarflexion) during syndesmotic screw fixation does not significantly affect postoperative dorsiflexion or clinical outcomes. This refutes the historical teaching that the ankle must be maximally dorsiflexed to accommodate the wider anterior talar dome.

Question 77

A 60-year-old poorly controlled diabetic male presents with a markedly swollen, erythematous, and warm right foot. He denies fevers or systemic symptoms. Radiographs show fragmentation, osteopenia, and early subluxation of the tarsometatarsal joints. What is the most appropriate initial management?

Explanation

This patient presents with acute Eichenholtz Stage I (developmental/fragmentation) Charcot neuroarthropathy. The mainstay of initial treatment for acute Charcot is immediate offloading and immobilization, most effectively achieved with a total contact cast (TCC) to prevent further deformity.

Question 78

Which of the following statements accurately compares functional rehabilitation with early weight-bearing in the non-operative management of acute Achilles tendon ruptures to surgical repair?

Explanation

Current AAOS guidelines and meta-analyses show that non-operative management utilizing early functional rehabilitation and weight-bearing provides equivalent functional outcomes and similar re-rupture rates compared to operative repair, while completely avoiding surgical soft-tissue complications.

Question 79

A 22-year-old soccer player presents with chronic anterolateral ankle pain. MRI reveals an osteochondral lesion of the talus (OCL). Which of the following best describes the typical etiology and morphology of this specific lesion compared to posteromedial talar dome lesions?

Explanation

Anterolateral talar osteochondral lesions are typically traumatic in origin and morphologically shallow/wafer-shaped (remember the mnemonic DIAL: Dorsiflexion Inversion, AnteroLateral). Posteromedial lesions are usually non-traumatic (or insidious) and deep/cup-shaped (PIMP: Plantarflexion Inversion, Medial Posterior).

Question 80

A 19-year-old elite collegiate basketball player sustains an acute, non-displaced fracture of the fifth metatarsal at the metaphyseal-diaphyseal junction (Zone 2). To minimize the risk of nonunion and expedite return to play, what is the most appropriate management?

Explanation

Zone 2 fifth metatarsal fractures (Jones fractures) occur in a vascular watershed area and have a high rate of nonunion. In elite athletes, early intramedullary screw fixation is recommended to significantly decrease nonunion rates and allow for a faster return to sport compared to non-operative management.

Question 81

A 24-year-old professional football player sustains a severe hyperdorsiflexion injury to his great toe. Clinical exam shows gross instability of the first metatarsophalangeal (MTP) joint, and MRI confirms a complete rupture of the plantar plate with proximal retraction of the sesamoid complex. What is the most appropriate management?

Explanation

This describes a Grade 3 "turf toe" injury with frank instability and sesamoid retraction. In a competitive athlete, a complete tear of the plantar plate with gross instability or sesamoid retraction necessitates primary surgical repair to restore push-off strength and joint stability.

Question 82

When evaluating a patient with end-stage post-traumatic ankle osteoarthritis, which of the following is considered an absolute contraindication to performing a Total Ankle Arthroplasty (TAA)?

Explanation

Charcot neuroarthropathy with lack of protective sensation is an absolute contraindication to Total Ankle Arthroplasty due to the unacceptably high risk of catastrophic implant failure, peri-prosthetic fracture, and progressive deformity. These patients are better managed with a tibiotalocalcaneal arthrodesis if surgical intervention is necessary.

Question 83

A 28-year-old skier presents with lateral ankle pain and a snapping sensation behind the lateral malleolus after an acute dorsiflexion-inversion injury. Examination reveals subluxation of the lateral tendons over the fibula with resisted active eversion. Injury to which of the following structures is the primary cause of this pathology?

Explanation

Peroneal tendon subluxation or dislocation is primarily caused by an injury to the superior peroneal retinaculum (SPR), which normally acts to restrain the tendons in the retromalleolar groove. This classically occurs during forceful dorsiflexion and inversion, such as catching a ski tip.

Orthopedic Foot And Ank Review | Dr Hutaif Foot & Ankle -...

Foot And Ankle Free Orthopedics Review | Dr Hutaif Foot -...

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Foot And Ankle Free Orthopedics Review | Dr Hutaif Foot -...

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