AAOS Foot & Ankle MCQs Set 1: Orthopedic Board Prep

Question 1

The main advantage of surgical repair of an acute Achilles tendon rupture, when compared with nonsurgical management, is reduced

Explanation

The literature supports similar clinical outcomes after surgical and nonsurgical methods. The chief difference lies in the complications between the groups. Surgical patients experience more wound problems but a significantly lower rerupture rate. Although suturing the tendon allows earlier mobility, the tendon healing time is unchanged. Nonsurgical methods are less expensive to provide. Maffulli N: Rupture of the Achilles tendon. J Bone Joint Surg Am 1999;81:1019-1036. Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen U: Operative versus nonoperative treatment of Achilles tendon rupture: A prospective randomized study and review of the literature. Am J Sports Med 1993;21:791-799.

Question 2

A 25-year-old farm worker sustained a grade III open fracture of the midshaft of the left tibia after falling from a ladder. Which of the following antibiotic regimens is best for this patient?

Explanation

Patients who sustain grade III open fractures that are related to a farm environment require ampicillin or penicillin for Clostridium coverage. Holton PD, Mader J, Nelson CL, Osmon DR, Patzakis MJ: Antibiotics for the practicing orthopaedic surgeon. Instr Course Lect 2000;341:36-42.

Question 3

A 60-year-old man reports that he has had shoe pressure pain over his right great toe for several years but has minimal discomfort when barefoot or in sandals. A clinical photograph and radiographs are shown in Figures 1a through 1c. Management should consist of

Explanation

Some patients have minimal symptoms associated with hallux rigidus despite significant radiographic evidence of osteoarthritis. This patient's symptoms are primarily related to shoe pressure from the exostosis and can be managed with extra-depth shoe wear. Smith RW, Katchis SD, Ayson LC: Outcomes in hallux rigidus patients treated nonoperatively: A long-term follow-up study. Foot Ankle Int 2000;21:906-913.

Question 4

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?

Explanation

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. Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J: Fractures of the talus: Experience of two level 1 trauma centers. Foot Ankle Int 2000;21:1023-1029.

Question 5

A 28-year-old woman who is training for the New York Marathon reports pain in the posteromedial aspect of her right ankle. Examination reveals tenderness just posterior to the medial malleolus. Radiographs are normal. An MRI scan is shown in Figure 3. What is the most likely diagnosis?

Explanation

Any of the above conditions is credible with a limited history. The MRI scan unequivocally shows the stress fracture in the distal tibia. Most tibial stress fractures can be managed with rest and immobilization. Boden BP, Osbahr DC: High risk stress fractures: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-353.

Question 6

A 50-year-old laborer sustained an isolated closed injury to his heel after falling 11 feet off a wall. A radiograph and a CT scan are shown in Figures 4a and 4b. To minimize the patient's temporary disability and allow him to return to work most rapidly, management should consist of

Explanation

With a severe articular injury to the calcaneus, the ability to achieve satisfactory results with open reduction and internal fixation diminishes. An arthrodesis is often needed to allow a person who works as a laborer to return to work. Recent literature suggests that this can be successfully performed primarily, improving the odds of an earlier return to the labor force at 1 year. Huefner T, Thermann H, Geerling J, Pape HC, Pohlemann T: Primary subtalar arthrodesis of calcaneal fractures. Foot Ankle Int 2001;22:9-14. Coughlin MJ: Calcaneal fractures in the industrial patient. Foot Ankle Int 2000;21:896-905.

Question 7

Figures 5a and 5b show the clinical photograph and radiograph of a patient who has difficulty wearing shoes and has persistent symptoms medially and laterally at the first and fifth metatarsophalangeal joints. Because shoe modifications have failed to provide relief, management should now consist of

Explanation

A significant bunionette deformity that fails to respond to conservative management is best addressed surgically, in this case with the bunion deformity. The radiograph reveals a prominent lateral condyle at the fifth metatarsal head without a significant increase in the intermetatarsal angle. Simple exostectomy is preferred with less risk of complications. Complete excision would risk transfer lesions to the medial metatarsals. Mann RA, Coughlin MJ: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 415-435.

Question 8

What is the most appropriate orthotic management for the lesion shown in Figure 6?

Explanation

The figure shows an intractable plantar keratosis (IPK). The keratoma usually forms beneath a bony prominence. This can occur under the sesamoids, most commonly the tibial sesamoid, or under the fibular condyle of a prominent metatarsal head. The initial treatment of an IPK consists of paring down the callused lesion and placing a metatarsal pad proximal to the lesion to provide posting to unload the bony prominence.

Question 9

Examination of a 45-year-old man with Charcot-Marie-Tooth disease reveals a cavus foot, a tight Achilles tendon, and forefoot callus formation. Radiographs reveal advanced degenerative changes in the hindfoot. Shoe wear modifications have failed to provide relief. Treatment should now consist of

Explanation

The patient has the typical end stage residuals from long-standing Charcot-Marie-Tooth disease. Initial management consisting of shoe wear modifications and orthotic devices is preferred, but these are not successful when the disease process has progressed. Surgical correction with calcaneal osteotomy or Achilles tendon lengthening and Steindler stripping is not indicated in the presence of significant hindfoot arthritis. Because this patient has findings consistent with hindfoot arthritis, a triple arthrodesis with correction of the cavus deformity is the preferred treatment. Roper BA, Tibrewal SB: Soft tissue surgery in Charcot-Marie-Tooth disease. J Bone Joint Surg Br 1989;71:17-20.

Question 10

A Canale view best visualizes which of the following structures?

Explanation

The Canale view, which visualizes the talar neck, is taken with the ankle in maximum plantar flexion and the foot pronated 15 degrees. The radiograph is directed at a 75 degree 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. 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.

Question 11

A 45-year-old woman with a long-standing history of diabetes mellitus has a large draining plantar ulcer of the right foot. Examination reveals some local cellulitis and erythema surrounding the ulcer. A clinical photograph is shown in Figure 7. Based on these findings, what is the most appropriate antibiotic?

Explanation

Combination drugs with activity against both aerobic and anaerobic organisms have been determined to be the best approach. The first-generation cephalosporins do not provide adequate coverage for gram-negative and anaerobic organisms. Gentamicin alone would not provide adequate activity against anaerobes, and there is the risk of renal and auditory toxicity. Pinzur MS, Slovenkai MD, Trepman E: Guidelines for diabetic foot care. Foot Ankle Int 1999;20:695-702.

Question 12

A 35-year-old man reports forefoot pain with weight-bearing activities. He reports that he has had high arches since adolescence but has never been treated. Examination reveals stiff cavus feet. He has no plantar callus or hammer toe formation. The ankle can be passively dorsiflexed 10 degrees. Initial management should consist of

Explanation

The patient has cavus feet with minimal clinical symptoms. At this stage, conservative management is preferred. The use of a molded orthosis will allow better support of the midfoot and provide cushioning of the forefoot. This will most likely result in long-term relief. In more advanced cases with forefoot callus formation, Achilles tendon lengthening or calcaneal osteotomy and Steindler stripping are effective in correcting the cavus deformity. In the presence of arthritic changes in the hindfoot, a triple arthrodesis with corrective bone resection may be necessary. Janisse DJ: Indications and prescriptions for orthoses in sports. Orthop Clin North Am 1994;25:95-107.

Question 13

A 70-year-old woman had poliomyelitis as a young child, and the residual weakness she has as an adult principally involves the lower extremities. She now notes progressive weakness in both legs and she tires easily. What is the best course of action?

Explanation

The most likely diagnosis is postpolio syndrome, which is characterized by increasing weakness in both the paretic and previously normal muscles. Fatigability, joint pain, muscle atrophy, respiratory insufficiency, dysphagia, and sleep apnea are also seen. Gentle exercise and modification in lifestyle demands are generally recommended. Vigorous rehabilitation is likely to be detrimental in this condition. Further diagnostic work-up is not indicated at this time. Dalakas MC, Elder G, Hallett M, et al: A long-term follow-up study of patients with post-poliomyelitis neuromuscular symptoms. N Eng J Med 1986;314:959-963.

Question 14

A patient with Charcot-Marie-Tooth disease has a progressively rigid cavovarus foot deformity. The patient states that the pain is restricted to the forefoot, where rigid claw toe deformities have developed. Which of the following structures is primarily involved in creation of a claw toe deformity?

Explanation

Diseases such as Charcot-Marie-Tooth result in spasticity to the extrinsic flexor tendons. This results in hyperflexion of the proximal and distal interphalangeal joints of the involved toe, as well as hyperextension at the metatarsophalangeal joint. The tendon often becomes contracted with progressive equinus of the ankle. Correction of ankle equinus exaggerates the claw toe deformity. The interosseous tendon plays no role in the etiology of a claw toe but may become contracted in later stages of the disease. Laxity of the volar plate may precipitate a claw toe deformity in a nonspastic situation. In patients with a head injury, claw toe deformities are generally the result of overactivity of the extensor tendons. Keenan MA, Gorai AP, Smith CW, Garland DE: Intrinsic toe flexion deformity following correction of spastic equinovarus deformity in adults. Foot Ankle 1987;7:333-337. Pichney GA, Derner R, Lauf E: Digital "V" arthrodesis. J Foot Ankle Surg 1993;32:473-479.

Question 15

A 45-year-old man who underwent an ankle arthrodesis reports that for the first 6 years he had significant pain relief after the fusion healed. However, he now has increasing pain in the sinus tarsi. AP and lateral radiographs are shown in Figures 8a and 8b. What is the most likely cause of the patient's symptoms?

Explanation

The patient has a solid ankle fusion radiographically. With a tibiotalar arthrodesis, the adjacent joints (subtalar and transverse tarsal) take additional stress. Over time, progressive degenerative arthritis will occur in these adjacent joints, often necessitating further surgery. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 613-631.

Question 16

What is the most common surgical cause of the foot deformity shown in Figure 9?

Explanation

The radiograph shows a hallux varus deformity. Iatrogenically acquired hallux varus is most often the result of excessive lateral soft-tissue release, sesamoidectomy, or both. It also can be caused by a medial tibial sesamoid subluxation in conjunction with excessive postoperative dressing application, overcorrection of the intermetatarsal angle, or excessive medial eminence resection. Donley BG: Acquired hallux varus. Foot Ankle Int 1997;18:586-592.

Question 17

What is the reported failure rate for surgical treatment of a Morton's neuroma?

Explanation

The reported failure rate is in the range of 15%, which may be the result of incorrect diagnosis, improper web space selection, or formation of a stump neuroma. Therefore, the procedure should be approached with caution, measures should be taken to ensure that the diagnosis is accurate, and nonsurgical options should be exhausted. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 101-111. Beskin JL: Nerve entrapment syndromes of the foot and ankle. J Am Acad Orthop Surg 1997;5:261-269.

Question 18

A 35-year-old woman who runs long distance has had posterior calf tenderness for the past 3 months. A clinical photograph is shown in Figure 10a, and MRI scans are shown in Figures 10b and 10c. Management at this point should consist of

Explanation

The initial treatment for peritendinitis should consist of calf stretching in an eccentric mode and physical therapy. In a recent study, this treatment has been found superior to surgical debridement in nonextensive peritendinitis and pantendinitis. A non-weight-bearing cast, while useful in reducing inflammation, will result in calf atrophy and poorly organized collagen repair. Cortisone is contraindicated because of the danger of tendon damage. Tendon debridement at this stage is not indicated. Alfredson H, Pietila T, Jansson P, Lorentzon R: Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998;26:360-366.

Question 19

A 35-year-old laborer who sustained a forefoot injury 10 years ago has returned to work but reports a progressively painful deformity of the hallux and continued midfoot pain that is aggravated by weight-bearing activities. Shoe wear modifications have failed to provide relief. Direct palpation reveals no pain at the first metatarsocuneiform joint. A radiograph is shown in Figure 11. What is the next most appropriate step in management?

Explanation

The patient has nonunions of the metatarsal fractures and a hallux valgus deformity with arthritic changes. To address all of the findings, management should consist of open treatment of the metatarsal nonunions and hallux metatarsophalangeal arthrodesis. Cast immobilization and a bone stimulator are unlikely to be beneficial at this time. Isolated correction of the hallux valgus deformity will not address the metatarsal nonunions or the arthritis at the hallux metatarsophalangeal joint. Kitaoka HB, Patzer GL: Arthrodesis versus resection arthroplasty for failed hallux valgus operations. Clin Orthop 1998;347:208-214. McGarvey WC, Braly WG: Bone graft in hindfoot arthrodesis: Allograft vs autograft. Orthopedics 1996;19:389-394.

Question 20

The use of posting (a wedge added to the medial or lateral side of an insole) is useful to balance forefoot or hindfoot malalignment. Assuming normal subtalar joint pronation, what is the maximum amount of recommended hindfoot posting?

Explanation

Generally, patients cannot tolerate more than 5 degrees of hindfoot posting. Donatelli RA, Hurlbert C, Conaway D, et al: Biomechanics foot orthotics: A retrospective study. J Orthop Sports Phys Ther 1988;10:205-212. Michaud TM: Foot Orthoses and Other Forms of Conservative Foot Care. Baltimore, MD, Williams & Wilkins, 1993, pp 61-65, 186.

Question 21

A 40-year-old woman has a symptomatic mass on the anterior aspect of the ankle. She reports no constitutional symptoms. An MRI scan is shown in Figure 12. What is the most likely diagnosis?

Explanation

The MRI scan reveals a lobular mass that is below the vitamin E tablet marker taped to the skin. This is juxtaposed to the tibialis anterior tendon. It is slightly more enhanced than the surrounding subcutaneous fat and is consistent with a ganglion. Osteosarcoma, aneurysmal bone cyst, or unicameral bone cyst all would demonstrate enhancement or pathology in the bone. This is clearly a well-defined soft-tissue mass. Gouty tophi show low to intermediate signal on T1- and T2-weighted images. Kransdorf MJ, Jelinek JS, Moser RP Jr, et al: Soft tissue masses: Diagnosis using MR imaging. Am J Roentgenol 1989;153:541-547. Wetzel LH, Levine E: Soft-tissue tumors of the foot: Value of MR imaging for specific diagnosis. Am J Roentgenol 1990;155:1025-1030.

Question 22

A 35-year-old woman who is training for a triathlon has had a 2-month history of heel pain with weight bearing and is unable to run. History reveals that she is amenorrheic. Examination reveals that she is thin and has pain over the heel that is exacerbated with medial and lateral compression. Range of motion and motor and sensory function are normal. Radiographs are normal. What is the most likely diagnosis?

Explanation

The most likely diagnosis is a stress fracture of the calcaneus and is supported by the history of running, female gender, and amenorrhea. Reproducing pain with medial and lateral compression of the heel also supports the diagnosis. A bone scan or MRI would most likely confirm the diagnosis. Plantar fasciitis would result in pain on the bottom of the heel with point tenderness. The lack of other areas of involvement or other symptoms does not support a seronegative inflammatory arthritis. Tarsal tunnel syndrome and peripheral neuropathy are unlikely because of the normal neurologic examination. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 597-612.

Question 23

A 28-year-old woman has a moderate hallux valgus deformity and a prominence of the medial eminence. She can participate in all activities and reports that she could wear 3-inch heels in the past, but she now notes medial eminence pain even while wearing a soft leather flat shoe with a cushioned sole. She requests recommendations regarding surgical correction. Examination reveals a 1-2 intermetatarsal angle of 10 degrees. A clinical photograph and radiograph are shown in Figures 13a and 13b. What is the best course of action?

Explanation

Based on her symptoms and prior shoe wear modifications, the treatment of choice is surgical correction of the hallux valgus with a chevron osteotomy. There are no data to support the use of a custom orthosis to delay the progression of a hallux valgus deformity. Steroid injection would only risk infection, as well as joint and capsule damage. Extra-depth shoes are an option; however, the patient is interested in surgical options. Chou LB, Mann RA, Casillas MM: Biplanar chevron osteotomy. Foot Ankle Int 1998;19:579-584. Coughlin MJ: Roger A. Mann Award: Juvenile hallux valgus. Etiology and treatment. Foot Ankle Int 1995;16:682-697.

Question 24

A 20-year-old woman has lateral foot and ankle pain after sustaining an inversion injury of the ankle while playing soccer 3 months ago. Activity modifications and physical therapy have failed to provide relief. She describes burning pain that extends from the anterior aspect of the ankle to the foot and lateral two toes. The pain is often worse at night. Plain radiographs, a bone scan, and an MRI scan are normal. Stress examination reveals no instability. What is the most likely diagnosis?

Explanation

Persistent pain following an ankle sprain can present a diagnostic dilemma. All of the injuries listed should be considered in the differential diagnosis. The superficial peroneal nerve courses in the lateral compartment and exits the crural fascia 12 to 15 cm above the level of the ankle. Muscle herniation through the fascial defect has been reported to be associated with entrapment of this nerve. The fascial hiatus also may serve as a potential tether in cases of inversion injuries causing injury to the superficial peroneal nerve. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 101-111.

Question 25

A 35-year-old runner has pain beneath the second metatarsophalangeal joint. He reports that he has significantly decreased his running distance since the onset of the pain. He denies any history of trauma or injury to the foot. A radiograph is shown in Figure 14. Initial management should consist of

Explanation

The presence of the relatively long second metatarsal, along with the close approximation of the second and third metatarsal heads, are consistent with second metatarsophalangeal tenosynovitis. The hallmark of initial management is conservative. Modalities include taping, nonsteroidal anti-inflammatory drugs, metatarsal pads, and cortisone injections. Trepman and Yeo combined the use of a cortisone injection with a rocker bottom sole. Mizel and Michelson reported their results using an extended rigid steel shank shoe along with a cortisone injection. Trepman E, Yeo SJ: Nonoperative treatment of metatarsophalangeal joint synovitis. Foot Ankle Int 1995;16:771-777.

Question 26

A 24-year-old football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the first and second metatarsals. What is the most appropriate definitive management?

Explanation

Lisfranc injuries with >2 mm diastasis or any instability require operative intervention. ORIF or primary arthrodesis restores anatomic alignment and optimizes functional outcomes.

Question 27

A 55-year-old woman complains of painful bunions. Examination reveals a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate?

Explanation

A Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (HVA >40, IMA >15) associated with first TMT joint hypermobility.

Question 28

A 21-year-old collegiate basketball player sustains an acute fifth metatarsal fracture in the metaphyseal-diaphyseal junction (Zone 2). To minimize the risk of nonunion and expedite return to play, what is the best treatment?

Explanation

Acute Jones fractures (Zone 2) in elite or competitive athletes are best treated with intramedullary screw fixation to reduce nonunion rates and allow faster return to play.

Question 29

A 30-year-old man falls from a height and sustains a Hawkins Type III talar neck fracture. This fracture pattern involves displacement of the talar neck with subluxation or dislocation of which joints?

Explanation

A Hawkins Type III talar neck fracture involves displacement of the talar body with dislocation of both the subtalar and tibiotalar joints. It carries a high risk of avascular necrosis.

Question 30

A 58-year-old patient with poorly controlled type 2 diabetes presents with a red, hot, swollen right foot. There is no history of trauma or open wounds. Radiographs show periarticular debris, joint subluxation, and fragmentation of the midfoot. What is the most appropriate initial management?

Explanation

The clinical presentation is classic for acute Charcot arthropathy (Eichenholtz stage I). The standard initial treatment is offloading with a total contact cast to prevent further deformity.

Question 31

A 40-year-old recreational tennis player feels a 'pop' in his posterior ankle. Examination shows a positive Thompson test. If he elects for non-operative management with early functional rehabilitation, he should be counseled that compared to surgical repair, he has a:

Explanation

Non-operative management of Achilles tendon ruptures has historically been associated with a slightly higher rerupture rate compared to surgical repair, though modern functional rehab protocols have narrowed this gap. Surgery carries higher wound complication risks.

Question 32

A 24-year-old athlete sustains a midfoot injury after an axial load was applied to his plantarflexed foot. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the first and second metatarsals, alongside a "fleck sign". Which of the following is the most common mechanism for this specific injury pattern?

Explanation

The typical mechanism for a Lisfranc injury is an indirect axial load to a plantarflexed foot, causing hyperplantarflexion and rupture of the ligamentous complex. The "fleck sign" represents an avulsion of the Lisfranc ligament from the base of the second metatarsal.

Question 33

When comparing functional rehabilitation protocols to open surgical repair for the management of an acute Achilles tendon rupture, recent randomized controlled trials demonstrate which of the following regarding functional non-operative management?

Explanation

Recent studies support that early functional rehabilitation for non-operative management yields re-rupture rates equivalent to operative repair. Additionally, non-operative management avoids the wound healing complications associated with surgery.

Question 34

A 28-year-old football player sustains a high ankle sprain. A positive stress radiograph confirms a syndesmotic injury. During surgical repair, an understanding of the syndesmotic anatomy is critical. Which of the following ligaments provides the greatest structural strength and primary stabilization to the distal tibiofibular syndesmosis?

Explanation

The posterior inferior tibiofibular ligament (PITFL) is the strongest component of the syndesmotic complex, contributing approximately 40% to 45% of the total syndesmotic resistance to fibular displacement.

Question 35

A 35-year-old man sustains a Hawkins type II fracture of the talar neck after a motor vehicle collision. By definition, a Hawkins type II talar neck fracture is characterized by displacement and subluxation or dislocation at which of the following articulations?

Explanation

A Hawkins II talar neck fracture involves a fracture of the talar neck with subluxation or dislocation of the subtalar joint. The tibiotalar joint remains anatomically aligned.

Question 36

A 45-year-old woman presents with painful bilateral bunions. Examination reveals significant hypermobility of the first tarsometatarsal (TMT) joint. Weight-bearing radiographs show a hallux valgus angle (HVA) of 38 degrees and an intermetatarsal angle (IMA) of 16 degrees. Which of the following is the most appropriate surgical intervention?

Explanation

The Lapidus procedure (arthrodesis of the first TMT joint) is the procedure of choice for moderate to severe hallux valgus deformities associated with clinical hypermobility of the first ray.

Question 37

A 55-year-old woman with stage IIb adult-acquired flatfoot deformity (posterior tibial tendon dysfunction) presents for surgical evaluation. She has a flexible flatfoot, inability to perform a single heel rise, and >40% uncovering of the talonavicular joint indicating substantial forefoot abduction. Which of the following is the most appropriate combination of surgical procedures?

Explanation

Stage IIb posterior tibial tendon dysfunction features significant forefoot abduction (talonavicular uncoverage). Optimal correction requires an FDL transfer, a medializing calcaneal osteotomy (for hindfoot valgus), and a lateral column lengthening to correct the forefoot abduction.

Question 38

A 40-year-old construction worker falls from a ladder and sustains an isolated tongue-type calcaneus fracture. Clinical examination reveals severe posterior skin tenting and blanching with impending tissue necrosis.

What is the most urgent step in management?

Explanation

Tongue-type calcaneus fractures can exert direct pressure on the thin posterior skin, rapidly leading to full-thickness necrosis. Urgent reduction and percutaneous fixation are required to relieve tension on the soft tissues.

Question 39

A 60-year-old patient with poorly controlled type 2 diabetes presents with a unilaterally swollen, red, and warm foot without any open ulceration or history of trauma. Radiographs reveal fragmentation and periarticular debris around the tarsometatarsal joints.

What is the gold standard initial management?

Explanation

The patient is presenting with acute Eichenholtz stage I (fragmentation) Charcot neuroarthropathy. The gold standard initial treatment to prevent progressive collapse is immobilization in a total contact cast with strict non-weight-bearing.

Question 40

A 22-year-old alpine skier reports a painful "snapping" sensation behind his lateral malleolus during a run. Examination reveals swelling and tenderness posterior to the lateral malleolus, with visible subluxation of tendons upon resisted foot eversion. Which retinacular structure is most likely disrupted?

Explanation

Peroneal tendon subluxation or dislocation is typically caused by a sudden force of dorsiflexion and inversion, leading to avulsion or disruption of the superior peroneal retinaculum from the fibula.

Question 41

A 45-year-old woman complains of burning pain in the third web space of her foot, which radiates into her toes. A "click" is palpated when compressing the metatarsal heads together (Mulder's sign). She has failed conservative management. When proceeding with surgical excision, what is the primary advantage of a dorsal approach over a plantar approach?

Explanation

The primary advantage of the dorsal approach for excising a Morton's neuroma is avoiding a plantar incision, which can result in a painful, functionally limiting plantar scar on a weight-bearing surface.

Question 42

A 21-year-old collegiate basketball player sustains a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal (Zone 2) during practice. To optimize his return to play and minimize the risk of nonunion, what is the most appropriate management strategy?

Explanation

Acute Jones fractures (Zone 2) in elite or high-demand athletes are best treated with intramedullary screw fixation. This provides faster clinical healing, lower nonunion rates, and quicker return to play compared to conservative cast immobilization.

Question 43

A 30-year-old runner presents with deep, aching ankle pain 6 months after a severe ankle sprain. MRI confirms an osteochondral lesion on the posteromedial aspect of the talar dome. Based on classic descriptions of injury mechanics, this specific lesion is most commonly caused by which of the following mechanisms?

Explanation

Posteromedial osteochondral defects (OCDs) of the talus are classically caused by an inversion injury while the ankle is in plantarflexion. Anterolateral lesions are typically associated with inversion and dorsiflexion.

Question 44

A professional American football player sustains a severe hyperextension injury to his great toe. MRI demonstrates a complete rupture of the plantar plate from the base of the proximal phalanx, with dorsal subluxation of the MTP joint. What grade is this injury, and what is the standard recommended treatment for an elite athlete?

Explanation

A complete tear of the plantar plate complex with MTP joint instability constitutes a Grade 3 turf toe injury. In high-demand professional athletes, operative repair is frequently recommended to restore push-off strength and joint stability.

Question 45

A patient presents with burning and tingling on the plantar aspect of the foot, which worsens at night. Tinel's sign is positive over the posteromedial ankle. Tarsal tunnel syndrome is suspected. This syndrome is caused by entrapment of which nerve beneath which anatomic structure?

Explanation

Tarsal tunnel syndrome is a compressive neuropathy of the posterior tibial nerve (or its branches) as it passes through the tarsal tunnel, which is roofed by the flexor retinaculum posterior to the medial malleolus.

Question 46

A 14-year-old boy presents with bilateral cavovarus feet. A Coleman block test is performed by placing his heel and lateral border of the foot on a block, allowing the first metatarsal to hang free. Upon doing so, his hindfoot varus corrects to neutral. What does this test result indicate regarding his deformity?

Explanation

The Coleman block test evaluates hindfoot flexibility. If a hindfoot varus corrects to neutral when the plantarflexed first ray is allowed to hang free, it indicates the varus is secondary (flexible) and driven by the forefoot deformity.

Question 47

A 68-year-old man with end-stage post-traumatic ankle arthritis is discussing surgical options with his orthopedic surgeon. He is considering a total ankle arthroplasty (TAA) versus an ankle arthrodesis. Which of the following conditions is considered an absolute contraindication to performing a total ankle arthroplasty?

Explanation

Charcot neuroarthropathy, active infection, absent leg sensation, and avascular necrosis of the talus (>50%) are absolute contraindications to total ankle arthroplasty due to unacceptably high rates of failure.

Question 48

A 22-year-old football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs demonstrate a 2 mm diastasis between the base of the first and second metatarsals, with a 'fleck sign' present. What is the most appropriate management?

Explanation

The presence of a 'fleck sign' (avulsion of the Lisfranc ligament from the base of the 2nd metatarsal) and diastasis greater than 2 mm indicates an unstable Lisfranc injury. Operative management with ORIF or primary arthrodesis is required to restore stable midfoot anatomy.

Question 49

A 22-year-old collegiate football player sustains a high-energy axial load injury to his plantarflexed foot. Weight-bearing radiographs and MRI confirm a purely ligamentous Lisfranc injury with 3 mm of widening between the medial and middle cuneiforms. What is the most appropriate surgical management to minimize the risk of long-term disability and reoperation?

Explanation

Recent literature demonstrates that primary arthrodesis yields superior functional outcomes and a lower reoperation rate compared to ORIF for purely ligamentous Lisfranc injuries. ORIF is typically reserved for injuries with significant bony fracture involvement.

Question 50

A 35-year-old man sustains a Hawkins Type III talar neck fracture following a motor vehicle collision. Which of the following blood vessels, which provides the dominant blood supply to the talar body, is most likely disrupted in this injury?

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, provides the dominant blood supply to the talar body. It is highly susceptible to disruption in displaced talar neck fractures, leading to a high risk of avascular necrosis.

Question 51

A 45-year-old woman presents with a symptomatic hallux valgus deformity. Clinical examination reveals profound hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate to address both the deformity and the underlying pathomechanics?

Explanation

The modified Lapidus procedure (first TMT arthrodesis) is the procedure of choice for moderate to severe hallux valgus associated with first ray hypermobility. It stabilizes the medial column and effectively corrects the intermetatarsal angle.

Question 52

A 28-year-old aggressive skier experiences a sudden "pop" behind her lateral malleolus while aggressively edging. She now reports a painful snapping sensation over the lateral ankle with active dorsiflexion and eversion. Disruption of which of the following structures is the primary cause of this condition?

Explanation

The patient is presenting with peroneal tendon subluxation, which is caused by a tear or avulsion of the superior peroneal retinaculum (SPR) from the lateral malleolus. Surgical repair with or without groove deepening is often required for active individuals.

Question 53

A 55-year-old woman presents with progressive medial ankle pain and a new-onset flatfoot deformity. She is unable to perform a single-limb heel rise on the affected side, but her hindfoot remains passively correctable to neutral. What is the most appropriate surgical treatment?

Explanation

The patient has Stage II adult-acquired flatfoot deformity (flexible, unable to perform single-heel rise). The gold standard surgical treatment consists of an FDL tendon transfer to substitute for the incompetent posterior tibial tendon, combined with a medial displacement calcaneal osteotomy to correct hindfoot valgus.

Question 54

An 18-year-old man with Charcot-Marie-Tooth disease presents with bilateral progressive cavovarus foot deformities. A Coleman block test demonstrates that the hindfoot varus is fully correctable. Which of the following muscle imbalances is the primary driver of the plantarflexed first ray in this patient?

Explanation

In Charcot-Marie-Tooth disease, the typical cavovarus deformity is driven by the relatively preserved peroneus longus overpowering the weak tibialis anterior, causing a plantarflexed first ray. The Coleman block test confirms that the hindfoot varus is flexible and secondary to this forefoot driven deformity.

Question 55

A 40-year-old man presents with chronic lateral heel and ankle pain one year after being treated non-operatively for a joint-depressed calcaneus fracture. Examination reveals tenderness below the lateral malleolus and an inability to accommodate uneven terrain. Impingement of which of the following structures is most likely contributing to his pain?

Explanation

Non-operative management of a displaced calcaneus fracture can lead to malunion with lateral wall blow-out. This results in subfibular impingement of the peroneal tendons and the sural nerve, causing chronic lateral pain.

Question 56

A 21-year-old Division I basketball player sustains a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal. Given his athletic status, what is the most appropriate definitive management to ensure the fastest return to play and lowest nonunion risk?

Explanation

Jones fractures (metaphyseal-diaphyseal junction) have a high propensity for delayed union or nonunion due to watershed blood supply. In elite athletes, early intramedullary screw fixation is recommended to decrease nonunion rates and expedite return to play.

Question 57

A professional American football lineman sustains a severe hyperextension injury to his first metatarsophalangeal (MTP) joint. MRI shows a complete disruption of the plantar plate with 5 mm proximal retraction of the sesamoids. What is the most appropriate management?

Explanation

This is a Grade 3 turf toe injury, characterized by a complete capsuloligamentous tear and proximal migration of the sesamoids. Surgical repair is indicated in high-level athletes to restore push-off strength and prevent chronic instability or deformity.

Question 58

A 50-year-old man undergoes surgical debridement for chronic, refractory insertional Achilles tendinopathy with a prominent Haglund's deformity. Intraoperatively, extensive calcifications are removed, resulting in detachment of 60% of the Achilles tendon insertion. What is the most appropriate next step in the procedure?

Explanation

When debridement of insertional Achilles tendinopathy requires detachment of more than 50% of the tendon footprint, augmentation with a Flexor Hallucis Longus (FHL) transfer is recommended to provide vascularity and biomechanical strength.

Question 59

During a pronation-external rotation (PER) injury of the ankle, the distal tibiofibular syndesmosis is subjected to significant stress. Which of the following syndesmotic ligaments is typically the first to rupture in this sequence?

Explanation

In external rotation injuries of the ankle involving the syndesmosis, the anterior inferior tibiofibular ligament (AITFL) is typically the first structure to fail, followed by the interosseous ligament and finally the posterior inferior tibiofibular ligament (PITFL).

Question 60

A 60-year-old man presents with dorsal midfoot pain during push-off. Radiographs reveal a dorsal osteophyte at the first metatarsophalangeal (MTP) joint, mild dorsal joint space narrowing, but preservation of the plantar articular cartilage (Coughlin and Shurnas Grade 2). He has failed conservative management. What is the most appropriate surgical intervention?

Explanation

For early-to-mid stage hallux rigidus (Grades 1 and 2) where the plantar cartilage is preserved and pain is primarily at the extremes of dorsiflexion, a cheilectomy (excision of the dorsal osteophyte and dorsal one-third of the metatarsal head) is the procedure of choice.

Question 61

A 25-year-old woman complains of deep, aching anterior ankle pain 8 months after a severe ankle sprain. MRI demonstrates an intact lateral ligament complex but reveals a 1.1 cm x 1.1 cm osteochondral lesion on the anterolateral talar dome with no subchondral cyst. What is the most appropriate first-line surgical treatment?

Explanation

Arthroscopic bone marrow stimulation (microfracture) is the primary surgical treatment for symptomatic, small-to-medium (< 1.5 cm diameter) osteochondral lesions of the talus. OATS or allografts are reserved for larger lesions, cystic lesions, or revision surgery.

Question 62

A 22-year-old track athlete presents with an 8-week history of vague, ill-defined midfoot pain that worsens with sprinting. A CT scan confirms a non-displaced stress fracture of the tarsal navicular. The high risk of delayed union or nonunion of this fracture is primarily due to relative avascularity in which region of the navicular?

Explanation

The tarsal navicular receives its blood supply from branches of the dorsalis pedis and medial plantar arteries, which form a rich network medially and laterally. This creates a watershed, relatively avascular zone in the central third, making stress fractures here prone to nonunion.

Question 63

A 55-year-old patient with poorly controlled type 2 diabetes presents with a unilaterally swollen, erythematous, and warm foot. There are no skin breaks or ulcers, and inflammatory markers are normal. Radiographs demonstrate fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints. What is the most appropriate immediate management?

Explanation

The presentation is classic for acute Eichenholtz Stage I Charcot arthropathy (fragmentation stage). The mainstay of initial treatment to prevent progressive deformity is rigid immobilization, typically with a total contact cast, and strict non-weight-bearing.

Question 64

A 34-year-old man sustains a displaced talar neck fracture. At 8 weeks postoperatively, a plain AP radiograph of the ankle demonstrates subchondral lucency in the dome of the talus. What does this radiographic finding indicate?

Explanation

This describes the Hawkins sign, which is subchondral osteopenia of the talar dome. It indicates that the talar body has sufficient blood supply to undergo resorption, making avascular necrosis highly unlikely.

Question 65

During the surgical reconstruction of a severe Lisfranc injury, anatomic restoration of the primary Lisfranc ligament is essential. What are the correct anatomical attachments of this ligament?

Explanation

The primary Lisfranc ligament is a strong interosseous ligament that runs from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal.

Question 66

A 45-year-old woman presents with severe hallux valgus. Clinical examination reveals hypermobility of the first tarsometatarsal (TMT) joint. Radiographs show an intermetatarsal angle (IMA) of 19 degrees and a hallux valgus angle (HVA) of 45 degrees. Which of the following surgical procedures is most appropriate?

Explanation

In patients with severe hallux valgus (IMA > 15 degrees) and first TMT hypermobility, a first TMT arthrodesis (Lapidus procedure) provides powerful correction and stabilizes the medial column.

Question 67

A 55-year-old woman presents with a flexible flatfoot deformity, marked forefoot abduction, and an inability to perform a single-leg heel raise. Radiographs demonstrate more than 40% uncoverage of the talar head. What is the most appropriate surgical management for this Stage IIb posterior tibial tendon dysfunction?

Explanation

Stage IIb PTTD is characterized by a flexible deformity with significant forefoot abduction. Treatment requires an FDL transfer, a medialuating calcaneal osteotomy for valgus, and a lateral column lengthening (Evans osteotomy) to correct the forefoot abduction.

Question 68

A 22-year-old man with Charcot-Marie-Tooth disease presents with a rigid cavovarus foot deformity. A Coleman block test demonstrates that the hindfoot varus corrects to neutral when the first ray is allowed to drop off the block. Which of the following describes the primary deforming force in this condition?

Explanation

In Charcot-Marie-Tooth disease, the cavovarus deformity is primarily driven by the peroneus longus overpowering a weak tibialis anterior, causing plantarflexion of the first ray and secondary hindfoot varus.

Question 69

An 18-year-old collegiate football player sustains an acute hyperextension injury to his great toe. MRI confirms a complete tear of the plantar plate at the first metatarsophalangeal joint. What is the most appropriate management for this athlete?

Explanation

A complete (Grade 3) tear of the plantar plate (Turf Toe) in an elite athlete requires surgical repair to restore push-off strength and joint stability.

Question 70

A 21-year-old professional basketball player sustains a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal. Which of the following anatomical factors most directly contributes to the high risk of nonunion in this specific fracture pattern?

Explanation

A Jones fracture occurs at the metaphyseal-diaphyseal junction (Zone 2), which is a vascular watershed area supplied poorly by both intraosseous and extraosseous vessels, leading to higher rates of nonunion.

Question 71

A 28-year-old man presents with deep ankle pain after an inversion injury. MRI reveals a cup-shaped osteochondral lesion on the posteromedial aspect of the talar dome. What is the classic mechanism of injury that produces this specific lesion?

Explanation

Posteromedial osteochondral defects of the talus are classically deep, cup-shaped, and caused by inversion and plantarflexion forces. Anterolateral lesions are shallow and caused by inversion and dorsiflexion.

Question 72

A 55-year-old diabetic patient presents with a severely swollen, erythematous, and warm foot with no history of trauma. Radiographs reveal periarticular debris, joint subluxation, and fragmentation of the midfoot. Which of the following is the most appropriate initial management?

Explanation

This patient has acute Eichenholtz Stage I Charcot arthropathy. The gold standard initial treatment to prevent further deformity while the acute inflammatory phase resolves is total contact casting.

Question 73

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

Explanation

Charcot neuroarthropathy, active infection, severe avascular necrosis of the talus, and profound peripheral neuropathy are absolute contraindications for total ankle arthroplasty due to high failure rates.

Question 74

A 26-year-old runner complains of posterolateral ankle pain and a snapping sensation behind the lateral malleolus. Physical exam demonstrates subluxation of the peroneal tendons with resisted eversion. This condition is most directly associated with incompetence of which of the following structures?

Explanation

Peroneal tendon subluxation is caused by an injury or incompetence of the superior peroneal retinaculum (SPR), often requiring surgical deepening of the fibular groove and SPR repair.

Question 75

A 13-year-old boy sustains a Salter-Harris III fracture of the anterolateral distal tibia. The avulsion of this fragment is caused by the pull of which of the following ligaments?

Explanation

This describes a juvenile Tillaux fracture. It occurs because the anterolateral distal tibial physis is the last to close, and the fragment is avulsed by the anterior inferior tibiofibular ligament (AITFL).

Question 76

A 20-year-old track athlete presents with chronic midfoot pain. CT scan reveals a non-displaced stress fracture of the tarsal navicular. In which anatomic region of the navicular do these fractures predominantly occur and why?

Explanation

Navicular stress fractures typically occur in the central third of the bone, which represents a vascular watershed area, placing it at a significantly higher risk for delayed union or nonunion.

Question 77

During a percutaneous repair of an acute Achilles tendon rupture, the surgeon must be particularly careful to avoid injury to the sural nerve. At approximately what distance proximal to the calcaneal insertion does the sural nerve cross the lateral border of the Achilles tendon?

Explanation

The sural nerve crosses from the midline to the lateral aspect of the Achilles tendon at an average of 9.8 cm (roughly 10 cm) proximal to the calcaneal insertion, making it highly vulnerable during percutaneous repairs.

Question 78

A 14-year-old girl presents with pain over the dorsal aspect of her forefoot. Radiographs show flattening, sclerosis, and fragmentation of the second metatarsal head. Which of the following is the most likely diagnosis?

Explanation

Freiberg infraction is an avascular necrosis of the metatarsal head, most commonly affecting the second metatarsal in adolescent females.

Question 79

A 40-year-old man falls from a roof and sustains a closed, highly comminuted pilon fracture with severe soft tissue swelling and fracture blisters. What is the most appropriate initial management?

Explanation

In high-energy pilon fractures with severe soft-tissue compromise, a staged approach using initial spanning external fixation allows soft-tissue recovery and significantly reduces the risk of wound dehiscence and deep infection before definitive ORIF.

Question 80

A 35-year-old woman complains of burning pain in her forefoot that radiates into her toes, particularly when wearing tight shoes. Examination reveals a palpable click when compressing the metatarsal heads together. Which intermetatarsal space is most commonly affected in this condition?

Explanation

This patient has a Morton neuroma, which is a perineural fibrosis of the common digital nerve. It most frequently occurs in the third intermetatarsal space.

Question 81

A 28-year-old construction worker undergoes open reduction and internal fixation for a displaced intra-articular calcaneus fracture. Based on the Sanders classification, which utilizes coronal CT imaging, what specific anatomical structure is evaluated to determine the fracture grade?

Explanation

The Sanders classification for intra-articular calcaneal fractures is based strictly on the number of fracture lines extending through the posterior facet as seen on coronal CT images.

Question 82

A patient with refractory plantar fasciitis receives multiple local corticosteroid injections. Six weeks later, he experiences a sudden 'pop' in the arch of his foot followed by flattening of the longitudinal arch. What complication has most likely occurred?

Explanation

Repeated corticosteroid injections for plantar fasciitis carry a significant risk of plantar fascia rupture, which can present acutely with a 'pop' and subsequent medial arch flattening.

Question 83

In evaluating a patient with a suspected syndesmotic injury of the ankle, the 'Cotton test' is performed intraoperatively. Which of the following best describes this test?

Explanation

The Cotton test is an intraoperative stress test where a bone hook is used to apply a lateral pull to the fibula to evaluate the integrity of the tibiofibular syndesmosis.

Question 84

A 22-year-old collegiate football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs demonstrate widening of the 1st and 2nd metatarsal bases without fracture. MRI confirms a purely ligamentous Lisfranc injury. What is the most appropriate definitive management?

Explanation

Purely ligamentous Lisfranc injuries have a high failure rate with ORIF alone. Primary arthrodesis of the medial columns (1st-3rd TMT joints) is associated with better functional outcomes and lower reoperation rates in pure ligamentous injuries compared to ORIF.

Question 85

A 20-year-old elite basketball player experiences acute lateral foot pain during practice. Radiographs reveal a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal.

What is the recommended treatment to minimize the risk of nonunion and allow early return to play?

Explanation

Zone 2 proximal fifth metatarsal fractures (Jones fractures) in elite athletes are best treated with intramedullary screw fixation. This provides the highest union rate and allows for the fastest return to sports compared to nonoperative management.

Question 86

A 55-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. Examination reveals a "too many toes" sign laterally, and she is unable to perform a single-leg heel rise. Her hindfoot valgus deformity is passively correctable. What is the most appropriate surgical treatment?

Explanation

The patient has a Stage II adult acquired flatfoot deformity (flexible). The gold standard surgical management includes a joint-sparing procedure such as flexor digitorum longus (FDL) transfer to the navicular combined with a medial displacement calcaneal osteotomy.

Question 87

Six weeks following open reduction and internal fixation of a Hawkins Type II talar neck fracture, an AP ankle radiograph demonstrates a subchondral radiolucent band in the talar dome. What does this radiographic finding indicate?

Explanation

A subchondral radiolucent band in the talar dome 6 to 8 weeks post-injury is known as the Hawkins sign. It represents subchondral atrophy due to hyperemia, confirming that the vascular supply to the talar body is intact.

Question 88

A 28-year-old man with a family history of neuropathy presents with a progressive cavovarus foot deformity. A Coleman block test demonstrates that his hindfoot varus corrects to neutral when the first ray drops off the block. Which of the following is the primary deforming force driving the forefoot deformity?

Explanation

In Charcot-Marie-Tooth disease, the typical muscle imbalance involves a strong peroneus longus outpulling a weak anterior tibialis, causing a rigidly plantarflexed first ray. The Coleman block test showing correction confirms the hindfoot varus is flexible and driven entirely by this forefoot deformity.

Question 89

A 45-year-old roofer falls from a ladder, sustaining a closed, displaced intra-articular calcaneus fracture.

Examination reveals severe swelling with intact skin and fracture blisters. What is the most reliable clinical indicator that the soft tissues are ready for surgical intervention via an extensile lateral approach?

Explanation

The presence of a positive wrinkle sign indicates that soft-tissue swelling has subsided sufficiently to proceed with surgery safely. Operating through severely swollen tissue increases the risk of wound dehiscence and deep infection.

Question 90

A professional running back sustains an injury to his great toe during a tackle, resulting in forced hyperextension of the first metatarsophalangeal (MTP) joint. MRI reveals a complete tear of the plantar plate with retraction of the sesamoids. Which of the following is the most appropriate management?

Explanation

A Grade 3 turf toe injury involves a complete tear of the plantar plate with sesamoid retraction. Surgical repair is indicated in high-level athletes to restore push-off strength and prevent chronic instability.

Question 91

During an open reduction and internal fixation of a Weber C fibula fracture, the surgeon performs a Cotton test to assess the syndesmosis. Which of the following accurately describes this intraoperative assessment?

Explanation

The Cotton test involves applying a direct lateral pull to the fibula using a bone hook under fluoroscopy to evaluate for syndesmotic instability. Widening of the tibiofibular clear space indicates a syndesmotic injury requiring fixation.

Question 92

A 32-year-old woman presents with chronic deep ankle pain following an inversion sprain 2 years ago. MRI demonstrates a 12 mm x 10 mm deep osteochondral lesion on the posteromedial aspect of the talar dome. No cystic changes are noted. What is the best initial surgical intervention if conservative management fails?

Explanation

For symptomatic osteochondral lesions of the talus smaller than 1.5 cm squared (150 mm squared), arthroscopic debridement and bone marrow stimulation (microfracture) is the recommended initial surgical treatment. Larger or highly cystic lesions may require OATS or an allograft.

Question 93

A 48-year-old recreational runner complains of chronic, severe posterior heel pain located directly at the insertion of the Achilles tendon. Radiographs show a prominent Haglund deformity and intratendinous calcification. Conservative measures have failed. Surgical management should include:

Explanation

Insertional Achilles tendinopathy with a Haglund deformity and calcification often requires aggressive open management if conservative care fails. This includes debridement of the diseased tendon, excision of the prominent posteriosuperior calcaneal tuberosity (Haglund excision), and reattachment of the tendon using suture anchors.

Question 94

A 21-year-old track athlete presents with insidious onset, vague midfoot pain that worsens with sprinting. Exam reveals tenderness localized over the dorsal aspect of the navicular (N-spot). Radiographs are negative. MRI shows a linear signal abnormality in the central third of the navicular.

Why is this region particularly prone to nonunion?

Explanation

The central third of the tarsal navicular has a precarious blood supply and is considered an avascular zone. This watershed area makes stress fractures at high risk for delayed union or nonunion.

Question 95

A 25-year-old snowboarder sustains an inversion injury to the ankle. He complains of pain and a snapping sensation over the lateral malleolus. Examination reveals swelling behind the lateral malleolus and subluxation of the peroneal tendons with resisted dorsiflexion and eversion. What is the primary anatomical structure injured in this condition?

Explanation

Peroneal tendon subluxation or dislocation is typically caused by a rupture, avulsion, or attenuation of the superior peroneal retinaculum (SPR). Snowboarding is a classic mechanism due to forced dorsiflexion and forceful inversion.

Question 96

A 52-year-old woman presents with a painful bunion. Weight-bearing radiographs show a hallux valgus angle of 45 degrees, an intermetatarsal angle of 18 degrees, and hypermobility at the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate?

Explanation

A modified Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA > 15 degrees) especially when accompanied by first TMT joint hypermobility. A distal chevron osteotomy would be inadequate for this severe deformity.

Question 97

Which of the following patients with end-stage tibiotalar osteoarthritis is considered the most ideal candidate for a Total Ankle Arthroplasty (TAA)?

Explanation

The ideal candidate for a total ankle arthroplasty is an older, relatively sedentary patient with low physical demands, a well-aligned ankle/hindfoot, and no significant bone loss or neuropathy. Charcot arthropathy, substantial AVN, active infection, and high physical demands are strong contraindications.

AAOS & ABOS Foot & Ankle Board Review MCQs (Set 2): Ankle Fractures, Lisfranc, Diabetic Foot

AAOS Foot & Ankle MCQs (Set 1): Fractures, Deformities & Sports Injuries | Board Prep

Key Takeaway

AAOS Foot & Ankle MCQs (Set 1): Fractures, Deformities & Sports Injuries | Board Prep

Chapter Index