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

Figures 15a and 15b show the radiographs of an 18-year-old mountain biker who came off of a 15-foot ramp and sustained an injury to his ankle. Because the local rural hospital had no orthopaedic surgeon available, he was transported to a Level 1 emergency department 10 hours after his initial injury. Examination reveals that the injury remains closed. Management should consist of

A 47-year-old woman has had medial ankle pain and swelling for the past 3 months. She recalls no specific injury, and casting and nonsteroidal anti-inflammatory drugs have failed to provide relief. Examination reveals a pes planus with heel valgus that is passively correctable. Radiographs show no evidence of arthritis. An MRI scan is shown in Figure 16. What is the most appropriate surgical procedure to alleviate her pain?

A 38-year-old woman has a lesion on her left foot that has increased in size over the past 6 months. The clinical photograph is shown in Figure 17a, and a photomicrograph of the biopsy specimen is shown in Figure 17b. What is the most likely diagnosis?

A 16-year-old boy has had a painful ingrown nail on his great toe for the past 3 months. When initial management consisting of soaking the foot in Epsom salts and trimming the nail failed to provide relief, his family physician recommended 2 weeks of oral antibiotics. His symptoms persist, and he is now seeking a second opinion. A clinical photograph is shown in Figure 18. Management should now consist of

A 28-year-old man has a painful nodule on the plantar aspect of his foot in the midarch. Use of a soft orthosis has failed to provide relief. Examination reveals that the mass is approximately 2 1/2 cm in diameter, firm, and tender to palpation. An MRI scan confirms the presence of a plantar fibroma. Management should now consist of

A child born with myelomeningocele is expected to be an ambulator with bracing. Examination by the consulting orthopaedic surgeon reveals rigid clubfeet in addition to the neurologic issues. Management should consist of

A 42-year-old man has a symptomatic flatfoot deformity and walks with a slight limp after falling off a scaffold 9 months ago. He also reports that he has had difficulty returning to work. Orthotics have failed to provide relief. Current radiographs are shown in Figures 19a and 19b. To relieve his pain and return the patient to work, treatment should consist of

A 16-year-old boy has a symptomatic flatfoot deformity that is causing pain, skin breakdown, and shoe wear problems. Shoe modification and an orthosis have failed to provide relief. Examination reveals hindfoot valgus, talonavicular sag, and forefoot abduction that are all passively correctable. Treatment should consist of

A 48-year-old man has had pain and swelling of the hallux metatarsophalangeal joint for the past 9 months. A rocker bottom stiff-soled shoe has failed to provide relief; however, two cortisone injections have temporarily alleviated his symptoms. The radiographs shown in Figures 20a and 20b reveal diffuse arthritis of the entire hallux metatarsophalangeal joint. What is the most definitive surgical treatment?

During reconstruction of insertional gaps of a chronic Achilles tendon rupture, what tendon provides the most direct route of transfer?

A 27-year-old woman with Down syndrome has a severe bunion with pain and deformity in the left forefoot. Nonsurgical management has failed to provide relief. She does not use any assistive ambulatory devices. A radiograph is shown in Figure 21. Treatment should now consist of

Which of the following is considered the most important factor in eliminating infection in chronic osteomyelitis?

A 35-year-old woman reports worsening pain after undergoing a neurectomy in the third interspace for a Morton's neuroma 12 months ago. She states that the pain is sharp and electrical, worse than before her surgery, and prevents her from participating in her usual work and exercise activities. Use of wider shoes and pads used before her surgery have failed to provide relief. Examination does not reveal any deformity or inflammation. Tenderness along with neuritic pain occurs with compression of the plantar aspect of the foot between the third and fourth metatarsal head area. To most reliably alleviate her pain, management should consist of

What type of brace is shown in Figures 22a and 22b?

A 23-year-old man has pain and a callus beneath the second metatarsal head. Initial management should consist of

Figures 23a and 23b show the radiograph and clinical photograph of a patient who reports a reduced ability to flex the interphalangeal joint of her great toe after undergoing a Chevron-Akin bunionectomy. What is the most likely cause?

A 45-year-old man has persistent hindfoot pain that is aggravated by weight-bearing activities. History reveals that he sustained a calcaneus fracture 2 years ago, and he underwent a subtalar fusion 1 year ago. Examination reveals tenderness in the sinus tarsi and across the transverse tarsal joint. A plain radiograph and a CT scan are shown in Figures 24a and 24b. A technetium Tc 99m bone scan reveals uptake at the subtalar joint and at the transverse tarsal joints. Management should now consist of

A 21-year-old college student reports hearing a pop and has acute pain laterally over the ankle after twisting it during a recreational basketball game. Examination 1 hour after the injury reveals minimal swelling and ecchymosis. The anterior drawer sign is positive. Radiographs reveal no evidence of a fracture. What is the best course of action?

What significant structure is most at risk during a posterior approach of the Achilles tendon near its musculotendinous junction?

Figure 25 shows the clinical photograph of a 48-year-old man who has had a forefoot ulcer for the past 4 months. History reveals that he has had type II diabetes mellitus for the past 10 years. Examination reveals sensory and motor neuropathy, with weak ankle dorsiflexion. The ankle cannot be passively dorsiflexed past a neutral position. Initial management should consist of

An active 36-year-old woman with rheumatoid arthritis has continued forefoot discomfort despite the use of orthotics and shoe wear modifications. A radiograph and a clinical photograph are shown in Figures 26a and 26b. Treatment at this point should consist of

The Keller proximal phalanx resection procedure is most useful for which of the following conditions?

An active 60-year-old man is evaluated 4 years following surgical correction of a hallux valgus deformity. The patient reports that a hallux varus deformity developed rapidly following his initial surgery. Conservative management consisting of wider shoes, toe strapping, and anti-inflammatory drugs has failed to provide relief. Examination reveals a hallux varus deformity with restricted painful motion of the metatarsophalangeal joint and callus formation under the second metatarsal head. What is the next most appropriate step in management?

A newborn has been referred for evaluation of a deformed foot. Prenatal and birth history are unremarkable. Examination reveals a rocker bottom appearance to the foot, and a longitudinal arch cannot be created. A palpable lump is appreciated on the plantar medial surface. What is the best course of action?

Which of the following is considered an inherent problem in using the distal oblique shortening (Weil) metatarsal osteotomy for dorsal metatarsophalangeal subluxation?

A 28-year-old male sustains an unstable syndesmotic injury requiring screw fixation. Which of the following ligaments provides the greatest contribution to the stability of the distal tibiofibular syndesmosis?

A 45-year-old female sustains a closed twisting injury to her right ankle. Radiographs demonstrate a displaced supination-external rotation (SER) IV ankle fracture. During surgical fixation, what is the most critical biomechanical factor in restoring normal tibiotalar contact area and pressures?

A 35-year-old male sustains a trimalleolar ankle fracture. The posterior malleolus fragment involves 15% of the articular surface. Following rigid fixation of the medial and lateral malleoli, intraoperative stress testing reveals persistent syndesmotic instability. What is the most biomechanically stable method to address this?

A 60-year-old diabetic patient undergoes open reduction and internal fixation for a displaced bimalleolar ankle fracture.

What postoperative protocol modification is most strongly recommended for this patient compared to a non-diabetic patient?

A 28-year-old male sustains a high-energy closed tibial pilon fracture with severe fracture blisters and massive soft tissue swelling. What is the most appropriate initial management?

A 30-year-old female presents with an irreducible ankle fracture-dislocation after a skiing accident. Radiographs reveal the proximal fibular fragment is entrapped behind the posterior tubercle of the distal tibia. What is the eponymous name for this specific injury pattern?

A 40-year-old male presents 8 months after non-operative treatment of an ankle fracture. He complains of chronic lateral pain and instability. Radiographs show a healed fibula that is shortened and externally rotated, with a widened medial clear space. What is the most appropriate surgical management?

In a suspected midfoot injury, subtle widening is noted between the 1st and 2nd metatarsal bases.

The critical Lisfranc ligament, responsible for stability in this region, anatomically connects which two structures?

A 35-year-old female sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial cuneiform and 2nd metatarsal. Based on recent prospective randomized trials, what is the recommended surgical management for optimal functional outcomes?

A 19-year-old athlete complains of severe midfoot pain after an axial load was applied to his plantarflexed foot. Non-weight-bearing radiographs in the emergency department are normal. What is the most appropriate next step in diagnosis?

During open reduction and internal fixation of a severe, multi-column Lisfranc fracture-dislocation, what is the universally accepted correct sequence of reduction and fixation?

A 55-year-old male presents with severe midfoot pain and a progressive planovalgus deformity. He was diagnosed with a 'foot sprain' 1 year ago. Radiographs demonstrate advanced degenerative changes at the tarsometatarsal joints with lateral subluxation. What is the most appropriate surgical treatment?

A 58-year-old male with long-standing, poorly controlled diabetes presents with a red, hot, swollen foot. He has bounding pedal pulses and intact skin. Radiographs show early fragmentation and subluxation of the midfoot. What is the most appropriate initial management?

A 62-year-old female with neuropathy presents with a chronic, uninfected plantar forefoot ulcer beneath the 3rd metatarsal head. It is classified as Wagner Grade 1. What intervention has the highest level of evidence for achieving ulcer healing?

A 50-year-old diabetic male has a chronic plantar midfoot ulcer overlying a rocker-bottom deformity. An MRI is ordered to differentiate chronic inactive Charcot osteoarthropathy from osteomyelitis. Which MRI finding is most specific for osteomyelitis rather than Charcot changes alone?

A diabetic patient is being evaluated for a minor forefoot amputation due to a non-healing distal ulcer. Which of the following non-invasive vascular parameters represents the minimum threshold predictive of reliable wound healing?

A 65-year-old diabetic patient has a recurrent uninfected plantar ulcer beneath the 1st metatarsal head despite optimal orthotics. Examination demonstrates 5 degrees of ankle plantarflexion with the knee extended, but 15 degrees of dorsiflexion with the knee flexed. What is the most appropriate surgical adjunct to aid in offloading?

A 52-year-old diabetic male has a stable, rigid midfoot Charcot deformity with a prominent plantar-medial bony bossing. He has developed 3 recurrent, non-infected ulcers over this specific prominence despite custom total contact orthotics. What is the most appropriate surgical management?

A 40-year-old female sustains a pronation-abduction (PAB) ankle fracture. According to the Lauge-Hansen classification system, what represents the first stage (Stage I) of this specific injury mechanism?

Total contact casting (TCC) is considered the gold standard for offloading diabetic plantar foot ulcers. Which of the following is an absolute contraindication to the application of a TCC?

A subtle radiographic finding indicative of a Lisfranc injury is the "fleck sign". This sign represents a bony avulsion of the Lisfranc ligament from which of the following anatomic locations?

A 62-year-old diabetic male has a recurrent, non-healing plantar ulcer under the first metatarsal head despite 12 weeks of total contact casting. Ankle dorsiflexion is -10 degrees with the knee extended and -10 degrees with the knee flexed. Which of the following is the most appropriate surgical treatment to facilitate ulcer healing?

In the surgical management of a trimalleolar ankle fracture, anatomic reduction and internal fixation of the posterior malleolus is most strongly indicated to achieve which of the following biomechanical goals?

A 45-year-old construction worker sustains a purely ligamentous Lisfranc injury involving the 1st, 2nd, and 3rd tarsometatarsal (TMT) joints. What is the most appropriate definitive management?

A 55-year-old female with poorly controlled type 2 diabetes presents with a red, hot, swollen left foot. Radiographs show soft tissue swelling and mild osteopenia but no fractures. MRI shows diffuse marrow edema without focal fluid collections. Her ESR and CRP are normal. What is the most appropriate initial management?

Which of the following radiographic parameters is the most accurate and reliable indicator of a syndesmotic injury on standard weight-bearing ankle radiographs?

A 28-year-old male sustains a twisting injury to his foot. Radiographs demonstrate a small bony avulsion fragment in the space between the bases of the first and second metatarsals. This fragment represents an avulsion of a structure that originates from which of the following bones?

Which of the following magnetic resonance imaging (MRI) findings is the most sensitive and specific for distinguishing osteomyelitis from acute Charcot neuroarthropathy in the diabetic foot?

According to the Lauge-Hansen classification, a Supination-Adduction stage II ankle fracture typically presents with which of the following distinct fracture patterns?

A 65-year-old patient with severe peripheral neuropathy and diabetes sustains a bimalleolar ankle fracture. Which surgical strategy is most appropriate to minimize the risk of catastrophic fixation failure and secondary Charcot arthropathy?

A 32-year-old athlete complains of persistent midfoot pain after a fall. Non-weight bearing radiographs in the emergency department appear normal. What is the next best step to evaluate for a subtle Lisfranc injury?

A patient requires a Syme amputation for a severe diabetic forefoot infection. Which of the following technical steps is absolutely essential for a successful outcome and a durable, weight-bearing stump?

A 40-year-old sustains an ankle injury. Radiographs reveal a widened medial clear space and a short oblique fracture of the fibula 6 cm proximal to the joint line. According to Lauge-Hansen, what was the first structure injured in this sequence?

A 58-year-old diabetic male presents with a deep plantar ulcer extending to the joint capsule, but with no bone involvement, no abscess, and no gangrene. According to the Wagner classification, what grade is this ulcer?

A patient presents with a severe ankle injury where the proximal fibular fragment is entrapped behind the posterior tubercle of the tibia, rendering closed reduction impossible. Which mechanism is primarily responsible for this specific injury pattern (Bosworth fracture-dislocation)?

The primary osseous stability of the midfoot is provided by the interlocking 'keystone' configuration of the tarsometatarsal joints. Which anatomical structure forms this critical keystone?

A 60-year-old diabetic patient presents with a chronic, rigid, 'rocker-bottom' foot deformity (Eichenholtz Stage III) and a recurrent midfoot plantar ulcer under the cuboid. Nonoperative management with a CROW boot has failed multiple times. What is the most appropriate surgical intervention?

The 'logsplitter' injury of the ankle is best described by which of the following pathomechanical processes?

A 35-year-old male is 2 years out from an open reduction and internal fixation of a severe Lisfranc injury. He now complains of severe, localized midfoot pain with weight-bearing. Radiographs show advanced degenerative changes at the 2nd and 3rd TMT joints. Management should consist of:

A 50-year-old diabetic woman has severe flexible claw toe deformities and recurrent distal tip ulcerations on digits 2-4. She has palpable pulses and a normal ABI. What is the most appropriate prophylactic surgical procedure to heal the ulcers and prevent recurrence?

A 65-year-old poorly controlled diabetic patient sustains a closed, displaced bimalleolar equivalent ankle fracture. What is the most appropriate surgical strategy compared to a non-diabetic patient?

Which of the following accurately describes the primary attachment sites of the Lisfranc ligament?

A 30-year-old male sustains a purely ligamentous Lisfranc injury. Weight-bearing radiographs demonstrate 4 mm of diastasis between the first and second metatarsal bases without fracture. Which of the following is the most appropriate definitive management?

A 55-year-old diabetic patient presents with a swollen, erythematous, and warm right foot without an open ulcer. Radiographs show fragmentation and subluxation of the midfoot. ESR and WBC are normal. What is the most appropriate initial management?

In the operative management of a trimalleolar ankle fracture, traditional guidelines indicate fixation of the posterior malleolus if the fragment involves what minimum percentage of the articular surface?

A 60-year-old diabetic male has a recurrent neuropathic ulcer under the first metatarsal head. He has a rigid equinus deformity with limited ankle dorsiflexion. What is the best surgical intervention to prevent recurrence after ulcer healing?

A 25-year-old male sustains an ankle injury. Radiographs reveal a fracture-dislocation of the ankle. During closed reduction in the emergency department, the ankle remains irreducible. What is the most likely anatomic block to reduction?

A 62-year-old diabetic patient with a chronic midfoot ulcer presents with erythema and swelling. Radiographs show bone destruction. Which of the following is the most reliable imaging modality to differentiate acute Charcot neuroarthropathy from osteomyelitis?

During ORIF of a supination-external rotation type IV ankle fracture, the surgeon suspects a syndesmotic injury. After fixing the fibula, what intraoperative maneuver is best to test the integrity of the syndesmosis?

A patient presents with a painful, swollen midfoot after a fall from a horse. Plain anteroposterior radiographs reveal a small avulsion fracture in the space between the base of the first and second metatarsals. What is this radiographic finding called and what does it signify?

A patient undergoes a transmetatarsal amputation (TMA) for a gangrenous diabetic foot infection. Post-operatively, the patient is at highest risk for developing which of the following foot deformities?

A 40-year-old female sustains an ankle fracture. Radiographs show a transverse fracture of the lateral malleolus at the level of the joint line and a vertical fracture of the medial malleolus. Which Lauge-Hansen classification best describes this injury pattern?

Regarding lower extremity amputations in diabetic patients, which level of amputation requires the least increase in energy expenditure for ambulation compared to normal gait?

A 35-year-old patient presents with chronic lateral ankle pain 2 years after nonoperative treatment of an ankle fracture. Radiographs reveal a malunion with lateral talar shift. Disruption of which radiographic line on the AP view is the most sensitive indicator of fibular shortening?

A 28-year-old male sustains a severe crush injury to his midfoot. Radiographs show a divergent Lisfranc fracture-dislocation with significant comminution of the cuboid (nutcracker fracture). When performing ORIF, what is the primary goal of managing the lateral column (4th and 5th TMT joints)?

A 35-year-old construction worker undergoes open reduction and internal fixation for a highly comminuted bimalleolar equivalent ankle fracture with syndesmotic disruption. Intraoperatively, the syndesmosis is reduced and stabilized with two trans-syndesmotic screws. What is the most accurate imaging modality to assess the accuracy of the syndesmotic reduction postoperatively?

A 24-year-old collegiate football player presents with severe midfoot pain after an axial loading injury to a plantar-flexed foot. Non-weight-bearing radiographs in the emergency department show no fractures or malalignment. What is the most appropriate next step in diagnosis?

A 55-year-old poorly controlled diabetic patient presents with a red, hot, and swollen left foot. Radiographs are negative for fracture or overt destruction. Which of the following clinical findings best differentiates acute Charcot neuroarthropathy from a deep infection?

Current orthopedic literature suggests that direct open reduction and internal fixation of a posterior malleolus fracture fragment, as opposed to percutaneous AP screw fixation or nonoperative management, offers which of the following distinct biomechanical advantages?

A 30-year-old recreational athlete sustains a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal (TMT) joints. What surgical intervention has been shown in recent prospective literature to yield the most favorable functional outcomes and lowest reoperation rate for this specific injury pattern?

A 62-year-old diabetic patient is successfully treated for an infection associated with a Wagner Grade 3 plantar ulcer beneath the first metatarsal head. Clinical examination reveals a severe equinus contracture. Which of the following adjunctive surgical interventions will best prevent recurrence of the ulcer?

A 65-year-old patient with long-standing, poorly controlled diabetes mellitus and peripheral neuropathy sustains an unstable bimalleolar ankle fracture. Which of the following modifications to the standard surgical protocol is most appropriate?

During the surgical exposure and reduction of a Lisfranc fracture-dislocation, an understanding of the local anatomy is critical. The primary Lisfranc ligament connects which of the following two structures?

A 58-year-old diabetic man requires a transmetatarsal amputation for a non-healing, gangrenous toe wound. Preoperative non-invasive vascular testing is ordered to predict wound healing. Which of the following parameters is generally accepted as the minimum threshold indicating adequate perfusion for healing of the amputation?

A 40-year-old male sustains an irreducible fracture-dislocation of the right ankle following a fall from a height. The injury is classified as a Bosworth fracture-dislocation. Which of the following anatomic blocks to reduction is the hallmark of this injury?

A patient with long-standing diabetes presents with a markedly swollen, warm, and erythematous foot. Radiographs demonstrate severe periarticular debris, joint dislocation, and fragmentation of the midfoot bones.

According to the Eichenholtz classification of Charcot neuroarthropathy, this represents which stage?

Based on the classic biomechanical studies by Ramsey and Hamilton regarding ankle congruency following a fracture, 1 mm of lateral talar shift results in approximately what percentage decrease in tibiotalar contact area?

What is the most common mechanism of injury that results in a longitudinal Lisfranc fracture-dislocation in an athletic population?

A Total Contact Cast (TCC) is considered the gold standard for offloading plantar diabetic foot ulcers. What is its primary biomechanical mechanism of action in promoting ulcer healing?

A diabetic patient presents with a midfoot ulcer and deep soft tissue swelling. Which of the following MRI findings is most indicative of osteomyelitis rather than acute Charcot neuroarthropathy?

During the operative treatment of a complex ankle fracture, an avulsed bony fragment is identified attached to the anterior inferior tibiofibular ligament (AITFL). If this fragment originated from the tibia, it is anatomically referred to as the:

According to the Lauge-Hansen classification system, what is the sequence of injury in a Pronation-Abduction (PA) Stage III ankle fracture?