ABOS Foot & Ankle MCQs (Set 3): Trauma & Pathology Questions

Question 1

A 47-year-old woman underwent a distal chevron bunionectomy 2 months ago. Her postoperative recovery had been uneventful until 1 week ago. She now has new onset pain and dorsal swelling in the area of the third metatarsal. A radiograph is shown in Figure 27. What is the most likely diagnosis?

Explanation

Based on findings of a sudden increase in pain with associated swelling, the most likely diagnosis is a stress fracture. The initial radiographic findings usually will be negative. Morton's neuroma and transfer metatarsalgia are not associated with swelling. Metatarsophalangeal synovitis usually involves the second metatarsophalangeal joint. Freiberg's infraction is seen clearly on a radiograph.

Question 2

A 32-year-old runner has pain in the medial arch that radiates into the medial three toes. He reports the presence of pain only when running. Examination reveals normal hindfoot alignment. There is a weakly positive Tinel's sign over the posterior tibial nerve. Tenderness is noted with palpation over the plantar medial area in the vicinity of the navicular tuberosity. What is the most likely diagnosis?

Explanation

The examination findings reveal that there is specific involvement of the medial plantar nerve by the distribution of the pain medially. The symptoms exclude the possibility of plantar fasciitis and anterior tibial tendinitis. Sinus tarsi syndrome would produce anterolateral symptoms rather than medial symptoms. Rask MR: Medial plantar neurapraxia (jogger's foot): Report of three cases. Clin Orthop 1978;134:193-195. Murphy PC, Baxter DE: Nerve entrapment of the foot and ankle in runners. Clin Sports Med 1985;4:753-763.

Question 3

A 58-year-old woman with rheumatoid arthritis and a severe hindfoot valgus deformity now reports recurrent lateral ankle pain. Examination reveals pain over the fibula and sinus tarsi, with a valgus hindfoot that is passively correctable. Despite the use of an ankle-foot orthosis, this is the second time this problem has occurred. Radiographs and a clinical photograph are shown in Figures 28a through 28c. What is the next most appropriate step in treatment?

Explanation

Excessive hindfoot valgus can lead to abutment between the calcaneus and fibula. This valgus force can lead to a stress fracture of the distal fibula. Surgery may be required if an insufficiency fracture recurs despite orthotic management. Of the choices listed, a subtalar arthrodesis is most likely to achieve rebalancing of the foot at the level of the deformity. Stephens HM, Walling AK, Solmen JD, Tankson CJ: Subtalar repositional arthrodesis for adult acquired flatfoot. Clin Orthop 1999;365:69-73

Question 4

A 7-year-old girl reports foot pain and has difficulty ambulating. History reveals that she fell off a scooter 1 week ago, and there is possible exposure to a tick bite. A radiograph is shown in Figure 29. What is the best course of action?

Explanation

The child has Kohler's disease. This is a self-limiting osteochondritis of the navicular. It is treated symptomatically with initial cast immobilization for 6 to 12 weeks, followed possibly by orthotic management. Findings shown in the radiograph usually will normalize within 1 year, and there are no long-term sequelae. Borges JL, Guille JT, Bowen JR: Kohler's bone disease of the tarsal navicular. J Pediatr Orthop 1995;15:596-598.

Question 5

A 45-year-old man has severe pain in both feet after his boots become wet while hunting. Examination 3 hours after the onset of symptoms reveals that his feet are cold to touch and the skin appears blanched. Management should consist of

Explanation

The patient has frostbite involving both feet. Rapid rewarming in a protected environment is the initial treatment. A footbath with water at 104.0 degrees F to 107.6 degrees F (40 degrees C to 42 degrees C) is ideal. This facilitates a uniform rewarming of the involved tissue. The other choices are less than ideal. Appliances such as heating pads provide uneven heating and may actually burn the skin. Pinzur MS: Frostbite: Prevention and treatment. Biomechanics 1997;4:14-21.

Question 6

An 83-year-old woman with diabetes mellitus has a history of recurrent infection over the medial aspect of her great toe and has had a painless bunion for the past 45 years. Shoe wear modifications have failed to provide relief. Pedal pulses are palpable. Figures 30a and 30b show the clinical photograph and radiograph. Management should now consist of

Explanation

The presence of recurrent breakdown over the medial eminence despite shoe wear modifications is an indication for surgery. A number of factors must be considered when deciding on an appropriate course of treatment. These include age, activity level, joint congruency, joint degeneration, and the patient's symptoms and expectations. The indications for a simple bunionectomy are rather limited. In this patient, the goal of surgery is to alleviate the recurrent infection by removal of a large medial eminence. Because the bunion is painless and long-standing, it does not warrant treatment. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 123-134.

Question 7

Varus deformity after talar fractures is often seen due to collapse of the medial cortex. What artery supplies this portion of the talus?

Explanation

The artery of the tarsal canal is a branch of the posterior tibial artery. Among the branches of the artery of the tarsal canal is the deltoid artery. This arterial complex supplies the medial one third of the talar body. Disruption of this artery may lead to osteonecrosis of the medial body and subsequent collapse into varus. This is most commonly seen with talar body fractures but may be seen in Hawkins type 3 talar neck fractures. The artery of the tarsal sinus arises from the dorsalis pedis, lateral malleolar, and perforating peroneal arteries. The peroneal artery anastomoses with the calcaneal branches of the posterior tibial artery to form a plexus of vessels that supplies the posterior tubercle of the talus. Disruption of this artery would not result in collapse of the medial body, and thus would not lead to a varus deformity. Halibruton RA, Sullivan CR, Kelly PJ, et al: The extra-osseous and intra-osseous blood supply of the talus. J Bone Joint Surg Am 1958;40:1115.

Question 8

Which of the following is considered the most useful screening method for the evaluation of protective foot sensation in a patient with diabetes mellitus?

Explanation

Patients with diabetes mellitus should be screened for the presence of protective foot sensation. In the absence of protective foot sensation, patients are at increased risk for the development of neuropathic ulcerations and neuropathic arthropathy. The most reliable screening tool for the presence of protective sensation is the ability to feel the 5.07 Semmes-Weinstein monofilament. Pinzur MS, Shields N, Trepman E, Dawson P, Evans A: Current practice patterns in the treatment of Charcot foot. Foot Ankle Int 2000;21:916-920.

Question 9

A 17-year-old high school track athlete has had progressive midfoot pain for the past 3 weeks that prevents him from running. Examination reveals pain over the tarsal navicular. Radiographs are normal, but a CT scan reveals a nondisplaced sagittally oriented fracture line. Management should consist of

Explanation

The patient has a nondisplaced stress fracture of the tarsal navicular. Weight bearing is associated with a high rate of nonunion; therefore, management should consist of immobilization and no weight bearing for 8 weeks. Delayed union or nonunion is treated by excision of sclerotic fracture margins and bone grafting, with or without internal fixation. Generally, CT should be repeated to document healing before permitting a return to sports. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 597-612.

Question 10

A construction worker sustained a comminuted calcaneus fracture 2 years ago. He now reports progressive hindfoot pain with the recent onset of anterior ankle pain. A lateral hindfoot radiograph is shown in Figure 31. Treatment should consist of

Explanation

The patient has subtalar arthrosis, a loss of heel height with anterior ankle impingement. The mechanics of the ankle are impaired, and dorsiflexion is painful and limited. The talar declination angle is measured by drawing a line through the longitudinal axis of the talus and the plane of support of the foot on a weight-bearing lateral radiograph. Anterior impingement is suggested with any value below 20°. By performing a distraction arthrodesis through the subtalar joint, the normal declination of the talus is reestablished, eliminating the anterior ankle impingement. Tibiotalocalaneal fusion would be inappropriate because the patient does not have arthritic symptoms in the ankle. Ankle arthroscopy or in situ arthrodesis would not reestablish appropriate ankle mechanics, and the osteophytes would be prone to redevelop. Lateral wall ostectomy may help with impingement at the level of the fibula or the lateral ankle but would provide no benefit to anterior ankle impingement. Carr JB, Hansen ST, Benirschke SK: Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle 1988;9:81-86.

Question 11

What is the most common long-term complication of the fracture shown in Figure 32?

Explanation

The fracture pattern shown in the radiograph involves both a talar neck fracture and a talar body fracture. The body fracture propagates into the subtalar joint, with significant risk for the development of arthritis in that surface even with an anatomic reduction. In addition, Canale and Kelly reported a 25% incidence of malunion of talar neck fractures, with varus angulation occurring most frequently. Of these patients, 50% required a secondary surgical procedure because of the development of degenerative joint disease 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 12

A 62-year-old man has a severe pes planus and pain in the hindfoot. Radiographs show advanced degenerative changes at the talonavicular and subtalar joints with good preservation of the ankle joint. What is the most appropriate surgical procedure to alleviate his pain?

Explanation

Once degenerative changes have occurred, soft-tissue procedures are not indicated. Triple arthrodesis is the treatment of choice for adult-acquired flatfoot. Isolated fusion of the subtalar or talonavicular joint will not be sufficient to correct the problem. Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 269-282.

Question 13

A 46-year-old woman reports pain and a shortened appearance of her toe after undergoing a Keller resection arthroplasty 2 years ago for hallux rigidus. Examination reveals mild swelling and motion limited to 25 degrees at the metatarsophalangeal joint. Radiographs show large dorsal osteophytes on the first metatarsal head, 50% resection of the proximal phalanx, and complete loss of the metatarsophalangeal joint space. Which of the following is considered the most reliable procedure to improve her pain and the appearance of her toe?

Explanation

Because the patient has significant arthritis, arthrodesis is the treatment of choice. Adding a bone graft will prevent further shortening and add length to her toe, resulting in improved cosmesis. A cheilectomy will not alleviate her arthritis pain. The toe is too short for an effective Moberg phalangeal dorsiflexion osteotomy. A Waterman first metatarsal dorsal osteotomy will not address the degenerative joint disease or shortening. Silastic arthroplasty may help, but there is the risk of additional problems with foreign body reaction and a significant risk of failure known to occur with Silastic materials. Myerson MS, Schon LC, McGuigan FX, Oznur A:Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int 2000;21:297-306. 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 252-253.

Question 14

Which of the following is considered the most appropriate shoe modification following transmetatarsal amputation?

Explanation

Most patients who undergo transmetatarsal amputation do not require custom shoe wear or an orthosis above the ankle. A molded toe filler is used to prevent excessive shear that can lead to ulceration. Use of a soft toe filler without stiffening of the sole results in excessive flexibility from the shortened lever arm, which reduces the efficiency of gait. A firm footplate or carbon fiber base adds rigidity to aid in push-off. A rocker bottom also may be added to the shoe. Philbin TM, Leyes M, Sferra JJ, Donley BG: Orthotic and prosthetic devices in partial foot amputations. Foot Ankle Clin 2001;6:215-228.

Question 15

A 35-year-old man has had a mass on the bottom of his foot for the past 6 months. He reports that initially the mass was exquisitely painful but now is minimally tender. Examination reveals a 2.5- x 2.0-cm firm, noncompressible, nonmobile mass contiguous with the plantar fascia in the distal arch. The mass is particularly prominent with passive dorsiflexion of the ankle and toes. What is the best course of action?

Explanation

The history is most consistent with a plantar fibroma. The nodules typically are located within the substance of the plantar aponeurosis. The clinical appearance is usually diagnostic without the need for advanced imaging studies. While the lesion may be prominent and painful to direct palpation, the anatomic location is usually off of the weight-bearing surface. Observation with or without an accommodative orthotic is the treatment of choice. Recurrence is common following attempted excision. Sammarco GJ, Mangone PG: Classification and treatment of plantar fibromatosis. Foot Ankle Int 2000;21:563-569.

Question 16

A 25-year-old woman has significant pain and swelling in her left ankle after falling off her bicycle. Examination reveals that she is neurovascularly intact. Radiographs are shown in Figures 33a through 33c. What is the next most appropriate step in management?

Explanation

The radiographs show a displaced ankle fracture with widening of the syndesmosis. Open reduction and internal fixation is indicated with fixation of the mortise with syndesmotic screws. Wuest TK: Injuries to the distal lower extremity syndesmosis. J Am Acad Orthop Surg 1997;5:172-181.

Question 17

A 55-year-old woman with type I diabetes mellitus has a chronic ulcer over the dorsum of her right foot and reports forefoot pain. Examination reveals 1- x 2-cm nondraining ulcer over the dorsum of the foot. The patient has 1-2+ pain with compression of the foot and ankle. She has a weakly palpable posterior tibial pulse and an absent dorsalis pedis pulse. There is no erythema, cellulitis, or drainage. Radiographs are normal. Which of the following diagnostic studies should be obtained?

Explanation

The presence of a dorsal ulcer in the presence of weak or absent pulses strongly suggests the possibility of arterial insufficiency. The best initial noninvasive study to assess for ischemia is the Doppler arterial study. A determination of the vascular status is of a greater priority than an assessment for infection or neuropathy because of the location and presentation of the ulcer. If ankle pressures are less than 45 mm Hg, there is a high risk that these lesions will not heal without revascularization. Wagner FW Jr: The dysvascular foot: A system for diagnosis and treatment. Foot Ankle 1981;2:64-122.

Question 18

A 57-year-old woman with diabetes mellitus has purulent drainage from a lateral incision after undergoing open reduction and internal fixation of a displaced ankle fracture 10 days ago. Examination reveals moderate erythema and a foul odor coming from the wound. Cultures are obtained. What is the next most appropriate step in management?

Explanation

Early postoperative wound infections after open reduction and internal fixation should be treated with aggressive debridement and maintenance of stability of the fracture. If infection persists following healing of the fracture, the hardware should be removed. Carragee EJ, Csongradi JJ, Bleck EE: Early complications in the operative treatment of ankle fractures: Influence of delay before operation. J Bone Joint Surg Br 1991;73:79-82.

Question 19

A 67-year-old woman has had pain in the area of the metatarsal heads and toes bilaterally for the past 18 months. She describes a diffuse discomfort and a constant burning sensation. She notes that the area feels swollen. Examination reveals that her pulses are normal, and there is no frank swelling or focal tenderness. What is the most likely diagnosis?

Explanation

Patients with peripheral neuropathy will often initially see an orthopaedic surgeon and report symptoms of burning, numb, dead, or wooden feet. A simple diagnostic evaluation with a tuning fork (to test vibratory sensibility) or use of the Semmes-Weinstein monofilaments will help make the diagnosis. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 113-121.

Question 20

A 19-year-old woman has had a painful prominence on the lateral border of her fifth metatarsal head since she was a young girl. Nonsurgical management, including the use of a wide toe box shoe, has failed to provide relief. Examination reveals a callus over the lateral prominence and on the plantar portion as well. A clinical photograph and a radiograph are shown in Figures 34a and 34b. Treatment should consist of

Explanation

The type of deformity described is a type 2 bunionette. There is often a congenital component to this deformity. The bowing of the fifth shaft differentiates a large intermetatarsal angle from a type 3 deformity. A distal chevron osteotomy corrects 1 degree in the intermetatarsal angle for every 1-mm shift. Because of limitations in the width of the fifth metatarsal neck, the allowable shift is generally 3 to 4 mm. This shift will not compensate for the large intermetatarsal angle. The floating osteotomy has a high rate of delayed union/nonunion and a low satisfaction rate. Metatarsal head excision has a high complication rate, including severe shortening, transfer metatarsalgia, stiffness, and pain. A more proximal procedure is necessary to correct the large intermetatarsal angle and the lateral bowing. The osteotomy of choice is a diaphyseal shaft osteotomy. Because this patient has a plantar callosity and a lateral callosity, the osteotomy is angled superiorly to elevate the fifth shaft with the shift, eliminating overload of the plantar metatarsal head and subsequent callus formation. Shereff MJ, Yang QM, Kummer FJ, Frey CC, Greenidge N: Vascular anatomy of the fifth metatarsal. Foot Ankle 1991;11:350-353. Coughlin MJ: Treatment of bunionette deformity with longitudinal diaphyseal osteotomy with distal soft tissue repair. Foot Ankle 1991;11:195-203.

Question 21

A 61-year-old woman has increasing pain in her left great toe. She states that she has had discomfort for years but now has pain with all shoe wear. A radiograph is shown in Figure 35. To provide the most predictable pain-free result, treatment should consist of

Explanation

Because the patient has a hallux valgus with increased intermetatarsal and hallux valgus angles and advanced degenerative arthritis of the joint, arthrodesis of the first metatarsophalangeal joint will provide the most predictable pain-free result. An attempt to correct the bunion with a bunionectomy or osteotomy would most likely fail. The hallux valgus and advanced degenerative changes put the foot beyond the indications for a cheilectomy. Long-term results with silicone arthroplasty have been disappointing. Mann RA: Disorders of the first metatarsophalangeal joint. J Am Acad Orthop Surg 1995;3:34-43.

Question 22

The most favorable outcomes from release of the tarsal tunnel are in patients who have which of the following findings?

Explanation

Numerous causes of tarsal tunnel syndrome have been reported. The most favorable outcomes from release of the tarsal tunnel are in patients who have a space-occupying lesion (eg, ganglion, lipoma, or neurilemoma). While electrodiagnostic studies may be abnormal preoperatively, there is a low correlation between clinical outcome and electromyographic findings. Intrinsic weakness is a late finding in long-standing nerve dysfunction. Beskin JL: Nerve entrapment syndromes of the foot and ankle. J Am Acad Orthop Surg 1997;5:261-269.

Question 23

An active 48-year-old woman has had progressive retrocalcaneal pain for the past 2 years. She reports that an injection into the retrocalcaneal bursa 3 weeks ago provided relief, but she now has swelling and weakness after tripping on the stairs 3 days ago. The Thompson test is positive. A radiograph is shown in Figure 36. What is the next most appropriate step in management?

Explanation

The patient's long-standing symptoms and radiograph indicate a chronic insertional Achilles tendinopathy that has progressed to complete rupture. This situation is best treated with tendon debridement and repair, often requiring supplementation graft from the flexor hallucis longus. MRI could provide additional information on the quality of the Achilles tendon, but neither MRI nor ultrasound is necessary to make a diagnosis or determine the surgical indication. Conservative management will be unpredictable with a chronic degenerative tendon injury. Myerson MS, McGarvey W: Disorders of the Achilles tendon: Insertion and Achilles tendinitis. Instr Course Lect 1999;48:211-218. Wilcox DK, Bohay DR, Anderson JG: Treatment of chronic Achilles tendon disorders with flexor hallucis longus tendon transfer/augmentation. Foot Ankle Int 2000;21:1004-1010.

Question 24

A 47-year-old woman has a right bunion that has been symptomatic despite modifications in shoe wear. She requests surgical correction. An AP radiograph is shown in Figure 37. Treatment should consist of

Explanation

Because the radiograph reveals an intermetatarsal angle of greater than 15 degrees and an incongruent metatarsophalangeal joint, the treatment of choice is a proximal first metatarsal osteotomy with distal soft-tissue realignment. A distal chevron procedure would not correct this degree of deformity. A Keller procedure is reserved for a less active elderly individual. Arthrodesis is appropriate for a patient with advanced arthritis of the metatarsophalangeal joint. The double osteotomy is reserved for the congruent metatarsophalangeal joint with hallux valgus. Coughlin MJ, Carlson RE: Treatment of hallux valgus with an increased distal metatarsal articular angle: Evaluation of double and triple first ray osteotomies. Foot Ankle Int 1999;20:762-770.

Question 25

A 68-year-old woman stepped on a needle while walking barefoot 10 days ago. She is not certain but thinks it is imbedded in her foot, and she notes local tenderness at the puncture site and drainage. Her primary care physician has been treating her with oral antibiotics. A plain radiograph is shown in Figure 38. What is the best course of action?

Explanation

Based on the radiographic findings, the patient has a metallic foreign body in her foot that is consistent with a needle. She has local infection secondary to the continued presence of the foreign body. CT is not necessary to localize the foreign body as it is adequately visualized on the plain radiographs. The infection cannot be adequately treated until the foreign body is removed. Attempted removal of foreign bodies without proper anesthesia and fluoroscopy frequently results in frustration because of the inability to localize the foreign body. Removal in a surgical suite with proper anesthesia and fluoroscopy is the preferred option. Once the foreign body is removed, the local infection will resolve rapidly. Combs AH, Kernek CB, Heck DA: Orthopedic grand rounds: Retained wooden foreign body in the foot detected by computed tomography. Orthopedics 1986;9:1434-1435.

Question 26

A 45-year-old female sustains a purely ligamentous Lisfranc injury with 3 mm of displacement between the medial and middle cuneiforms. She has no significant past medical history. Which surgical treatment has been shown in prospective studies to yield superior functional outcomes and a lower rate of revision compared to traditional open reduction and internal fixation (ORIF)?

Explanation

Prospective randomized trials have demonstrated that primary arthrodesis for purely ligamentous Lisfranc injuries results in superior functional outcomes and lower revision rates compared to traditional ORIF.

Question 27

A 35-year-old male presents with persistent lateral foot pain 18 months after nonoperative management of a displaced intra-articular calcaneus fracture. Examination reveals localized tenderness inferior to the lateral malleolus, swelling, and pain exacerbated by passive foot inversion and active eversion. What is the most likely etiology of his current symptoms?

Explanation

Lateral wall blowout from a conservatively managed calcaneus fracture can cause subfibular impingement of the peroneal tendons, presenting with lateral pain and mechanical symptoms during active eversion.

Question 28

A 21-year-old Division I collegiate basketball player sustains an acute fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal (Zone 2). He desires to return to competition as rapidly and safely as possible. What is the most appropriate management?

Explanation

High-level athletes with acute Jones fractures (Zone 2) are best treated with early intramedullary screw fixation to minimize the high risk of nonunion and expedite return to play.

Question 29

A 30-year-old woman is brought to the emergency department after a high-speed motor vehicle collision. Radiographs demonstrate a Hawkins Type III fracture of the talar neck. What is the approximate reported rate of avascular necrosis (AVN) of the talar body associated with this specific injury pattern?

Explanation

A Hawkins Type III talar neck fracture involves subluxation or dislocation of both the subtalar and tibiotalar joints. Because this disrupts all three major sources of blood supply to the talar body, the AVN risk approaches 80 to 100%.

Question 30

A 55-year-old patient with long-standing, poorly controlled type 2 diabetes presents with a unilaterally red, hot, and swollen right midfoot. There are no open ulcerations. Radiographs reveal acute bone fragmentation, periarticular debris, and joint subluxation at the midfoot. What is the most appropriate initial management?

Explanation

This presentation is classic for Eichenholtz Stage I (Acute/Fragmentation) Charcot neuroarthropathy. The gold standard for initial management in the absence of an open wound or deep infection is immediate offloading with a total contact cast.

Question 31

A 62-year-old woman presents with progressive flattening of her left medial longitudinal arch and medial hindfoot pain. On examination, she is unable to perform a single-leg heel raise, and her hindfoot valgus is passively correctable to neutral. Weight-bearing radiographs show no subtalar or talonavicular osteoarthritis. If conservative measures fail, what is the most appropriate surgical intervention?

Explanation

The patient has Stage II posterior tibial tendon dysfunction (flexible flatfoot without arthritis). Treatment typically requires reconstruction using an FDL tendon transfer to replace the diseased tendon, combined with an MDCO to correct the mechanical hindfoot valgus.

Question 32

A 45-year-old male construction worker complains of dorsal big toe pain with push-off. Radiographs show moderate dorsal osteophytes at the first metatarsophalangeal (MTP) joint, but the plantar joint space remains well preserved. He has failed shoe modifications and NSAIDs. What is the most appropriate surgical option?

Explanation

For early to moderate hallux rigidus (Coughlin and Shurnas Grade 1 or 2) with preserved plantar cartilage and pain primarily with dorsiflexion, a cheilectomy (removal of the dorsal osteophyte and dorsal third of the metatarsal head) is the procedure of choice.

Question 33

A 14-year-old boy presents with a history of recurrent ankle sprains and a rigid, painful flatfoot. A computed tomography (CT) scan confirms an osseous bridge between the calcaneus and the navicular. What is the initial recommended treatment for this condition?

Explanation

Symptomatic tarsal coalitions initially warrant a trial of conservative management, such as a short leg walking cast or orthotics, to relieve secondary peroneal spasm and inflammation before considering surgical resection.

Question 34

A 25-year-old man sustains a foot injury in a motor vehicle collision. He has severe midfoot swelling and plantar ecchymosis. Radiographs reveal widening between the first and second metatarsal bases. The primary stabilizing ligament disrupted in this injury connects which of the following structures?

Explanation

The Lisfranc ligament is the critical primary stabilizer of the midfoot. It originates on the lateral aspect of the medial cuneiform and inserts on the medial aspect of the base of the second metatarsal.

Question 35

A 45-year-old roofer falls 15 feet, sustaining a displaced intra-articular calcaneus fracture. An extensile lateral approach is planned for open reduction and internal fixation. To prevent flap necrosis, the surgeon must preserve the primary blood supply to the corner of this flap. Which artery provides this critical vascularity?

Explanation

The lateral calcaneal artery, a branch of the peroneal artery, provides the primary blood supply to the corner of the standard extensile lateral approach flap. Injury to this artery significantly increases the risk of apical wound necrosis.

Question 36

A 32-year-old man sustains a Hawkins Type III talar neck fracture after a high-energy motorcycle crash. The fracture exhibits displacement of the talar body with dislocation from both the subtalar and tibiotalar joints. What is the approximate rate of avascular necrosis (AVN) of the talar body associated with this specific injury pattern?

Explanation

Hawkins Type III talar neck fractures involve dislocation of the talar body from both the subtalar and tibiotalar joints, disrupting the major blood supplies. The risk of AVN is historically reported to be between 80% and 100%.

Question 37

A 21-year-old elite collegiate basketball player sustains an acute, displaced fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal (Jones fracture). What is the most appropriate management to ensure the fastest return to sport and lowest risk of nonunion?

Explanation

In high-level athletes, an acute Jones fracture (Zone 2) is best treated with intramedullary screw fixation. This provides the most reliable healing and fastest return to play compared to non-operative management, which has a high nonunion rate due to the watershed blood supply.

Question 38

A 24-year-old female runner presents with chronic, deep-seated ankle pain following an inversion sprain 8 months ago. MRI reveals a posteromedial osteochondral lesion of the talus (OCLT). Which of the following best describes the typical characteristics of a posteromedial talar dome lesion compared to an anterolateral lesion?

Explanation

Posteromedial OCLTs are characteristically deeper, cup-shaped, and often present insidiously without a clear history of a single traumatic event. In contrast, anterolateral lesions are typically shallow, wafer-like, and associated with acute trauma.

Question 39

A 19-year-old male track athlete complains of vague dorsal midfoot pain that worsens with running. Radiographs are negative. An MRI confirms a stress fracture involving the central third of the tarsal navicular. The fracture is non-displaced. What is the standard recommended treatment?

Explanation

The central third of the navicular is an avascular watershed area, making stress fractures prone to nonunion. The gold standard for an acute, non-displaced navicular stress fracture is strict non-weight-bearing in a cast for 6 to 8 weeks.

Question 40

A 55-year-old woman presents with a progressive flatfoot deformity. Examination shows a "too many toes" sign, and she is unable to perform a single-leg heel rise on the affected side. The hindfoot remains flexible and passively correctable to neutral. If conservative management fails, which surgical procedure is most appropriate?

Explanation

This patient has Stage II adult acquired flatfoot deformity (posterior tibial tendon dysfunction) characterized by a flexible deformity. The standard surgical treatment involves an FDL transfer combined with a joint-sparing medial displacement calcaneal osteotomy.

Question 41

A 28-year-old downhill skier feels a sudden pop behind the lateral malleolus during a sharp turn. He presents with swelling and point tenderness over the distal fibula. Radiographs show a small longitudinal cortical avulsion fracture off the posterolateral margin of the distal fibula. What is the most likely diagnosis?

Explanation

A "fleck sign" off the posterolateral cortex of the distal fibula indicates an avulsion of the superior peroneal retinaculum. This is pathognomonic for peroneal tendon subluxation or dislocation.

Question 42

A 40-year-old man sustains a severe tibial pilon fracture with massive soft-tissue swelling and clear fracture blisters over the anterior ankle. Initial management consists of a spanning external fixator. What is the most reliable clinical indicator that the soft tissues are ready for definitive open reduction and internal fixation?

Explanation

The "wrinkle sign" indicates that soft-tissue swelling has subsided enough to allow for safe surgical incisions with minimal risk of wound dehiscence or infection. This typically takes 10 to 21 days following a high-energy pilon fracture.

Question 43

A 60-year-old man with long-standing poorly controlled diabetes presents with a unilaterally swollen, red, and warm right foot. He denies trauma. Pedal pulses are bounding. Radiographs demonstrate mild osteopenia but no fractures or dislocations. What is the most appropriate initial management?

Explanation

The clinical presentation is classic for Eichenholtz Stage 0 Charcot arthropathy (inflammation without radiographic destruction). Prompt offloading with a total contact cast is required to prevent progression to bone destruction and deformity.

Question 44

A 48-year-old man complains of pain localized to the dorsal aspect of his right first metatarsophalangeal (MTP) joint, particularly during the push-off phase of walking. Radiographs demonstrate a prominent dorsal osteophyte on the first metatarsal head, but the joint space remains well-preserved. What is the best initial surgical option if non-operative management fails?

Explanation

In early-stage hallux rigidus (Coughlin and Shurnas Grade 1 or 2) where the joint space is preserved but dorsal osteophytes limit dorsiflexion, a cheilectomy (removal of the dorsal bone spur and dorsal 30% of the metatarsal head) is the procedure of choice.

Question 45

A 22-year-old collegiate football player sustains a hyperextension injury to his first MTP joint. MRI confirms a complete tear of the plantar plate with 4 mm of proximal retraction of the sesamoids. What is the most appropriate treatment?

Explanation

This is a Grade 3 turf toe injury. Surgical repair is indicated for Grade 3 injuries demonstrating significant instability, proximal migration of the sesamoids (>3 mm), or an intra-articular sesamoid fracture.

Question 46

A 26-year-old man sustains an external rotation injury to his right ankle. Radiographs show a proximal third fibula fracture (Maisonneuve fracture) and widening of the medial clear space on the AP ankle view. For this specific injury pattern to occur, which of the following structures MUST be disrupted?

Explanation

A Maisonneuve fracture involves a proximal fibular fracture associated with a syndesmotic injury. The force transmission tears the deltoid ligament (or medial malleolus), the anterior inferior tibiofibular ligament, and the interosseous membrane up to the level of the fibular fracture.

Question 47

A 67-year-old woman with end-stage post-traumatic ankle osteoarthritis is considering surgical options. She asks about a total ankle arthroplasty (TAA). Which of the following conditions is an absolute contraindication to performing a TAA?

Explanation

Severe peripheral neuropathy (often associated with diabetes or Charcot arthropathy), active infection, and extensive avascular necrosis of the talus are absolute contraindications for total ankle arthroplasty.

Question 48

A 35-year-old weekend warrior undergoes minimally invasive surgical repair for an acute midsubstance Achilles tendon rupture. Postoperatively, he reports numbness along the lateral aspect of his foot. Which nerve was most likely injured during the procedure?

Explanation

The sural nerve crosses from medial to lateral over the Achilles tendon approximately 10 cm proximal to its insertion. It is the structure most at risk during percutaneous or minimally invasive Achilles repairs.

Question 49

A 25-year-old snowboarder presents with acute lateral ankle pain after a hard landing. He has point tenderness just inferior to the tip of the lateral malleolus. Plain radiographs of the ankle are initially interpreted as normal, but a CT scan is obtained due to high clinical suspicion. What occult fracture is classically associated with this mechanism?

Explanation

Fractures of the lateral process of the talus ("snowboarder's fracture") occur via a combination of dorsiflexion and inversion. They are frequently misdiagnosed as lateral ankle sprains because they are difficult to visualize on standard plain radiographs.

Question 50

A 50-year-old man is undergoing operative intervention for severe, recalcitrant insertional Achilles tendinopathy with a prominent Haglund's deformity. The surgeon plans a retrocalcaneal exostectomy and debridement of the diseased tendon. Up to what percentage of the Achilles tendon insertion can typically be detached and primarily repaired without requiring an augmentation transfer (e.g., FHL)?

Explanation

Most literature supports that up to 50% of the Achilles tendon insertion can be safely detached and repaired using suture anchors. If more than 50% is compromised, a flexor hallucis longus (FHL) transfer is typically recommended to augment the repair.

Question 51

A 16-year-old girl presents with a 3-month history of insidious forefoot pain, localized to the second metatarsophalangeal joint. Radiographs show flattening, sclerosis, and fragmentation of the second metatarsal head. What is the most likely diagnosis?

Explanation

Freiberg's infraction is avascular necrosis of a metatarsal head, most commonly affecting the second metatarsal in adolescent females. Radiographs classically show flattening and subchondral sclerosis of the metatarsal head.

Question 52

A 30-year-old construction worker sustains a severe crush injury to his foot. The foot is tensely swollen, and he has excruciating pain with passive toe extension. If a foot compartment syndrome is missed and left untreated, what is the classic late clinical deformity that develops?

Explanation

Unrecognized compartment syndrome of the foot leads to ischemic contracture of the intrinsic foot musculature. The classic late sequela is severe, rigid claw toe deformities.

Question 53

A 45-year-old man sustains a closed intra-articular calcaneal fracture. The surgeon relies on the Sanders classification to determine the fracture pattern and prognosis. This classification system is based on the number of articular fracture lines passing through the posterior facet as seen on which imaging view?

Explanation

The Sanders classification for calcaneal fractures is based on the number and location of fracture lines extending through the posterior articular facet on coronal CT scan images.

Question 54

A 24-year-old football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs show a 3 mm diastasis between the base of the first and second metatarsals without associated fractures.

What is the most appropriate management for this purely ligamentous injury?

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the first, second, and third tarsometatarsal joints provides better long-term functional outcomes and lower revision rates compared to ORIF. ORIF is generally preferred for bony Lisfranc fracture-dislocations.

Question 55

A 45-year-old man undergoes percutaneous repair of an acute Achilles tendon rupture. Postoperatively, he notes numbness along the lateral aspect of his foot. At what location relative to the calcaneal insertion was the injured nerve most likely compromised during the percutaneous approach?

Explanation

The sural nerve is at greatest risk during percutaneous Achilles repair. It crosses the lateral border of the Achilles tendon from lateral to medial at an average of 9.8 cm (range, 7-13 cm) proximal to the calcaneal insertion.

Question 56

A 30-year-old motorcyclist sustains a high-energy trauma resulting in a severe foot and ankle injury. Radiographs reveal a talar neck fracture with complete dislocation of the talar body from both the subtalar and tibiotalar joints.

According to the Hawkins classification, what is the estimated rate of avascular necrosis (AVN) of the talar body?

Explanation

This is a Hawkins type III talar neck fracture, characterized by displacement of the talar body from the subtalar and tibiotalar joints. The disruption of all three major blood supplies leads to an AVN rate approaching 80-100%.

Question 57

A 42-year-old woman sustains a trimalleolar equivalent ankle fracture with a large posterior malleolus fragment involving 35% of the articular surface. During operative fixation, which of the following interventions provides the greatest biomechanical stability to the distal tibiofibular syndesmosis?

Explanation

The posterior inferior tibiofibular ligament (PITFL) provides the majority of syndesmotic stability. Anatomical fixation of a posterior malleolus fragment restores the PITFL tension, providing greater syndesmotic stiffness than trans-syndesmotic screws alone.

Question 58

During an extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, screws are directed medially into the sustentaculum tali. Penetration of the medial cortex places which of the following structures at greatest immediate risk?

Explanation

The flexor hallucis longus (FHL) tendon runs directly in the groove beneath the sustentaculum tali. Plunging drills or long screws directed into the sustentaculum from lateral to medial put the FHL at the highest risk of iatrogenic injury.

Question 59

A 55-year-old patient with poorly controlled diabetes mellitus presents with a red, hot, swollen, and painless left foot.

Radiographs demonstrate acute periarticular fragmentation and debris around the midfoot, with no clinical signs of an open ulcer or osteomyelitis. Which of the following is the most appropriate initial management?

Explanation

This patient has acute Eichenholtz Stage I Charcot arthropathy. The gold standard for initial management is strict immobilization and offloading, typically achieved with a total contact cast (TCC).

Question 60

A 21-year-old collegiate basketball player sustains an acute, non-displaced fracture of the proximal fifth metatarsal at the metaphyseal-diaphyseal junction. What is the most appropriate treatment to optimize his return to play and minimize the risk of nonunion?

Explanation

A fracture at the metaphyseal-diaphyseal junction is a true Jones fracture. In elite or competitive athletes, early intramedullary screw fixation is recommended to reduce nonunion rates and facilitate a faster return to play.

Question 61

A 60-year-old man presents with severe pain and stiffness in his first metatarsophalangeal (MTP) joint. Radiographs show joint space obliteration, a large dorsal osteophyte, and subchondral sclerosis. He has pain throughout the entire arc of motion. What is the most reliable surgical treatment for long-term pain relief?

Explanation

The patient has advanced (Grade 3/4) hallux rigidus with pain through the entire range of motion. Arthrodesis of the first MTP joint is the gold standard, providing the most reliable long-term pain relief and functional improvement.

Question 62

A 21-year-old collegiate basketball player complains of acute lateral foot pain after a pivoting maneuver. Radiographs demonstrate a fracture at the base of the fifth metatarsal extending into the fourth-fifth intermetatarsal articulation.

What is the most appropriate management to minimize the risk of nonunion and expedite his return to sports?

Explanation

Zone II (Jones) fractures in competitive athletes are best treated with early intramedullary screw fixation to decrease the risk of nonunion and allow an earlier return to play compared to non-operative management.

Question 63

A 30-year-old equestrian falls from a horse, landing with her foot plantarflexed. She presents with midfoot pain, significant dorsal swelling, and plantar ecchymosis. Initial non-weight-bearing radiographs appear unremarkable.

What is the best initial diagnostic step to evaluate for a subtle Lisfranc injury?

Explanation

Weight-bearing radiographs are essential for identifying subtle, dynamic Lisfranc instability, which is indicated by a gap greater than 2 mm between the bases of the first and second metatarsals or subtle dorsal displacement on the lateral view.

Question 64

A 14-year-old girl twists her ankle while playing soccer. Radiographs reveal a Salter-Harris III fracture of the anterolateral distal tibia. Avulsion of this bony fragment is caused by tension from which of the following structures?

Explanation

The juvenile Tillaux fracture is an avulsion of the anterolateral distal tibial epiphysis by the anterior inferior tibiofibular ligament (AITFL). This occurs in adolescents because the medial aspect of the distal tibial physis closes before the lateral aspect.

Question 65

A 35-year-old man sustained a displaced talar neck fracture 8 weeks ago, which was treated with open reduction and internal fixation. A follow-up AP radiograph of the ankle shows a subchondral radiolucent band in the talar dome. What does this radiographic finding indicate?

Explanation

The Hawkins sign is a subchondral radiolucent band seen 6 to 8 weeks post-injury, indicating active bone resorption. This confirms that the vascular supply to the talar body is intact and avascular necrosis is unlikely.

Question 66

A 55-year-old woman presents with a painful, progressive flatfoot deformity. Clinical examination reveals a "too-many-toes" sign, flexible hindfoot valgus, and more than 30% uncovering of the talonavicular joint with forefoot abduction. She is unable to perform a single-limb heel rise. What is the most appropriate surgical management if conservative treatment fails?

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction (flexible flatfoot with significant forefoot abduction). Lateral column lengthening, combined with an FDL transfer, is required to correct the severe forefoot abduction.

Question 67

A 50-year-old man presents with pain in his right big toe that is worse during the toe-off phase of gait. Examination shows a palpable dorsal prominence and limited, painful dorsiflexion. Radiographs reveal dorsal osteophytes with preservation of the plantar joint space. What is the most appropriate initial surgical treatment if orthotics fail?

Explanation

This describes Coughlin and Shurnas Grade 2 hallux rigidus. Symptomatic Grade 1 and 2 hallux rigidus with preserved plantar articular cartilage is appropriately treated with dorsal cheilectomy to remove impinging bone and improve dorsiflexion.

Question 68

A 40-year-old construction worker falls from a roof, sustaining a high-energy pilon fracture.

On presentation, the limb is grossly swollen with fracture blisters developing. What is the most appropriate initial management?

Explanation

High-energy pilon fractures with severe soft tissue compromise require a staged approach. Initial management consists of a spanning external fixator to stabilize the bone and allow soft tissue swelling to resolve before definitive ORIF.

Question 69

A 60-year-old man with poorly controlled diabetes presents with a unilaterally red, hot, swollen, and painless foot. Pulses are bounding. Initial radiographs show soft tissue swelling but no acute fracture or dislocation. What is the most appropriate immediate management?

Explanation

This is a classic presentation of acute, Stage 0 Charcot arthropathy. The immediate priority is mechanical offloading with a total contact cast to prevent catastrophic structural collapse during the active inflammatory phase.

Question 70

A 14-year-old boy presents with recurrent ankle sprains, a rigid flatfoot, and peroneal muscle spasm. Suspecting the most common type of tarsal coalition, which radiographic view is most likely to demonstrate the pathology?

Explanation

Calcaneonavicular coalition is the most common tarsal coalition and is best visualized on a 45-degree internal oblique radiograph, often presenting as the "anteater nose" sign.

Question 71

Recent meta-analyses comparing operative versus non-operative management of acute Achilles tendon ruptures using early functional rehabilitation bracing protocols have demonstrated which of the following outcomes?

Explanation

When early functional rehabilitation protocols are utilized, the re-rupture rates between operative and non-operative management are nearly identical. However, operative management carries an inherently higher risk of wound complications and infection.

Question 72

A 25-year-old man complains of persistent lateral ankle pain 6 months after a severe inversion sprain. MRI demonstrates an osteochondral lesion of the talar dome. Which of the following best describes the typical characteristics of an anterolateral talar osteochondral lesion?

Explanation

Anterolateral osteochondral lesions of the talus are classically shallow, wafer-like, and nearly always associated with a prior traumatic event (inversion and dorsiflexion). Posteromedial lesions are typically deep, cup-shaped, and less consistently tied to acute trauma.

Question 73

A 38-year-old man sustains a displaced intra-articular calcaneus fracture.

The widely used Sanders classification system evaluates the severity of this fracture based on the number and location of primary fracture lines seen on which imaging plane and anatomical structure?

Explanation

The Sanders classification is strictly based on the number of primary fracture lines extending through the posterior articular facet of the calcaneus, as visualized on coronal CT images at the widest portion of the facet.

Question 74

A 28-year-old professional football player suffers a forced hyperextension injury to his first MTP joint. Clinical examination reveals profound weakness with active hallux plantarflexion. MRI demonstrates a complete rupture of the plantar plate with 1 cm of proximal retraction of the sesamoids. What is the most appropriate management?

Explanation

This is a Grade 3 "turf toe" injury characterized by complete rupture of the plantar capsuloligamentous complex and proximal migration of the sesamoids. In a high-level athlete, this requires surgical repair to restore push-off strength and joint stability.

Question 75

A 45-year-old woman with chronic forefoot pain and a positive Mulder's click in the third webspace undergoes surgical excision of the symptomatic lesion after failing conservative management. Histologic examination of the excised specimen is most likely to reveal which of the following?

Explanation

Despite the name, a Morton's neuroma is not a true tumor. Histologically, it is characterized by reactive perineural fibrosis, demyelination, and axonal degeneration resulting from repetitive mechanical irritation.

Question 76

A 52-year-old man who was treated non-operatively for a displaced intra-articular calcaneus fracture 2 years ago now complains of persistent, severe lateral ankle pain and an inability to fit into narrow shoes. Pain is exacerbated by walking on uneven ground. What is the most likely anatomic cause of his current symptoms?

Explanation

A common complication of a non-operatively treated or malunited calcaneus fracture is lateral wall blowout (exostosis), which causes loss of heel height, increased width, and impingement of the peroneal tendons against the tip of the fibula (subfibular impingement).

Question 77

A 28-year-old male sustains a Hawkins type III talar neck fracture. Six weeks postoperatively, AP radiographs of the ankle reveal a linear radiolucent band in the subchondral bone of the talar dome. What does this radiographic finding indicate?

Explanation

The Hawkins sign is a subchondral radiolucency observed 6-8 weeks after a talar neck fracture, indicating intact vascular supply and active resorption of bone (disuse osteopenia). Its presence makes the development of avascular necrosis highly unlikely.

Question 78

A 24-year-old football player sustains a midfoot injury during a game. Weight-bearing radiographs show 3 mm of widening between the base of the first and second metatarsals. What is the most appropriate definitive management for this purely ligamentous Lisfranc injury in an elite athlete?

Explanation

In purely ligamentous Lisfranc injuries, primary arthrodesis of the medial column (1st, 2nd, and 3rd tarsometatarsal joints) has been shown to have superior functional outcomes and a lower reoperation rate compared to ORIF.

Question 79

A 55-year-old poorly controlled diabetic patient presents with a swollen, erythematous, and warm left foot and ankle but no open wounds. Radiographs demonstrate periarticular debris, fragmentation, and subluxation of the midfoot. What is the most appropriate initial treatment?

Explanation

The patient is in the acute (Eichenholtz stage I) phase of Charcot arthropathy. The gold standard initial management is immobilization with a total contact cast and strict non-weight-bearing to prevent further deformity until the acute inflammatory phase resolves.

Question 80

A 22-year-old collegiate basketball player sustains an acute fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal. He wishes to return to play as soon as possible. What is the most appropriate treatment?

Explanation

Acute Jones fractures in high-level athletes are best treated with intramedullary screw fixation. This provides the highest union rate and allows for the quickest return to competitive sports compared to nonoperative management.

Question 81

A 30-year-old man sustains a lateral subtalar dislocation after a fall from a height. Closed reduction in the emergency department is unsuccessful. Which of the following anatomic structures is most likely blocking the reduction?

Explanation

In a lateral subtalar dislocation, the calcaneus is displaced laterally, and the posterior tibial tendon is the most common structure to become incarcerated, blocking closed reduction. Medial subtalar dislocations are more common and are typically blocked by the extensor retinaculum or the extensor digitorum brevis.

Question 82

A 45-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. Examination reveals a "too many toes" sign and an inability to perform a single-leg heel rise. The deformity is passively correctable. What is the most appropriate surgical treatment after failed conservative measures?

Explanation

The patient has Stage II posterior tibial tendon dysfunction (PTTD), characterized by a flexible planovalgus deformity. Appropriate surgical management includes a soft tissue reconstruction (FDL transfer) combined with a bony procedure (calcaneal osteotomy) to correct the deformity.

Question 83

A 14-year-old boy presents with recurrent lateral ankle sprains and rigid flatfeet. Subtalar motion is markedly decreased. Oblique radiographs of the foot reveal an "anteater sign." Which of the following conditions is most likely present?

Explanation

The "anteater sign" on an oblique foot radiograph represents a calcaneonavicular coalition, which is an abnormal elongation of the anterior process of the calcaneus towards the navicular. Talocalcaneal coalitions are typically identified by the "C-sign" on a lateral radiograph.

Question 84

Which of the following statements comparing operative and nonoperative management of acute Achilles tendon ruptures using early functional rehabilitation is most accurate?

Explanation

Recent high-quality studies have shown that when early functional rehabilitation (early weight-bearing and mobilization) is employed, there is no significant difference in re-rupture rates between operative and nonoperative management of acute Achilles tendon ruptures.

Question 85

A 35-year-old roofer falls from a ladder and sustains a displaced, intra-articular calcaneus fracture. If surgical intervention via a lateral extensile approach is planned, what is the most significant risk factor for postoperative wound complications?

Explanation

Smoking is the most significant modifiable risk factor for wound complications following an open reduction and internal fixation of a calcaneus fracture via a lateral extensile approach. Delaying surgery until swelling diminishes also reduces complication rates.

Question 86

A 42-year-old man sustains a severe, high-energy tibial pilon fracture with massive soft tissue swelling and fracture blisters. What is the most appropriate initial management strategy?

Explanation

The standard of care for high-energy tibial pilon fractures with severe soft tissue compromise is a staged protocol. Initial spanning external fixation protects soft tissues, followed by delayed definitive open reduction and internal fixation once the soft tissue envelope heals.

Question 87

A 20-year-old running back sustains a hyperextension injury to his first metatarsophalangeal (MTP) joint. MRI demonstrates a complete tear of the plantar plate and sesamoid complex with proximal migration of the sesamoids. What is the recommended treatment?

Explanation

Grade III "turf toe" injuries involving complete disruption of the plantar capsuloligamentous complex with proximal migration of the sesamoids typically require surgical repair in high-level athletes to restore push-off strength and joint stability.

Question 88

A 60-year-old man presents with dorsal midfoot pain and limited dorsal extension of the great toe. Radiographs show significant joint space narrowing of the first metatarsophalangeal joint with large dorsal osteophytes. He fails conservative management. What is the most reliable surgical option for long-term pain relief?

Explanation

First metatarsophalangeal (MTP) joint arthrodesis is the gold standard and most reliable surgical treatment for advanced (Grade 3 or 4) hallux rigidus, providing predictable pain relief and high patient satisfaction.

Question 89

A 25-year-old male presents with deep ankle pain after a severe inversion injury 6 months ago. MRI reveals a 1.2 cm osteochondral lesion on the anterolateral aspect of the talar dome. The cartilage is intact but there is subchondral edema. What is the most appropriate initial surgical intervention after failed conservative therapy?

Explanation

For primary, symptomatic osteochondral lesions of the talus that are smaller than 1.5 cm2 and have failed conservative management, arthroscopic debridement and bone marrow stimulation (microfracture) is the initial surgical treatment of choice.

Question 90

A 28-year-old skier experiences a sudden snapping sensation over the lateral aspect of her ankle during a fall. Examination reveals tenderness over the posterior fibula and a palpable subluxation of the tendons with resisted foot eversion. What is the primary anatomical structure injured in this condition?

Explanation

Peroneal tendon subluxation is caused by an injury or incompetence of the superior peroneal retinaculum (SPR). It frequently occurs in skiing injuries due to sudden, forceful dorsiflexion and eversion.

Question 91

A 45-year-old obese man receives a third corticosteroid injection for chronic plantar fasciitis. Two weeks later, he feels a sudden "pop" in his heel while walking. He notices decreased arch height and an improvement in his chronic heel pain, but now has lateral column foot pain. What has most likely occurred?

Explanation

Multiple corticosteroid injections for plantar fasciitis increase the risk of spontaneous plantar fascia rupture. A rupture often paradoxically relieves the classic tension-related heel pain but can lead to arch collapse and lateral column overload pain.

Question 92

A 40-year-old woman has a symptomatic bunion. Radiographs reveal a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. There is no hypermobility of the first tarsometatarsal joint. What is the most appropriate surgical approach?

Explanation

For a severe hallux valgus deformity (HVA > 40 degrees, IMA > 15 degrees) without hypermobility or arthritis, a proximal first metatarsal osteotomy combined with a distal soft-tissue release provides the necessary correction power.

Question 93

A 19-year-old male track athlete complains of vague dorsal midfoot pain. Radiographs are normal, but an MRI demonstrates a stress fracture in the central third of the navicular body without displacement. What is the best initial management?

Explanation

Nondisplaced navicular stress fractures occur in the relatively avascular central third of the bone. The gold standard nonoperative treatment is strict non-weight-bearing in a short leg cast for 6 to 8 weeks to prevent nonunion.

Question 94

A 55-year-old man presents with persistent weakness in ankle plantar flexion 4 months after feeling a 'pop' in his calf during a tennis match. MRI confirms a chronic Achilles tendon rupture with a 6-cm gap between the tendon ends. Which of the following is the most appropriate surgical management for this patient?

Explanation

For chronic Achilles tendon ruptures with a defect gap greater than 5 cm, local tendon transfer, typically using the FHL, is indicated. The FHL provides strong plantar flexion force, fires in phase with the Achilles, and its harvest carries minimal donor site morbidity.

Question 95

A 28-year-old hockey player sustains a high ankle sprain. Intraoperative stress testing reveals gross syndesmotic instability, and the patient undergoes surgical stabilization. Which of the following factors is the most significant predictor of poor long-term clinical outcome and post-traumatic arthritis in this patient?

Explanation

Anatomic reduction of the distal tibiofibular syndesmosis is the most critical prognostic factor in determining long-term functional outcomes and preventing post-traumatic arthritis. Suture-button constructs and screws have comparable clinical outcomes, and routine deltoid repair is generally not required if the syndesmosis is anatomically reduced.

Question 96

A 34-year-old man falls from a ladder and sustains a displaced fracture of the talar neck. Radiographs demonstrate displacement of the talar neck with subluxation of the subtalar joint, while the tibiotalar and talonavicular joints remain congruent. According to the Hawkins classification, what is the historically reported risk of avascular necrosis (AVN) of the talar body for this specific injury pattern?

Explanation

This injury represents a Hawkins Type II talar neck fracture, defined by displacement with subtalar joint subluxation or dislocation while the ankle joint remains intact. The risk of avascular necrosis (AVN) of the talar body in Hawkins Type II fractures is classically reported as 20% to 50%.

Question 97

A 60-year-old woman with poorly controlled type 2 diabetes presents with a unilaterally swollen, warm, and erythematous right foot. She denies any open wounds or fevers. Radiographs demonstrate bony fragmentation, periarticular debris, and subluxation of the tarsometatarsal joints. What is the most appropriate initial management for this condition?

Explanation

This patient is presenting with acute Eichenholtz stage I Charcot arthropathy, characterized by fragmentation, joint subluxation, and significant inflammation without infection. The gold standard for initial treatment is offloading with total contact casting to stabilize the foot and prevent further deformity until the acute inflammatory phase resolves.

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

AAOS Orthopedic MCQs (Set 3): Foot & Ankle Trauma & Pathology | ABOS Board Prep

Key Takeaway

AAOS Orthopedic MCQs (Set 3): Foot & Ankle Trauma & Pathology | ABOS Board Prep

Chapter Index