Foot & Ankle Orthopedic MCQs: Fractures & Deformities

Question 1

When performing surgery on a patient with insertional Achilles tendinitis and a Haglund's deformity, how much of the Achilles tendon insertion can be safely detached without having to consider reattachment with bone anchors?

Explanation

The Achilles tendon insertion encompasses a broad area on the posterior area of the calcaneus. A biomechanical study has shown that up to 50% of the Achilles tendon insertion point can be detached before the strength of the attachment point starts to weaken. It is recommended that if more than this amount is detached to remove the posterior superior calcaneal prominence, consideration should be given to either securing the tendon to the bone with suture anchors or performing a tendon transfer. Kolodziej P, Glisson RR, Nunley JA: Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendinitis and Haglund's deformity: A biomechanical study. Foot Ankle Int 1999;20:433-437.

Question 2

A 12-year-old child with spina bifida paraplegia requires brace management for ankle stability. Which of the following principles applies to brace management in this individual?

Explanation

Bracing for spina bifida paraplegia provides both support and improved function of the movable limb. An orthosis has value in controlling unstable joints. The three-point pressure effect applies a force above and below the joint to prevent it from buckling. A four-point pressure effect is only required for a two-joint system (this patient has problems only at the ankle). A longer lever arm brace and a brace with a greater area of support provide better stability. Finally, a straighter limb, without contracture, applies less pressure to the brace and lessens overload to the skin. Gage JR: An overview of normal walking. Instr Course Lect 1990;39:291-303. Bleck EE: Current concepts review: Management of the lower extremities in children who have cerebral palsy. J Bone Joint Surg Am 1990;72:140-144.

Question 3

A 64-year-old man with a history of diabetes mellitus underwent open reduction and internal fixation of a displaced ankle fracture 8 weeks ago. Examination now reveals recent onset erythema, warmth, and swelling of the midfoot. Radiographs are shown in Figures 23a through 23d. What is the most likely reason for the swelling of the foot?

Explanation

A Charcot flare in adjacent joints is not uncommon in patients with neuropathy who undergo surgery or other trauma. Venous thrombosis would present with swelling of the entire leg, while infection would present earlier in the postoperative period. The radiographs are pathognomonic of Charcot arthropathy, not an unrecognized fracture or gout. A compartment syndrome this late after injury is extremely rare, and there would be no bony distraction associated with compartment syndrome.

Question 4

When considering a flexor digitorum longus tendon transfer as part of the surgical treatment in patients with symptomatic flatfoot deformity caused by posterior tibial tendon insufficiency, which of the following patients is the most appropriate candidate?

Explanation

Transfer of the flexor digitorum longus tendon is a common technique combined with other procedures to treat patients with posterior tibial tendon insufficiency. However, it is contraindicated in patients with a fixed hindfoot deformity, hypermobility, or neuromuscular compromise. It is relatively contraindicated in patients who are obese, and those older than age 60 to 70 years. Pedowitz WJ, Kovatis P: Flatfoot in the adult. J Am Acad Orthop Surg 1995;3:293-302.

Question 5

What is the most likely cause of recurrent symptoms following excision of a third web space neuroma?

Explanation

When a recurrent neuroma forms at the end of the resected nerve, it does not retract far enough because either the transection was not proximal enough or it is tethered by plantar neural branches. The transverse intermetatarsal ligament may reform, but it is not associated with pathology. Synovial cysts and synovitis are part of the differential diagnosis but are not associated with neuroma excision. Complex regional pain syndrome may result from neuroma excision, but this is rare and the symptoms are different. Beskin JL: Recurrent interdigital neuromas, in Nunley JA, Pfeffer GB, Sanders RW, Trepman E (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 481-484.

Question 6

A 45-year-old woman has had radiating pain in the medial ankle for the past 3 months. Examination reveals a small mass in the retromedial ankle region and a positive Tinel's sign. An intraoperative photograph and a hematoxylin/eosin biopsy specimen are shown in Figures 24a and 24b. Treatment should consist of

Explanation

Neurilemoma is a benign tumor of nerve sheath origin, and peak incidence is in the third through sixth decades. The tumor is well encapsulated on the surface of a peripheral nerve. MRI findings may be significant for a "string sign." A positive Tinel's sign in the distribution of the nerve affected may be present. Grossly, the lesion is well encapsulated in a nerve sheath. Microscopically, there are structures referred to as Antoni A (a pattern of spindle cells arranged in intersecting bundles) and Antoni B (areas with less cellularity with loosely arranged cells). These lesions are benign, and treatment should consist of marginal excision. Nerve function may be preserved by careful dissection, excising the lesion parallel to the nerve fascicles so the lesion may be extruded. Recurrence is rare. Walling AK: Soft tissue and bone tumors, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1007-1032.

Question 7

An 83-year-old woman with a long history of her foot slowly and progressively "turning out" now reports significant ankle pain. History reveals that she has significant cardiac disease and exercise-induced angina. Examination reveals a deficiency in the posterior tibial tendon; however, the hindfoot remains moderately supple. Radiographs reveal a valgus tilt of the tibiotalar joint and early arthrosis. What is the most appropriate orthotic management?

Explanation

The patient will continue to have pain secondary to the ankle arthrosis with both the UCBL and the molded articulated ankle-foot orthosis. The total contact orthotic does not provide enough hindfoot control to support the progressive collapse of the ankle into valgus positioning. A molded leather gauntlet will not only control tibiotalar motion but also control hindfoot motion and allow support of the longitudinal arch.

Question 8

What complication is frequently associated with the Weil lesser metatarsal osteotomy (distal, oblique) in the treatment of claw toe deformities?

Explanation

Weil osteotomies are useful in achieving shortening of a lesser metatarsal with preservation of the distal articular surface. The osteotomy is oriented from distal-dorsal to proximal-plantar; therefore, proximal displacement of the distal fragment is associated with plantar (not dorsal) displacement as well. Plantar displacement can result in the intrinsics acting dorsal to the center of the metatarsophalangeal joint and the development of an extended or "floating toe." Nonunion, osteonecrosis, and inadequate shortening are infrequent complications associated with the Weil lesser metatarsal osteotomy. Trnka HJ, Nyska M, Parks BG, et al: Dorsiflexion contracture after the Weil osteotomy: Results of cadaver study and three-dimensional analysis. Foot Ankle Int 2001;22:47-50.

Question 9

What are the five major compartments of the foot?

Explanation

The five major compartments of the foot are medial, lateral, central, interosseous, and calcaneal. There is no dorsal compartment in the foot. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 262-264.

Question 10

Figures 25a and 25b show the radiographs of a 66-year-old man who has had a long history of bilateral painful flatfoot deformities. Examination reveals that his foot is partially correctable passively, albeit with discomfort, and he has an Achilles tendon contracture. An ankle-foot orthosis has failed to provide relief. Treatment should now consist of

Explanation

The patient has a pronounced deformity with pain and degenerative arthritis; therefore, triple arthrodesis is the treatment of choice. Gastrocnemius or Achilles tendon lengthening may be a necessary adjunct to the triple arthrodesis, but alone is inadequate to allow for correction. Because the ankle-foot orthosis has failed to provide relief, a UCBL is not likely to help. Osteotomy procedures are designed for lesser deformities and well-preserved joints. Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 115-120.

Question 11

A 77-year-old man with diabetes mellitus has had a nonhealing Wagner grade I ulcer under the medial sesamoid for the past 3 months. He smokes tobacco regularly. He has undergone several debridements and total contact casting. Examination reveals no palpable pulses. He has no erythema or purulence, and he is afebrile. Radiographs reveal no abnormalities. What is the best initial diagnostic test to help determine why the ulcer has failed to heal?

Explanation

The best initial test for this patient is to assess the vascular supply to the foot. An elderly smoker with diabetes mellitus has a high risk of peripheral vascular disease. Decreased weight bearing has not been successful. Although a bone scan might be helpful, it would take secondary consideration to the patient's vascular supply, especially in the absence of any acute infection. Monofilament testing would help diagnosis neuropathy, which is a root cause behind the ulcer forming, but does not prevent it from healing. The Thompson's test is used to diagnosis an Achilles tendon rupture.

Question 12

A 28-year-old man who sustained an ankle fracture in a motor vehicle accident underwent open reduction and internal fixation 3 months ago. He continues to report significant ankle pain with ambulation. Radiographs are shown in Figure 26. What is the next most appropriate step in management?

Explanation

The patient sustained a bimalleolar ankle fracture with a syndesmosis disruption. The initial open reduction and internal fixation did not successfully reduce the distal tibiofibular joint. The patient may need a derotational distraction osteotomy of the fibula to reduce the syndesmosis. The other procedures do not address the primary problem of the fibular malunion and syndesmosis malreduction. There is no radiographic evidence of significant arthritis; therefore, ankle arthrodesis is not indicated.

Question 13

The first branch of the lateral plantar nerve innervates the

Explanation

The first branch of the lateral plantar nerve innervates the abductor digiti quinti, and more distal branches of the lateral plantar nerve supply the quadratus plantae and the interossei. The medial plantar nerve supplies the abductor hallucis brevis and the flexor digitorum brevis. Pansky B, House EH: Review of Gross Anatomy, ed 3. New York, NY, Macmillan, 1975, pp 464-476.

Question 14

The radiograph shown in Figure 27 shows measurement of what angle?

Explanation

The relationship between the distal articular surface of the first metatarsal head and the long axis of the first metatarsal is called the distal metatarsal articular angle. This angle has been validated by Richardson and associates to measure and determine the congruence of the first metatarsophalangeal joint. This angle is critical in determining the appropriate surgical procedure to perform on a patient with a bunion deformity because a congruent joint requires a procedure to maintain congruence of the articular surfaces following osteotomy. Therefore, a chevron becomes a biplanar chevron, and a Lapidus procedure adds a second osteotomy of the distal metatarsal to tilt the metatarsal head into a congruent location. Coughlin MJ: Juvenile hallux valgus: Etiology and treatment. Foot Ankle Int 1995;16:682-697. Steel MW III, Johnson KA, DeWitz MA, et al: Radiographic measurements of the normal foot. Foot Ankle 1980;1:151-158.

Question 15

Which of the following orthotic features best reduces pain in patients with hallux rigidus?

Explanation

Nonsurgical care for hallux rigidus involves limiting the motion of the first metatarsophalangeal joint during toe-off and ensuring that there is a deep enough toe box to accommodate dorsal osteophytes. A rigid shank or forefoot rocker both help to reduce the forces of extension during toe-off. Beskin JL: Hallux rigidus. Foot Ankle Clin 1999;4:335-353.

Question 16

An 11-year-old girl sustained an injury to her right foot when a 500-lb headstone fell on it. The headstone was removed after 3 minutes. Radiographs show multiple midfoot fractures. Examination reveals severe pain that is worse with passive toe motion. Clinical photographs are shown in Figure 28. Management should consist of

Explanation

The patient has a classic history and examination for an acute compartment syndrome of the foot. CT, MRI, or stress radiographs are not necessary prior to emergent fasciotomies of the foot. These studies can be performed after the initial fasciotomies to determine the best long-term management of the fractures. There are nine compartments in the foot. These are decompressed through three incisions (two on the dorsal foot and one medially). A short leg cast does not address the compartment syndrome and could be limb threatening with excessive swelling in a circumferential cast. It is preferable to splint severe crush injuries rather than apply a cast. Fulkerson E, Razi A, Tejwani N: Review: Acute compartment syndrome of the foot. Foot Ankle Int 2003;24:180-187.

Question 17

A 5-year-old boy has had midfoot pain with activity for the past 3 months. He has no pain at rest. Radiographs are shown in Figures 29a and 29b. Management should consist of

Explanation

The radiographs show classic findings for Koehler's disease (osteochondrosis of the navicular). The patient's age and clinical history are typical for this self-limiting condition. Patients will improve with time, but the duration of symptoms is much shorter if the patient is placed in a cast. There is no role for surgery in this disease.

Question 18

A 62-year-old man with diabetes mellitus has had a persistent 2-cm ulcer under the third metatarsal head for the past 4 months. He reports that he has had similar ulcers twice before, and both healed with nonsurgical management. He has used multiple types of commercial walking braces, shoes, and commercial dressings without resolution. He is insensate to the Semmes-Weinstein 5.07 monofilament. When the wound is probed with culture swab, there is no communication with the metatarsal head. Radiographs, bone scans, and laboratory studies reveal no evidence of osteomyelitis. What is the most predictable method of accomplishing wound healing without recurrence?

Explanation

The patient has a persistent diabetic foot ulcer without evidence of osteomyelitis. He has evidence of a sensory peripheral neuropathy and a concomitant motor neuropathy, leading to a dynamic motor imbalance. Use of a total contact cast would offer a high probability of healing the resistant ulcer but with a high potential for recurrence. Combining the total contact cast with Achilles tendon lengthening allows wound healing without a high risk for recurrence. Excision of the noninfected metatarsal head would make the patient vulnerable to the development of a transfer lesion under one of the remaining metatarsal heads. Robertson DD, Mueller MJ, Smith KE, et al: Structural changes in the forefoot of individuals with diabetes and a prior plantar ulcer. J Bone Joint Surg Am 2002;84:1395-1404.

Question 19

Figure 30 shows the radiograph of a 38-year-old man who reports persistent pain laterally and plantarly about the fifth metatarsal head. Examination reveals calluses dorsolaterally and plantarly about the fifth metatarsal head. Nonsurgical management has failed to provide relief. Surgical treatment should include

Explanation

The patient has painful lateral and plantar keratoses with metatarsus quintus valgus deformity. This combination of problems is best addressed with an oblique mid-diaphyseal osteotomy that allows the distal metatarsal to be displaced medially and dorsally. Lateral eminence resection alone will not address the painful plantar keratosis. A distal chevron osteotomy has a more limited ability to address the plantar keratosis (if translated medially and slight dorsally). Proximal diaphyseal osteotomies of the fifth metatarsal are associated with an increased risk of delayed union or nonunion secondary to the relative hypovascularity in the proximal diaphysis. Excision of the fifth metatarsal head can result in a floppy fifth toe and transfer metatarsalgia. Coughlin MJ: Treatment of bunionette deformity with longitudinal diaphyseal osteotomy with distal soft tissue repair. Foot Ankle 1991;11:195-203.

Question 20

An 11-year-old boy stepped on a nail and sustained a puncture to the right forefoot 6 days ago. He was wearing tennis shoes at the time of injury. Treatment in the emergency department consisted of local debridement and tetanus prophylaxis; a radiograph was negative for foreign body, chondral defect, or fracture. He was discharged with a 3-day prescription of amoxicillin and clavulanate. The patient now has increasing pain and tenderness at the puncture site. What is the best course of action?

Explanation

The initial treatment consisting of oral antibiotics was appropriate but with progressive symptoms, surgical debridement is necessary. Ciprofloxacin is contraindicated in children, and at this stage, oral antibiotics are inadequate. Intravenous antibiotics may be necessary, but surgical debridement is paramount. Failure to respond to the initial management precludes further observation. Riegler HP, Routson T: Complications of deep puncture wounds of the foot. J Trauma 1979;19:18-22.

Question 21

An 20-year-old elite college football player has ecchymosis, swelling, and pain on the lateral side of his foot after a game. Radiographs are shown in Figures 31a through 31c. Management should consist of

Explanation

Metaphyseal-diaphyseal junction fractures of the fifth metatarsal require careful evaluation. In athletes, early intervention with a 4.5-mm intramedullary screw correlates with an earlier return to activity. One study examining the failure of surgically managed Jones fractures revealed that use of anything other than a 4.5-mm malleolar screw for internal fixation correlated with failure. Glasgow MT, Naranja RJ Jr, Glasgow SG, et al: Analysis of failed surgical management of fractures of the base of the fifth metatarsal distal to the tuberosity: The Jones fracture. Foot Ankle Int 1996;17:449-457.

Question 22

Which of the following structures are found in the anterior tarsal tunnel?

Explanation

The contents of the anterior tarsal tunnel are the extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, and the deep peroneal nerve. The term "anterior tarsal tunnel syndrome" is used to specifically describe the compression of the deep peroneal nerve under the inferior extensor retinaculum. With nerve compression, patients report a burning sensation across the dorsum of the foot with paresthesias in the first web space. There also may be wasting and weakness of the extensor digitorum brevis. Kuritz HM: Anterior entrapment syndromes. J Foot Surg 1976;15:143-148.

Question 23

A 55-year-old man who runs on the weekends reports a 1-year history of continued pain directly posteriorly in the heel. Management consisting of anti-inflammatory drugs, icing techniques, a heel-counter in his shoe split, and physical therapy consisting of stretching, contrast baths, custom orthotics, and iontophoresis has failed to provide relief. Not only is his lifestyle disrupted with respect to running, but he now has pain with normal ambulation with all forms of shoe wear. He is not necessarily concerned with returning to running; he is primarily seeking pain relief. A lateral radiograph and clinical photograph are shown in Figures 32a and 32b. Treatment should now consist of

Explanation

The patient has severe calcifications at the insertion of the Achilles tendon. Failure to address the Haglund's exostosis and the calcifications will leave the patient with persistent pain. Steroids should not be injected directly into the tendon because of the increased risk of tendon rupture. Shock wave treatment may have some value in treating plantar fasciitis, but its efficacy has not been documented with insertional calcifications and Haglund's exostosis treatment. Brisement is injection of saline solution around the Achilles tendon in an attempt to decompress the peritenon. This may be valuable in intrasubstance Achilles tendinosis or peritendinitis but has no value with insertional disease. Symptoms persisting beyond 6 months are difficult to treat nonsurgically; therefore, the appropriate treatment protocol is aggressive and must address all pathology. The patient may not be able to run at the level achieved prior to surgery, but the goal of the surgery is pain relief. Clain M, Baxter D: Achilles tendinitis. Foot Ankle 1992;13:482-487. Schepsis A, Wagner C, Leach R: Surgical management of Achilles tendon overuse injuries: A long-term follow-up study. Am J Sports Med 1994;22:611-619. Schepsis A, Leach R: Surgical management of Achilles tendinitis. Am J Sports Med 1987;15:308-315.

Question 24

A 45-year-old man who has had recurrent pain and swelling of the left Achilles tendon insertion for the past 10 years reports that physical therapy and activity modification have provided relief in the past. He now has continued pain despite these efforts. He also reports occasional bouts of dysuria that he attributes to a history of prostatitis. He also notes recent eye irritation that he attributes to allergies. A lateral heel radiograph is shown in Figure 33. Which of the following laboratory studies would best aid in diagnosis?

Explanation

Reiter's syndrome is a seronegative spondyloarthropathy characterized most commonly by a triad of asymmetric arthritis, urethritis, and uveitis. Tendon ensethopathies can also be present. It is most often seen in men and is associated with a positive HLA-B27 marker. Rheumatoid arthritis does not usually present with these features; more commonly it causes forefoot pain and synovitis of the metatarsophalangeal joints. A CBC count with differential would be helpful in a situation of possible infection. The urethral swab would help to diagnose a gonococcal infection which can cause a monoarticular septic arthritis. Antiphospholipid antibody is associated with a hypercoaguable state and increased risk of deep venous thrombosis.

Question 25

A 29-year-old man reports severe knee instability and popliteal pain. History reveals that he had polio of the left lower extremity as a child and has been brace-free his entire life. Examination reveals that he walks with 40 degrees of knee hyperextension and has a fixed ankle equinus deformity of 30 degrees. He has no active motors about the knee or ankle. Which of the following methods will provide knee stability and pain relief?

Explanation

The ankle equinus allows the patient to keep his weight-bearing line anterior to the axis of the hyperextended knee joint. With time, pain has developed because of continued stretching and now incompetence of the posterior capsule of the knee joint. Several soft-tissue and bony procedures have been designed to provide knee stability in this situation; however, the results have been either short-lived or inconsistent. Tenodeses, capsular plications, and bony blocks have had limited success and generally fail over time. Current orthotic technology makes soft-tissue release and orthotic control the most predictable option. To decrease the hyperextension moment on the knee joint, the ankle deformity also must be corrected. The most predictable method of achieving stability and diminished pain during walking is with soft-tissue release of the ankle and a knee-ankle-foot orthosis with a locked ankle and drop-lock knee joint.

Question 26

A 45-year-old female presents with severe insertional Achilles tendinopathy that has failed 6 months of conservative management. During surgical debridement of the tendon and excision of the Haglund's deformity, it is determined that 60% of the Achilles insertion must be detached. Which of the following is the most appropriate next step in management?

Explanation

When more than 50% of the Achilles tendon insertion is compromised or detached during debridement, augmentation with a tendon transfer is indicated. The flexor hallucis longus (FHL) is the preferred transfer due to its strength, axis of pull, and proximity.

Question 27

A 14-year-old boy with Charcot-Marie-Tooth (CMT) disease presents with a progressive bilateral cavovarus foot deformity. Which of the following muscle imbalances is the primary driver of the hindfoot varus deformity in this patient?

Explanation

In CMT, the hindfoot varus is primarily driven by a strong tibialis posterior overpowering a weak peroneus brevis. The forefoot cavus (plantarflexed first ray) is caused by a strong peroneus longus overpowering a weak tibialis anterior.

Question 28

A 24-year-old snowboarder presents with lateral ankle pain and swelling after a hard landing. Radiographs are negative for an acute lateral malleolus fracture, but a CT scan reveals a displaced fracture of the lateral process of the talus. Which of the following is the most appropriate management for a lateral process fracture displaced by 4 mm?

Explanation

Fractures of the lateral process of the talus (snowboarder's fracture) that are displaced >2 mm or involve a significant articular step-off should be treated with ORIF. Nonoperative management of displaced fractures can lead to subtalar arthritis and chronic pain.

Question 29

A 22-year-old collegiate football player sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial and middle cuneiforms. He undergoes operative intervention. According to recent literature, which of the following outcomes is associated with primary arthrodesis compared to open reduction and internal fixation (ORIF) for this specific injury pattern?

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis has been shown to result in a decreased incidence of secondary procedures (such as hardware removal or salvage fusion) compared to ORIF. Short- and mid-term functional scores are generally similar or slightly favor primary arthrodesis in purely ligamentous patterns.

Question 30

A 28-year-old marathon runner presents with vague, aching dorsal midfoot pain. A T1-weighted MRI reveals a linear hypointense signal in the central third of the navicular body consistent with a stress fracture. There is no displacement or cystic changes. What is the recommended initial management?

Explanation

The navicular is a high-risk stress fracture due to its watershed blood supply in the central third. The standard of care for a non-displaced navicular stress fracture without cystic changes is strict non-weight-bearing in a cast for 6 to 8 weeks.

Question 31

A 55-year-old woman presents with progressive flattening of her left arch and medial ankle pain. Examination reveals a flexible hindfoot valgus, inability to perform a single-leg heel raise, and forefoot abduction of 30 degrees (positive 'too many toes' sign). Radiographs confirm Stage IIb posterior tibial tendon dysfunction. Which surgical intervention is most appropriate?

Explanation

Stage IIb adult acquired flatfoot deformity involves a flexible hindfoot with significant forefoot abduction (often >30-40% uncoverage of the talar head). Management typically requires FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening (Evans osteotomy or calcaneocuboid distraction arthrodesis) to correct the abduction.

Question 32

A 30-year-old man sustains a Hawkins Type III talar neck fracture following a motor vehicle collision. Which of the following represents the primary blood supply to the talar body that is most commonly 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. In a Hawkins Type III fracture (talar neck fracture with subtalar and ankle joint dislocation), this blood supply is reliably disrupted, leading to high rates of avascular necrosis.

Question 33

Which of the following descriptions best localizes a true Jones fracture, which is known for its high risk of nonunion?

Explanation

A true Jones fracture occurs at the metaphyseal-diaphyseal junction of the fifth metatarsal and must involve the fourth-fifth intermetatarsal articulation (Zone 2). Fractures distal to this are diaphyseal stress fractures (Zone 3), and proximal are tuberosity avulsion fractures (Zone 1).

Question 34

A 60-year-old male complains of progressive dorsal foot pain and stiffness of his great toe. Radiographs show severe joint space narrowing, dorsal osteophytes, and subchondral sclerosis at the first metatarsophalangeal (MTP) joint. Clinical exam demonstrates less than 10 degrees of dorsiflexion. What is the most reliable surgical treatment for long-term pain relief in this patient?

Explanation

This patient has severe (Coughlin Grade 3 or 4) hallux rigidus. First MTP joint arthrodesis is the gold standard and most reliable surgical treatment for end-stage hallux rigidus, providing predictable pain relief and functional restoration.

Question 35

Which of the following is true regarding the nonoperative management of acute Achilles tendon ruptures when utilizing an early functional rehabilitation protocol?

Explanation

Recent high-quality evidence shows that when early functional rehabilitation (early weight-bearing and ROM in a boot) is utilized, the re-rupture rates between nonoperative and operative management of Achilles tendon ruptures are statistically similar. Operative management does, however, carry a higher risk of complications such as infection and sural nerve injury.

Question 36

During the operative fixation of a severely displaced intra-articular calcaneus fracture, the surgeon must identify the 'constant fragment' to aid in the reduction of the remaining fracture pieces. Which of the following anatomical structures defines the constant fragment?

Explanation

The anteromedial fragment, which includes the sustentaculum tali, remains firmly attached to the talus via the strong interosseous talocalcaneal and deltoid ligaments. This is known as the 'constant fragment' and serves as the foundation to which the rest of the calcaneus is reduced.

Question 37

A 21-year-old soccer player presents with recurrent snapping over the lateral malleolus. Physical examination reveals subluxation of the peroneal tendons with resisted eversion and dorsiflexion. Surgical exploration is planned. Which of the following structures is most likely injured or incompetent in this patient?

Explanation

Recurrent peroneal tendon subluxation is primarily caused by an injury to, or incompetence of, the superior peroneal retinaculum (SPR). Surgical treatment typically involves repair of the SPR and deepening of the fibular groove.

Question 38

A 13-year-old female sustains a fracture of the anterolateral aspect of the distal tibial epiphysis following an external rotation injury to her ankle. Which of the following explains the anatomic basis for this specific fracture pattern (Tillaux fracture)?

Explanation

The distal tibial physis closes in a predictable pattern: central, then medial, then posterior, and finally anterolateral. Because the anterolateral physis remains open the longest, an avulsion force from the anterior inferior tibiofibular ligament (AITFL) causes a Salter-Harris III fracture of this region (Tillaux fracture).

Question 39

A 12-year-old boy presents with rigid flatfeet and recurrent ankle sprains. Radiographs are suspicious for a tarsal coalition. Which imaging view is most appropriate to clearly identify a talocalcaneal coalition involving the middle facet?

Explanation

The Harris axial view (calcaneal axial view) is specifically utilized to visualize the posterior and middle facets of the subtalar joint. It is the best plain radiographic view to diagnose a talocalcaneal coalition.

Question 40

A professional wide receiver sustains a severe hyperextension injury to his first MTP joint ('turf toe'). MRI demonstrates a complete disruption of the plantar plate with 4 mm of proximal retraction of the sesamoids. Which of the following is an absolute indication for operative repair in turf toe injuries?

Explanation

Operative intervention for turf toe (plantar plate rupture) is indicated for Grade 3 injuries with significant instability. Absolute indications include >3 mm of proximal migration of the sesamoids, intra-articular sesamoid fractures with diastasis, or traumatic hallux valgus/varus deformity.

Question 41

During the physical examination of a patient with a suspected syndesmotic injury, the examiner stabilizes the tibia and externally rotates the foot. This test primarily stresses which of the following syndesmotic ligaments?

Explanation

External rotation of the talus within the mortise pushes the fibula laterally and posteriorly, placing the greatest initial stress on the anterior inferior tibiofibular ligament (AITFL), making it the most frequently injured component of the syndesmosis.

Question 42

A 58-year-old male with long-standing, poorly controlled type 2 diabetes presents with a red, hot, swollen right foot. He denies any recent trauma or systemic symptoms. White blood cell count and ESR are normal. Radiographs reveal soft tissue swelling, periarticular osteopenia, and early fragmentation at the tarsometatarsal joints. What is the most appropriate initial management?

Explanation

This patient has an acute (Eichenholtz Stage I) Charcot neuroarthropathy. The gold standard for initial management is strict immobilization and offloading, typically achieved with a total contact cast, to halt the progression of deformity until the active inflammatory phase resolves.

Question 43

A patient sustains a supination-external rotation (SER) type IV ankle fracture. On the mortise radiograph, the medial clear space is measured. An abnormal medial clear space indicative of deep deltoid ligament rupture and lateral talar shift is generally defined as greater than what measurement?

Explanation

An abnormal medial clear space on an AP or mortise radiograph is widely defined as greater than 4 mm (or >5 mm in some literature, but 4 mm is a standard threshold indicating deep deltoid incompetence when compared to the superior clear space).

Question 44

A 40-year-old female presents with a painful bunion. Clinical examination and weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 28 degrees and an intermetatarsal angle (IMA) of 11 degrees. The first tarsometatarsal joint shows no hypermobility. Which of the following procedures is most appropriate?

Explanation

A distal chevron osteotomy is indicated for mild-to-moderate hallux valgus deformities (HVA < 30-40 degrees, IMA < 13 degrees) without first ray hypermobility. More severe deformities or those with hypermobility typically require proximal procedures or a Lapidus fusion.

Question 45

A 35-year-old woman complains of burning pain in the plantar aspect of her forefoot that radiates into her third and fourth toes. Symptoms worsen with tight shoes and improve when barefoot. A Mulder's click is present. Which of the following best describes the underlying histologic pathology of her condition?

Explanation

The patient has a Morton's neuroma, most commonly occurring in the third webspace. Histologically, it is not a true neoplasm but rather a compressive neuropathy characterized by perineural fibrosis, local vascular changes, and degeneration of the nerve fibers.

Question 46

A 32-year-old male sustains an acute Achilles tendon rupture. He is managed with a functional rehabilitation protocol. Compared to surgical repair, which of the following is true regarding his expected outcome?

Explanation

Recent literature shows that functional rehabilitation for acute Achilles ruptures yields similar re-rupture rates compared to surgical repair, while completely avoiding surgical wound complications.

Question 47

A 24-year-old football player sustains an axial load injury to a plantarflexed foot. Clinical examination reveals plantar ecchymosis. Weight-bearing radiographs demonstrate a 3 mm diastasis between the base of the first and second metatarsals. What is the most appropriate surgical management for a purely ligamentous injury in this patient?

Explanation

Primary arthrodesis for purely ligamentous Lisfranc injuries has been shown to yield better functional outcomes and lower reoperation rates compared to open reduction and internal fixation (ORIF).

Question 48

A 55-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. She can perform a single-leg heel rise but it is painful and accompanied by hindfoot valgus. On examination, the deformity is entirely flexible. Which of the following procedures is most appropriate?

Explanation

This patient has Stage II posterior tibial tendon dysfunction characterized by a flexible deformity. The gold standard surgical treatment involves a flatfoot reconstruction, typically an FDL transfer combined with a calcaneal osteotomy.

Question 49

During open reduction and internal fixation of a pronation-external rotation ankle fracture, the syndesmosis is found to be unstable after fibular fixation. Two trans-syndesmotic screws are placed. According to recent evidence, what is the recommendation regarding routine removal of these screws?

Explanation

Routine removal of asymptomatic syndesmotic screws is no longer recommended. Retained or broken screws do not significantly worsen clinical outcomes, and elective removal carries unnecessary surgical risks.

Question 50

A 60-year-old diabetic male presents with a red, hot, swollen unilateral foot. There are no open ulcers. To clinically differentiate acute Charcot arthropathy from a deep infection, which of the following bedside tests is most useful?

Explanation

Elevating the leg for 5 to 10 minutes will typically result in a decrease in erythema in acute Charcot arthropathy. Conversely, erythema caused by acute infection will persist despite elevation.

Question 51

A 45-year-old woman presents with a symptomatic hallux valgus deformity. Radiographs show a hallux valgus angle (HVA) of 26 degrees and an intermetatarsal angle (IMA) of 11 degrees. Clinical examination reveals hypermobility of the first tarsometatarsal joint. What is the most appropriate surgical procedure?

Explanation

While a distal chevron osteotomy is suitable for mild deformities, the presence of first ray hypermobility necessitates a Lapidus procedure (first TMT arthrodesis) to prevent recurrence and fully correct the deformity.

Question 52

A 35-year-old roofer falls from a height and sustains a closed, displaced intra-articular calcaneus fracture (Sanders Type III). He undergoes ORIF via an extensile lateral approach. Which of the following is the most common complication associated with this surgical approach?

Explanation

Wound complications, including edge necrosis, dehiscence, and infection, occur in up to 10-25% of cases utilizing the standard extensile lateral approach for calcaneus fractures.

Question 53

A 28-year-old male sustains a Hawkins Type III talar neck fracture. Six weeks postoperatively, an AP radiograph of the ankle reveals a subchondral radiolucent band in the dome of the talus. What does this radiographic finding indicate?

Explanation

The Hawkins sign (a subchondral radiolucent band) indicates active subchondral bone resorption. This physiologic process requires an intact blood supply, thereby effectively ruling out avascular necrosis of the talar body.

Question 54

A 22-year-old skier presents with lateral ankle pain and a snapping sensation behind the lateral malleolus when circumducting the foot. Radiographs demonstrate a 'fleck sign' avulsed from the lateral malleolus. Which anatomic structure is compromised?

Explanation

The fleck sign represents a bony avulsion of the superior peroneal retinaculum from the posterolateral fibula. This injury commonly leads to peroneal tendon subluxation or dislocation.

Question 55

A 20-year-old collegiate basketball player sustains an acute Zone II fracture of the proximal fifth metatarsal (Jones fracture). To minimize the risk of nonunion and allow early return to play, what is the treatment of choice?

Explanation

Intramedullary screw fixation is recommended for acute Jones fractures in high-level athletes to decrease the high nonunion rate associated with conservative care and to accelerate the return to competitive sports.

Question 56

A professional football running back sustains a hyperextension injury to his first metatarsophalangeal (MTP) joint. MRI confirms a complete tear of the plantar plate with proximal retraction of the sesamoids. What is the most appropriate management?

Explanation

A Grade 3 turf toe injury, characterized by a complete plantar plate tear and sesamoid retraction in a professional athlete, is generally treated with primary surgical repair to restore critical push-off strength.

Question 57

A 45-year-old distance runner undergoes a surgical plantar fascia release for recalcitrant plantar fasciitis after 18 months of failed conservative management. The surgeon completely releases the entire fascial band. What is the most likely biomechanical complication of this procedure?

Explanation

Complete release of the plantar fascia significantly decreases the longitudinal arch height and shifts peak plantar pressures laterally. This frequently results in lateral column overload and iatrogenic cuboid syndrome.

Question 58

A 60-year-old man complains of severe pain and stiffness in his right great toe. Examination reveals less than 10 degrees of dorsiflexion with pain throughout the entire range of motion. Radiographs show joint space obliteration and large dorsal osteophytes of the first MTP joint. What is the most reliable surgical treatment for pain relief?

Explanation

For advanced (Grade 3 or 4) hallux rigidus with pain throughout the range of motion and joint space obliteration, first MTP arthrodesis provides the most reliable, durable, and functional pain relief.

Question 59

A 55-year-old female presents with progressive medial ankle pain and a severe flatfoot deformity. Examination reveals a flexible hindfoot and forefoot abduction with greater than 30 percent talonavicular uncoverage on weight-bearing radiographs. She cannot perform a single-leg heel rise. What is the most appropriate surgical management for this Stage IIb adult acquired flatfoot deformity?

Explanation

Stage IIb posterior tibial tendon dysfunction is characterized by a flexible hindfoot with significant forefoot abduction (greater than 30% talonavicular uncoverage). Lateral column lengthening is necessary to correct the severe forefoot abduction and restore talonavicular joint alignment, combined with a medial displacement calcaneal osteotomy and FDL transfer.

Question 60

A 22-year-old collegiate football player sustains a hyperplantarflexion injury to his midfoot. He complains of severe midfoot pain and inability to bear weight. Non-weight-bearing radiographs of the foot appear completely normal. What is the most appropriate next step in confirming the diagnosis of a subtle Lisfranc injury?

Explanation

Weight-bearing radiographs are the essential next initial step to provoke and demonstrate subtle diastasis or instability at the Lisfranc (tarsometatarsal) articulation when non-weight-bearing films are negative. If weight-bearing films remain equivocal, an MRI or weight-bearing CT is indicated.

Question 61

A 40-year-old male is undergoing a percutaneous repair of an acute Achilles tendon rupture. During the passage of sutures in the proximal aspect of the tendon, which nerve is at the greatest risk of iatrogenic injury, and what is its typical anatomical relationship to the tendon?

Explanation

The sural nerve crosses the lateral border of the Achilles tendon roughly 10 to 12 cm proximal to its calcaneal insertion. This anatomical path places it at significant risk of capture or injury during percutaneous or minimally invasive Achilles repairs.

Question 62

A 35-year-old male presents after a high-speed motor vehicle collision with a displaced talar neck fracture. Radiographs confirm a Hawkins Type III injury. By definition, this classification indicates dislocation or subluxation of which of the following joints?

Explanation

The Hawkins classification for talar neck fractures is based on displacement. Type I is nondisplaced; Type II involves subtalar subluxation/dislocation; Type III involves both subtalar and tibiotalar dislocation; Type IV adds talonavicular dislocation.

Question 63

When performing open reduction and internal fixation of a displaced intra-articular calcaneus fracture with a flattened Bohler angle, what is the primary biomechanical and anatomical goal of the reconstruction?

Explanation

The primary goals of calcaneal ORIF are anatomical restoration of the posterior facet congruity, restoration of calcaneal height (Bohler's angle), and reduction of calcaneal width (lateral wall blowout) to prevent subfibular impingement.

Question 64

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

Explanation

In the setting of a severe hallux valgus deformity (IMA greater than 15 degrees) complicated by first ray hypermobility, a first TMT arthrodesis (Lapidus procedure) provides optimal multiplanar correction and restores stability to the medial column.

Question 65

A 25-year-old basketball player sustains a fifth metatarsal base fracture located strictly at the metaphyseal-diaphyseal junction (Zone 2). This specific fracture pattern has a notoriously high rate of delayed union and nonunion due to which of the following vascular characteristics?

Explanation

Zone 2 fractures (Jones fractures) occur at the metaphyseal-diaphyseal junction of the fifth metatarsal. This region is a vascular watershed area between the metaphyseal arterial supply and the distal nutrient artery, making it highly susceptible to nonunion.

Question 66

A 28-year-old downhill skier sustains an acute lateral ankle injury characterized by a popping sensation and subsequent retromalleolar pain. Examination reveals a subluxating peroneus brevis tendon. What is the most common mechanism of injury leading to acute disruption of the superior peroneal retinaculum (SPR)?

Explanation

Acute tears of the superior peroneal retinaculum typically occur from sudden dorsiflexion and eversion of the ankle while the peroneal muscles are undergoing a strong reflexive eccentric contraction.

Question 67

A 21-year-old elite football player suffers an acute hyperextension injury to his first metatarsophalangeal (MTP) joint. MRI confirms a complete rupture of the plantar plate with proximal retraction of the sesamoids (Grade 3 Turf Toe). What is the recommended management?

Explanation

Grade 3 turf toe injuries involve a complete tear of the plantar plate complex with sesamoid retraction. In elite athletes, surgical repair is indicated to restore push-off strength, stabilize the MTP joint, and prevent chronic deformity.

Question 68

A 60-year-old male with poorly controlled diabetes presents with a unilaterally red, hot, and swollen foot. There is no open ulceration. Radiographs show early bone fragmentation and joint subluxation at the tarsometatarsal joints. Inflammatory markers are mildly elevated. What is the most appropriate initial management?

Explanation

This presentation is characteristic of acute Eichenholtz stage I (fragmentation stage) Charcot neuroarthropathy. The gold standard for initial management is strict immobilization and offloading using a total contact cast to arrest deformity progression until the acute inflammatory phase resolves.

Question 69

During clinical evaluation of an acute ankle injury, the external rotation stress test produces severe pain anterior to the lateral malleolus. Which ligament is the primary restraint to anterior translation of the distal fibula and is typically the first to tear in a syndesmotic injury?

Explanation

The anterior inferior tibiofibular ligament (AITFL) is the most anterior structure of the syndesmosis. It provides the primary restraint to external rotation and anterior translation of the fibula and is reliably the first ligament injured in a syndesmotic sprain.

Question 70

A 48-year-old woman complains of chronic plantar foot pain, burning, and numbness that worsens with prolonged standing. Examination reveals a positive Tinel's sign posterior to the medial malleolus. Entrapment of which nerve is the primary cause of her symptoms?

Explanation

Tarsal tunnel syndrome is a compressive neuropathy of the posterior tibial nerve or its branches as it travels deep to the flexor retinaculum posterior to the medial malleolus.

Question 71

A 38-year-old construction worker falls from a height and sustains a high-energy tibial plafond (pilon) fracture. On presentation, the leg is massively swollen with multiple fracture blisters over the ankle. What is the standard protocol for surgical management of this injury?

Explanation

High-energy pilon fractures are associated with profound soft tissue compromise. A staged approach using initial spanning external fixation allows the swelling and fracture blisters to resolve (typically 10-21 days), significantly reducing the high risk of catastrophic wound complications during definitive ORIF.

Question 72

A 24-year-old professional ballet dancer presents with chronic posteromedial ankle pain, especially when en pointe. Examination reveals pseudo-hallux rigidus and triggering of the great toe during active motion. In this specific tendinopathy, where is the most common site of stenosing tenosynovitis?

Explanation

Flexor hallucis longus (FHL) tenosynovitis, often called dancer's tendinitis, most frequently occurs at the fibro-osseous tunnel at the posterior aspect of the talus, bordered by the medial and lateral talar tubercles.

Question 73

A 45-year-old female with chronic, severe plantar fasciitis has failed 6 months of conservative care, including dedicated Achilles and plantar fascia stretching, custom orthotics, and NSAIDs. She wishes to avoid surgery if possible. What is the most appropriate next step in her management?

Explanation

For plantar fasciitis refractory to primary non-operative measures, second-line conservative treatments such as local corticosteroid injections or extracorporeal shockwave therapy (ESWT) are indicated before resorting to surgical intervention. Calcaneal spur excision is rarely indicated.

Question 74

A 45-year-old female presents with a painful bunion. Radiographs reveal a hallux valgus angle of 35 degrees, an intermetatarsal angle of 14 degrees, and an abnormally increased distal metatarsal articular angle (DMAA) of 25 degrees. To appropriately correct the deformity while restoring joint congruency, which of the following procedures is required?

Explanation

A high DMAA indicates the articular surface is laterally deviated. A distal medial closing wedge osteotomy (such as a modified Chevron or Reverdin) is required to correct the articular orientation and achieve a congruent joint.

Question 75

During surgical fixation of a displaced intra-articular calcaneus fracture via an extensile lateral approach, meticulous soft tissue handling is necessary. Which nerve is at greatest risk of iatrogenic injury during the dissection and retraction of the inferior limb of this incision?

Explanation

The sural nerve courses posterior to the fibula and along the lateral aspect of the hindfoot. It is highly susceptible to injury or traction neuritis during the inferior horizontal limb of the extensile lateral approach to the calcaneus.

Question 76

A 55-year-old woman is diagnosed with acquired adult flatfoot deformity secondary to posterior tibial tendon dysfunction. Examination and weight-bearing radiographs reveal flexible hindfoot valgus and greater than 40% uncoverage of the talonavicular joint. What is the most appropriate surgical reconstruction?

Explanation

This patient has Stage IIb flatfoot deformity characterized by significant forefoot abduction (talonavicular uncoverage > 40%). Lateral column lengthening combined with an FDL transfer is required to adequately correct the severe abduction deformity.

Question 77

A 22-year-old competitive rugby player sustains a purely ligamentous Lisfranc injury with dynamic instability demonstrated on weight-bearing radiographs. To minimize the risk of articular cartilage damage and hardware breakage while allowing early return to sport, what is the current recommended surgical treatment?

Explanation

Dorsal spanning plates have become the preferred treatment for purely ligamentous Lisfranc injuries. They provide rigid fixation without violating the articular cartilage, avoiding the joint damage associated with transarticular screws.

Question 78

A 24-year-old professional soccer player presents with acute lateral foot pain after a cutting maneuver. Radiographs demonstrate a non-displaced fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal, extending into the fourth-fifth intermetatarsal articulation. What is the best management to ensure rapid return to sport and minimize nonunion risk?

Explanation

This is a Zone 2 (Jones) fracture, which occurs in a watershed vascular area and has a high rate of nonunion. In elite athletes, early intramedullary screw fixation is recommended to reduce nonunion risk and expedite return to play.

Question 79

A 35-year-old recreational athlete sustains an acute Achilles tendon rupture. The patient is debating between operative repair and nonoperative management utilizing a modern functional rehabilitation protocol with early weight-bearing. Based on current Level 1 evidence, how do the outcomes of these two approaches compare?

Explanation

Recent high-quality studies have demonstrated that when early functional rehabilitation protocols are utilized, the rerupture rates between nonoperative and operative management of Achilles tendon ruptures are statistically equivalent.

Question 80

A 30-year-old man underwent open reduction and internal fixation for a displaced Hawkins type III talar neck fracture. Six weeks postoperatively, an AP mortise radiograph reveals a distinct subchondral radiolucent band in the talar dome. What is the clinical significance of this radiographic finding?

Explanation

The subchondral radiolucent band, known as Hawkins sign, indicates subchondral osteopenia secondary to disuse. It is a highly reliable indicator that the talar body retains its blood supply, ruling out avascular necrosis.

Question 81

A 45-year-old construction worker falls from a ladder, sustaining a severely displaced, high-energy OTA type 43-C pilon fracture. The ankle exhibits massive soft tissue swelling and multiple fracture blisters. What is the safest and most appropriate initial management?

Explanation

High-energy pilon fractures with severe soft tissue compromise should be managed with a staged protocol. Initial spanning external fixation allows soft tissues to recover before definitive internal fixation, significantly reducing the risk of wound dehiscence and deep infection.

Question 82

A 24-year-old patient with Charcot-Marie-Tooth disease presents with a bilateral cavovarus foot deformity. During physical examination, a Coleman block test is performed and the hindfoot varus corrects to neutral. What does this specific finding indicate?

Explanation

The Coleman block test drops the first metatarsal off the block to eliminate its effect on the hindfoot. If the hindfoot varus corrects to neutral, it confirms a flexible hindfoot driven by a rigid plantarflexed first ray (forefoot-driven varus).

Question 83

A 28-year-old skier presents with chronic posterolateral ankle pain and a popping sensation when circumducting the ankle against resistance. Examination reveals the peroneal tendons translating anterior to the lateral malleolus. Incompetence of which anatomical structure is primarily responsible for this pathology?

Explanation

Peroneal tendon subluxation is caused by injury, avulsion, or incompetence of the superior peroneal retinaculum. Surgical repair or reconstruction of this structure is typically required to restore stability.

Question 84

A 70-year-old low-demand community ambulator reports feeling a "snap" over his anterior ankle while walking down stairs. He presents with a painless foot drop, a palpable step-off anterior to the ankle joint, and inability to actively dorsiflex the ankle. What is the most appropriate initial management?

Explanation

Atraumatic ruptures of the tibialis anterior tendon in elderly, low-demand patients are generally well-tolerated and best managed nonoperatively with an AFO. Operative management has higher complication rates and is reserved for younger, high-demand individuals.

Question 85

A 62-year-old patient with long-standing, poorly controlled diabetes mellitus and peripheral neuropathy sustains a displaced bimalleolar ankle fracture equivalent. When planning operative fixation, which technical modification is highly recommended to minimize the risk of catastrophic failure?

Explanation

Diabetic patients with neuropathy are at extremely high risk for hardware failure, nonunion, and Charcot neuroarthropathy following ankle fractures. Augmented fixation (e.g., locking plates, multiple syndesmotic screws, transarticular pins) and prolonged non-weight-bearing (often double the standard time) are essential.

Question 86

A 50-year-old diabetic patient presents with a swollen, erythematous, and warm unilateral foot. There are no open ulcers or signs of systemic infection. Radiographs demonstrate marked periarticular debris, bone fragmentation, and early subluxation of the tarsometatarsal joints. What is the current Eichenholtz stage and the standard of care treatment?

Explanation

The clinical and radiographic presentation is classic for Eichenholtz Stage I (Development/Fragmentation) Charcot neuroarthropathy. The gold standard for initial management is strict immobilization using a total contact cast to arrest the inflammatory process and prevent severe structural collapse.

Question 87

A 14-year-old boy presents with a history of recurrent ankle sprains and a rigid, painful flatfoot. Clinical exam reveals peroneal muscle spasm. A lateral radiograph demonstrates a tubular elongation of the anterior process of the calcaneus known as the "anteater nose" sign. Which anatomic joints are involved in this coalition?

Explanation

The "anteater nose" sign is a classic radiographic feature seen on the lateral projection, representing an elongated anterior calcaneal process that bridges toward the navicular. It is pathognomonic for a calcaneonavicular coalition.

Question 88

A 25-year-old professional athlete lands awkwardly on a plantarflexed foot. He complains of severe midfoot pain. Initial non-weight-bearing radiographs are normal, but subsequent weight-bearing radiographs reveal a 3 mm widening between the base of the 1st and 2nd metatarsals. What is the most appropriate management for this injury?

Explanation

Weight-bearing radiographs showing >2 mm diastasis between the 1st and 2nd metatarsal bases indicate an unstable Lisfranc injury. Surgical stabilization (ORIF or primary arthrodesis) is indicated for any evidence of instability to restore midfoot anatomy and prevent post-traumatic arthritis.

Question 89

A 45-year-old male sustains an acute Achilles tendon rupture while playing tennis. He opts for non-operative management. According to recent literature, which of the following is the most critical factor for optimizing his functional outcome and minimizing the risk of rerupture?

Explanation

Recent high-quality studies demonstrate that non-operative management utilizing early functional rehabilitation protocols yields functional outcomes and rerupture rates comparable to operative treatment, while avoiding surgical complications.

Question 90

A 55-year-old female presents with medial ankle pain and a progressive flatfoot deformity. Examination reveals she is unable to perform a single-leg heel raise, but the hindfoot remains flexible and corrects to neutral. Which of the following is the most commonly accepted surgical intervention for this condition?

Explanation

The patient has Stage II posterior tibial tendon dysfunction (PTTD), characterized by a flexible planovalgus deformity. Standard operative treatment involves a tendon transfer (typically FDL to navicular) combined with a medial displacement calcaneal osteotomy to correct the biomechanical axis.

Question 91

A 30-year-old man falls from a height and sustains a Hawkins Type III talar neck fracture. Based on the classification and typical vascular disruption, what is the approximate historical risk of developing avascular necrosis (AVN) of the talar body?

Explanation

Hawkins Type III fractures involve a talar neck fracture with dislocation of both the subtalar and tibiotalar joints. This disrupts all three major blood supplies to the talar body, leading to an exceptionally high risk of AVN, historically reported as 80-100%.

Question 92

A 21-year-old elite collegiate basketball player sustains an acute Zone 2 fracture of the proximal 5th metatarsal base (Jones fracture). To minimize the risk of nonunion and expedite his return to play, what is the recommended treatment?

Explanation

Zone 2 base of the 5th metatarsal fractures (Jones fractures) have a high propensity for nonunion due to watershed vascularity. In high-level athletes, intramedullary screw fixation is recommended to significantly decrease nonunion rates and allow a faster return to sports.

Question 93

A 40-year-old female presents with painful hallux valgus. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 38 degrees and an intermetatarsal angle (IMA) of 16 degrees. There is no hypermobility at the first tarsometatarsal joint. Which of the following surgical procedures is most appropriate to correct her deformity?

Explanation

An intermetatarsal angle (IMA) > 13 degrees indicates moderate to severe hallux valgus. A proximal metatarsal osteotomy or scarf osteotomy is necessary to provide the magnitude of correction required, as distal osteotomies are insufficient for an IMA of 16 degrees.

Question 94

A 62-year-old poorly controlled diabetic male who smokes 2 packs of cigarettes a day sustains a severely displaced intra-articular calcaneus fracture (Sanders Type III). His foot exhibits massive swelling and fracture blisters. What is the most appropriate definitive management?

Explanation

Patients with severe medical comorbidities, including poorly controlled diabetes, peripheral neuropathy, and heavy smoking, are at an unacceptably high risk for catastrophic soft tissue complications and infection with surgical intervention. Nonoperative management is generally preferred in this population.

Question 95

A 35-year-old patient undergoes open reduction and internal fixation of a Weber C fibula fracture. Following anatomic fixation of the fibula, an intraoperative intra-articular hook test is performed, demonstrating 4 mm of lateral shift of the fibula. What is the most appropriate next step in management?

Explanation

A positive intraoperative hook test after fibular fixation confirms an unstable syndesmotic disruption. Operative stabilization utilizing either syndesmotic screws or dynamic suture button devices is imperative to maintain the anatomic relationship of the distal tibiofibular joint.

Question 96

A 28-year-old downhill skier experiences acute posterolateral ankle pain after catching an edge, causing sudden forced dorsiflexion and inversion. Examination reveals swelling posterior to the lateral malleolus and a palpable snapping sensation with ankle circumduction. This clinical presentation is primarily associated with injury to which structure?

Explanation

Acute peroneal tendon subluxation or dislocation classically occurs following forced dorsiflexion and inversion, which ruptures or avulses the superior peroneal retinaculum from its attachment on the posterolateral fibula.

Question 97

A 14-year-old boy with Charcot-Marie-Tooth (CMT) disease presents with a progressive bilateral cavovarus foot deformity. Which specific muscle imbalance is the primary driver of the plantarflexed first ray commonly seen in this condition?

Explanation

In Charcot-Marie-Tooth disease, the hallmark cavovarus deformity is largely driven by a strong peroneus longus muscle overpowering a weakened tibialis anterior. This specific imbalance forces the first metatarsal into fixed plantarflexion.

Question 98

A collegiate football lineman sustains a severe hyperextension injury to his 1st metatarsophalangeal (MTP) joint. MRI reveals a complete rupture of the plantar plate with proximal retraction of the sesamoids (Grade III Turf Toe). What is the recommended treatment to restore function and allow return to elite play?

Explanation

A Grade III Turf Toe involves a complete tear of the plantar plate-sesamoid complex leading to gross instability. In high-level athletes, operative repair of the plantar plate is recommended to restore push-off strength and prevent chronic pain or progressive hallux rigidus.

Question 99

A 20-year-old cross-country runner complains of vague, aching midfoot pain that worsens with activity. Plain radiographs are unremarkable, but an MRI demonstrates a nondisplaced stress fracture involving the central third of the navicular bone. What is the gold standard initial non-operative management?

Explanation

Navicular stress fractures occur in the relatively avascular central third of the bone, placing them at high risk for nonunion. The gold standard non-operative treatment requires strict non-weight-bearing in a short leg cast for 6 to 8 weeks to allow adequate healing.

Question 100

A 65-year-old active male with end-stage post-traumatic ankle osteoarthritis is considering surgical intervention. He has well-aligned hindfoot joints and good bone stock. Compared to ankle arthrodesis, what is the primary biomechanical advantage of performing a Total Ankle Arthroplasty (TAA)?

Explanation

Total Ankle Arthroplasty (TAA) preserves sagittal plane motion, which improves gait kinematics and effectively reduces the biomechanical stress transferred to adjacent joints (e.g., subtalar, talonavicular). This theoretically protects adjacent joints from the development or progression of secondary osteoarthritis.

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

Foot & Ankle Orthopedic MCQs (Set 3): Fractures, Deformities & Tendon Injuries | AAOS & ABOS

Key Takeaway

Foot & Ankle Orthopedic MCQs (Set 3): Fractures, Deformities & Tendon Injuries | AAOS & ABOS

Chapter Index