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

OITE & ABOS Orthopedic Board Prep: Foot & Fracture MCQs Part 26

23 Apr 2026 138 min read 62 Views
OITE & ABOS Orthopedic Board Prep: Practice Exam Part 26

Key Takeaway

This page offers Part 26 of a comprehensive orthopedic surgery board review. It features 50 high-yield MCQs, mirroring OITE and AAOS exam formats, designed for orthopedic residents and surgeons. Utilize Study or Exam Mode to enhance your preparation for board certification exams.

OITE & ABOS Orthopedic Board Prep: Foot & Fracture MCQs Part 26

Comprehensive 100-Question Exam


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Question 1

A 35-year-old male sustains a high-energy motor vehicle collision resulting in an isolated Hawkins Type III talus neck fracture. Which of the following vessels provides the dominant blood supply to the talar body, placing it at the highest risk of avascular necrosis (AVN) in this injury pattern?





Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, provides the dominant blood supply to the talar body. It enters the talus inferiorly through the neck. Disruption of this vessel, along with others in displaced talar neck fractures (Hawkins III involves subtalar, tibiotalar, and talonavicular dislocation), drastically increases the risk of AVN.

Question 2

A 45-year-old roofer falls 15 feet and sustains a closed Sanders Type III calcaneus fracture. According to the Canadian Orthopaedic Trauma Society (COTS) multicenter randomized trial comparing operative versus nonoperative management of displaced intra-articular calcaneus fractures, which patient subgroup demonstrated significantly better outcomes with operative treatment?





Explanation

The landmark COTS trial (Buckley et al.) demonstrated that while overall functional outcomes were not significantly different between the operative and nonoperative groups as a whole, specific subgroups had significantly better outcomes with ORIF. These subgroups included women, younger patients, patients with a higher initial Böhler's angle, and patients who were not receiving worker's compensation.

Question 3

The Lisfranc ligament complex is critical for providing stability to the midfoot, particularly the tarsometatarsal joints. Anatomically, from which to which bones does the primary, strongest intra-articular band of the Lisfranc ligament attach?





Explanation

The Lisfranc ligament is a stout interosseous ligament that runs from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. There is no direct ligamentous connection between the first and second metatarsal bases, making this ligament crucial for midfoot stability.

Question 4

A 21-year-old collegiate basketball player sustains a zone 2 proximal fifth metatarsal fracture (Jones fracture). To maximize return to play, operative fixation with a solid intramedullary screw is planned. To ensure the screw threads completely bypass the fracture site without breaching the medial or plantar cortex, what is the ideal starting point for the guidewire on the fifth metatarsal tuberosity?





Explanation

The ideal starting point for intramedullary screw fixation of a Jones fracture is "high and inside" (dorsal and medial) on the fifth metatarsal tuberosity. Because the fifth metatarsal has a lateral and plantar bow, a starting point that is too lateral or plantar will result in eccentric screw placement and potential medial or plantar cortical breach.

Question 5

A 45-year-old male sustains a high-energy closed OTA/AO 43-C3 pilon fracture. A staged protocol (spanning external fixation followed by definitive ORIF) is selected. What is the most critical clinical indicator guiding the safe timing of definitive open reduction and internal fixation?





Explanation

Soft tissue condition strictly dictates the timing of definitive fixation in pilon fractures to minimize catastrophic wound complications. The appearance of skin wrinkles (the "wrinkle sign") indicates that soft-tissue edema has subsided sufficiently to allow surgical incisions to be closed without excessive tension.

Question 6

A 20-year-old track athlete complains of vague dorsal midfoot pain over the last 3 months. A CT scan confirms a non-displaced stress fracture through the central third of the tarsal navicular. What is the recommended initial management?





Explanation

Non-displaced navicular stress fractures are typically treated with strict non-weight-bearing in a short leg cast for 6-8 weeks. The central third of the navicular is relatively avascular (a vascular watershed area), making these fractures highly prone to nonunion or delayed union if weight-bearing is allowed early.

Question 7

A 28-year-old professional football player sustains an acute hyperextension injury to his first metatarsophalangeal (MTP) joint (Turf Toe). MRI demonstrates a complete rupture of the plantar plate. Which of the following is considered an absolute indication for operative repair rather than conservative management?





Explanation

Operative indications for turf toe (plantar plate injury) include a large intra-articular bony avulsion, diastasis of a bipartite sesamoid, a sesamoid fracture with diastasis, traumatic hallux valgus, frank vertical instability, or failure of conservative treatment. Traumatic hallux valgus indicates complete failure of the medial stabilizing structures requiring surgical repair.

Question 8

A 30-year-old male sustains a Gustilo-Anderson Grade IIIA open tibial shaft fracture. Based on the results of the Fluid Lavage of Open Wounds (FLOW) trial, which of the following irrigation strategies is recommended during the initial surgical debridement?





Explanation

The FLOW trial demonstrated that low-pressure irrigation is an acceptable, cost-effective alternative to high-pressure lavage, and that there was no benefit to using castile soap compared to normal saline. Low-pressure normal saline resulted in a lower reoperation rate for infection or wound healing problems compared to high-pressure lavage.

Question 9

A 25-year-old male presents with a closed, highly displaced tibial shaft fracture. Continuous compartment pressure monitoring reveals an absolute pressure of 35 mmHg in the anterior compartment. His current blood pressure is 115/80 mmHg. The patient is awake, alert, and reports moderate pain that is adequately controlled with oral analgesics. What is the most appropriate next step in management?





Explanation

Acute compartment syndrome diagnosis via monitoring is based on the delta pressure (Diastolic BP - Compartment Pressure). A delta pressure of < 30 mmHg is the accepted threshold for fasciotomy. Here, the delta pressure is 80 - 35 = 45 mmHg. Because delta pressure is > 30 mmHg and clinical signs do not indicate definitive ACS (pain is well-controlled), continued observation and monitoring are indicated.

Question 10

A 42-year-old recreational athlete sustains an acute Achilles tendon rupture. He discusses treatment options with his surgeon, who offers nonoperative management coupled with a functional rehabilitation protocol. Compared to operative repair, what does current level 1 evidence conclude regarding this nonoperative functional approach?





Explanation

Recent high-quality randomized controlled trials and meta-analyses show that when dynamic functional rehabilitation (early weight-bearing and early ROM in an orthosis) is employed, nonoperative management has an equivalent re-rupture rate and equivalent functional outcome compared to operative management, while entirely avoiding surgical complications such as infection.

Question 11

A 28-year-old female sustains a vertically oriented (Pauwels Type III) femoral neck fracture following a high-energy trauma. ORIF with a sliding hip screw and a derotational screw is planned. Biomechanically, what is the primary mode of construct failure for this specific fracture pattern?





Explanation

Pauwels Type III femoral neck fractures have a vertical fracture line (angle > 50 degrees). Biomechanically, they experience massive shear forces rather than compressive forces. The primary mode of failure is varus collapse and subsequent superior cut-out of the internal fixation construct.

Question 12

A 45-year-old pedestrian struck by a car presents with a hemodynamically stable APC-II (Anteroposterior Compression Type II) pelvic ring injury. Radiographs show a 3 cm pubic symphysis diastasis and widening of the anterior sacroiliac joints. According to the Young-Burgess classification, which of the following ligaments remains intact, preventing vertical instability?





Explanation

In an APC-II injury, the pubic symphysis, anterior sacroiliac ligaments, sacrotuberous, and sacrospinous ligaments are disrupted. The posterior sacroiliac ligaments remain intact. This allows the hemipelvis to externally rotate (rotational instability or "open book") but prevents cranial migration (maintains vertical stability).

Question 13

A 31-year-old male undergoes ORIF of a Weber C fibula fracture. Intraoperative external rotation stress testing reveals widening of the medial clear space, confirming a syndesmotic injury. A solid syndesmotic screw is planned. According to standard AO principles, what is an acceptable technique for screw placement?





Explanation

Syndesmotic screws are typically placed 2 to 4 cm proximal to the tibial plafond, parallel to the joint line, and angled 20-30 degrees anteriorly. Engaging either 3 cortices (tibia + fibula near cortex) or 4 cortices (both fibula and both tibia cortices) are both accepted techniques with similar long-term clinical outcomes.

Question 14

A 24-year-old skier presents with acute lateral ankle pain and a snapping sensation posterior to the fibula after an inversion and forced dorsiflexion injury. Radiographs reveal a "fleck sign" adjacent to the lateral malleolus. Injury to which anatomic structure is most strongly indicated by this radiographic finding?





Explanation

The "fleck sign" represents a bony avulsion from the posterolateral ridge of the fibula, which is the attachment site of the superior peroneal retinaculum (SPR). Injury to the SPR is the hallmark of peroneal tendon subluxation or dislocation.

Question 15

A 22-year-old snowboarder presents with lateral ankle pain mimicking a severe ankle sprain following a hard landing. Point tenderness is maximized just inferior and anterior to the lateral malleolus. CT confirms a displaced fracture of the lateral process of the talus. If left untreated, this injury most commonly leads to post-traumatic arthritis in which joint?





Explanation

A "snowboarder's fracture" is a fracture of the lateral process of the talus. This anatomical structure articulates with the fibula superiorly and the calcaneus inferiorly (forming part of the posterior facet of the subtalar joint). Displaced, unrecognized fractures frequently lead to subtalar osteoarthritis and chronic lateral ankle pain.

Question 16

A horseback rider falls and catches their foot in the stirrup, causing forced plantarflexion and abduction of the forefoot. They sustain a comminuted "nutcracker" fracture of the cuboid. What is the primary biomechanical goal of operative treatment (e.g., ORIF and bone grafting) for this specific injury?





Explanation

A "nutcracker" fracture of the cuboid is a compression/crush injury resulting in severe shortening of the lateral column of the foot. The primary goal of operative management is to restore lateral column length and maintain alignment of the midfoot, often requiring a bridging plate and structural bone graft.

Question 17

A 33-year-old male sustains a midfoot crush injury in a high-speed motorcycle crash. Imaging reveals a combined Chopart and Lisfranc dislocation. Following closed reduction, a temporary spanning external fixator is placed. Which sequence of bones anatomically defines the medial column of the foot that must eventually be restored to proper length for normal foot biomechanics?





Explanation

The foot is divided longitudinally into columns. The medial column consists of the talus, navicular, medial cuneiform, and first metatarsal. Restoring the length and alignment of the medial column is vital for re-establishing the longitudinal arch and normal gait biomechanics.

Question 18

A 72-year-old female with profound osteoporosis sustains a displaced 4-part proximal humerus fracture. A reverse total shoulder arthroplasty (RTSA) is chosen over hemiarthroplasty. What is the primary biomechanical rationale for utilizing RTSA in this specific patient scenario?





Explanation

In elderly patients with 4-part proximal humerus fractures, the tuberosities (and thus the rotator cuff attachments) frequently fail to heal or resorb. Hemiarthroplasty relies on tuberosity healing for function. RTSA bypasses this need by medializing and distalizing the joint's center of rotation, which increases the deltoid's moment arm and allows it to elevate the arm even in the absence of a functional rotator cuff.

Question 19

A 65-year-old female presents 8 weeks after successful closed reduction and casting of a non-displaced distal radius fracture. She now reports a sudden inability to actively extend her thumb interphalangeal joint. What is the most likely pathophysiologic mechanism for her current presentation?





Explanation

Extensor pollicis longus (EPL) tendon rupture is a well-known complication of distal radius fractures, occurring most frequently in non-displaced or minimally displaced fractures. The tendon undergoes vascular ischemia (it is in a watershed zone) and mechanical attrition as it glides over fracture callus or sharp cortical edges at Lister's tubercle in the third dorsal compartment.

Question 20

A 22-year-old farmer sustains an open tibial shaft fracture after his leg is caught in a tractor power take-off. The wound is 12 cm long with extensive muscle crushing, but pulses are intact (Gustilo-Anderson IIIA). The wound is heavily contaminated with soil and manure. In addition to a first-generation cephalosporin and an aminoglycoside, what prophylactic antibiotic should be strongly considered in this specific environment?





Explanation

In agricultural injuries or wounds heavily contaminated with soil, there is a significantly increased risk of anaerobic infections, specifically Clostridium perfringens, which can cause devastating gas gangrene. High-dose Penicillin (or Ampicillin) is classically added to the standard antibiotic regimen (Cephalosporin + Aminoglycoside) to provide coverage against these anaerobes.

Question 21

Which radiographic parameter is the most reliable indicator of syndesmotic widening on a mortise radiograph of the ankle?





Explanation

The tibiofibular clear space (measured 1 cm proximal to the plafond) should be less than 5 mm on both the AP and mortise views. It is considered the most reliable radiographic parameter for assessing syndesmotic integrity because, unlike tibiofibular overlap, it is relatively independent of ankle rotation. A clear space > 5 mm indicates widening of the syndesmosis.

Question 22

The artery of the tarsal canal provides the dominant blood supply to the body of the talus. This vessel is a direct branch of which of the following arteries?





Explanation

The artery of the tarsal canal is a branch of the posterior tibial artery. It typically arises 1-2 cm proximal to the bifurcation into the medial and lateral plantar arteries. It supplies the medial two-thirds of the talar body and gives off the deltoid artery. The artery of the tarsal sinus (which anastomoses with the artery of the tarsal canal) is formed by branches from the dorsalis pedis and perforating peroneal arteries.

Question 23

A 35-year-old male presents with a stiff, painful foot one year after undergoing ORIF for a displaced talar neck fracture. Radiographs reveal a varus malunion of the talar neck. Which of the following biomechanical consequences is the primary cause of his restricted foot motion?





Explanation

Varus malunion is the most common complication following talar neck fractures. A varus malunion decreases the ability of the subtalar joint to evert. Because the axes of the talonavicular and calcaneocuboid joints must become parallel (which occurs during hindfoot eversion) to unlock the transverse tarsal (Chopart) joint and allow midfoot flexibility, a loss of subtalar eversion effectively 'locks' the transverse tarsal joint. This results in a rigid, stiff foot and a supinated forefoot that cannot compensate during gait.

Question 24

A 24-year-old professional football player sustains a purely ligamentous Lisfranc injury. Based on prospective randomized data (e.g., Ly and Coetzee), which of the following statements comparing primary arthrodesis to open reduction internal fixation (ORIF) is true?





Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the first, second, and third tarsometatarsal joints has been shown to provide better functional outcomes and lower rates of hardware removal and secondary salvage procedures (due to post-traumatic arthritis) compared to ORIF. Ly and Coetzee's landmark prospective randomized study demonstrated superiority of primary arthrodesis over ORIF in purely ligamentous injuries.

Question 25

Recent meta-analyses (such as Willits et al.) comparing early functional rehabilitation (non-operative) to surgical repair for acute Achilles tendon ruptures have demonstrated which of the following?





Explanation

Recent high-level evidence, including randomized controlled trials and meta-analyses, has shown that when an early functional rehabilitation protocol (early weight-bearing and ROM in a boot) is utilized, the re-rupture rates between operative and non-operative management of acute Achilles tendon ruptures are statistically similar. However, surgical repair is associated with a higher risk of complications, such as infection, wound healing issues, and sural nerve injury.

Question 26

A 22-year-old track athlete is diagnosed with a stress fracture of the navicular. This is considered a 'high-risk' stress fracture primarily due to a relative avascular zone located in which anatomic region of the navicular?





Explanation

The navicular is prone to stress fractures, particularly in jumping and sprinting athletes. It is considered a high-risk stress fracture (high risk of delayed union or nonunion) due to a watershed area of poor blood supply in the central third of the navicular body. Blood vessels enter the navicular medially and laterally, leaving the central portion relatively avascular.

Question 27

When utilizing the extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, creating a full-thickness subperiosteal flap is critical to avoid wound necrosis. Which artery serves as the primary vascular supply to this flap?





Explanation

The lateral calcaneal artery, a branch of the peroneal artery, provides the main angiosome for the lateral skin of the hindfoot. During an extensile lateral approach to the calcaneus, a full-thickness 'no-touch' subperiosteal flap must be elevated off the lateral wall of the calcaneus to preserve this vascular supply and minimize the risk of wound slough and necrosis.

Question 28

A 45-year-old female sustains a Bosworth fracture-dislocation of the ankle. Standard closed reduction attempts in the emergency department are unsuccessful. This irreducibility is due to the proximal fibular fragment becoming entrapped behind which anatomic structure?





Explanation

A Bosworth fracture-dislocation is a rare injury characterized by an irreducible fracture-dislocation of the ankle where the proximal fragment of the fractured fibula displaces posteriorly and becomes mechanically locked behind the posterior tubercle of the distal tibia. Closed reduction is typically impossible, necessitating emergent open reduction.

Question 29

A 20-year-old collegiate basketball player presents with lateral foot pain. Radiographs reveal a non-displaced fracture of the proximal fifth metatarsal diaphysis, distal to the fourth and fifth metatarsal articulation (Zone 3). What is the recommended primary treatment to ensure optimal return to play?





Explanation

The patient has a Zone 3 fracture of the fifth metatarsal, which is a stress fracture of the proximal diaphysis. These fractures have a high rate of nonunion due to poor blood supply. In an elite athlete, early surgical intervention with intramedullary screw fixation is highly recommended to decrease the risk of nonunion and expedite return to sport. Zone 1 fractures (pseudo-Jones/tuberosity) are treated symptomatically; Zone 2 (Jones) fractures occur at the metaphyseal-diaphyseal junction and can be treated non-operatively in non-athletes, but athletes often undergo IM screw fixation as well.

Question 30

A 28-year-old wide receiver sustains a hyperextension injury to his first metatarsophalangeal (MTP) joint, resulting in a severe turf toe. Which of the following is considered an absolute indication for surgical intervention?





Explanation

Turf toe is a sprain of the first MTP joint plantar plate complex. Grade 3 injuries involve complete tears of the plantar plate. Indications for operative management of turf toe include: large intra-articular loose bodies/fractures, traumatic hallux valgus deformity, gross clinical instability, and proximal migration of the sesamoids > 3 mm (indicating a complete tear of the plantar plate and flexor hallucis brevis from the base of the proximal phalanx).

Question 31

A 35-year-old male sustains a high-energy Type C tibial pilon fracture. He is initially placed in a spanning external fixator. Which of the following is the most reliable clinical indicator that the soft tissue envelope has recovered sufficiently to proceed with definitive open reduction and internal fixation?





Explanation

Timing of definitive surgery for pilon fractures is dictated by the status of the soft tissue envelope to avoid catastrophic wound complications. The most reliable clinical sign that the swelling has subsided adequately is the return of normal skin creases, often assessed by the 'wrinkle test' (epithelializing skin wrinkles). This typically takes 10 to 21 days.

Question 32

In the management of an unstable ankle fracture, the posterior malleolus is often evaluated for fixation. Biomechanical studies have shown that direct osteosynthesis of the posterior malleolus provides greater syndesmotic stability than isolated trans-syndesmotic screws because it directly restores the tension of which ligament?





Explanation

The posterior inferior tibiofibular ligament (PITFL) attaches to the posterior malleolus. The PITFL provides approximately 40-50% of the stability of the syndesmosis. Anatomically reducing and fixing a posterior malleolus fracture directly restores the PITFL's stabilizing function, providing superior biomechanical strength to the syndesmosis compared to trans-syndesmotic screw fixation alone.

Question 33

A 14-year-old girl presents with a unilateral cavovarus foot deformity. A Coleman block test is performed by placing her heel and lateral border of the foot on a 1-inch block, allowing the first metatarsal to drop off the edge. During the test, her hindfoot varus completely corrects to neutral. This finding indicates which of the following?





Explanation

The Coleman block test evaluates the flexibility of hindfoot varus in a cavovarus foot. By allowing the plantarflexed first ray to hang off the block, it eliminates the forefoot's contribution to the hindfoot posture. If the hindfoot varus corrects to neutral, the deformity is flexible and primarily driven by the plantarflexed first ray. In this scenario, correction should focus on the forefoot, such as a dorsiflexion osteotomy of the first metatarsal (often accompanied by soft tissue releases).

Question 34

A 13-year-old boy presents with frequent ankle sprains and rigid, painful flatfeet. Radiographs demonstrate a 'C-sign', and a CT scan confirms a talocalcaneal coalition involving approximately 60% of the posterior facet with evidence of degenerative changes. Non-operative management has failed. What is the most appropriate surgical treatment?





Explanation

Tarsal coalitions typically present as rigid flatfeet. The 'C-sign' on a lateral radiograph is indicative of a talocalcaneal coalition. Surgical resection of the coalition is typically indicated if the coalition involves less than 50% of the subtalar joint surface and there is no degenerative arthritis. If the coalition involves >50% of the joint or if degenerative arthritic changes are present, a subtalar arthrodesis (or triple arthrodesis if adjacent joints are involved) is the recommended treatment.

Question 35

A 55-year-old female presents with stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible flatfoot deformity and greater than 40% uncovering of the talonavicular joint on the AP radiograph. What is the standard of care surgical reconstruction for this specific stage?





Explanation

Stage II PTTD is a flexible deformity. Stage IIa has minimal forefoot abduction, while Stage IIb has significant forefoot abduction (typically >30-40% talonavicular uncovering). To correct the severe forefoot abduction in Stage IIb, a lateral column lengthening (such as an Evans calcaneal osteotomy or calcaneocuboid distraction arthrodesis) is required in addition to an FDL transfer and often a medial displacement calcaneal osteotomy (MDCO) to correct the hindfoot valgus.

Question 36

A 58-year-old patient with poorly controlled diabetes mellitus presents with a warm, swollen, erythematous right foot. There are no open wounds or ulcers. Radiographs demonstrate periarticular bony fragmentation and subluxation at the tarsometatarsal joints. Laboratory studies show a normal ESR, normal CRP, and WBC count of 7.0. What is the most appropriate initial management?





Explanation

This patient has an acute Charcot arthropathy (Eichenholtz Stage I - Fragmentation phase). The presentation mimics infection (red, hot, swollen foot), but the lack of an ulcer and normal inflammatory markers support a diagnosis of Charcot neuroarthropathy rather than osteomyelitis. The gold standard initial treatment in the acute fragmentation phase is immobilization with a total contact cast (TCC) and strict non-weight-bearing to prevent further deformity until the active inflammatory phase resolves.

Question 37

A 40-year-old female presents with a painful bunion. Clinical examination reveals hypermobility of the first tarsometatarsal (TMT) joint. Weight-bearing radiographs demonstrate a hallux valgus angle of 45 degrees and an intermetatarsal angle of 18 degrees. Which of the following surgical procedures is most appropriate to address her deformity?





Explanation

This patient has a severe hallux valgus deformity (IMA > 15 degrees, HVA > 40 degrees) associated with clinical hypermobility of the first TMT joint. The Lapidus procedure involves arthrodesis of the first TMT joint. It provides powerful correction for large intermetatarsal angles and inherently addresses the hypermobility of the first ray, making it the procedure of choice in this scenario.

Question 38

A 66-year-old male presents with severe pain in his great toe with walking. Examination reveals only 5 degrees of dorsiflexion and pain at all ranges of motion. Radiographs show a complete loss of the first MTP joint space, severe flattening of the metatarsal head, and large dorsal and lateral osteophytes (Coughlin and Shurnas Grade 4 Hallux Rigidus). Which of the following is the most definitive and reliable surgical option?





Explanation

For advanced (Grade 3 or 4) hallux rigidus where there is near complete loss of the joint space and pain throughout the entire range of motion (Grade 4), a dorsal cheilectomy will fail because the articular cartilage is already destroyed. First MTP joint arthrodesis is the gold standard and most reliable surgical option for pain relief and functional improvement in severe hallux rigidus.

Question 39

When performing a medial approach to release the compartments of the foot for acute compartment syndrome, the surgeon makes an incision along the medial border of the foot. Which muscle must be mobilized and retracted superiorly to gain access to the central and deep (calcaneal) compartments?





Explanation

The foot has 9 discrete compartments. A common approach for complete fasciotomy utilizes two dorsal incisions and one medial incision. Through the medial incision (made along the inferior border of the first metatarsal to the medial calcaneus), the abductor hallucis muscle and its investing fascia are identified and retracted superiorly (dorsally). This allows the surgeon to access and release the central, interosseous, and deep calcaneal compartments.

Question 40

An 8-week postoperative AP radiograph of an ankle after open reduction and internal fixation of a Hawkins Type II talar neck fracture reveals a subchondral radiolucent band in the dome of the talus. This radiographic finding (Hawkins sign) is indicative of which of the following processes?





Explanation

The Hawkins sign is a subchondral radiolucent band seen in the dome of the talus on an AP or mortise ankle radiograph, typically visible 6 to 8 weeks after a talar neck fracture. It represents subchondral osteopenia/resorption due to disuse. Because bone resorption requires an active blood supply, the presence of a Hawkins sign is a highly reliable indicator that the talar body retains sufficient vascularity and that avascular necrosis is unlikely to occur.

Question 41

A 32-year-old male sustains a Hawkins Type II talar neck fracture. At his 8-week follow-up, an AP radiograph of the ankle reveals a subchondral radiolucent band in the dome of the talus (Hawkins sign). What does this radiographic finding indicate?





Explanation

The Hawkins sign is a subchondral radiolucent band seen in the talar dome on an AP or mortise radiograph 6 to 8 weeks after a talar neck fracture. It represents subchondral atrophy from disuse in the presence of an intact blood supply, thereby indicating intact vascularity and serving as a reliable negative predictor of avascular necrosis.

Question 42

A 24-year-old snowboarder presents with lateral ankle pain after a hard landing. Radiographs are negative for a lateral malleolus fracture, but a CT scan reveals a displaced fracture of the lateral process of the talus. What is the typical mechanism of injury for this specific fracture pattern?





Explanation

Fractures of the lateral process of the talus (Snowboarder's fracture) typically occur due to dorsiflexion and axial loading combined with inversion or eversion, most commonly eversion. They are often misdiagnosed as severe ankle sprains. Large or displaced fragments (>2 mm) typically require ORIF or excision.

Question 43

When evaluating a patient for a suspected syndesmotic injury on standard ankle radiographs, which of the following parameters is the most accurate radiographic indicator of syndesmosis widening on an AP view?





Explanation

The tibiofibular clear space is measured 1 cm proximal to the joint line. A distance of >5 mm on the AP or mortise view is considered abnormal and is the most reliable radiographic indicator of syndesmotic injury. Tibiofibular overlap is highly dependent on rotation and is therefore less reliable.

Question 44

In the context of a pilon fracture, the anterior inferior tibiofibular ligament (AITFL) remains attached to which of the following specific fracture fragments?





Explanation

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

Question 45

To minimize wound complications when utilizing an extensile lateral approach for a calcaneus fracture, the surgical flap must be elevated as a full-thickness subperiosteal flap. Which of the following arteries is the primary vascular supply to this flap?





Explanation

The extensile lateral approach creates a large L-shaped flap. To prevent tip necrosis and wound breakdown, it must be elevated as a 'no-touch' full-thickness subperiosteal flap. The primary blood supply to this flap is the lateral calcaneal artery, which is a terminal branch of the peroneal artery.

Question 46

A 21-year-old track athlete is diagnosed with a delayed union of a navicular stress fracture. Which of the following anatomic factors primarily contributes to the high risk of nonunion in this specific bone?





Explanation

The tarsal navicular has a watershed (avascular) zone in its central third. The blood supply enters dorsally and plantarly, leaving the central third relatively avascular. This anatomic feature predisposes central third navicular stress fractures to a higher rate of delayed union and nonunion.

Question 47

A 35-year-old equestrian falls from a horse, sustaining a 'nutcracker' fracture of the cuboid with 4 mm of lateral column shortening. What is the most appropriate surgical management?





Explanation

A 'nutcracker' fracture of the cuboid involves compression of the cuboid between the calcaneus and the 4th/5th metatarsals, leading to lateral column shortening. Symptomatic shortening (>3 mm) alters foot biomechanics, leading to midfoot abductus. The standard of care is ORIF with structural bone grafting (often from the iliac crest or allograft) to restore lateral column length.

Question 48

A 40-year-old male sustains an irreducible ankle fracture-dislocation. Radiographs show a fibula fracture with the proximal fibular fragment entrapped behind the posterior tubercle of the distal tibia. What is this specific injury pattern named?





Explanation

A Bosworth fracture-dislocation is a rare injury where the proximal fibular shaft fragment displaces posteriorly and becomes mechanically entrapped behind the posterior tubercle of the tibia. This typically requires open reduction because closed reduction is blocked by the intact interosseous membrane and the bony anatomy of the posterolateral tibia.

Question 49

A 28-year-old football player sustains a midfoot injury. An AP radiograph reveals a small bony avulsion fragment in the space between the bases of the first and second metatarsals (Fleck sign). From which anatomic structure did this fragment avulse?





Explanation

The 'Fleck sign' represents an avulsion of the Lisfranc ligament. The Lisfranc ligament connects the lateral aspect of the medial cuneiform to the medial aspect of the second metatarsal base. The avulsion fragment (Fleck sign) typically originates from the medial base of the second metatarsal.

Question 50

A 22-year-old elite basketball player sustains a fracture of the fifth metatarsal. Radiographs show a transverse fracture extending into the intermetatarsal articulation between the 4th and 5th metatarsals. What is the most appropriate initial management for this specific injury to ensure the fastest return to play and lowest nonunion rate?





Explanation

This describes a true Jones fracture (Zone 2), which involves the metaphyseal-diaphyseal junction and extends into the 4th-5th intermetatarsal facet. Due to the watershed blood supply in this region, there is a high risk of nonunion. In elite or competitive athletes, early intramedullary screw fixation is recommended to decrease the time to return to play and reduce the nonunion risk compared to conservative management.

Question 51

According to the Lauge-Hansen classification, a Supination-External Rotation (SER) stage II ankle injury is characterized by which of the following?





Explanation

In the Lauge-Hansen Supination-External Rotation (SER) classification: Stage I is injury to the AITFL; Stage II is a spiral or short oblique fracture of the distal fibula (posteroinferior to anterosuperior); Stage III is injury to the PITFL or a posterior malleolus fracture; Stage IV is a transverse fracture of the medial malleolus or deltoid ligament rupture.

Question 52

A 28-year-old gymnast sustains a superior peroneal retinaculum (SPR) tear, resulting in peroneal tendon subluxation. Which anatomical variation is most frequently associated with an increased risk of this specific pathology?





Explanation

A convex, flat, or shallow retromalleolar fibular groove is a significant predisposing anatomic factor for peroneal tendon subluxation and dislocation. Surgical treatment often involves groove deepening procedures in addition to SPR repair. While a low-lying peroneus brevis muscle belly can contribute by overcrowding the space, the groove morphology is the most classic and surgically addressed structural risk factor.

Question 53

When performing fasciotomies for acute compartment syndrome of the foot using a combined dorsal and medial approach, the surgeon must access the calcaneal compartment. Which of the following muscles is uniquely located within the calcaneal compartment?





Explanation

The foot has 9 distinct fascial compartments. The calcaneal compartment contains the quadratus plantae muscle and the lateral plantar neurovascular bundle. The medial compartment contains the abductor hallucis and flexor hallucis brevis. The superficial compartment contains the flexor digitorum brevis. The adductor compartment contains the adductor hallucis.

Question 54

During anterior ankle arthroscopy, the anterolateral portal is established. Which nerve is at greatest risk of iatrogenic injury during the placement of this specific portal?





Explanation

The anterolateral portal is placed just lateral to the peroneus tertius tendon. The intermediate dorsal cutaneous branch of the superficial peroneal nerve (SPN) crosses the joint very close to this area and is at high risk of injury. The anteromedial portal risks the saphenous nerve. The anterocentral portal risks the deep peroneal nerve and dorsalis pedis artery.

Question 55

A 45-year-old roofer falls from a ladder and sustains an intra-articular calcaneus fracture. On the lateral radiograph, the Crucial Angle of Gissane is measured. An abnormal increase in this angle typically indicates which of the following mechanical derangements?





Explanation

The Crucial Angle of Gissane is formed by the intersection of the downward slope of the posterior facet and the upward slope of the anterior process. An increase in this angle (normally 100-130 degrees) usually indicates collapse of the posterior facet (the posterior facet is driven plantarly), which flattens the angle.

Question 56

Recent literature regarding the fixation of posterior malleolus fractures in the setting of rotational ankle injuries emphasizes which of the following as the primary indication for open reduction and internal fixation of the posterior fragment?





Explanation

Historically, a fragment size >25-30% of the articular surface was the main indication for fixing the posterior malleolus. However, recent biomechanical and clinical studies emphasize that fixation of the posterior malleolus directly restores the posterior inferior tibiofibular ligament (PITFL) footprint, reconstituting the incisura fibularis and providing superior syndesmotic stability compared to trans-syndesmotic screws alone, regardless of the fragment's articular size.

Question 57

A 55-year-old patient with poorly controlled type 2 diabetes presents with a swollen, erythematous, and warm left foot. Radiographs demonstrate periarticular fragmentation, bony debris, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what is the current stage of this patient's Charcot arthropathy?





Explanation

Eichenholtz Stage I (Developmental/Fragmentation) is characterized clinically by a red, hot, swollen foot and radiographically by bony debris, fragmentation, subluxation/dislocation, and osteopenia. Stage II (Coalescence) shows absorption of debris and early fusion. Stage III (Reconstruction) shows consolidation, remodeling, and smoothing of bone edges.

Question 58

A 20-year-old collegiate wide receiver sustains an acute hyper-dorsiflexion injury to his first metatarsophalangeal (MTP) joint. MRI confirms a Grade III 'Turf Toe' injury with complete rupture of the plantar plate from the base of the proximal phalanx, associated with proximal migration of the sesamoids. What is the most appropriate definitive management?





Explanation

Grade III Turf Toe injuries involve a complete tear of the plantar plate and capsuloligamentous complex. In high-level athletes, especially when accompanied by frank instability or proximal migration of the sesamoids (indicating loss of the flexor hallucis brevis mechanical advantage), surgical repair is indicated to restore push-off strength and joint stability. Grades I and II are generally managed nonoperatively.

Question 59

A 35-year-old male is involved in a high-speed motor vehicle collision and sustains a purely ligamentous Chopart joint dislocation. Which two specific articulations comprise the Chopart joint line?





Explanation

The Chopart joint, or transverse tarsal joint, connects the hindfoot to the midfoot. It is composed of two articulations: the talonavicular joint medially and the calcaneocuboid joint laterally.

Question 60

A 42-year-old female presents with a high-energy pilon fracture. On examination, the anteromedial ankle exhibits several blood-filled fracture blisters. What histological difference distinguishes blood-filled fracture blisters from clear fluid-filled fracture blisters?





Explanation

Clear fluid blisters represent cleavage within the epidermis, leaving the basal layer intact. Blood-filled blisters represent a deeper injury, characterized by complete separation of the epidermis from the dermis, which disrupts the dermal vascular plexus. Re-epithelialization takes much longer for blood-filled blisters, and surgical incisions through these areas carry a significantly higher risk of wound breakdown.

Question 61

A 24-year-old snowboarder presents with lateral ankle pain after a hard landing. Radiographs are negative, but CT reveals a comminuted fracture of the lateral process of the talus. Which of the following is the most appropriate management for a displaced (>2mm) fracture of this structure?





Explanation

Displaced (>2mm) or large fractures of the lateral process of the talus (snowboarder's fracture) are best treated with ORIF to restore the subtalar joint surface and prevent early post-traumatic arthritis. Small comminuted fragments that are not amenable to fixation may be excised.

Question 62

A 32-year-old man sustained a Hawkins type II talar neck fracture and underwent open reduction and internal fixation. At 8 weeks postoperatively, an AP radiograph of the ankle reveals subchondral radiolucency in the talar dome. What does this radiographic finding indicate?





Explanation

The Hawkins sign is subchondral radiolucency of the talar dome visible on an AP radiograph typically 6 to 8 weeks after injury. It indicates subchondral atrophy from disuse and relies on intact vascularity to the talar body, thereby essentially ruling out avascular necrosis.

Question 63

A 21-year-old collegiate basketball player sustains an acute Jones fracture (Zone 2 of the fifth metatarsal base). He desires the fastest possible return to play. Which of the following treatments provides the most reliable and rapid return to sports?





Explanation

Zone 2 fractures (Jones fractures) occur at the metaphyseal-diaphyseal junction and involve the 4-5 intermetatarsal articulation. In elite athletes, early intramedullary screw fixation is recommended to reduce the risk of nonunion and allow for an accelerated return to play compared to nonoperative management.

Question 64

A 19-year-old track athlete complains of vague dorsal midfoot pain that worsens with sprinting. Radiographs are normal. MRI shows a linear signal abnormality in the central third of the navicular. CT scan confirms an incomplete, non-displaced fracture in the sagittal plane. What is the recommended initial management?





Explanation

Non-displaced navicular stress fractures are initially treated with a strict non-weight bearing cast for 6-8 weeks. Weight-bearing or walking boots have an unacceptably high rate of failure and nonunion. Surgical fixation is indicated for displaced fractures, nonunions, or recurrent fractures.

Question 65

The Sanders classification for intra-articular calcaneus fractures is based on the number of fracture lines through the posterior facet as seen on which specific imaging view?





Explanation

The Sanders classification of intra-articular calcaneus fractures relies on coronal CT images. The classification is based on the number and location of fracture lines entering the posterior facet at the widest point of the undersurface of the posterior facet of the talus.

Question 66

A 35-year-old man injures his foot while missing a step. An AP radiograph shows a small bony avulsion fragment in the space between the medial cuneiform and the base of the second metatarsal. This 'fleck sign' represents an avulsion of a ligament that connects which two structures?





Explanation

The Lisfranc ligament is a strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. The 'fleck sign' is a small bony avulsion from the base of the second metatarsal indicating rupture of this ligament.

Question 67

A 60-year-old patient with poorly controlled type 2 diabetes and profound peripheral neuropathy sustains a trimalleolar ankle fracture. Which of the following modifications to standard internal fixation is most appropriate to minimize complications in this patient?





Explanation

Diabetic patients with peripheral neuropathy are at high risk for hardware failure, Charcot arthropathy, and skin breakdown. Standard fixation is often inadequate. Enhanced rigid fixation (e.g., locking plates, multiple syndesmotic screws, trans-articular Kirschner wires, or tibiotalocalcaneal nailing) and prolonged non-weight bearing (often double the standard time) are recommended.

Question 68

During the surgical planning for a complex tibial pilon fracture, the surgeon notes a distinct anterolateral distal tibia fracture fragment. Which ligament provides the primary soft tissue attachment to this fragment (Chaput fragment)?





Explanation

The anterolateral fragment of the distal tibia in pilon and Tillaux fractures is known as the Chaput fragment. It serves as the tibial attachment for the anterior inferior tibiofibular ligament (AITFL).

Question 69

A 25-year-old man presents with medial ankle pain and swelling after an external rotation injury. Radiographs show a widening of the medial clear space but no medial malleolar fracture. Which of the following is the most appropriate next step in radiographic evaluation?





Explanation

Medial clear space widening without a medial malleolus fracture indicates a deltoid ligament rupture and a syndesmotic injury. An external rotation force often transmits proximally, causing a proximal third fibula fracture (Maisonneuve fracture). Full-length tibia/fibula radiographs are required to identify this fracture.

Question 70

A 30-year-old woman is evaluated for a severe ankle fracture-dislocation. Attempts at closed reduction in the emergency department are unsuccessful. Radiographs show a posterior subluxation of the talus with the proximal fibular fragment entrapped behind the posterior tubercle of the tibia. What is the eponym for this specific injury?





Explanation

A Bosworth fracture-dislocation is a rare injury characterized by a severe external rotation force resulting in a fibular fracture where the proximal fibular fragment becomes locked behind the posterior tubercle of the distal tibia. Closed reduction is typically impossible, necessitating urgent open reduction.

Question 71

A 42-year-old equestrian sustains a foot injury when her foot is crushed while plantarflexed. Radiographs show a comminuted fracture of the cuboid with lateral column shortening. Which of the following best describes the pathomechanics of this 'nutcracker' fracture?





Explanation

A 'nutcracker' fracture of the cuboid occurs when severe abduction and eversion forces are applied to the forefoot, compressing the cuboid between the calcaneus and the base of the fourth and fifth metatarsals. Treatment involves restoring lateral column length.

Question 72

A 28-year-old man is involved in a motor vehicle collision and sustains a displaced fracture of the talar head. Which joint is most directly impacted and at risk for post-traumatic arthritis as a result of this injury?





Explanation

Talar head fractures directly involve the talonavicular joint, a crucial component of the transverse tarsal (Chopart) joint complex. Displaced fractures require open reduction and internal fixation to restore the congruity of the talonavicular joint and prevent stiffness and early arthritis.

Question 73

A professional football player presents with severe pain and swelling at the plantar aspect of the first metatarsophalangeal (MTP) joint after hyperextending his toe on artificial turf. MRI confirms a complete rupture of the plantar plate with proximal retraction of the sesamoids. What is the most appropriate management?





Explanation

A complete rupture of the plantar plate with proximal retraction of the sesamoids (Grade III turf toe) typically requires surgical repair, especially in a competitive athlete, to restore the push-off strength and stability of the first MTP joint.

Question 74

A 22-year-old dancer complains of chronic pain under the first metatarsal head. Radiographs reveal a bipartite medial sesamoid. Which radiographic feature best differentiates a true sesamoid fracture from a normal bipartite sesamoid?





Explanation

Bipartite sesamoids (most commonly the medial sesamoid) are often bilateral and have smooth, corticated margins. True fractures will present with sharp, irregular, and uncorticated edges on radiographs.

Question 75

A 65-year-old woman with severe hallux rigidus is scheduled for a first metatarsophalangeal (MTP) joint arthrodesis. To optimize her postoperative gait and shoe wear, what is the ideal position for fusion of the first MTP joint?





Explanation

The ideal position for first MTP arthrodesis is approximately 10-15 degrees of valgus and 10-15 degrees of dorsiflexion relative to the floor (which often correlates to about 20-25 degrees of dorsiflexion relative to the first metatarsal shaft). This position accommodates normal shoe wear and allows for optimal roll-off during the gait cycle.

Question 76

A 72-year-old woman with diabetes sustains a displaced calcaneal tuberosity avulsion fracture with blanching of the overlying posterior heel skin. What is the most critical next step in management?





Explanation

A calcaneal tuberosity avulsion fracture that causes skin tenting or blanching is an orthopedic emergency. The posterior skin is highly susceptible to necrosis due to the pressure from the displaced fragment. Urgent surgical reduction and fixation are required to relieve the tension and prevent full-thickness skin loss.

Question 77

A 35-year-old woman presents with persistent lateral foot pain 4 weeks after an inversion ankle injury initially diagnosed as an ankle sprain. Examination reveals maximal tenderness 2 cm anterior and inferior to the lateral malleolus. Radiographs demonstrate a displaced fracture of the anterior process of the calcaneus. Which ligament's avulsion is most commonly responsible for this injury?





Explanation

Fractures of the anterior process of the calcaneus are often avulsion fractures caused by tension on the bifurcate ligament during a forced inversion and plantarflexion injury. The bifurcate ligament connects the anterior calcaneus to both the cuboid and navicular.

Question 78

A 28-year-old skier sustains an acute dorsiflexion-inversion injury to his ankle. He reports a popping sensation behind the lateral malleolus. Radiographs reveal a small cortical avulsion fracture off the posterolateral ridge of the distal fibula. This 'fleck sign' is highly suggestive of which of the following injuries?





Explanation

A cortical avulsion off the posterolateral margin of the distal fibula (fleck sign) is pathognomonic for an avulsion of the superior peroneal retinaculum (SPR). This injury leads to acute dislocation or subluxation of the peroneal tendons out of the retromalleolar groove.

Question 79

A 45-year-old weekend warrior sustains an acute Achilles tendon rupture. Non-operative management is chosen. To ensure healing in the most appropriate position and prevent elongation, the ankle is initially placed in a cast in resting equinus. During ultrasound evaluation to confirm apposition of the tendon ends, what is the maximum acceptable gap between the tendon ends when the ankle is placed in 20 degrees of plantarflexion?





Explanation

When managing an acute Achilles tendon rupture non-operatively, ultrasound is often used to ensure the tendon ends approximate adequately in equinus. The maximum acceptable gap between the tendon ends is typically cited as 5 mm. A gap larger than this increases the risk of elongation, weakness, or non-healing, prompting consideration for surgical repair.

Question 80

A 14-year-old boy presents with ankle pain after an external rotation injury. Radiographs show a Salter-Harris III fracture of the anterolateral aspect of the distal tibia. Which of the following best explains the specific location of this fracture?





Explanation

A juvenile Tillaux fracture is a Salter-Harris III fracture of the anterolateral distal tibia. It occurs in adolescents because the distal tibial physis closes in a specific pattern: central, then medial, and finally lateral. Because the anterolateral physis is the last to close, it remains vulnerable to avulsion by the anterior inferior tibiofibular ligament (AITFL) during an external rotation injury.

Question 81

A 24-year-old professional snowboarder presents with acute lateral ankle pain after a hard landing. Radiographs of the ankle are mostly unremarkable except for a tiny osseous fleck inferior to the lateral malleolus. A subsequent CT scan reveals a displaced fracture of the lateral process of the talus. Which of the following best describes the typical mechanism for this specific injury?





Explanation

Fractures of the lateral process of the talus, commonly known as 'snowboarder's fractures,' typically occur from an axial load combined with dorsiflexion and forceful inversion. This mechanism shears the lateral process against the fibula. They are often missed on standard radiographs, mimicking lateral ankle sprains, and frequently require a CT scan for accurate diagnosis and surgical planning.

Question 82

A 35-year-old industrial worker sustains a severe crush injury to the foot. The physical exam reveals tense swelling, severe pain with passive stretch of the toes, and decreased two-point discrimination. Intracompartmental pressure monitoring is ordered to evaluate for foot compartment syndrome. To ensure all distinct fascial compartments of the foot are evaluated, how many compartments must ideally be considered?





Explanation

The foot contains 9 distinct fascial compartments: the medial, lateral, superficial, calcaneal, four interosseous compartments, and the central compartment. Accurate diagnosis and treatment of foot compartment syndrome may require decompression of these compartments, typically via a dual dorsal incision approach or a medial approach, to prevent long-term sequelae such as claw toes and chronic pain.

Question 83

In the surgical management of a trimalleolar ankle fracture, recent biomechanical and clinical studies have emphasized the importance of fixing the posterior malleolus, even if it involves less than 25% of the articular surface. What is the primary biomechanical advantage of open reduction and internal fixation of the posterior malleolus in this setting?





Explanation

Fixation of the posterior malleolus directly restores the footprint of the posteroinferior tibiofibular ligament (PITFL). Biomechanical studies demonstrate that anatomic fixation of the posterior malleolus restores syndesmotic stability better than or equal to syndesmotic screws alone, making it a critical step in stabilizing the syndesmosis in trimalleolar fractures.

Question 84

A 22-year-old collegiate basketball player presents with a Zone 2 fracture of the proximal fifth metatarsal (Jones fracture). Operative intervention with intramedullary screw fixation is chosen to facilitate an early return to play. Which of the following screw characteristics is associated with the lowest risk of clinical failure and refracture?





Explanation

In the intramedullary fixation of Jones fractures, biomechanical and clinical studies indicate that a solid, largest-diameter screw that fits the medullary canal provides the highest pull-out and bending strength. Cannulated screws are weaker in bending and more prone to breakage. The strong fixation minimizes micromotion, preventing delayed union and refracture in high-level athletes.

Question 85

During an extensile lateral approach for the open reduction and internal fixation of a displaced intra-articular calcaneus fracture, careful full-thickness subperiosteal dissection is critical to prevent necrosis of the flap apex. The primary blood supply to the critical corner of this flap is derived from which of the following vessels?





Explanation

The blood supply to the corner of the lateral extensile flap in a calcaneus fracture approach is primarily provided by the lateral calcaneal artery, which is a terminal branch of the peroneal artery. The flap must be raised as a full-thickness "no-touch" subperiosteal flap to preserve this delicate vascular network and minimize wound necrosis.

Question 86

A 20-year-old cross-country runner presents with 4 weeks of vague, aching dorsal midfoot pain that worsens with training. Radiographs are negative, but an MRI reveals bone marrow edema in the navicular. A subsequent CT scan confirms an incomplete, non-displaced stress fracture of the navicular body. What is the most appropriate initial management?





Explanation

Navicular stress fractures have a high risk of delayed union or nonunion due to the relatively avascular central third of the bone. For non-displaced or incomplete fractures, strict non-weight-bearing in a cast for 6-8 weeks is the gold standard initial treatment. Surgery (screw fixation) is reserved for displaced fractures, nonunions, or early failures of conservative management in elite athletes.

Question 87

A 45-year-old male is brought to the emergency department after an ankle injury. Radiographs reveal a severe fracture-dislocation of the ankle. Closed reduction under conscious sedation is attempted but is completely unsuccessful, with the ankle remaining rigidly dislocated. Radiographs show the proximal fibular shaft fragment located posterior to the tibia. This specific injury pattern is best described as which of the following?





Explanation

A Bosworth fracture-dislocation is an irreducible fracture-dislocation of the ankle where the proximal fibular fragment becomes entrapped behind the posterior lateral tubercle of the tibia. This mechanical block prevents closed reduction, necessitating emergent open reduction and internal fixation.

Question 88

A professional football lineman sustains a severe hyperextension injury to his first metatarsophalangeal (MTP) joint ('turf toe'). Which of the following physical or radiographic findings is considered a definitive indication for surgical intervention?





Explanation

Operative indications for a turf toe injury (plantar plate rupture) include a Grade 3 injury characterized by gross instability, complete tear of the plantar plate with significant proximal retraction of the sesamoids, large intra-articular loose bodies, or persistent pain and instability preventing push-off in an elite athlete after conservative care.

Question 89

A 28-year-old skier falls forward with her ankles flexed, experiencing a sudden snapping sensation and acute pain posterior to the lateral malleolus. Radiographs demonstrate a small avulsion fracture ('fleck sign') off the posterolateral margin of the distal fibula. This radiographic finding is pathognomonic for an injury to which of the following structures?





Explanation

A 'fleck sign' or rim fracture off the posterolateral border of the distal fibula represents an avulsion of the superior peroneal retinaculum (SPR). This injury leads to peroneal tendon subluxation or dislocation. It classically occurs during forceful dorsiflexion and reflex contraction of the peroneal muscles.

Question 90

A 60-year-old male with poorly controlled diabetes and severe peripheral neuropathy sustains a closed, displaced bimalleolar ankle fracture. Which of the following surgical strategies is most appropriate to minimize the high risk of fixation failure and Charcot arthropathy in this patient?





Explanation

Ankle fractures in diabetic patients with neuropathy have complication rates (nonunion, malunion, Charcot, infection) often exceeding 40%. The standard of care demands rigid 'super-construct' augmented fixation (longer plates, extra screws, locked constructs, or sometimes primary TTC nailing) combined with an extended period of strict non-weight-bearing (typically double the duration of a non-diabetic patient) to prevent mechanical failure.

Question 91

Recent high-quality, randomized controlled trials comparing operative repair versus non-operative management with early functional rehabilitation for acute Achilles tendon ruptures have consistently demonstrated which of the following outcomes?





Explanation

Landmark RCTs (e.g., Willits et al.) have established that when an early functional rehabilitation protocol is utilized, there is no statistically significant difference in the re-rupture rate between operative and non-operative management of acute Achilles tendon ruptures. However, operative management is associated with a significantly higher risk of complications, particularly superficial and deep wound infections.

Question 92

A 32-year-old horseback rider sustains a forced plantarflexion and abduction injury to the midfoot when her foot gets caught in the stirrup during a fall. Radiographs show an intra-articular impaction fracture of the cuboid. This 'nutcracker' fracture mechanism compresses the cuboid between which two osseous structures?





Explanation

A 'nutcracker' fracture of the cuboid occurs via forceful plantarflexion and abduction of the forefoot. This mechanism forcefully compresses the cuboid bone between the anterior process of the calcaneus proximally and the rigid bases of the fourth and fifth metatarsals distally, leading to a crush or impaction injury.

Question 93

A 13-year-old female presents with ankle pain after an external rotation injury. Radiographs reveal a Salter-Harris type III fracture of the anterolateral aspect of the distal tibial epiphysis. This fracture pattern (Tillaux fracture) is primarily due to an avulsion force from which of the following ligaments?





Explanation

A juvenile Tillaux fracture is a Salter-Harris III fracture of the anterolateral distal tibia epiphysis. It occurs in adolescents due to the asymmetric closure of the distal tibial physis (central first, then medial, with lateral being the last to close). External rotation causes the anterior inferior tibiofibular ligament (AITFL) to avulse the anterolateral epiphyseal fragment.

Question 94

A 40-year-old male sustains a high-energy tibial pilon fracture (OTA/AO 43-C3) in a motor vehicle collision. On arrival, there is massive soft tissue swelling, fracture blisters over the medial ankle, and threatened skin. What is the current gold standard sequence of management for this injury?





Explanation

High-energy tibial pilon fractures are associated with a severe soft tissue envelope injury. Immediate ORIF carries an unacceptably high risk of wound dehiscence and deep infection. The standard of care is a staged approach: immediate application of a spanning external fixator (with or without fibular fixation) to restore length and alignment, followed by definitive ORIF 10-21 days later when the soft tissue swelling has subsided (positive "wrinkle sign").

Question 95

A 26-year-old male sustained a severe midfoot injury during a high-speed motorcycle crash. Radiographs demonstrate a pure dislocation through the transverse tarsal joint. The Chopart joint complex involves dislocations of which of the following specific articulations?





Explanation

The transverse tarsal joint, historically known as the Chopart joint, represents the anatomic boundary between the hindfoot and midfoot. It consists of two distinct articulations: the talonavicular joint medially and the calcaneocuboid joint laterally.

Question 96

A 45-year-old male falls from a ladder and sustains an intra-articular calcaneus fracture. The orthopedic surgeon is deciding between non-operative management and an open reduction internal fixation via an extensile lateral approach. Which of the following patient factors is widely considered a strong relative or absolute contraindication to the extensile lateral approach due to a drastically increased risk of wound complications?





Explanation

Active heavy smoking drastically impairs microvascular circulation and wound healing. It is well documented that patients who smoke have unacceptably high rates of flap necrosis, wound dehiscence, and deep infection after an extensile lateral approach for calcaneus fractures. Many surgeons consider heavy smoking a strong relative or absolute contraindication for this specific surgical approach.

Question 97

A 30-year-old pilot survives a small plane crash and presents with a displaced fracture of the talar neck. Radiographs demonstrate dislocation of both the subtalar joint and the ankle (tibiotalar) joint, while the talonavicular joint remains reduced. According to the Hawkins classification and historical literature, what is the approximate rate of avascular necrosis (AVN) of the talar body associated with this specific injury type?





Explanation

The patient has a Hawkins Type III talar neck fracture (fracture of the neck with dislocation of the subtalar and tibiotalar joints). In this severe injury, all three major sources of blood supply to the talar body (artery of the tarsal canal, deltoid branches, and dorsalis pedis branches) are disrupted. Historically, the rate of AVN for Hawkins Type III fractures approaches 80% to 100%.

Question 98

A 25-year-old soccer player sustains an external rotation ankle injury. Standard AP, mortise, and lateral radiographs are obtained to evaluate for a syndesmotic injury. Which of the following radiographic measurements is the most reliable and widely accepted indicator of syndesmotic widening?





Explanation

The tibiofibular clear space is the distance between the medial border of the fibula and the incisura fibularis of the tibia, typically measured 1 cm above the joint line. A clear space greater than 5 mm on either the AP or mortise view is abnormal and highly indicative of a syndesmotic injury. Tibiofibular overlap is highly dependent on rotation and is less reliable.

Question 99

A 55-year-old female presents with painful hallux valgus that has failed shoe modification. Standing radiographs reveal a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. To achieve adequate correction and minimize the risk of recurrence, which surgical approach is most biomechanically appropriate?





Explanation

Severe hallux valgus is defined by a hallux valgus angle (HVA) > 40 degrees and an intermetatarsal angle (IMA) > 15 to 20 degrees. Distal osteotomies (like the Chevron) do not provide sufficient medial translation to correct a large IMA. Therefore, severe deformities necessitate proximal procedures, such as a proximal metatarsal osteotomy (Ludloff, crescentic) or a first TMT joint arthrodesis (Lapidus procedure).

Question 100

A 42-year-old marathon runner presents with chronic, severe plantar heel pain that has not improved with 6 months of stretching, orthotics, and cortisone injections. He notes the pain frequently radiates distally and laterally across the plantar aspect of his foot. On exam, there is maximal tenderness over the medial aspect of the heel, and a Tinel's sign is positive just inferior to the medial malleolus. The patient likely suffers from entrapment of which of the following nerves?





Explanation

Entrapment of the first branch of the lateral plantar nerve (often called Baxter's nerve) is a well-recognized cause of chronic heel pain that mimics or coexists with recalcitrant plantar fasciitis. The nerve typically becomes compressed between the deep fascia of the abductor hallucis muscle and the medial head of the quadratus plantae. Symptoms may include radiating pain and sometimes atrophy of the abductor digiti minimi.

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