Orthopedic Board Prep MCQs: Ankle & Foot Deformity

Question 1

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

Explanation

DISCUSSION: Foot deformity and decreased joint motion have been associated with increased plantar pressures and an increased risk of ulceration. In a partial-thickness ulcer without exposed bone or tendon, total contact casting is highly effective. Concomitant Achilles tendon lengthening increases the likelihood that healing of the ulcer can be obtained and perhaps more importantly, maintained.
REFERENCES: Lin SS, Lee TH, Wapner KL: Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients: The effect of tendo-Achilles lengthening and total contact casting. Orthopedics 1996;19:465-475.
Armstrong DG, Stacpoole-Shea S, Nguyen H, Harkless LB: Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. J Bone Joint Surg Am 1999;81:535-538.

Question 2

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

Explanation

DISCUSSION: In a patient with inflammatory arthritis, advanced hallux valgus deformity in conjunction with lesser metatarsophalangeal joint destruction and subluxation warrants fusion of the first metatarsophalangeal joint and lesser metatarsal head resections. Hallux valgus correction will fail because of incompetent soft tissues. A Keller resection arthroplasty is not indicated in this age group. Synovectomy is contraindicated because of evidence of erosive changes of the lesser metatarsophalangeal joints.
REFERENCES: Ouzounian T: Rheumatoid arthritis of the foot & ankle, in Myerson MS (ed): Foot & Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, vol 2, pp 1189-1204.
Mann RA, Thompson FM: Arthrodesis of the first metatarsophalangeal joint for hallux valgus in rheumatoid arthritis. J Bone Joint Surg Am 1984;66:687-692.
Coughlin MJ: Rheumatoid forefoot reconstruction: A long-term followup study. J Bone Joint Surg Am 2000;82:322-341.

Question 3

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

Explanation

DISCUSSION: A Keller proximal phalanx resection procedure usually results in reduced weight bearing under the first ray because of shortening of the toe and disruption of intrinsic flexor function. This can be an effective method of offloading a neuropathic ulcer under the great toe at the interphalangeal or metatarsophalangeal joint area. However, these features are generally undesirable in young active patients. The procedure has a high rate of recurrent deformity in patients with rheumatoid arthritis. It would exacerbate transfer metatarsalgia in a patient with a hypermobile first ray.
REFERENCES: Lin SS, Bono CM, Lee TH: Total contact casting and Keller arthroplasty for diabetic great toe ulceration under the interphalangeal joint. Foot Ankle Int 2000;21:588-593.
Downs DM, Jacobs RL: Treatment of resistant ulcers on the plantar surface of the great toe in diabetics. J Bone Joint Surg Am 1982;64:930-933.

Question 4

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

Explanation

DISCUSSION: Hallux varus may occur as a complication following hallux valgus surgery, most commonly a modified McBride-type procedure. Conservative management is the initial treatment of choice; however, if unsuccessful, surgical options for reconstruction include soft-tissue reconstruction or metatarsophalangeal joint arthrodesis. The patient has evidence of joint arthrosis, making an arthrodesis the preferred method of reconstruction. Fascial arthroplasty, Silastic arthroplasty, and Keller resection arthroplasty will not correct the underlying deformity.
REFERENCES: Kitaoka HB, Patzer GL: Arthrodesis versus resection arthroplasty for failed hallux valgus operations. Clin Orthop 1998;347:208-214.
Ouzounian TJ: Metatarsophalangeal arthrodesis for salvage of failed hallux valgus surgery. Foot Ankle Clin 1997;2:741-752.

Question 5

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

Explanation

DISCUSSION: The patient has congenital vertical talus. The navicular is irreducibly dorsally dislocated on the talus with the talar head prominent on the plantar medial aspect of the foot. Initial management involves corrective casting for 3 months to stretch the dorsal tendons, skin, and neurovascular structures. Surgical reconstruction is often needed and is indicated when the patient is age 6 to 12 months. Reconstruction requires both bony and soft-tissue procedures.
REFERENCES: Napiontek M: Congenital vertical talus: A retrospective and critical review of 32 feet operated on by peritalar reduction. J Pediatr Orthop 1995;4:179-187.
Oppenheim W, Smith C, Christie W: Congenital vertical talus. Foot Ankle 1985;5:198-204.

Question 6

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

Explanation

DISCUSSION: The distal oblique shortening (Weil) metatarsal osteotomy has not been associated with transfer lesions to the extent of other shortening osteotomies, and malunions and nonunions are unusual complications. Recurrent dorsal contracture of the toe has been reported. Recommendations to reduce this problem include release of the dorsal capsule and tendons, as well as a flexor tendon transfer. A potential cause suspected for this phenomenon is the relatively dorsal positioning of the intrinsic tendons after plantar displacement of the metatarsal head.
REFERENCES: Trnka HJ, Nyska M, Parks BG, Myerson MS: Dorsiflexion contracture after the Weil osteotomy: Results of cadaver study and three-dimensional analysis. Foot Ankle Int 2001;22:47-50.
Trnka HJ, Muhlbauer M, Zettl R, Myerson MS, Ritschl P: Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int 1999;20:72-79.
Vandeputte G, Dereymaeker G, Steenwerckx A, Peeraer L: The Weil osteotomy of the lesser metatarsals: A clinical and pedobarographic follow-up study. Foot Ankle Int 2000;21:370-374.

Question 7

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

Explanation

DISCUSSION: Based on findings of a sudden increase in pain with associated swelling, the most likely diagnosis is a stress fracture. The initial radiographic findings usually will be negative. Morton’s neuroma and transfer metatarsalgia are not associated with swelling. Metatarsophalangeal synovitis usually involves the second metatarsophalangeal joint. Freiberg’s infraction is seen clearly on a radiograph.
REFERENCE: Boden BP, Osbahr DC: High risk stress fractures: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-353.

Question 8

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

Explanation

DISCUSSION: The examination findings reveal that there is specific involvement of the medial plantar nerve by the distribution of the pain medially. The symptoms exclude the possibility of plantar fasciitis and anterior tibial tendinitis. Sinus tarsi syndrome would produce anterolateral symptoms rather than medial symptoms.
REFERENCES: Rask MR: Medial plantar neurapraxia (jogger’s foot): Report of three cases. Clin Orthop 1978;134:193-195.
Murphy PC, Baxter DE: Nerve entrapment of the foot and ankle in runners. Clin Sports Med 1985;4:753-763.
Lutter LD: Surgical decisions in athletes’ subcalcaneal pain. Am J Sports Med 1986;14:481-485.

Question 9

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

Explanation

DISCUSSION: Excessive hindfoot valgus can lead to abutment between the calcaneus and fibula. This valgus force can lead to a stress fracture of the distal fibula. Surgery may be required if an insufficiency fracture recurs despite orthotic management. Of the choices listed, a subtalar arthrodesis is most likely to achieve rebalancing of the foot at the level of the deformity.
REFERENCES: Stephens HM, Walling AK, Solmen JD, Tankson CJ: Subtalar repositional arthrodesis for adult acquired flatfoot. Clin Orthop 1999;365:69-73
Easley ME, Trnka HJ, Schon LC, Myerson MS: Isolated subtalar arthrodesis. J Bone Joint Surg Am 2000;82:613-624.

Question 10

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

Explanation

DISCUSSION: The child has Kohler’s disease. This is a self-limiting osteochondritis of the navicular. It is treated symptomatically with initial cast immobilization for 6 to 12 weeks, followed possibly by orthotic management. Findings shown in the radiograph usually will normalize within 1 year, and there are no long-term sequelae.
REFERENCES: Borges JL, Guille JT, Bowen JR: Kohler’s bone disease of the tarsal navicular. J Pediatr Orthop 1995;15:596-598.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 65-78.

Question 11

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

Explanation

DISCUSSION: The patient has frostbite involving both feet. Rapid rewarming in a protected environment is the initial treatment. A footbath with water at 104.0 degrees F to 107.6 degrees F (40 degrees C to 42 degrees C) is ideal. This facilitates a uniform rewarming of the involved tissue. The other choices are less than ideal. Appliances such as heating pads provide uneven heating and may actually burn the skin.
REFERENCES: Pinzur MS: Frostbite: Prevention and treatment. Biomechanics 1997;4:14-21.
Fritz RL, Perrin DH: Cold exposure injuries: Prevention and treatment. Clin Sports Med 1989;8:111-128.

Question 12

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

Explanation

DISCUSSION: The presence of recurrent breakdown over the medial eminence despite shoe wear modifications is an indication for surgery. A number of factors must be considered when deciding on an appropriate course of treatment. These include age, activity level, joint congruency, joint degeneration, and the patient’s symptoms and expectations. The indications for a simple bunionectomy are rather limited. In this patient, the goal of surgery is to alleviate the recurrent infection by removal of a large medial eminence. Because the bunion is painless and long-standing, it does not warrant treatment.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 123-134.
Abidi NA, Conti SF: The clinical and radiographic anatomy of hallux valgus and surgical algorithm. Foot Ankle Clin 1997;2:599-626.

Question 13

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

Explanation

DISCUSSION: The artery of the tarsal canal is a branch of the posterior tibial artery. Among the branches of the artery of the tarsal canal is the deltoid artery. This arterial complex supplies the medial one third of the talar body. Disruption of this artery may lead to osteonecrosis of the medial body and subsequent collapse into varus. This is most commonly seen with talar body fractures but may be seen in Hawkins type 3 talar neck fractures. The artery of the tarsal sinus arises from the dorsalis pedis, lateral malleolar, and perforating peroneal arteries. The peroneal artery anastomoses with the calcaneal branches of the posterior tibial artery to form a plexus of vessels that supplies the posterior tubercle of the talus. Disruption of this artery would not result in collapse of the medial body, and thus would not lead to a varus deformity.
REFERENCES: Halibruton RA, Sullivan CR, Kelly PJ, et al: The extra-osseous and intra-osseous blood supply of the talus. J Bone Joint Surg Am 1958;40:1115.
Mulfinger GL, Trueta J: The blood supply of the talus. J Bone Joint Surg Br 1970;52:160-167.

Question 14

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

Explanation

DISCUSSION: Patients with diabetes mellitus should be screened for the presence of protective foot sensation. In the absence of protective foot sensation, patients are at increased risk for the development of neuropathic ulcerations and neuropathic arthropathy. The most reliable screening tool for the presence of protective sensation is the ability to feel the 5.07 Semmes-Weinstein monofilament.
REFERENCES: Pinzur MS, Shields N, Trepman E, Dawson P, Evans A: Current practice patterns in the treatment of Charcot foot. Foot Ankle Int 2000;21:916-920.
Smith KD, Emerzian GJ, Petrov O: A comparison of calibrated and non-calibrated 5.07 nylon monofilaments. Foot Ankle Int 2000;21:852-855.

Question 15

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

Explanation

DISCUSSION: The patient has a nondisplaced stress fracture of the tarsal navicular. Weight bearing is associated with a high rate of nonunion; therefore, management should consist of immobilization and no weight bearing for 8 weeks. Delayed union or nonunion is treated by excision of sclerotic fracture margins and bone grafting, with or without internal fixation. Generally, CT should be repeated to document healing before permitting a return to sports.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 597-612.
Torg J, Pavlov H, Cooley LH, et al: Stress fractures of the tarsal navicular: A retrospective review of twenty-one cases. J Bone Joint Surg Am 1982;64:700-712.

Question 16

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

Explanation

DISCUSSION: The patient has subtalar arthrosis, a loss of heel height with anterior ankle impingement. The mechanics of the ankle are impaired, and dorsiflexion is painful and limited. The talar declination angle is measured by drawing a line through the longitudinal axis of the talus and the plane of support of the foot on a weight-bearing lateral radiograph. Anterior impingement is suggested with any value below 20 . By performing a distraction arthrodesis through the subtalar joint, the normal declination of the talus is reestablished, eliminating the anterior ankle impingement. Tibiotalocalaneal fusion would be inappropriate because the patient does not have arthritic symptoms in the ankle. Ankle arthroscopy or in situ arthrodesis would not reestablish appropriate ankle mechanics, and the osteophytes would be prone to redevelop. Lateral wall ostectomy may help with impingement at the level of the fibula or the lateral ankle but would provide no benefit to anterior ankle impingement.
REFERENCES: Carr JB, Hansen ST, Benirschke SK: Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle 1988;9:81-86.
Myerson M, Quill GE Jr: Late complications of fractures of the calcaneus. J Bone Joint Surg Am 1993;75:331.

Question 17

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

Explanation

DISCUSSION: The fracture pattern shown in the radiograph involves both a talar neck fracture and a talar body fracture. The body fracture propagates into the subtalar joint, with significant risk for the development of arthritis in that surface even with an anatomic reduction. In addition, Canale and Kelly reported a 25% incidence of malunion of talar neck fractures, with varus angulation occurring most frequently. Of these patients, 50% required a secondary surgical procedure because of the development of degenerative joint disease of the subtalar joint.
REFERENCES: Canale ST, Kelly FB Jr: Fractures of the neck of the talus: Long-term evaluation of seventy-one cases. J Bone Joint Surg Am 1978;60:143-156.
Higgins TF, Baumgaertner MR: Diagnosis and treatment of fractures of the talus: A comprehensive review of the literature. Foot Ankle Int 1999;20:595-605.

Question 18

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

Explanation

DISCUSSION: Once degenerative changes have occurred, soft-tissue procedures are not indicated. Triple arthrodesis is the treatment of choice for adult-acquired flatfoot. Isolated fusion of the subtalar or talonavicular joint will not be sufficient to correct the problem.
REFERENCES: Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 269-282.
Graves SC, Stephenson K: The use of subtalar and triple arthrodesis in the treatment of posterior tibial tendon dysfunction. Foot Ankle Clin 1997;2:319.

Question 19

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

Explanation

DISCUSSION: Because the patient has significant arthritis, arthrodesis is the treatment of choice. Adding a bone graft will prevent further shortening and add length to her toe, resulting in improved cosmesis. A cheilectomy will not alleviate her arthritis pain. The toe is too short for an effective Moberg phalangeal dorsiflexion osteotomy. A Waterman first metatarsal dorsal osteotomy will not address the degenerative joint disease or shortening. Silastic arthroplasty may help, but there is the risk of additional problems with foreign body reaction and a significant risk of failure known to occur with Silastic materials.
REFERENCES: Myerson MS, Schon LC, McGuigan FX, Oznur A:Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int 2000;21:297-306.
Mann RA, Coughlin MJ: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 252-253.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 293-303.

Question 20

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

Explanation

DISCUSSION: Most patients who undergo transmetatarsal amputation do not require custom shoe wear or an orthosis above the ankle. A molded toe filler is used to prevent excessive shear that can lead to ulceration. Use of a soft toe filler without stiffening of the sole results in excessive flexibility from the shortened lever arm, which reduces the efficiency of gait. A firm footplate or carbon fiber base adds rigidity to aid in push-off. A rocker bottom also may be added to the shoe.
REFERENCES: Philbin TM, Leyes M, Sferra JJ, Donley BG: Orthotic and prosthetic devices in partial foot amputations. Foot Ankle Clin 2001;6:215-228.
Marks RM: Mid-foot/mid-tarsus amputations. Foot Ankle Clin 1999;4:1-16.

Question 21

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

Explanation

DISCUSSION: The history is most consistent with a plantar fibroma. The nodules typically are located within the substance of the plantar aponeurosis. The clinical appearance is usually diagnostic without the need for advanced imaging studies. While the lesion may be prominent and painful to direct palpation, the anatomic location is usually off of the weight-bearing surface. Observation with or without an accommodative orthotic is the treatment of choice. Recurrence is common following attempted excision.
REFERENCES: Sammarco GJ, Mangone PG: Classification and treatment of plantar fibromatosis. Foot Ankle Int 2000;21:563-569.
Durr HR, Krodel A, Trouillier H, Lienemann A, Refior HJ: Fibromatosis of the plantar fascia: Diagnosis and indications for surgical treatment. Foot Ankle Int 1999;20:13-17.

Question 22

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

Explanation

DISCUSSION: The radiographs show a displaced ankle fracture with widening of the syndesmosis. Open reduction and internal fixation is indicated with fixation of the mortise with syndesmotic screws.
REFERENCES: Wuest TK: Injuries to the distal lower extremity syndesmosis. J Am Acad Orthop Surg 1997;5:172-181.
Harper MC: Delayed reduction and stabilization of the tibiofibular syndesmosis. Foot Ankle Int 2001;22:15-18.

Question 23

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

Explanation

DISCUSSION: The presence of a dorsal ulcer in the presence of weak or absent pulses strongly suggests the possibility of arterial insufficiency. The best initial noninvasive study to assess for ischemia is the Doppler arterial study. A determination of the vascular status is of a greater priority than an assessment for infection or neuropathy because of the location and presentation of the ulcer. If ankle pressures are less than 45 mm Hg, there is a high risk that these lesions will not heal without revascularization.
REFERENCES: Wagner FW Jr: The dysvascular foot: A system for diagnosis and treatment. Foot Ankle 1981;2:64-122.
Apelqvist J, Castenfors J, Larson J, Stenstrom A, Agardh CD: Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer. Diabetes Care 1989;12:373-378.

Question 24

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

Explanation

DISCUSSION: Early postoperative wound infections after open reduction and internal fixation should be treated with aggressive debridement and maintenance of stability of the fracture. If infection persists following healing of the fracture, the hardware should be removed.
REFERENCES: Carragee EJ, Csongradi JJ, Bleck EE: Early complications in the operative treatment of ankle fractures: Influence of delay before operation. J Bone Joint Surg Br 1991;73:79-82.
Blotter RH, Connolly E, Wasan A, Chapman MW: Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus. Foot Ankle Int 1999;20:687-694.

Question 25

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

Explanation

DISCUSSION: Patients with peripheral neuropathy will often initially see an orthopaedic surgeon and report symptoms of burning, numb, dead, or wooden feet. A simple diagnostic evaluation with a tuning fork (to test vibratory sensibility) or use of the Semmes-Weinstein monofilaments will help make the diagnosis.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 113-121.
Gorson KC, Ropper AH: Idiopathic distal small fiber neuropathy. Acta Neurol Scand 1995;92:376-382.

Question 26

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

Explanation

DISCUSSION: The type of deformity described is a type 2 bunionette. There is often a congenital component to this deformity. The bowing of the fifth shaft differentiates a large intermetatarsal angle from a type 3 deformity. A distal chevron osteotomy corrects 1 degree in the intermetatarsal angle for every 1-mm shift. Because of limitations in the width of the fifth metatarsal neck, the allowable shift is generally 3 to 4 mm. This shift will not compensate for the large intermetatarsal angle. The floating osteotomy has a high rate of delayed union/nonunion and a low satisfaction rate. Metatarsal head excision has a high complication rate, including severe shortening, transfer metatarsalgia, stiffness, and pain. A more proximal procedure is necessary to correct the large intermetatarsal angle and the lateral bowing. The osteotomy of choice is a diaphyseal shaft osteotomy. Because this patient has a plantar callosity and a lateral callosity, the osteotomy is angled superiorly to elevate the fifth shaft with the shift, eliminating overload of the plantar metatarsal head and subsequent callus formation.
REFERENCES: Shereff MJ, Yang QM, Kummer FJ, Frey CC, Greenidge N: Vascular anatomy of the fifth metatarsal. Foot Ankle 1991;11:350-353.
Coughlin MJ: Treatment of bunionette deformity with longitudinal diaphyseal osteotomy with distal soft tissue repair. Foot Ankle 1991;11:195-203.
Kitaoka HB, Holiday AD Jr: Metatarsal head resection for bunionette: Long-term follow-up. Foot Ankle 1991;11:345-349.

Question 27

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

Explanation

DISCUSSION: Because the patient has a hallux valgus with increased intermetatarsal and hallux valgus angles and advanced degenerative arthritis of the joint, arthrodesis of the first metatarsophalangeal joint will provide the most predictable pain-free result. An attempt to correct the bunion with a bunionectomy or osteotomy would most likely fail. The hallux valgus and advanced degenerative changes put the foot beyond the indications for a cheilectomy. Long-term results with silicone arthroplasty have been disappointing.
REFERENCES: Mann RA: Disorders of the first metatarsophalangeal joint. J Am Acad Orthop Surg 1995;3:34-43.
Coughlin MJ, Abdo RV: Arthrodesis of the first metatarsophalangeal joint with Vitallium plate fixation. Foot Ankle Int 1994;15:18-28.

Question 28

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

Explanation

DISCUSSION: Numerous causes of tarsal tunnel syndrome have been reported. The most favorable outcomes from release of the tarsal tunnel are in patients who have a space-occupying lesion (eg, ganglion, lipoma, or neurilemoma). While electrodiagnostic studies may be abnormal preoperatively, there is a low correlation between clinical outcome and electromyographic findings. Intrinsic weakness is a late finding in long-standing nerve dysfunction.
REFERENCES: Beskin JL: Nerve entrapment syndromes of the foot and ankle. J Am Acad Orthop Surg 1997;5:261-269.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 101-111.

Question 29

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

Explanation

DISCUSSION: The patient’s long-standing symptoms and radiograph indicate a chronic insertional Achilles tendinopathy that has progressed to complete rupture. This situation is best treated with tendon debridement and repair, often requiring supplementation graft from the flexor hallucis longus. MRI could provide additional information on the quality of the Achilles tendon, but neither MRI nor ultrasound is necessary to make a diagnosis or determine the surgical indication. Conservative management will be unpredictable with a chronic degenerative tendon injury.
REFERENCES: Myerson MS, McGarvey W: Disorders of the Achilles tendon: Insertion and Achilles tendinitis. Instr Course Lect 1999;48:211-218.
Wilcox DK, Bohay DR, Anderson JG: Treatment of chronic Achilles tendon disorders with flexor hallucis longus tendon transfer/augmentation. Foot Ankle Int 2000;21:1004-1010.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 253-277.

Question 30

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

Explanation

DISCUSSION: Because the radiograph reveals an intermetatarsal angle of greater than 15 degrees and an incongruent metatarsophalangeal joint, the treatment of choice is a proximal first metatarsal osteotomy with distal soft-tissue realignment. A distal chevron procedure would not correct this degree of deformity. A Keller procedure is reserved for a less active elderly individual. Arthrodesis is appropriate for a patient with advanced arthritis of the metatarsophalangeal joint. The double osteotomy is reserved for the congruent metatarsophalangeal joint with hallux valgus.
REFERENCES: Coughlin MJ, Carlson RE: Treatment of hallux valgus with an increased distal metatarsal articular angle: Evaluation of double and triple first ray osteotomies. Foot Ankle Int 1999;20:762-770.
Coughlin MJ: Hallux valgus. Instr Course Lect 1997;46:357-391.

Question 31

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

Explanation

DISCUSSION: Based on the radiographic findings, the patient has a metallic foreign body in her foot that is consistent with a needle. She has local infection secondary to the continued presence of the foreign body. CT is not necessary to localize the foreign body as it is adequately visualized on the plain radiographs. The infection cannot be adequately treated until the foreign body is removed. Attempted removal of foreign bodies without proper anesthesia and fluoroscopy frequently results in frustration because of the inability to localize the foreign body. Removal in a surgical suite with proper anesthesia and fluoroscopy is the preferred option. Once the foreign body is removed, the local infection will resolve rapidly.
REFERENCES: Combs AH, Kernek CB, Heck DA: Orthopedic grand rounds: Retained wooden foreign body in the foot detected by computed tomography. Orthopedics 1986;9:1434-1435.
Markiewitz AD, Karns DJ, Brooks PJ: Late infections of the foot due to incomplete removal of foreign bodies: A report of two cases. Foot Ankle Int 1994;15:52-55.

Question 32

A 50-year-old woman who underwent a joint replacement of the hallux metatarsophalangeal joint 6 months ago now has pain and swelling about the great toe. Radiographs are shown in Figures 39a and 39b. What is the next most appropriate step in management?

Explanation

DISCUSSION: The radiographs show displacement of the prosthesis, and there has been large amounts of bone resected to insert the implant. Arthrodesis is indicated with interposition bone graft to stabilize the joint and restore length to the first ray.
REFERENCE: Myerson MS: Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 265-266.

Question 33

What is the most common foot and ankle deformity in patients with arthrogryposis?

Explanation

DISCUSSION: Clubfoot (talipes equinovarus) in patients with arthrogryposis is a rigid and resistant deformity. However, multiple studies document limited success with nonsurgical management. Manipulation and casting are generally a preliminary treatment before surgery; successful correction will most like require a talectomy.
REFERENCES: Guidera KJ, Drennan JC: Foot and ankle deformities in arthrogryposis multiplex congenita. Clin Orthop 1985;194:93-98.
Handelsman JE, Badalamente MA: Neuromuscular studies in clubfoot. J Pediatr Orthop 1981;1:23-32.
Dias LS, Stern LS: Talectomy in the treatment of resistant talipes equinovarus deformity in myelomeningocele and arthrogryposis. J Pediatr Orthop 1987;7:39-41.

Question 34

A 16-year-old girl has had pain and swelling along the medial arch of her left foot for the past 3 months. She also reports pain from shoe wear and while running. Nonsteroidal anti-inflammatory drugs have failed to provide relief. Radiographs are shown in Figures 40a through 40c. What is the next most appropriate step in management?

Explanation

DISCUSSION: Nonsurgical management of a symptomatic accessory navicular should be attempted prior to surgery. Good relief is often obtained with a semi-rigid orthosis with a medial arch support.
REFERENCES: Myerson MS: Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, p 655.
Bennett GL, Weiner DS, Leighley B: Surgical treatment of symptomatic accessory tarsal navicular. J Pediatr Orthop 1990;10:445-449.

Question 35

A 28-year-old man was shot in the foot with a .22 caliber handgun approximately 2 hours ago. Examination reveals an entrance wound dorsally and a plantar exit wound. The foot is neurovascularly intact. Radiographs reveal a nondisplaced fracture of the third metatarsal. Soft-tissue management for this injury should consist of

Explanation

DISCUSSION: The patient has sustained a low-velocity, low-caliber gunshot wound to the foot. Because the injury occurred within a period of 8 hours, this is classified as a type I wound. Several studies support the use of surface debridement, cleansing, and sterile dressings as the treatment of choice. More aggressive measures are reserved for high-velocity injuries and shotgun injuries.
REFERENCES: Brettler D, Sedlin ED, Mendes DG: Conservative treatment of low velocity gunshot wounds. Clin Orthop 1979;140:26-31.
Hampton OD: The indications for debridement of gunshot bullet wounds of the extremities in civilian practice. J Trauma 1961;1:368-372.
Marcus NA, Blair WF, Shuck JM, Omer GE Jr: Low-velocity gunshot wounds to extremities. J Trauma 1980;20:1061-1064.

Question 36

The photomicrograph seen in Figure 41 shows which of the following conditions?

Explanation

DISCUSSION: The photomicrograph shows a synovial cell sarcoma with a characteristic histology of a biphasic pattern of pleomorphic spindle cells and well-differentiated cuboidal to columnar cells forming gland-like spaces. The glandular zones contain mucous-like material that stains positively with periodic acid Schiff. Microscopic calcifications are usually found. Synovial cell sarcoma has a high rate of local recurrence as well as metastases. It is the most common malignancy found in the foot.
REFERENCES: Krall RA, Kostianovsky M, Patchefsky AS: Synovial sarcoma: A clinical, pathological and ultrastructural study of 26 cases supporting the recognition of a monophasic variant. Am J Surg Pathol 1981;5:137-151.
Wright PH, Sim FH, Soule EH, Taylor WF: Synovial sarcoma. J Bone Joint Surg Am 1982;64:112-122.

Question 37

A 33-year-old man had his foot run over by a forklift 1 hour ago. Examination reveals that the head of the fifth metatarsal is extruded through the plantar aspect of the foot. The foot is severely swollen and pale, there is no sensation in the toes, and the pulses are not palpable. Radiographs are shown in Figures 42a and 42b. Emergent management should consist of

Explanation

DISCUSSION: Following a severe crush injury, the patient has an acute compartment syndrome. Even though there is an open fracture, this is not sufficient to decompress the compartment syndrome. Therefore, splinting and observation are not appropriate. The surgical treatment of choice is fasciotomy with fixation of the multiple fractures. A primary amputation is not indicated because there is potential for salvage of this devastating injury.
REFERENCES: Fakhouri AJ, Manoli A II: Acute foot compartment syndromes. J Orthop Trauma 1992;6:223-228.
Myerson MS: Management of compartment syndromes of the foot. Clin Orthop 1991;271:239-248.
Ziv I, Mosheiff R, Zeligowski A, Liebergal M, Lowe J, Segal D: Crush injuries of the foot with compartment syndrome: Immediate one-stage management. Foot Ankle 1989;9:185-189.

Question 38

A 2-year-old boy has been referred for musculoskeletal evaluation. Examination reveals shortened proximal limbs, hip and knee flexion contractures, an abducted thumb, and ear abnormalities. His parents are concerned about his deformed feet. What is the most common foot deformity associated with this patient’s diagnosis?

Explanation

DISCUSSION: The patient has diastrophic dysplasia. Affected individuals have rhizomelic short stature, cauliflower ears, severe joint contractures (especially knees and hips), hitchhiker’s thumb, and a cleft palate. The most common foot abnormality is a rigid equinovarus deformity. Surgical results are poorer than those for idiopathic clubfeet and often require bony procedures or talectomy.
REFERENCES: Ryoppy S, Poussa M, Merikanto J, Marttinen E, Kaitila I: Foot deformities in diastrophic dysplasia: An analysis of 102 patients. J Bone Joint Surg Br 1992;74:441-444.
Bussett GS: The osteochondrodysplasias, in Morrissy RT, Weinstein S (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, p 219.

Question 39

A 31-year-old woman has a history of a painful ankle that has failed to respond to conservative management. She has associated night pain that is relieved with nonsteroidal anti-inflammatory drugs. MRI and technetium Tc 99m scans are consistent with an osteoid osteoma. Management should now consist of

Explanation

DISCUSSION: Surgical curettage or en bloc resection is the treatment of choice for osteoid osteoma. Night pain and relief of symptoms with nonsteroidal anti-inflammatory drugs are classic findings for osteoid osteoma.
REFERENCES: Donley BG, Philbin T, Rosenberg GA, Schils JP, Recht M: Percutaneous CT guided resection of osteoid osteoma of the tibial plafond. Foot Ankle Int 2000;21:596-598.
Kenzora JE, Abrams RC: Problems encountered in the diagnosis and treatment of osteoid osteoma of the talus. Foot Ankle 1981;2:172-178.
Shereff MJ, Cullivan WT, Johnson KA: Osteoid-osteoma of the foot. J Bone Joint Surg Am 1983;65:638-641.

Question 40

A 13-year-old girl has had pain in her ankle and difficulty with sporting activities for the past 6 months. Nonsteroidal anti-inflammatory drugs and use of a short leg cast have provided minimal relief. A radiograph and MRI scan are shown in Figures 43a and 43b. What is the next most appropriate step in treatment?

Explanation

DISCUSSION: The MRI scan shows an obvious talocalcaneal coalition of the medial facet. Because nonsurgical management has failed, surgical resection of the coalition is indicated. Arthrodesis would be indicated only if resection fails to relieve pain or if advanced degeneration of the hindfoot joints is present.
REFERENCES: McCormack TJ, Olney B, Asher M: Talocalcaneal coalition resection: A 10-year follow-up. J Pediatr Orthop 1997;17:13-15.
Thometz J: Tarsal coalition. Foot Ankle Clin 2000;5:103-118.

Question 41

A 16-year-old female dancer has persistent posterior ankle pain, particularly after a vigorous dancing schedule. Examination reveals tenderness both posteromedially and posterolaterally. MRI scans are seen in Figures 44a and 44b. What is the most likely diagnosis?

Explanation

DISCUSSION: Posterior ankle impingement or os trigonum syndrome is well described in dancers, and it is often associated with flexor hallucis longus tendinitis. High-quality MRI imaging will reveal the inflammation about the os trigonum and flexor hallucis longus tendinitis.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont IL, American Academy of Orthopaedic Surgeons, 1998, pp 315-332.
Hamilton WG, Hamilton LH: Foot and ankle injuries in dancers, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1225-1256.

Question 42

Which of the following nerves is most commonly injured during ankle arthroscopy?

Explanation

DISCUSSION: The superficial peroneal nerve, which is adjacent to the location of the lateral arthroscopic portal is most commonly injured.
REFERENCES: Ferkel RD, Heath DD, Guhl JF: Neurological complications of ankle arthroscopy. Arthroscopy 1996;12:200-208.
Barber CL, Click J, Britt BT: Complications of ankle arthroscopy. Foot Ankle 1990;10:263-266.

Question 43

An obese 56-year-old woman with hypertension has had posterior heel pain for the past 6 months. She also notes some enlargement over the posterior aspect of the heel. Examination reproduces pain with palpation at the insertion of the Achilles tendon. A lateral radiograph is shown in Figure 45. What is the most likely diagnosis?

Explanation

DISCUSSION: The lateral radiograph shows a traction spur consistent with tendinopathy of the Achilles tendon. There is no displacement of the spur to suggest a rupture of the Achilles tendon, and os trigonum is not seen on the radiograph. The examination findings are not consistent with nerve entrapment.
REFERENCES: Schepsis AA, Wagner C, Leach RE: Surgical management of Achilles tendon overuse injuries: A long-term follow-up study. Am J Sports Med 1994;22:611-619.
Saltzman CL, Tearse DS: Achilles tendon injuries. J Am Acad Orthop Surg 1998;6:316-325.

Question 44

A 42-year-old woman has a history of nontraumatic ankle swelling with tenderness over the Achilles tendon and plantar fascia. She reports that while vacationing in Connecticut 2 months ago she noted the presence of a “red bull’s eye” rash. Management should consist of

Explanation

DISCUSSION: The most likely diagnosis is Lyme disease because of the patient’s recent vacation in an area with a high risk of exposure. The most effective treatment is doxycycline.
REFERENCES: Neu HC: A perspective on therapy of Lyme infection. Ann NY Acad Sci 1988;539:314-316.
Faller J, Thompson F, Hamilton W: Foot and ankle disorders resulting from Lyme disease. Foot Ankle 1991;11:236-238.

Question 45

A 50-year-old woman has a painful hallux valgus and a painful callus beneath the second metatarsal head. A radiograph is shown in Figure 46. To correct these problems, treatment of the great toe deformity should consist of

Explanation

DISCUSSION: The patient has a significant hallux valgus and instability of the first ray, causing transfer metatarsalgia to the second metatarsal head. Therefore, the best procedure is fusion of the metatarsal cuneiform joint with soft-tissue realignment of the first metatarsophalangeal joint. This procedure provides the best chance of relieving symptoms under the second metatarsal head, as well as correcting the hallux valgus.
REFERENCE: Sangeorzan BJ, Hansen ST Jr: Modified Lapidus procedure for hallux valgus. Foot Ankle 1989;9:262-266.

Question 46

The lower extremity motor dysfunction in Charcot-Marie-Tooth disease most commonly involves which of the following muscles?

Explanation

DISCUSSION: The motor dysfunction in Charcot-Marie-Tooth disease involves the tibialis anterior muscle. Charcot-Marie-Tooth disorders most commonly cause distal motor dysfunction in the foot intrinsics, anterior compartment musculature, and peroneals. There is evidence that the peroneus brevis is affected selectively and the peroneus longus is spared. This is based on clinical muscle testing, muscle cross-sections on MRI, and electrodiagnostic testing.
REFERENCES: Mann RA, Missirian J: Pathophysiology of Charcot-Marie-Tooth disease. Clin Orthop 1988;234:221-228.
Tynan MC, Klenerman L, Helliwell TR, Edwards RH, Hayward M: Investigation of muscle imbalance in the leg in symptomatic forefoot pes cavus: A multidisciplinary study. Foot Ankle 1992;13:489-501.

Question 47

Fixed hyperextension of the metatarsophalangeal joint is associated with

Explanation

DISCUSSION: Claw toe and hammer toe deformities are associated with dorsal subluxation of the interossei, which can no longer serve to flex the metatarsophalangeal joint. The extensor digitorum longus then loses its tenodesing effect on the proximal interphalangeal and distal interphalangeal joints and works unopposed to extend the metatarsophalangeal joint and the proximal phalanx. Without the antagonistic action of the extensor digitorum longus, the extrinsic flexors become unopposed flexors of the proximal and distal interphalangeal joints.
REFERENCES: Marks RM: Anatomy and pathophysiology of lesser toe deformities. Foot Ankle Clin 1998;3:199-213.
Myerson MS, Shereff MJ: The pathological anatomy of claw and hammer toes. J Bone Joint Surg Am 1989;71:45-49.

Question 48

The orthosis shown in Figure 47 is commonly used for

Explanation

DISCUSSION: The orthosis shown is a carbon reinforced Morton’s extension, and it is commonly used for hallux rigidus. It decreases motion of the first metatarsophalangeal joint and subsequently decreases pain.
REFERENCE: Clanton TO: Athletic injuries to the soft tissues of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 2, p 1185.

Question 49

A 14-year-old boy has medial ankle pain, progressive unilateral flatfoot deformity, and pain with most activities of daily living. He denies any recent injury. His parents recall that at age 7 years he sustained an injury that was treated as a sprain. Examination reveals valgus deformity with painless, unrestricted passive motion of the ankle. He has grossly equal limb lengths. A radiograph of the affected ankle is shown in Figure 48a, and the contralateral ankle is shown in Figure 48b. Management should consist of

Explanation

DISCUSSION: Angular deformities of the ankle can occur following physeal injury. While an orthosis may be beneficial, the deformity is at the level of the ankle rather than the hindfoot. An epiphysiodesis or physeal bar resection would not be indicated as the growth plates are closed. Correction of the angular deformity should level the ankle joint and normalize the weight-bearing stresses on the ankle. This is most easily achieved with a closing wedge distal tibial osteotomy with or without concomitant osteotomy of the fibula.
REFERENCES: Thompson DM, Calhoun JH: Advanced techniques in foot and ankle reconstruction. Foot Ankle Clin 2000;5:417-442.
Ting AJ, Tarr RR, Sarmiento A, Wagner K, Resnick C: The role of subtalar motion and ankle contact pressure changes from angular deformities of the tibia. Foot Ankle 1987;7:290-299.
Tarr RR, Resnick CT, Wagner KS, Sarmiento A: Changes in tibiotalar joint contact areas following experimentally induced tibial angular deformities. Clin Orthop 1985;199:72-80.

Question 50

What is the most common organism found following a nail puncture wound through tennis shoes in a host without immunocompromise?

Explanation

DISCUSSION: The association of a nail puncture wound with a gram-negative infection (Pseudomonas aeruginosa) has been attributed to the local environmental factors in shoes. Osteomyelitis is rare, occurring only in about 1% of patients. Tetanus prophylaxis should be given if it is not up to date. While the remaining organisms listed are periodically involved, they are more common in patients who are immunocompromised or who have diabetes mellitus. Therefore, obtaining a culture of the infected wound is appropriate in such individuals because of the multifactorial nature of the infection.
REFERENCES: Green NE, Bruno J III: Pseudomonas infections of the foot after puncture wounds. South Med J 1980;73:146-149.
Riegler HF, Routson GW: Complications of deep puncture wounds of the foot. J Trauma 1979;19:18-22.

Question 51

A 52-year-old woman presents with medial foot pain and a progressive flatfoot deformity. On examination, she has a flexible hindfoot valgus and is unable to perform a single-leg heel raise. Weight-bearing radiographs reveal 50% uncoverage of the talar head on the AP view. Which of the following surgical interventions is most appropriate for this patient?

Explanation

This patient has Stage IIB adult acquired flatfoot deformity, distinguished from Stage IIA by >40% talonavicular uncoverage (forefoot abduction). The addition of a lateral column lengthening to the FDL transfer and medial calcaneal osteotomy addresses this abduction deformity.

Question 52

A 14-year-old boy presents with a rigid, painful flatfoot and a history of recurrent ankle sprains. Computed tomography scans reveal a talocalcaneal coalition involving 60% of the posterior facet. There are no degenerative changes in the surrounding joints. What is the most appropriate definitive management?

Explanation

Resection of a talocalcaneal coalition is generally contraindicated if it involves >50% of the posterior facet due to the high risk of continued pain and joint instability. Isolated subtalar arthrodesis is the treatment of choice in this scenario.

Question 53

A 65-year-old woman presents with severe bunion pain. Radiographs show a hallux valgus angle of 45 degrees, an intermetatarsal angle of 18 degrees, and obvious plantar gapping at the first tarsometatarsal (TMT) joint on the lateral weight-bearing view indicating hypermobility. Which of the following procedures is most appropriate?

Explanation

The Lapidus procedure (first TMT fusion) is indicated for severe hallux valgus, especially in the presence of first ray hypermobility. It provides powerful correction of the intermetatarsal angle and stabilizes the medial column.

Question 54

A 22-year-old man with Charcot-Marie-Tooth disease presents with a progressive cavovarus foot deformity. A Coleman block test demonstrates that the hindfoot varus corrects to neutral when the first ray is allowed to drop off the block. What is the primary deforming force driving this patient's foot deformity?

Explanation

In Charcot-Marie-Tooth, the peroneus longus overpowers the weak tibialis anterior, causing a rigidly plantarflexed first ray. The Coleman block test proves the hindfoot varus is flexible and secondary to this forefoot deformity.

Question 55

A 55-year-old man requires surgical intervention for chronic, recalcitrant insertional Achilles tendinopathy. Intraoperatively, extensive calcific degeneration requires debridement of 60% of the Achilles tendon insertion. Which of the following is the most appropriate next step in management?

Explanation

When >50% of the Achilles tendon insertion is debrided for insertional tendinopathy, augmentation is required to prevent rupture and restore plantarflexion strength. Flexor hallucis longus (FHL) transfer is the gold standard for this augmentation.

Question 56

A 58-year-old man with a 15-year history of poorly controlled type II diabetes presents with a unilaterally red, hot, and swollen left foot. He denies trauma. Radiographs reveal fragmentation, periarticular debris, and subluxation of the midfoot joints. He is afebrile with normal inflammatory markers. What is the most appropriate initial treatment?

Explanation

This patient has acute Eichenholtz Stage I Charcot neuroarthropathy. The mainstay of initial treatment for the acute, active phase is rigid immobilization and offloading, most effectively achieved with total contact casting (TCC).

Question 57

Six months after undergoing a distal chevron osteotomy and modified McBride procedure for hallux valgus, a 45-year-old woman complains of pain and a deformity in the opposite direction. Examination reveals a flexible hallux varus deformity. Non-operative measures have failed. What is the most appropriate surgical treatment?

Explanation

For a flexible, iatrogenic hallux varus without degenerative joint changes, treatment involves medial soft tissue release and reconstruction of the lateral stabilizing structures, typically using an EHB tendon transfer.

Question 58

A 19-year-old collegiate track athlete complains of vague dorsal midfoot pain over the last 3 months. A CT scan confirms an incomplete stress fracture of the dorsal cortex of the tarsal navicular without displacement. What is the recommended initial management?

Explanation

Non-displaced or incomplete tarsal navicular stress fractures should be treated with strict non-weight-bearing in a short leg cast for 6 weeks. Weight-bearing modalities have an unacceptably high rate of delayed union or nonunion.

Question 59

A professional football player sustains a hyperdorsiflexion injury to his great toe. Examination reveals profound ecchymosis, loss of plantarflexion strength at the MTP joint, and a positive dorsal drawer test. Radiographs show proximal migration of the sesamoids compared to the uninjured side. What is the most appropriate management?

Explanation

This is a Grade 3 turf toe injury, characterized by complete disruption of the plantar plate-sesamoid complex with proximal sesamoid migration. Surgical repair is indicated in high-level athletes to restore push-off strength and prevent progressive deformity.

Question 60

During the Ponseti method for treating idiopathic clubfoot, a specific sequence of deformity correction must be strictly followed. Which of the following components of the deformity is corrected last?

Explanation

The Ponseti method corrects clubfoot in the sequence of CAVE: Cavus, Adductus, Varus, and finally Equinus. Equinus is addressed last, often requiring a percutaneous Achilles tenotomy.

Question 61

A 64-year-old male presents with end-stage post-traumatic ankle osteoarthritis and is considering a total ankle arthroplasty (TAA). Which of the following is considered an absolute contraindication to performing a TAA?

Explanation

Absolute contraindications to total ankle arthroplasty include Charcot neuroarthropathy, active infection, severe uncorrectable malalignment, and absent lower extremity sensation. Subtalar arthritis is actually a relative indication for TAA over ankle fusion to preserve remaining hindfoot motion.

Question 62

A 42-year-old male construction worker presents with severe pain and stiffness in his right great toe. Examination reveals palpable dorsal osteophytes and less than 10 degrees of dorsiflexion at the first MTP joint. Radiographs show joint space narrowing, subchondral sclerosis, and large dorsal osteophytes (Coughlin and Shurnas Grade 3 hallux rigidus). What is the most reliable surgical treatment for this patient?

Explanation

For young, active patients or heavy laborers with advanced (Grade 3 or 4) hallux rigidus, first MTP joint arthrodesis is the gold standard. It provides reliable pain relief and durability that arthroplasty or cheilectomy cannot match in this demographic.

Question 63

A 21-year-old elite collegiate basketball player sustains an acute, undisplaced fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal (Zone 2) during a game. What is the most appropriate treatment to optimize his safe return to play?

Explanation

Zone 2 fractures (Jones fractures) have a watershed blood supply and a high risk of nonunion. In elite athletes, early intramedullary screw fixation is recommended to decrease nonunion rates and expedite return to play compared to non-operative management.

Question 64

A 30-year-old man sustains a high-energy motor vehicle collision resulting in a talar neck fracture with posterior dislocation of the talar body (Hawkins Type III). Which of the following arteries provides the predominant blood supply to the talar body and is disrupted in this injury?

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, supplies the majority of the talar body. In a Hawkins Type III fracture, the blood supply from the neck, sinus tarsi, and tarsal canal are all disrupted, leading to a near 100% rate of avascular necrosis.

Question 65

A 28-year-old warehouse worker sustains a purely ligamentous Lisfranc injury involving the medial three tarsometatarsal joints. The injury is closed and neurovascularly intact, but radiographs show 3 mm of diastasis between the first and second metatarsal bases. What is the preferred surgical management?

Explanation

Current literature demonstrates that purely ligamentous Lisfranc injuries treated with ORIF have unacceptably high rates of hardware failure and post-traumatic arthritis. Primary arthrodesis of the medial columns yields superior long-term functional outcomes.

Question 66

A 25-year-old gymnast undergoes a modified Broström-Gould procedure for chronic lateral ankle instability after failing extensive physical therapy. Which anatomical structure is advanced and sutured to the fibula to augment the primary repair in the 'Gould' modification?

Explanation

The standard Broström procedure involves direct anatomic repair of the ATFL and CFL. The Gould modification augments this repair by mobilizing the inferior extensor retinaculum and anchoring it to the distal fibula to reinforce the lateral complex.

Question 67

During a minimally invasive percutaneous repair of an acute Achilles tendon rupture, the surgeon places percutaneous sutures proximally. Which nerve is at the greatest risk of iatrogenic injury during this proximal suture placement?

Explanation

The sural nerve crosses from medial to lateral posterior to the calf, sitting lateral to the Achilles tendon approximately 10 cm proximal to its insertion. It is highly susceptible to entrapment or injury during percutaneous or minimally invasive Achilles repair.

Question 68

A 40-year-old woman undergoes excision of a painful, swollen mass in the third intermetatarsal space after failing shoe modifications and injections. Histopathological examination of the excised 'Morton's neuroma' is most likely to show which of the following?

Explanation

A Morton's neuroma is not a true neoplastic neuroma. Histologically, it is characterized by perineural fibrosis, epineural degeneration, and demyelination of the interdigital nerve secondary to chronic repetitive microtrauma.

Question 69

A 55-year-old woman presents with chronic, insidious midfoot pain and a progressive flatfoot. Radiographs demonstrate a comma-shaped deformity of the tarsal navicular with lateral subluxation of the talar head and dorsal fragmentation. What is the most likely diagnosis?

Explanation

Müller-Weiss disease is spontaneous osteonecrosis of the tarsal navicular in adults, presenting with midfoot pain, a characteristic comma-shaped navicular, and lateral talar subluxation. Köhler disease is navicular osteonecrosis but occurs in young children.

Question 70

A 16-year-old female dancer complains of localized pain and swelling at the plantar aspect of her second metatarsophalangeal joint. Radiographs reveal sclerosis, flattening, and early fragmentation of the second metatarsal head. What is the diagnosis?

Explanation

Freiberg's infraction is avascular necrosis of the metatarsal head, most commonly affecting the second metatarsal in adolescent females (often dancers or athletes). It presents with localized pain, stiffness, and characteristic flattening of the articular surface.

Question 71

A 55-year-old patient with long-standing diabetes presents with a swollen, erythematous, and warm unilateral foot and ankle. Radiographs reveal periarticular debris, fragmentation, and subluxation of the midfoot joints. What is the most appropriate initial management?

Explanation

This patient is in the acute fragmentation phase (Stage 1) of Eichenholtz Charcot arthropathy. The gold standard initial treatment is offloading with a total contact cast to prevent further deformity.

Question 72

A 45-year-old woman presents with medial ankle pain and a progressively collapsing arch. Examination shows a flexible hindfoot valgus and inability to perform a single-leg heel rise. Radiographs demonstrate >50% uncovering of the talar head. Which of the following surgical interventions is most appropriate?

Explanation

This represents Stage IIb adult acquired flatfoot deformity (AAFD), characterized by greater than 50% talonavicular uncovering indicating significant forefoot abduction. Treatment requires a lateral column lengthening (e.g., Evans osteotomy) in addition to FDL transfer and medial calcaneal osteotomy.

Question 73

A 35-year-old woman presents with a painful bunion. Clinical examination reveals hypermobility of the first tarsometatarsal (TMT) joint. Radiographs show a hallux valgus angle of 45 degrees and an intermetatarsal angle of 18 degrees. Which of the following procedures is most appropriate?

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for moderate to severe hallux valgus associated with first ray hypermobility. It provides powerful correction of the intermetatarsal angle and stabilizes the medial column.

Question 74

A 24-year-old professional football player sustains a purely ligamentous Lisfranc injury. Weight-bearing radiographs show 3 mm of widening between the first and second metatarsal bases. What is the most appropriate definitive management?

Explanation

Recent evidence supports primary arthrodesis for purely ligamentous Lisfranc injuries, especially in active patients, due to lower rates of hardware failure and secondary procedures compared to ORIF. Purely bony injuries are typically managed with ORIF.

Question 75

Which of the following is the most significant potential advantage of non-operative management compared to operative repair for an acute Achilles tendon rupture?

Explanation

Non-operative management of acute Achilles tendon ruptures with early functional rehabilitation has re-rupture rates comparable to surgery. However, operative management carries a significantly higher risk of soft-tissue complications, such as infection and wound breakdown.

Question 76

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

Explanation

This is a Zone 2 (Jones) fracture, which has a high risk of delayed union or nonunion due to a watershed blood supply. In high-level athletes, intramedullary screw fixation is recommended to ensure healing and expedite return to play.

Question 77

Six weeks after sustaining a displaced talar neck fracture treated with open reduction and internal fixation, a patient's anteroposterior ankle radiograph demonstrates a subchondral radiolucent band in the talar dome. This radiographic finding indicates:

Explanation

This finding is the Hawkins sign, which represents subchondral osteopenia secondary to hyperemia. It is a highly reliable indicator that the vascular supply to the talar body is intact, effectively ruling out avascular necrosis.

Question 78

When utilizing a lateral extensile approach for the open reduction and internal fixation of a displaced intra-articular calcaneal fracture, which of the following structures is at greatest risk of iatrogenic injury during the inferior horizontal limb of the incision?

Explanation

The sural nerve crosses the lateral aspect of the hindfoot and is at significant risk during the creation of the inferior horizontal limb of the lateral extensile approach. Care must be taken to create full-thickness flaps to protect the nerve and the vascular supply to the skin.

Question 79

During the physical examination of a patient with a cavovarus foot deformity, the Coleman block test is performed. The hindfoot varus corrects to neutral when the lateral aspect of the foot is placed on the block while the first ray is allowed to drop off. This finding indicates that the hindfoot varus is:

Explanation

The Coleman block test evaluates the flexibility of hindfoot varus in a cavovarus foot. If the hindfoot corrects when the plantarflexed first ray is allowed to drop off the block, the hindfoot varus is flexible and forefoot-driven, indicating the need for a dorsiflexion osteotomy of the first metatarsal.

Question 80

A 62-year-old man presents with severe pain and stiffness in his right great toe. Examination shows less than 10 degrees of dorsiflexion and pain throughout the entire arc of motion. Radiographs reveal complete loss of joint space and large dorsal, medial, and lateral osteophytes at the first MTP joint. Which treatment offers the most reliable long-term pain relief?

Explanation

This patient has Grade 4 hallux rigidus (pain throughout ROM, complete joint space loss). Arthrodesis is the gold standard for end-stage hallux rigidus, providing the most reliable long-term pain relief and functional improvement.

Question 81

Histologic evaluation of a symptomatic mass excised from the third intermetatarsal space of a 45-year-old woman reveals marked perineural fibrosis, endoneurial edema, and demyelination of nerve fibers. What is the most likely diagnosis?

Explanation

The histologic findings of perineural fibrosis, local vascular changes, and endoneurial edema are characteristic of Morton's neuroma. It is an entrapment neuropathy causing a reactive degeneration, rather than a true neoplasm.

Question 82

To optimize gait biomechanics and minimize adjacent joint arthritis, what is the ideal position for a tibiotalar arthrodesis?

Explanation

The optimal position for ankle arthrodesis is neutral dorsiflexion, slight valgus (0-5 degrees), and slight external rotation (5-10 degrees) matching the contralateral limb. Plantarflexion or varus malalignment significantly impairs gait and accelerates adjacent joint arthritis.

Question 83

Which of the following is considered an absolute contraindication to a total ankle arthroplasty?

Explanation

Severe peripheral neuropathy (e.g., Charcot arthropathy) is an absolute contraindication to total ankle arthroplasty due to the high risk of catastrophic failure and infection. Inflammatory arthritis is actually a classic indication for TAA.

Question 84

A 28-year-old dancer reports a recurrent snapping sensation over her lateral ankle. Examination reveals palpable subluxation of the peroneal tendons over the distal fibula with resisted eversion. Surgical exploration is most likely to reveal an injury to which of the following structures?

Explanation

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

Question 85

A 52-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. Clinical examination reveals an inability to perform a single-leg heel rise and forefoot abduction with "too many toes" visible from behind. Weight-bearing radiographs show greater than 50% talonavicular uncoverage but no arthritic changes in the hindfoot or midfoot. Which of the following is the most appropriate surgical management?

Explanation

This patient has Stage IIB adult-acquired flatfoot deformity (posterior tibial tendon dysfunction), characterized by flexible hindfoot valgus and significant forefoot abduction (>40% or >50% talonavicular uncoverage). Surgical correction requires FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening to address the abduction.

Question 86

A 24-year-old man with Charcot-Marie-Tooth disease presents with a painful cavovarus foot deformity. On examination, the hindfoot varus corrects to neutral when the patient stands with the lateral border of his foot on a block and the first ray suspended off the medial edge (Coleman block test). What is the primary anatomic driver of his hindfoot deformity, and what is the indicated bony procedure?

Explanation

A positive Coleman block test (hindfoot corrects to neutral) indicates a flexible hindfoot driven by a rigid, plantarflexed first ray. A dorsiflexing osteotomy of the first metatarsal is required to correct the forefoot-driven hindfoot varus deformity.

Question 87

A 68-year-old man presents with severe, end-stage ankle osteoarthritis. Radiographs reveal bone-on-bone tibiotalar arthritis, 25 degrees of coronal plane varus deformity, and avascular necrosis involving 60% of the talar body. What is the most appropriate definitive surgical intervention?

Explanation

Significant avascular necrosis of the talus (>50%) and severe coronal plane deformity are absolute contraindications for standard total ankle arthroplasty. A tibiotalocalcaneal (TTC) arthrodesis is the most reliable treatment to address both the arthritis and the compromised talar bone stock.

Question 88

A 22-year-old collegiate football player sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial cuneiform and the base of the second metatarsal. He wishes to maximize his chances of returning to his pre-injury level of performance while minimizing the risk of post-traumatic arthritis. Which of the following treatments is most supported by recent literature for this specific injury pattern?

Explanation

Studies (such as Ly and Coetzee) have demonstrated that primary arthrodesis for purely ligamentous Lisfranc injuries yields superior functional outcomes and lower rates of secondary surgeries compared to traditional ORIF.

Question 89

A 28-year-old female runner complains of pain and stiffness localized to the dorsal aspect of her right first metatarsophalangeal (MTP) joint. Radiographs show a dorsal osteophyte but normal joint space width and no central cartilage loss (Grade 1 hallux rigidus). Nonoperative management has failed. Which of the following is the most appropriate surgical option?

Explanation

Dorsal cheilectomy is the surgical treatment of choice for early-stage (Grades 1 and 2) hallux rigidus with preserved joint space and pain primarily with dorsiflexion. It reliably relieves pain and preserves joint motion.

Question 90

A 55-year-old woman presents with a painful bunion deformity. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 42 degrees, an intermetatarsal angle (IMA) of 18 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate to provide long-term correction?

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus deformities (IMA > 15 degrees) and is especially preferred when there is concurrent first TMT joint hypermobility or arthritis.

Question 91

A 14-year-old boy presents with a rigid, flat foot and recurrent ankle sprains. Computed tomography (CT) confirms a talocalcaneal coalition involving the middle facet, which comprises approximately 30% of the posterior subtalar joint surface. There are no signs of subtalar osteoarthritis. What is the most appropriate initial surgical intervention after conservative measures fail?

Explanation

Resection with interposition (fat or tendon) is indicated for talocalcaneal coalitions involving less than 50% of the joint surface without degenerative changes. Arthrodesis is reserved for larger coalitions (>50%) or cases with significant arthritis.

Question 92

During open reduction and internal fixation of a pronation-external rotation ankle fracture, a positive Cotton test confirms syndesmotic instability. The surgeon chooses to use flexible suture-button fixation rather than rigid syndesmotic screws. Based on current literature, what is the primary advantage of the suture-button construct?

Explanation

Suture-button constructs permit physiologic motion of the syndesmosis, which leads to lower rates of required hardware removal and has been shown to reduce the incidence of syndesmotic malreduction compared to rigid screw fixation.

Question 93

A 64-year-old man with poorly controlled type 2 diabetes mellitus and profound peripheral neuropathy sustains a displaced bimalleolar ankle fracture. What specialized surgical modification is strongly recommended in this patient population to prevent catastrophic postoperative complications such as Charcot arthropathy or fixation failure?

Explanation

Diabetic patients with neuropathy have significantly higher rates of hardware failure and Charcot arthropathy following ankle fractures. Standard protocols recommend "maximized" augmented fixation constructs and doubling the standard duration of non-weight-bearing.

Question 94

A 30-year-old professional athlete suffers a forced hyperextension injury to the first MTP joint. Clinical examination and MRI confirm a Grade 3 "turf toe" injury with complete rupture of the plantar plate complex and proximal retraction of the sesamoids. What is the most appropriate management?

Explanation

A Grade 3 turf toe injury involves complete tearing of the plantar plate with sesamoid retraction and clinical instability. In high-level athletes, this necessitates primary surgical repair to restore push-off strength and joint stability.

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

Orthopedic Board Prep MCQs: Ankle, Foot & Deformity | Part 48

Key Takeaway

Orthopedic Board Prep MCQs: Ankle, Foot & Deformity | Part 48

Chapter Index