Orthopedic Foot & Ankle 2026 MCQs: Board Review Pt 2

Question 1

A 45-year-old man is seen in the emergency department after returning from a 2-hour airplane flight. He is reporting severe pain in his right leg but has no trouble moving his ankle, leg, or knee. Venous doppler testing reveals no evidence of deep venous thrombosis. He is placed on IV cephazolin but continues to worsen. On the third day in the hospital he has increased pain, some respiratory distress, and trouble maintaining his blood pressure. His leg takes on the appearance seen in Figure 15. An urgent MRI scan shows thickening of the subcutaneous tissues and superficial swelling in the leg but no evidence of an abscess. What is the next most appropriate step in management?

Explanation

The patient has necrotizing fasciitis, a rare and sometimes fatal disease that has many different etiologies. Signs that this is not a normal infection are the worsening clinical symptoms despite IV antibiotics and the systemic symptoms. He needs urgent surgical care before he becomes completely septic and unstable. He needs very aggressive debridement of his tissues. Hyperbaric oxygen and immunoglobulins are only anecdotally helpful, and would only be used after surgery. Fontes RA, Ogilvie CM, Miclau T: Necrotizing soft-tissue infections. J Am Acad Orthop Surg 2000;8:151-158.

Question 2

A 17-year-old girl with Charcot-Marie-Tooth disease reports the development of progressive instability when walking on uneven surfaces. Her involved heel is positioned in varus when viewed from behind. Examination reveals that she walks on the outer border of the involved foot. She has full passive motion of the ankle and hindfoot joints. She is able to dorsiflex the ankle against resistance. The heel varus fully corrects with the Coleman block test. Standing radiographs reveal a cavus deformity with valgus of the forefoot. She would like to avoid using an ankle-foot orthosis. What is the best surgical option?

Explanation

This deformity is early in the disease process. The foot is still flexible, as evidenced by correction with the Coleman block test. A simple dorsiflexion osteotomy of the first metatarsal should provide a plantigrade foot. More complex osteotomies are required later in the disease process when the foot is not flexible and the deformity does not correct with the Coleman block test. The patient may also require a tibialis anterior transfer later in the disease process but not at the present time. Richardson EG (ed): Orthopaedic Knowledge Upate: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 135-144.

Question 3

A 58-year-old man with type 1 diabetes mellitus is seen in the emergency department and he reports a 3-day history of a red swollen foot but no history of trauma. Examination reveals that the skin is intact, and the patient has discomfort with passive range of motion at the ankle, hindfoot, and midfoot joints. He denies any fever. Laboratory studies show a WBC count of 7,800/mm3, an erythrocyte sedimentation rate of 40 mm/h, a C-reactive protein level of 23, and a serum glucose of 100. A radiograph and MRI scans are shown in Figures 16a through 16c. What is the next most appropriate step in management?

Explanation

16b 16c Whereas it is difficult to distinguish between cellulitis, septic joint, osteomyelitis, and early Eichenholtz stage 1 Charcot, the presence of a fracture in the absence of ulcerations with a normal WBC count and serum glucose strongly indicates that the described symptoms are due to an early Charcot process alone. A technetium Tc 99m scan alone would not be helpful; however, the addition of a sulfur colloid marrow scan or indium In 111 scan may be more specific to rule out infection, though it is not warranted here. Total contact casting with non-weight-bearing or limited weight bearing during Eichenholtz stage 1 when the foot is warm, erythematous, and swollen is advised to help prevent deformity. Alternatively, stabilization with pneumatic bracing may also be considered. While some authors have proposed early fixation or arthrodesis for Eichenholtz stage 1, the gold standard is still total contact casting with no to limited weight bearing until the swelling resolves and evidence of consolidation is seen on radiographs. Trepman E, Nihal A, Pinzur MS: Current topics review: Charcot neuropathy of the foot and ankle. Foot Ankle Int 2005;26:46-63. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 123-134.

Question 4

Which of the following conditions is not associated with an increased risk of developing Achilles tendinopathy?

Explanation

Diabetes mellitus, obesity, and exposure to steroids have all been associated with the development of Achilles tendinopathy. In addition, Achilles tendinopathy has been associated with a history of hormone replacement therapy and the use of oral contraceptives. Quinolone antibiotics have also been linked to Achilles tendinopathy. Holmes GB, Lin J: Etiologic factors associated with symptomatic Achilles tendinopathy. Foot Ankle Int 2006;27:952-959.

Question 5

Figures 17a through 17c show the radiographs of a 38-year-old man following a motorcycle accident. The posterior portion of the talus extruded through a posterolateral wound. The extruded talar body is visible in the wound along with some road debris. Management should now consist of surgical irrigation, debridement, and

Explanation

17b 17c The extruded talus should be placed in sterile bacitracin solution, irrigated thoroughly, gently debrided, and immediately replanted in the OR. Open reduction and internal fixation of the talar fracture may be attempted immediately depending on the soft-tissue envelope, or delayed after soft-tissue stabilization with an external fixator. A retrospective study of 19 patients with an extruded talus reported that 12 patients had no subsequent surgery after definitive fixation, 7 had subsequent procedures, and 2 patients developed infections that were treated successfully at an average of 42-month follow-up. Successful outcome in this series was attributed to multiple debridements, soft-tissue stabilization, and primary wound closure. Smith CS, Nork SE, Sangeorzan BJ: The extruded talus: Results of reimplantation. J Bone Joint Surg Am 2006;88:2418-2424. Brewster NT, Maffulli N: Reimplantation of the totally extruded talus. J Orthop Trauma 1997;11:42-45.

Question 6

Figures 18a and 18b show the radiographs of a patient who has pain with walking. On careful questioning, it is determined that the discomfort occurs at push-off, or when the patient attempts to climb stairs. What nonsurgical option is most likely to ameliorate the symptoms?

Explanation

18b The patient has a malunion of an attempted open reduction of a Lisfranc dislocation. The pain occurs during the terminal stance phase of gait as load is being transferred from the hindfoot to the forefoot. The bending moment can be best neutralized with shoe modification with a cushioned heel and rocker sole, which best unloads the tarsal-metatarsal junction. Bono CM, Berberian WS: Orthotic devices: Degenerative disorders of the foot and ankle. Foot Ankle Clin 2001;6:329-340.

Question 7

An 18-year-old football player reports acute pain and swelling after a direct injury to his plantar flexed foot. Examination reveals midfoot swelling and tenderness. Nonstanding radiographs are normal. What is the next most appropriate step in management?

Explanation

Differentiating between a midfoot sprain and Lisfranc diastasis is critical in the management of the athlete with an acute injury to the midfoot. Greater than 2 mm of displacement between the first and second metatarsals on a weight-bearing radiograph is an indication for anatomic reduction with internal fixation of the tarsometatarsal joints. If no subluxation is noted, treatment should consist of a non-weight-bearing cast for 6 weeks, followed by a gradual return to activity. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.

Question 8

A 36-year-old woman is wearing an ankle-foot orthosis for a foot drop secondary to spastic hemiplegia following a postpartum stroke 2 years ago. Knee and hip motion and strength are within normal ranges. She has undergone multiple rounds of physical therapy but has seen no improvement over the past several months. No improvement has been recorded by electromyography (EMG) studies over the past year. Examination reveals a 5-degree plantar flexion contracture with clonus, heel varus, and compensatory knee hyperextension when standing. She has 4/5 power in the tibialis anterior and gastrocnemius soleus complex with resistance testing. Everters are 2/5 to resistance testing. EMG gait studies show that the tibialis anterior demonstrates activity during both swing and stance phase that is increased during swing phase. Premature firing of the triceps surae is noted when positioning the foot in equinus prior to floor contact. What is the most appropriate management?

Explanation

The patient has a dynamic varus deformity secondary to spasticity of the tibialis anterior during stance phase with inverter/everter imbalance. The patient still has active motion of the tibialis anterior; therefore, an out-of-phase posterior tibial tendon transfer should not be performed. The same is true of the Bridle procedure. Transfer of the posterior tibialis in this patient may also result in subsequent planovalgus deformity. Lengthening of the Achilles tendon through a percutaneous tenotomy will restore dorsiflexion and decrease clonus from the stretch response. If adequate dorsiflexion is not obtained intraoperatively, then posterior tibialis tendon lengthening may be considered. A split tibialis anterior tendon transfer to the lateral cuneiform, or, transfer of the entire tendon to the cuneiform should correct the varus component and compensate for the weakened peroneals. Yamamoto H, Okumura S, Morita S, et al: Surgical correction of foot deformities after stroke. Clin Orthop Relat Res 1992;282:213-218. Piazza SJ, Adamson RL, Moran MF, et al: Effects on tensioning errors in split transfers of tibialis anterior and posterior tendons. J Bone Joint Surg Am 2003;85:858-865.

Question 9

A 52-year-old woman slipped on ice in her driveway. Radiographs are shown in Figures 19a and 19b. The patient was treated in a short leg cast with weight bearing as tolerated for 6 weeks. Due to persistent tenderness at the fracture site, a CAM walker was used for an additional 8 weeks. Nine months after the injury, the patient still walks with a limp and reports pain with deep palpation at the fracture site. What is the next most appropriate step in management?

Explanation

19b Persistent pain at the fracture site in the absence of infection is most likely due to a nonunion, best detected by CT. Walsh and DiGiovanni reported on a series of closed rotational fibular fractures in which nonunions were detected by CT in the absence of standard ankle radiographic findings. Repeat immobilization would not be appropriate at this late date. Pain management/sympathetic blocks would be considered if the patient displayed pain with light touch and disproportionate pain consistent with a complex mediated pain syndrome. Acupuncture would be expected to be of limited benefit. Walsh EF, DiGiovanni C: Fibular nonunion after closed rotational ankle fracture. Foot Ankle Int 2004;25:488-495.

Question 10

What is the most frequent complication of percutaneous repair of an acute Achilles tendon rupture?

Explanation

Sural nerve entrapment is the major risk of percutaneous repair. A small mini-open technique with a suture guide can obviate that issue. Re-rupture rates after surgical repair are approximately 3%. Infection and wound problems are rarely encountered with percutaneous repair; they are issues with open repair. Aracil J, Pina A, Lozano JA, et al: Percutaneous suture of Achilles tendon ruptures. Foot Ankle 1992;13:350-351. Sutherland A, Maffulli N: A modified technique of percutaneous repair of the ruptured Achilles tendon. Oper Orthop Traumatol 1998;10:50-58.

Question 11

A 2-year-old child is brought in by his parents for evaluation of intoeing. The child has a normal neuromuscular examination, but the heel bisector line is in the fourth web space, indicating a severe flexible metatarsus adductus deformity. The remainder of the lower extremity examination is unremarkable. What is the most appropriate treatment?

Explanation

Weinstein reported on 31 patients (45 feet) with congenital metatarsus adductus followed for an average of 33 years. Twenty-nine feet had moderate to severe deformities treated with manipulation and casting with a 90% success rate. In a young child, surgery is not indicated until nonsurgical management has failed. In patients 2 to 4 years of age, tarsometatarsal capsulotomies are indicated, whereas multiple metatarsal osteotomies are reserved for recalcitrant deformities in children older than 4 years of age. Mild or moderate metatarsus adductus that is passively correctable will resolve without treatment. Beaty J: Congenital anomalies of the lower extremity, in Canale ST (ed): Campbell's Operative Orthopaedics, ed 10. Philadelphia PA, Mosby, 2003, pp 983-988. Katz K, David R, Soudry M: Below-knee plaster cast for the treatment of metatarsus adductus. J Pediatr Orthop 1999;19:49-50.

Question 12

A 34-year-old man has had a 13-month history of an equinovarus deformity of the foot and ankle after a motorcycle accident. His foot and ankle are flexible, but bracing has become uncomfortable. Active dorsiflexion and eversion are absent. What is the most appropriate treatment?

Explanation

Arthrodesis of any of the ankle or hindfoot joints should be reserved for fixed deformities or end-stage degenerative arthritis. Achilles tendon lengthening is necessary to correct the equinus and to improve dorsiflexion-plantar flexion balance. Similarly, transfer of the posterior tibialis tendon reduces both plantar flexion and inversion torque. Hansen ST: Function Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 442-447.

Question 13

Figures 20a and 20b show the radiographs of a 14-year-old boy who sustained a twisting injury to his ankle. If attempted closed reduction is unsuccessful, what is the primary reason to proceed with surgical treatment?

Explanation

20b Triplane fractures generally occur in children who are near skeletal maturity. The injury is generally caused by a supination external rotation mechanism. The number of fracture fragments present (two or three) depends on what part of the physes is closed at the time of injury. Articular congruity is the major concern in the management of these injuries since the patient has almost reached skeletal maturity. The goal is to restore articular congruity to minimize the development of posttraumatic arthritis. Vaccaro A (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 757-765. Kling TF Jr, Bright RW, Hensinger RN: Distal tibial physeal fractures in children that may require open reduction. J Bone Joint Surg Am 1984;66:647-657.

Question 14

A 75-year-old woman reports foot pain and states that her foot has become progressively "flatter" in the past 3 years. Custom inserts and physical therapy have failed to provide relief. Examination reveals a flexible hindfoot and mild heel cord contracture. The patient is able to perform a single limb heel rise. Weight-bearing radiographs are shown in Figures 21a through 21d. What is the most appropriate surgical management?

Explanation

21b 21c 21d The patient has end-stage midfoot arthritis, with a secondary flatfoot deformity through the midfoot. The ability to perform a single limb heel rise indicates that the posterior tibial tendon is functioning, and the weight-bearing radiographs show normal calcaneal pitch and talar head coverage, thus confirming that the flatfoot deformity is isolated to the midfoot. Therefore, the most appropriate treatment is medial column arthrodesis and heel cord lengthening. The other listed procedures are not indicated because they are used in the management of adult flatfoot from posterior tibial tendon insufficiency. Toolan BC: Midfoot arthrodesis: Challenges and treatment alternatives. Foot Ankle Clin 2002;7:75-93.

Question 15

A 52-year-old woman who underwent cheilectomy 1 year ago for hallux rigidus now reports continued pain in the first metatarsophalangeal joint. She did not have any incision healing problems, and has not had any fevers, erythema, or drainage. Which of the following procedures will provide the best combination of pain relief and function?

Explanation

All but the Moberg osteotomy are capable of providing pain relief; however, arthrodesis offers the best long-term results and restores weight bearing and propulsion function to the first ray. Machacek F Jr, Easley ME, Gruber F, et al: Salvage of a failed Keller resection arthroplasty. J Bone Joint Surg Am 2004;86:1131-1138.

Question 16

During a posterior approach to the right Achilles tendon, the surgeon encounters a nerve running with the small saphenous vein as shown in Figure 22. This nerve innervates what part of the foot?

Explanation

The sural nerve runs with the small saphenous vein on the posterior leg just lateral to the Achilles tendon. It is formed by contributions from both the tibial and common peroneal nerves and provides sensation on the dorso-lateral aspect of the foot. Aktan Ikiz ZA, Ucerler H, Bilge O: The anatomic features of the sural nerve with an emphasis on its clinical importance. Foot Ankle Int 2005;26:560-567.

Question 17

A 23-year-old woman has had a 14-month history of ankle pain after surgical treatment of multiple injuries resulting from a motor vehicle accident. Weight bearing began 4 months after surgery. The pain occurs with weight bearing and motion, but there is very little pain at rest. She has no pertinent medical history and does not smoke. Figures 23a and 23b show current radiographs. What is the most appropriate surgical option?

Explanation

23b The radiographs reveal nonunion of a talar neck fracture. There is no radiographic evidence of osteonecrosis or significant degenerative arthritis. The results of talectomy are suboptimal. Arthrodesis would be indicated for degenerative arthritis. Revision ORIF is feasible and preserves motion. A vascularized graft should be considered whenever osteonecrosis is present, but the talar body appears viable in this case. Calvert E, Younger A, Penner M: Post talus neck fracture reconstruction. Foot Ankle Clin 2007;12:137-151.

Question 18

What type of physical therapy is most effective for chronic noninsertional Achilles tendinopathy?

Explanation

Eccentric gastrocsoleus strengthening (especially with heavy loads) consistently has been shown to be superior in the management of Achilles tendinopathy. Decreases in pain and increases in strength have been demonstrated despite the frequently refractory nature of this condition. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 91-102.

Question 19

A 27-year-old man was struck by a taxi cab and sustained comminuted right distal third tibia and fibula fractures; treatment consisted of placement of an intramedullary nail in the tibia the following morning. At his 6-month follow-up, he has clawing of all five toes. Examination reveals flexion deformities of the distal and proximal interphalangeal joints that are flexible with plantar flexion and rigid with dorsiflexion. Calluses are present on the dorsum and tip of the toes. Single heel rise is normal. He has a mild equinus contracture (relative to the left leg) that is not relieved with knee flexion. What is the most appropriate treatment option?

Explanation

This is an example of tethering of the flexor hallucis longus/flexor digitorum longus (FHL/FDL) to the fracture site. Additional time and/or physical therapy and bracing would not be expected to be of benefit. Release of the FHL and FDL from the fracture site or retromalleolar lengthening will address the posttraumatic claw toe deformity and Achilles tendon lengthening will address the mild equinus. Posterior tibial tendon transfer is not appropriate as the patient demonstrates a normal heel rise. Midfoot releases and hallux fusion are also not indicated. Feeny MS, Williams RL, Stephens MM: Selective lengthening of the proximal flexor tendon in the management of acquired claw toes. J Bone Joint Surg Br 2001;83:335-338.

Question 20

A 24-year-old man reports the development of a foot drop following a knee dislocation 1 year ago. The common peroneal nerve was found to be in continuity at the time of surgical reconstruction of the posterolateral corner of the knee joint. He would like to eliminate the need for an ankle-foot orthosis. What is the best option to achieve elimination of the orthosis?

Explanation

The ankle dorsiflexor muscles have been denervated for too long a period to expect reinnervation to be successful. Even if the extensor hallucis longus tendon was functional, it is unlikely to have sufficient strength to achieve dynamic ankle dorsiflexion. The tibialis posterior tendon transfer has been shown to predictably achieve these goals in a high percentage of patients. Successful ankle fusion is likely to fail with time due to the development of forefoot equinus. Pinzur MS, Kett N, Trilla M: Combined anteroposterior tibial tendon transfer in post-traumatic peroneal palsy. Foot Ankle 1988;8:27l-275.

Question 21

A 21-year-old male construction worker fell from a roof and sustained an injury to his left foot. Radiographs and CT scans are shown in Figures 24a through 24e. Compared to nonsurgical management, surgical treatment offers which of the following advantages?

Explanation

24b 24c 24d 24e The radiographs and CT scans show a displaced intra-articular calcaneal fracture, with loss of calcaneal height and length. Recent multicenter, randomized, prospective studies suggest that surgical treatment of displaced intra-articular calcaneal fractures is associated with an almost six-fold decrease in the risk of posttraumatic subtalar arthritis (necessitating subtalar arthrodesis) compared to nonsurgical treatment. Despite ongoing controversy, surgical treatment has not been shown to be advantageous with respect to activity, time to return to work, or subtalar joint range of motion. A nonunion of a calcaneal fracture is exceedingly rare regardless of the treatment method. Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744.

Question 22

A 51-year-old plumber has a failed peroneus brevis tendon repair. He reports continued pain and swelling in the distal retrofibular area. MRI shows longitudinal tears of the peroneus longus and peroneus brevis. What is the surgical treatment of choice at this time?

Explanation

A flexor digitorum longus transfer, while not as strong as the peroneals, improves the tendon balance and maintains hindfoot mobility. Subtalar fusion is a salvage procedure. Posterior tibial tendon transfer compromises inversion strength and arch height. Functional absence of the peroneals results in an imbalance that could lead to forefoot varus. Redfern D, Myerson M: The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int 2004;25:695-707.

Question 23

Which of the following imaging modalities is most accurate in locating a toothpick in the plantar arch of the foot?

Explanation

Ultrasound is best at imaging abrupt changes in the density of adjacent tissue and therefore is best at imaging wood in the soft tissues of the foot. Mizel MS, Steinmetz ND, Trepman E: Detection of wooden foreign bodies in muscle tissue: Experimental comparison of computed tomography, magnetic resonance imaging, and ultrasonography. Foot Ankle Int 1994;15:437-443.

Question 24

A 35-year-old man is seen in the emergency department with a bullet wound to the foot that occurred 2 hours ago. Examination reveals a 0.5-cm entrance wound on the dorsum of the foot and a 1.5-cm exit wound on the plantar aspect. Exploration of the plantar wound in the emergency department reveals bone and metal fragments. Radiographs reveal a comminuted, unstable fracture of the base of the first metatarsal and cuneiform. Management should consist of tetanus toxoid, and

Explanation

The patient sustained a type I unstable fracture that requires debridement of superficial fragments from the sole and surgical stabilization. Low-velocity wounds less than 8 hours old are considered type I open fractures. In contrast, gunshot wounds with associated fractures more than 8 hours old are considered type II open fractures using the Gustilo and Anderson classification. Gustilo type I stable fractures due to gunshot wounds and seen within 8 hours can be treated with tetanus toxoid (if no history of immunization or booster within 5 years), surface irrigation, and casting or a hard sole shoe. Antibiotics are not required unless gross contamination is present. However, if the extent of contamination is unclear, or if a joint is penetrated, then routine antibiotic prophylaxis is recommended. Indications for surgery include: articular involvement, unstable fractures, presentation 8 or more hours after injury, tendon involvement, and superficial fragments in the palm or sole. Type I unstable fractures may be stabilized with internal or external fixation. Type II unstable fractures should be treated with external fixation and repeat debridements until clean. Holmes GB Jr: Gunshot wounds of the foot. Clin Orthop Relat Res 2003;408:86-91.

Question 25

What is the most frequent location of entrapment of the deep peroneal nerve?

Explanation

The most frequently described entrapment of the deep peroneal nerve is the anterior tarsal tunnel syndrome. This syndrome refers to entrapment of the deep peroneal nerve under the inferior extensor retinaculum. Entrapment can also occur as the nerve passes under the tendon of the extensor hallucis brevis. Compression by underlying dorsal osteophytes of the talonavicular joint and an os intermetatarseum (between the bases of the first and second metatarsals) have previously been described in runners. Kopell HP, Thompson WA: Peripheral entrapment neuropathies of the lower extremity. N Engl J Med 1960;262:56-60.

Question 26

A 25-year-old professional athlete sustains a twisting injury to his midfoot. Non-weight-bearing radiographs are normal. However, weight-bearing radiographs reveal a 3-mm diastasis between the base of the first and second metatarsals without any evidence of osseous avulsion fractures. Which of the following is the most appropriate definitive management to maximize his chances of returning to high-level athletics?

Explanation

Recent evidence favors primary arthrodesis for purely ligamentous Lisfranc injuries in high-level athletes. This approach reduces the need for hardware removal and avoids late post-traumatic arthritis seen frequently after ORIF.

Question 27

A 40-year-old man undergoes a percutaneous repair of an acute Achilles tendon rupture. Postoperatively, he complains of numbness along the lateral border of his foot. Injury to which of the following nerves is the most likely cause of his symptoms?

Explanation

The sural nerve crosses from the midline to the lateral border of the Achilles tendon approximately 10 cm proximal to its calcaneal insertion. It is highly susceptible to iatrogenic injury during percutaneous Achilles tendon repairs.

Question 28

A 50-year-old woman presents with medial ankle pain and an acquired flatfoot deformity. Examination reveals a flexible hindfoot valgus. Weight-bearing radiographs show greater than 30% uncoverage of the talar head on the AP view, indicating significant forefoot abduction. She has failed conservative management. Which surgical reconstruction is most appropriate for this Stage IIb posterior tibial tendon dysfunction?

Explanation

Stage IIb posterior tibial tendon dysfunction is characterized by a flexible flatfoot with severe forefoot abduction (>30% talonavicular uncoverage). It is best addressed with FDL transfer, medializing calcaneal osteotomy, and a lateral column lengthening to correct the abduction.

Question 29

A 60-year-old man presents with advanced ankle osteoarthritis and is inquiring about total ankle arthroplasty (TAA). Which of the following is considered an absolute contraindication for TAA?

Explanation

Severe sensory neuropathy and Charcot neuroarthropathy are absolute contraindications to total ankle arthroplasty due to unacceptably high rates of implant failure, subsidence, and infection. In these patients, arthrodesis is the preferred surgical option.

Question 30

A 22-year-old collegiate basketball player sustains a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal base. What is the most appropriate management to minimize the risk of nonunion and allow for an expedited return to play?

Explanation

Zone 2 fractures (Jones fractures) in elite athletes have a high risk of delayed union or nonunion due to watershed vascularity. Early intramedullary screw fixation accelerates the return to play and significantly lowers nonunion rates.

Question 31

A 45-year-old woman presents with a painful bunion. Weight-bearing radiographs reveal an intermetatarsal angle (IMA) of 16 degrees and a hallux valgus angle (HVA) of 38 degrees. Clinical examination demonstrates significant hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate?

Explanation

A Lapidus procedure (first TMT arthrodesis) is indicated for moderate-to-severe hallux valgus (IMA > 15 degrees) accompanied by first TMT joint hypermobility. It effectively restores stability to the medial column.

Question 32

A 20-year-old cross-country runner complains of vague midfoot pain. Radiographs are normal, but an MRI demonstrates a nondisplaced, incomplete stress fracture involving the central third of the navicular. What is the most appropriate initial management?

Explanation

Nondisplaced or incomplete navicular stress fractures should initially be treated with strict non-weight-bearing cast immobilization for 6 to 8 weeks. The central third is a vascular watershed area, making it highly susceptible to nonunion if weight-bearing is allowed too early.

Question 33

A 35-year-old construction worker falls from a ladder and sustains a displaced intra-articular calcaneus fracture. The surgeon plans an extensile lateral approach. Which vascular structure is most critical to the blood supply of the apex of the subperiosteal corner flap?

Explanation

The lateral calcaneal artery supplies the apex of the corner flap in an extensile lateral approach to the calcaneus. A full-thickness, subperiosteal "no-touch" dissection technique is vital to protect this vessel and prevent flap necrosis.

Question 34

A 28-year-old professional football player suffers a severe hyperextension injury to his first metatarsophalangeal (MTP) joint. MRI reveals a complete rupture of the plantar plate with 4 mm of proximal retraction of the sesamoids. What is the most appropriate management?

Explanation

Grade 3 turf toe injuries involving complete plantar plate ruptures and significant sesamoid retraction (>3 mm) generally require surgical repair. This is especially true in elite athletes to restore push-off strength and prevent chronic instability.

Question 35

A 55-year-old man requires surgery for chronic insertional Achilles tendinopathy with a large retrocalcaneal exostosis after failing conservative therapy. Intraoperatively, the diseased Achilles tendon is debrided. At what threshold of tendon detachment or debridement is a flexor hallucis longus (FHL) tendon transfer primarily indicated to augment the repair?

Explanation

Flexor hallucis longus (FHL) tendon transfer is indicated to augment an Achilles tendon repair when more than 50% of the diseased Achilles tendon is resected or detached. It provides vascularity and mechanical strength to the deficient insertion.

Question 36

A 30-year-old man sustains a displaced talar neck fracture with subluxation of the subtalar joint but an intact ankle joint (Hawkins Type II) after a motor vehicle collision. What is the approximate risk of developing avascular necrosis (AVN) of the talar body?

Explanation

Hawkins Type II talar neck fractures (involving subtalar subluxation or dislocation) carry a 20% to 50% risk of avascular necrosis. The presence of a Hawkins sign (subchondral radiolucency) at 6-8 weeks indicates intact vascularity.

Question 37

A 24-year-old woman has persistent deep ankle pain following an inversion sprain 6 months ago. MRI demonstrates an isolated 12-mm purely cartilaginous osteochondral lesion on the anterolateral aspect of the talar dome. What is the most appropriate first-line surgical treatment?

Explanation

For symptomatic, relatively small (<15 mm) and shallow anterolateral osteochondral lesions of the talus, arthroscopic excision, curettage, and bone marrow stimulation (microfracture) is the preferred first-line surgical treatment.

Question 38

A 45-year-old man presents with chronic heel pain that worsens at the end of the day. He has focal tenderness over the medial calcaneal tuberosity, and compression reproduces radiating pain. EMG reveals denervation of the abductor digiti minimi muscle. Which nerve is most likely entrapped?

Explanation

Baxter's nerve is the first branch of the lateral plantar nerve. Entrapment of this nerve typically causes chronic heel pain mimicking severe plantar fasciitis and leads to selective denervation of the abductor digiti minimi.

Question 39

A 40-year-old man sustains a high-energy distal tibia pilon fracture. Clinical examination reveals massive soft tissue swelling and multiple fracture blisters over the anterior ankle. What is the safest and most appropriate initial management?

Explanation

High-energy pilon fractures with severe soft tissue compromise are best treated with a staged approach. Early spanning external fixation allows the soft tissues to heal before definitive ORIF is performed, significantly reducing infection rates.

Question 40

A 26-year-old man undergoes evaluation for a pronation-external rotation ankle sprain. Radiographs are negative for fractures. Intraoperatively, the "Cotton test" is strongly positive. Which of the following ligaments is definitively disrupted in this scenario?

Explanation

A positive Cotton test (lateral translation of the fibula using a bone hook) indicates syndesmotic instability. The anterior inferior tibiofibular ligament (AITFL) is the primary constraint and the first syndesmotic ligament to rupture in this injury pattern.

Question 41

A 55-year-old man reports chronic dorsal midfoot pain at the first metatarsophalangeal (MTP) joint, worst during toe-off. Radiographs display moderate dorsal osteophytes but preservation of the plantar joint space (Coughlin/Shurnas Grade 2). Conservative measures have failed. Which surgical option is most indicated?

Explanation

Cheilectomy (excision of the dorsal osteophytes and the dorsal third of the metatarsal head) is highly effective for Grade 1 and 2 hallux rigidus where plantar cartilage is preserved. Arthrodesis is generally reserved for end-stage (Grade 3 or 4) disease.

Question 42

A 28-year-old man sustains a high-energy motor vehicle collision and presents with a closed Hawkins Type II talar neck fracture. Which of the following best represents the approximate rate of avascular necrosis (AVN) of the talar body associated with this specific injury pattern?

Explanation

Hawkins Type II talar neck fractures involve subtalar subluxation or dislocation and disrupt two of the three major blood supplies to the talus. This results in an avascular necrosis (AVN) rate of approximately 20% to 50%.

Question 43

A 45-year-old woman presents with severe bunion pain. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and clinical examination demonstrates gross hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate?

Explanation

First tarsometatarsal (TMT) arthrodesis, or the Lapidus procedure, is indicated for moderate to severe hallux valgus (IMA > 15 degrees) associated with first ray hypermobility. Distal osteotomies are insufficient for high intermetatarsal angles and do not address the TMT instability.

Question 44

A 55-year-old woman reports medial ankle pain and a progressively collapsing arch over the past year. Examination reveals a flexible flatfoot deformity and an inability to perform a single-leg heel rise on the affected side. Radiographs show no degenerative joint disease. What is the most appropriate surgical management if conservative care fails?

Explanation

Stage II posterior tibial tendon dysfunction presents with a flexible flatfoot and inability to perform a single-leg heel rise. The standard surgical treatment involves an FDL transfer to replace the diseased posterior tibial tendon, combined with a medial displacement calcaneal osteotomy to restore the mechanical axis.

Question 45

A 14-year-old boy presents with a rigid flatfoot and recurrent ankle sprains. Radiographs demonstrate a continuous bony bridge between the calcaneus and the navicular. He has failed 6 months of non-operative management including orthotics and casting. There is no evidence of subtalar arthritis. What is the best surgical option?

Explanation

Calcaneonavicular coalitions typically present in adolescents. If conservative management fails and there is no significant degenerative arthritis, surgical resection with interposition (fat pad or extensor digitorum brevis) is the gold standard procedure.

Question 46

A 60-year-old man requires surgical intervention for chronic insertional Achilles tendinopathy. Intraoperatively, after resecting the Haglund deformity and debriding the degenerative tendinosis, it is noted that 60% of the Achilles tendon insertion has been removed. What is the most appropriate adjunctive procedure?

Explanation

When more than 50% of the Achilles tendon insertion must be detached or debrided for insertional tendinopathy, the remaining tendon is at high risk for rupture. Augmentation with a flexor hallucis longus (FHL) transfer is the standard choice due to its strength, line of pull, and proximity.

Question 47

A 22-year-old elite collegiate football player sustains a proximal fifth metatarsal fracture at the metaphyseal-diaphyseal junction (Zone 2) during practice. To optimize his chance of union and early return to play, what is the recommended treatment?

Explanation

Zone 2 proximal fifth metatarsal fractures (Jones fractures) occur in a vascular watershed area and have a high rate of nonunion. In elite athletes, early intramedullary screw fixation is recommended to reduce nonunion risk and significantly accelerate return to play.

Question 48

A 50-year-old man presents with a painful, stiff great toe. Examination reveals 15 degrees of dorsiflexion with pain at the extremes of motion. Radiographs demonstrate a dorsal osteophyte but well-preserved plantar joint space (Coughlin Grade 2 hallux rigidus). Which of the following is the most appropriate surgical treatment?

Explanation

Cheilectomy, which involves removal of the dorsal osteophyte and the dorsal third of the metatarsal head, is indicated for early to moderate hallux rigidus (Grades 1 and 2) where the plantar cartilage is preserved. MTP arthrodesis is typically reserved for end-stage (Grade 3 or 4) arthritis.

Question 49

When evaluating a patient with end-stage ankle osteoarthritis for surgical intervention, which of the following is considered an absolute contraindication for total ankle arthroplasty (TAA)?

Explanation

Significant avascular necrosis (>50%) of the talar body is an absolute contraindication to total ankle arthroplasty because a viable bone bed is required for component support and ingrowth. Other absolute contraindications include active infection, Charcot arthropathy, and absent leg sensation.

Question 50

A 45-year-old female presents with a severe bunion deformity. Examination reveals hypermobility of the 1st tarsometatarsal (TMT) joint. Radiographs show a Hallux Valgus Angle of 45 degrees and an Intermetatarsal Angle of 18 degrees.

What is the most appropriate surgical intervention?

Explanation

The Lapidus procedure (1st TMT arthrodesis) is indicated for severe hallux valgus with an IMA >15 degrees, especially in the presence of 1st TMT hypermobility. Distal osteotomies are insufficient for this degree of deformity.

Question 51

A 28-year-old competitive runner sustains a subtle midfoot injury. Weight-bearing radiographs demonstrate 3 mm of diastasis between the medial and middle cuneiforms with no associated fractures. According to recent literature, what is the most appropriate definitive management for this purely ligamentous injury?

Explanation

Purely ligamentous Lisfranc injuries have a higher rate of failure with ORIF compared to primary arthrodesis. Arthrodesis restores stability and has been shown to yield better long-term functional outcomes in pure ligamentous disruptions.

Question 52

A 55-year-old woman presents with a flexible flatfoot deformity, medial ankle pain, and inability to perform a single heel raise. The hindfoot valgus completely corrects when the patient sits. Which surgical intervention is most appropriate after failure of nonoperative management?

Explanation

Stage II adult acquired flatfoot deformity is characterized by a flexible deformity and posterior tibial tendon dysfunction. An FDL transfer replaces the dysfunctional tendon, while a medializing calcaneal osteotomy corrects the hindfoot valgus.

Question 53

A 45-year-old man presents with dorsal midfoot pain and limited dorsiflexion of his first metatarsophalangeal (MTP) joint. Radiographs show a dorsal osteophyte and joint space narrowing isolated to the dorsal half of the 1st MTP joint. Which procedure is most appropriate?

Explanation

Coughlin Grade 2 hallux rigidus presents with dorsal osteophytes and preserved plantar joint cartilage. Cheilectomy removes the dorsal impingement, providing excellent pain relief and improved dorsiflexion.

Question 54

A 45-year-old man has severe insertional Achilles tendinopathy with a Haglund deformity. MRI shows tendinosis affecting 60% of the Achilles tendon insertion. What is the recommended surgical procedure after failed conservative therapy?

Explanation

When surgical debridement compromises more than 50% of the Achilles tendon insertion, a flexor hallucis longus (FHL) tendon transfer is indicated to provide vascularity and structural strength.

Question 55

Which of the following patient factors is considered an absolute or strong relative contraindication to a total ankle arthroplasty (TAA)?

Explanation

Neuropathy with loss of protective sensation (e.g., Charcot arthropathy risk) is a major contraindication for total ankle arthroplasty due to unacceptably high rates of implant failure and complications.

Question 56

A 21-year-old collegiate basketball player sustains an acute transverse fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal. What is the most appropriate management to minimize nonunion risk and expedite return to play?

Explanation

Acute metaphyseal-diaphyseal junction (Jones) fractures in elite athletes are best treated with early intramedullary screw fixation. This approach significantly reduces the risk of nonunion and shortens return-to-play time.

Question 57

A 62-year-old man with poorly controlled diabetes presents with an acutely swollen, erythematous, and warm right foot without ulcers. Radiographs reveal fragmentation of the midfoot. WBC count is normal. What is the most appropriate initial management?

Explanation

This is a classic presentation of acute Eichenholtz stage 0 or I Charcot arthropathy. Total contact casting and strict non-weight-bearing are the gold standard treatments to halt progressive bone destruction.

Question 58

A 30-year-old sustains a Hawkins Type III talar neck fracture. Which of the following best describes the disruption of the blood supply associated with this injury pattern?

Explanation

A Hawkins III fracture involves dislocation of the tibiotalar and subtalar joints. This disrupts all three major sources of talar blood supply, leading to a high risk of avascular necrosis.

Question 59

A professional athlete sustains a hyperextension injury to his first MTP joint. MRI confirms a complete tear of the plantar plate with proximal sesamoid retraction. He is unable to push off. What is the most appropriate management?

Explanation

A Grade 3 turf toe involves a complete tear of the plantar plate and sesamoid retraction. Surgical repair is indicated in high-level athletes to restore push-off strength and joint stability.

Question 60

A 35-year-old male sustains a high-energy motor vehicle collision resulting in a Hawkins Type III talar neck fracture. Despite urgent reduction, the patient is counseled on the high risk of avascular necrosis. Which of the following arterial structures provides the primary blood supply to the talar body that is disrupted in this injury pattern?

Explanation

The primary blood supply to the talar body is the artery of the tarsal canal, a branch of the posterior tibial artery. It enters the talar neck plantarly and anastomoses with the artery of the tarsal sinus to form a vascular sling. Disruption of this network, especially in displaced Hawkins III fractures, leads to a high rate of avascular necrosis.

Question 61

A 24-year-old professional football player sustains an axial load to a plantarflexed foot. Clinical evaluation and the radiograph shown indicate a midfoot injury.

Which of the following ligaments represents the primary stabilizer disrupted in this classic injury pattern?

Explanation

The clinical scenario and radiograph imply a Lisfranc injury, which requires disruption of the Lisfranc ligament complex. The thickest, strongest, and most critical component is the interosseous ligament passing from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. Rupture leads to diastasis and midfoot instability.

Question 62

A 45-year-old female presents with severe pain over the medial eminence of her left foot. Weight-bearing radiographs reveal a hallux valgus angle of 45 degrees, an intermetatarsal angle of 21 degrees, and marked hypermobility of the first tarsometatarsal joint. Which of the following procedures is most appropriate to achieve durable correction?

Explanation

A first tarsometatarsal arthrodesis (Lapidus procedure) is the procedure of choice for severe hallux valgus associated with first ray hypermobility or an intermetatarsal angle greater than 20 degrees. It addresses the apex of the deformity, stabilizes the medial column, and provides multiplanar correction.

Question 63

A 55-year-old female presents with progressive flattening of her left foot. On examination, she is unable to perform a single-leg heel rise, and her hindfoot is in valgus but passively correctable. AP radiographs show 45% talonavicular uncoverage. What is the most appropriate surgical intervention?

Explanation

The patient has Stage IIB adult acquired flatfoot deformity (flexible, >30-40% talonavicular uncoverage indicating severe forefoot abduction). A lateral column lengthening (Evans osteotomy) is required to correct the significant transverse plane deformity. This is combined with a medializing calcaneal osteotomy and FDL transfer to restore medial column function.

Question 64

A 30-year-old male sustains an acute, closed mid-substance Achilles tendon rupture. He elects for non-operative management. To achieve functional outcomes and rerupture rates most comparable to operative repair, what is the most critical element of his non-operative protocol?

Explanation

Recent evidence demonstrates that early functional rehabilitation with protected, accelerated weight-bearing in a functional brace yields rerupture rates equivalent to operative management. Prolonged non-weight-bearing cast immobilization is obsolete as it increases rates of stiffness, muscle atrophy, and rerupture.

Question 65

A 28-year-old male presents with a suspected syndesmotic injury following an external rotation ankle injury. During intraoperative assessment, a hook test reveals significant diastasis. Biomechanically, which of the following ligaments provides the greatest resistance to diastasis of the distal tibiofibular syndesmosis?

Explanation

Biomechanical studies have shown that the posterior inferior tibiofibular ligament (PITFL) provides the greatest resistance to syndesmotic diastasis, accounting for approximately 42% of the strength. The anterior inferior tibiofibular ligament (AITFL) provides about 35%.

Question 66

An orthopedic surgeon is performing an extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture. During the inferior horizontal limb of the incision, which neurological structure is at highest risk of iatrogenic injury?

Explanation

The extensile lateral approach to the calcaneus places the sural nerve at risk, particularly during the inferior horizontal limb of the incision. Utilizing full-thickness subperiosteal flaps and "no-touch" retraction techniques minimizes the risk of nerve injury and skin flap necrosis.

Question 67

A 22-year-old competitive skier presents with chronic posterolateral ankle pain and a snapping sensation behind the lateral malleolus. Examination demonstrates visible anterior subluxation of the retromalleolar tendons during resisted dorsiflexion and eversion. Attenuation or rupture of which structure is the primary cause of this condition?

Explanation

Anterior subluxation or dislocation of the peroneal tendons over the distal fibula pathognomonically indicates attenuation or rupture of the superior peroneal retinaculum (SPR). Surgical treatment typically involves primary SPR repair and, if necessary, deepening of the retro-malleolar fibular groove.

Question 68

A 60-year-old male presents with dorsal foot pain and stiffness of the great toe. Radiographs show a dorsal osteophyte at the first metatarsophalangeal (MTP) joint, but the joint space is relatively preserved with minimal subchondral sclerosis. Pain is reproduced strictly at terminal dorsiflexion. What is the most appropriate surgical treatment?

Explanation

This patient has early-stage (Grade 1 or 2) hallux rigidus, characterized by dorsal osteophytosis with preserved joint space and pain primarily at terminal dorsiflexion. A cheilectomy, which removes the dorsal third of the metatarsal head and the dorsal osteophyte, effectively eliminates impingement and preserves motion.

Question 69

A 12-year-old boy presents with recurrent ankle sprains and a rigid, painful flatfoot. A lateral weight-bearing radiograph of the foot reveals a continuous bony bridge outlining the posterior talar dome and sustentaculum tali, often referred to as the 'C-sign'. Which of the following is the most appropriate initial management?

Explanation

The 'C-sign' on a lateral ankle radiograph strongly suggests a talocalcaneal coalition involving the medial facet. Initial management for symptomatic, uncomplicated tarsal coalitions is non-operative, typically consisting of immobilization in a short leg cast or CAM boot for 4 to 6 weeks.

Question 70

A 21-year-old Division I basketball player sustains an acute fifth metatarsal base fracture located at the metaphyseal-diaphyseal junction without comminution. To minimize the risk of nonunion and allow the fastest return to play, what is the treatment of choice?

Explanation

An acute Zone 2 fracture of the fifth metatarsal base (Jones fracture) in a high-level athlete is best treated with early percutaneous intramedullary screw fixation. This method significantly lowers the nonunion rate associated with the tenuous vascular watershed zone and accelerates return to athletic activity.

Question 71

A 24-year-old female track athlete complains of vague dorsal midfoot pain that worsens with running. Radiographs are normal, but an MRI demonstrates an incomplete fracture through the central third of the navicular body. The pathophysiology of this fracture is heavily influenced by the region's blood supply. Which of the following best describes the vascularity of the navicular?

Explanation

The tarsal navicular has a precarious blood supply, with vessels entering the dorsal and plantar non-articular surfaces and branching inward. This leaves a central hypovascular 'watershed' zone, making the middle third highly susceptible to stress fractures and delayed union.

Question 72

A 45-year-old male undergoes surgery for severe insertional Achilles tendinopathy and a large Haglund's deformity. Intraoperatively, after aggressive debridement of calcific tendinosis, approximately 60% of the Achilles tendon insertion is detached. What is the most appropriate next step in surgical management?

Explanation

When more than 50% of the Achilles tendon insertion must be debrided or detached to treat insertional tendinopathy, the remaining tendon is mechanically insufficient. Augmentation with a flexor hallucis longus (FHL) tendon transfer is the gold standard to restore plantarflexion strength and vascularize the area.

Question 73

A 55-year-old male with poorly controlled type 2 diabetes presents with a red, hot, and swollen right foot. Radiographs demonstrate periarticular debris, osseous fragmentation, and subluxation of the tarsometatarsal joints. No ulcers or wounds are present. According to the Eichenholtz classification, what stage is this, and what is the best initial management?

Explanation

The clinical and radiographic findings of fragmentation, debris, and subluxation characterize Eichenholtz Stage 1 (developmental stage) of Charcot neuroarthropathy. The standard of care is immediate offloading and immobilization, typically using a total contact cast, to prevent further collapse.

Question 74

A 16-year-old female ballet dancer presents with chronic pain localized to the plantar aspect of the second metatarsal head. Radiographs show flattening, sclerosis, and widening of the second metatarsal head. Which of the following is the underlying pathophysiology of this condition?

Explanation

This patient has Freiberg's infraction, which most commonly affects the second metatarsal head in adolescent females. The pathophysiology involves repetitive microtrauma leading to avascular necrosis, subchondral collapse, and eventual flattening of the articular surface.

Question 75

A 45-year-old distance runner presents with chronic medial heel pain that radiates into the plantar-lateral foot. The pain worsens toward the end of the day and lacks the classic 'first-step' morning stiffness. MRI of the foot is notable for isolated fatty atrophy of the abductor digiti minimi muscle. Entrapment of which nerve is most likely responsible?

Explanation

Entrapment of the first branch of the lateral plantar nerve (Baxter's nerve) causes chronic heel pain distinct from typical plantar fasciitis. Because this nerve provides motor innervation to the abductor digiti minimi, chronic entrapment leads to the pathognomonic MRI finding of isolated fatty atrophy of this muscle.

Question 76

A 26-year-old female reports persistent anteromedial ankle pain 6 months after an inversion injury. MRI demonstrates a 1.2 cm by 1.0 cm osteochondral lesion on the medial talar dome with intact overlying cartilage but deep subchondral edema. Conservative management has failed. What is the most appropriate initial surgical treatment?

Explanation

For primary symptomatic osteochondral lesions of the talus (OCDs) smaller than 1.5 cm in diameter, arthroscopic bone marrow stimulation (microfracture) is the gold standard initial surgical treatment. This technique prompts bleeding and marrow element release, stimulating fibrocartilage (Type I collagen) formation to fill the defect.

Question 77

A 28-year-old man sustains a Hawkins Type II talar neck fracture and undergoes urgent open reduction and internal fixation. At his 8-week follow-up, an anteroposterior radiograph of the ankle demonstrates a subchondral radiolucent band in the talar dome. What does this radiographic finding indicate?

Explanation

A subchondral radiolucency in the talar dome 6 to 8 weeks post-injury is known as the Hawkins sign. It indicates intact vascularity and active bone resorption, meaning avascular necrosis is highly unlikely.

Question 78

A 35-year-old recreational athlete sustains an acute complete Achilles tendon rupture. After discussing treatment options, he opts for nonoperative management. What is the primary advantage of utilizing an early functional rehabilitation protocol compared to traditional cast immobilization?

Explanation

Early functional rehabilitation with protected weight-bearing for acute Achilles ruptures yields rerupture rates comparable to operative management. This approach avoids the significant wound complications associated with open surgery.

Question 79

A 52-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. Examination reveals a flexible hindfoot with inability to perform a single-leg heel rise. Standing radiographs show greater than 40% uncoverage of the talonavicular joint. What is the best surgical management?

Explanation

This patient has a Stage IIb adult acquired flatfoot, characterized by a flexible deformity with severe forefoot abduction (>40% talonavicular uncoverage). It requires lateral column lengthening in addition to FDL transfer and a medial calcaneal displacement osteotomy to correct the severe abduction.

Question 80

A 40-year-old manual laborer sustains a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal (TMT) joints. Which surgical treatment has shown superior long-term functional outcomes and lower reoperation rates for this specific injury pattern?

Explanation

Primary arthrodesis of the medial three rays provides superior short- and long-term functional outcomes with lower reoperation rates compared to ORIF for purely ligamentous Lisfranc injuries.

Question 81

A 22-year-old elite collegiate football player sustains a fracture of the base of the fifth metatarsal at the metaphyseal-diaphyseal junction (Zone 2). To minimize the risk of nonunion and expedite his return to play, what is the most appropriate management?

Explanation

Zone 2 fractures (Jones fractures) have high rates of delayed union or nonunion due to a watershed blood supply. Elite athletes benefit from early intramedullary screw fixation to expedite return to play and minimize nonunion risk.

Question 82

A 60-year-old woman presents with severe bunion pain. Radiographs reveal an intermetatarsal angle (IMA) of 22 degrees, a hallux valgus angle (HVA) of 55 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. What is the most appropriate surgical procedure?

Explanation

A first tarsometatarsal arthrodesis (Lapidus procedure) is indicated for severe hallux valgus deformities (IMA > 20 degrees), especially when accompanied by first ray hypermobility or TMT arthritis.

Question 83

A 45-year-old construction worker undergoes open reduction and internal fixation of a displaced intra-articular calcaneus fracture using an extensile lateral approach. Postoperatively, he reports numbness along the lateral border of his foot. Which nerve was most likely injured during the exposure?

Explanation

The sural nerve is at the greatest risk of injury during the extensile lateral approach to the calcaneus. The vertical limb of the L-shaped incision must be placed carefully to avoid it.

Question 84

A 12-year-old boy presents with recurrent ankle sprains and rigid, painful flatfeet. Oblique radiographs demonstrate the "anteater nose" sign. Nonoperative management has failed. What is the best initial operative intervention?

Explanation

The "anteater nose" sign indicates a calcaneonavicular coalition. The standard operative treatment for a symptomatic coalition without severe arthritis is resection with interposition of the extensor digitorum brevis (EDB) or fat pad.

Question 85

A 24-year-old professional rugby player sustains a severe hyperextension injury to his first metatarsophalangeal (MTP) joint. MRI confirms a complete tear of the plantar plate and proximal migration of the sesamoids (Grade 3 Turf Toe). What is the recommended management?

Explanation

Grade 3 turf toe injuries involve a complete tear of the plantar plate and sesamoid complex. Operative repair is recommended for high-level athletes to restore push-off strength and normal joint kinematics.

Question 86

A 65-year-old man with end-stage post-traumatic ankle osteoarthritis is being evaluated for a total ankle arthroplasty (TAA). He has a well-aligned hindfoot but a history of prior osteomyelitis in the distal tibia that was successfully treated 10 years ago. Which of the following is an absolute contraindication to total ankle arthroplasty?

Explanation

Active infection, Charcot neuroarthropathy, severe avascular necrosis of the talus, and severe uncorrectable malalignment are absolute contraindications to total ankle arthroplasty. Prior fracture and adjacent subtalar arthritis are common indications for TAA.

Question 87

A 55-year-old poorly controlled diabetic patient presents with a warm, swollen, and erythematous right foot. Elevation of the foot above the heart for 10 minutes results in complete resolution of the erythema.

Radiographs reveal early midfoot fragmentation. What is the most appropriate initial management?

Explanation

Resolution of erythema with leg elevation is typical of acute Charcot neuroarthropathy, differentiating it from an acute infection. The gold standard initial treatment for acute (Eichenholtz Stage 0 or 1) Charcot is immediate offloading with a total contact cast.

Question 88

A 25-year-old woman presents with deep, chronic anterior ankle pain 1 year after a severe inversion sprain. MRI shows a 1.2 cm^2 (10 mm diameter) primary osteochondral lesion of the medial talar dome. Nonoperative management has failed. What is the most appropriate next step?

Explanation

For symptomatic primary osteochondral lesions of the talus that are less than 1.5 cm^2 (or <15 mm in diameter), arthroscopic debridement and bone marrow stimulation (microfracture) is the first-line surgical treatment.

Question 89

A 48-year-old man undergoes a dorsal cheilectomy for Grade 2 hallux rigidus. He reports pain primarily with push-off during terminal stance. To achieve a successful outcome, approximately how much of the dorsal articular surface of the first metatarsal head is typically resected?

Explanation

During a cheilectomy for hallux rigidus, approximately 30% of the dorsal articular surface of the first metatarsal head is typically resected. This, along with removal of dorsal osteophytes, successfully restores functional dorsiflexion.

Question 90

A 28-year-old skier experiences a sudden forced dorsiflexion and inversion injury. He presents with pain posterior to the lateral malleolus and a snapping sensation when actively everting the foot. What anatomic structure is compromised in this injury?

Explanation

Peroneal tendon subluxation or dislocation classically results from a rupture or avulsion of the superior peroneal retinaculum (SPR). The mechanism is typically a forceful, sudden dorsiflexion with ankle inversion.

Question 91

A 40-year-old man sustains a high-energy pilon fracture with severe soft tissue swelling and multiple fracture blisters over the medial and lateral ankle. What is the standard staged surgical protocol for this injury?

Explanation

High-energy pilon fractures with severe soft tissue compromise are best managed with a staged approach. Immediate spanning external fixation allows the soft tissues to recover, reducing complication rates before delayed definitive tibial ORIF.

Question 92

A 13-year-old boy presents after an external rotation injury to his ankle. Radiographs show a Salter-Harris III fracture of the anterolateral distal tibia. The avulsed fragment in this injury is primarily pulled by which ligament?

Explanation

A juvenile Tillaux fracture is a Salter-Harris III fracture of the anterolateral distal tibia. The fragment is avulsed by the anterior inferior tibiofibular ligament (AITFL) due to the asymmetrical lateral-to-medial closure of the distal tibial physis.

Question 93

A 55-year-old man presents with chronic posterior heel pain that has failed 6 months of physical therapy, heel lifts, and shoe modifications. Examination reveals swelling and point tenderness directly over the central Achilles tendon insertion. A lateral radiograph reveals a prominent posterosuperior calcaneal exostosis.

Intraoperatively, extensive degenerative tearing and intrasubstance calcification are noted, necessitating debridement and detachment of 60% of the Achilles tendon from its insertion. Along with reattachment of the remaining tendon using suture anchors and calcaneal exostectomy, what is the most appropriate additional step in management?

Explanation

When surgical debridement for insertional Achilles tendinopathy dictates detachment of more than 50% of the tendon, augmentation is required to restore plantarflexion strength and minimize the risk of rupture. The flexor hallucis longus (FHL) is the ideal transfer due to its high tensile strength, anatomical proximity, and in-phase firing during the gait cycle.

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

Orthopedic Foot & Ankle 2026 MCQs: Board Review Questions & Answers (Part 2)

Key Takeaway

Orthopedic Foot & Ankle 2026 MCQs: Board Review Questions & Answers (Part 2)

Chapter Index