Orthopedic Foot & Ankle 2026 MCQs: Board Review

Question 1

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

Explanation

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

Question 2

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

Explanation

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

Question 3

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

Explanation

23b 23c 23d A Charcot flare in adjacent joints is not uncommon in patients with neuropathy who undergo surgery or other trauma. Venous thrombosis would present with swelling of the entire leg, while infection would present earlier in the postoperative period. The radiographs are pathognomonic of Charcot arthropathy, not an unrecognized fracture or gout. A compartment syndrome this late after injury is extremely rare, and there would be no bony distraction associated with compartment syndrome.

Question 4

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

Explanation

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

Question 5

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

Explanation

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

Question 6

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

Explanation

24b Neurilemoma is a benign tumor of nerve sheath origin, and peak incidence is in the third through sixth decades. The tumor is well encapsulated on the surface of a peripheral nerve. MRI findings may be significant for a "string sign." A positive Tinel's sign in the distribution of the nerve affected may be present. Grossly, the lesion is well encapsulated in a nerve sheath. Microscopically, there are structures referred to as Antoni A (a pattern of spindle cells arranged in intersecting bundles) and Antoni B (areas with less cellularity with loosely arranged cells). These lesions are benign, and treatment should consist of marginal excision. Nerve function may be preserved by careful dissection, excising the lesion parallel to the nerve fascicles so the lesion may be extruded. Recurrence is rare. Walling AK: Soft tissue and bone tumors, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1007-1032.

Question 7

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

Explanation

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

Question 8

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

Explanation

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

Question 9

What are the five major compartments of the foot?

Explanation

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

Question 10

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

Explanation

25b The patient has a pronounced deformity with pain and degenerative arthritis; therefore, triple arthrodesis is the treatment of choice. Gastrocnemius or Achilles tendon lengthening may be a necessary adjunct to the triple arthrodesis, but alone is inadequate to allow for correction. Because the ankle-foot orthosis has failed to provide relief, a UCBL is not likely to help. Osteotomy procedures are designed for lesser deformities and well-preserved joints. Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 115-120.

Question 11

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

Explanation

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

Question 12

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

Explanation

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

Question 13

The first branch of the lateral plantar nerve innervates the

Explanation

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

Question 14

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

Explanation

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

Question 15

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

Explanation

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

Question 16

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

Explanation

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

Question 17

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

Explanation

29b The radiographs show classic findings for Koehler's disease (osteochondrosis of the navicular). The patient's age and clinical history are typical for this self-limiting condition. Patients will improve with time, but the duration of symptoms is much shorter if the patient is placed in a cast. There is no role for surgery in this disease.

Question 18

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

Explanation

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

Question 19

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

Explanation

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

Question 20

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

Explanation

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

Question 21

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

Explanation

31b 31c Metaphyseal-diaphyseal junction fractures of the fifth metatarsal require careful evaluation. In athletes, early intervention with a 4.5-mm intramedullary screw correlates with an earlier return to activity. One study examining the failure of surgically managed Jones fractures revealed that use of anything other than a 4.5-mm malleolar screw for internal fixation correlated with failure. Glasgow MT, Naranja RJ Jr, Glasgow SG, et al: Analysis of failed surgical management of fractures of the base of the fifth metatarsal distal to the tuberosity: The Jones fracture. Foot Ankle Int 1996;17:449-457.

Question 22

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

Explanation

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

Question 23

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

Explanation

32b The patient has severe calcifications at the insertion of the Achilles tendon. Failure to address the Haglund's exostosis and the calcifications will leave the patient with persistent pain. Steroids should not be injected directly into the tendon because of the increased risk of tendon rupture. Shock wave treatment may have some value in treating plantar fasciitis, but its efficacy has not been documented with insertional calcifications and Haglund's exostosis treatment. Brisement is injection of saline solution around the Achilles tendon in an attempt to decompress the peritenon. This may be valuable in intrasubstance Achilles tendinosis or peritendinitis but has no value with insertional disease. Symptoms persisting beyond 6 months are difficult to treat nonsurgically; therefore, the appropriate treatment protocol is aggressive and must address all pathology. The patient may not be able to run at the level achieved prior to surgery, but the goal of the surgery is pain relief. Clain M, Baxter D: Achilles tendinitis. Foot Ankle 1992;13:482-487. Schepsis A, Wagner C, Leach R: Surgical management of Achilles tendon overuse injuries: A long-term follow-up study. Am J Sports Med 1994;22:611-619. Schepsis A, Leach R: Surgical management of Achilles tendinitis. Am J Sports Med 1987;15:308-315.

Question 24

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

Explanation

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

Question 25

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

Explanation

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

Question 26

A 55-year-old female with long-standing poorly controlled type 2 diabetes mellitus presents with a swollen, warm, and erythematous left foot and ankle. She recently started a walking program. Radiographs demonstrate early periarticular fragmentation at the tarsometatarsal joints. Which of the following best describes the underlying neurovascular pathogenesis of this condition?

Explanation

Charcot arthropathy has two main proposed theories: neurotraumatic and neurovascular. The neurovascular theory posits that autonomic neuropathy causes a loss of sympathetic vascular tone. This leads to increased peripheral blood flow with arteriovenous shunting, hyperemia, and subsequent increased osteoclastic bone resorption, predisposing the bone to fracture and collapse.

Question 27

When performing a calcaneal exostectomy and Achilles tendon debridement for insertional Achilles tendinopathy, what percentage of the Achilles tendon insertion can typically be detached before structural augmentation or reattachment with bone anchors is biomechanically required?

Explanation

Biomechanical studies and clinical experience have shown that up to 50% of the Achilles tendon insertion can be detached during a retrocalcaneal exostectomy without significant loss of pull-out strength or requirement for suture anchor repair. If greater than 50% is detached, reattachment with bone anchors is recommended to prevent avulsion.

Question 28

A 24-year-old professional football player sustains a hyperplantarflexion injury to his right foot. He has plantar ecchymosis and pain with pronation and abduction of the midfoot. Weight-bearing radiographs show a 2 mm diastasis between the base of the first and second metatarsals. What is the most appropriate definitive management?

Explanation

Plantar ecchymosis is highly suggestive of a Lisfranc injury. Weight-bearing radiographs showing >2 mm diastasis between the 1st and 2nd metatarsal bases indicate instability. The standard of care for a displaced or unstable Lisfranc injury in a young, active patient or athlete is operative intervention, typically open reduction and internal fixation (ORIF) or primary arthrodesis, to restore the anatomic alignment and stability of the midfoot.

Question 29

A 60-year-old male presents with dorsal foot pain and stiffness of the great toe. On examination, he has a palpable dorsal osteophyte at the first metatarsophalangeal (MTP) joint and pain primarily with dorsiflexion. Radiographs reveal joint space narrowing with a large dorsal osteophyte but preserved plantar joint space. According to the Coughlin and Shurnas classification, this is Grade 2. What is the most appropriate initial surgical management if conservative measures fail?

Explanation

For Coughlin and Shurnas Grade 1 and 2 hallux rigidus (mild to moderate joint space narrowing, dorsal osteophyte, pain with dorsiflexion but preserved plantar joint space), a cheilectomy (removal of the dorsal osteophyte and the dorsal third of the metatarsal head) is the recommended initial surgical procedure. Arthrodesis is typically reserved for Grade 3 or 4 disease.

Question 30

A 28-year-old male sustains an external rotation injury to his ankle. Radiographs show no fracture. An MRI reveals a complete tear of the anterior inferior tibiofibular ligament (AITFL) and interosseous membrane, with an intact posterior inferior tibiofibular ligament (PITFL). Intraoperative stress testing confirms syndesmotic instability. During fixation with suture button devices, what is the correct anatomical trajectory for drilling from the fibula to the tibia?

Explanation

The fibula sits slightly posterior to the tibia at the level of the syndesmosis. When drilling from the fibula to the tibia for syndesmotic screw or suture button fixation, the drill should be directed approximately 30 degrees anteriorly relative to the coronal plane to ensure it passes through the center of the tibia and avoids eccentric placement.

Question 31

A 32-year-old male falls from a height and sustains a Hawkins Type III talar neck fracture. Which of the following vascular structures provides the primary blood supply to the talar body and is at greatest risk of disruption in this injury pattern?

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, provides the dominant blood supply to the talar body. In a Hawkins Type III fracture (talar neck fracture with subluxation or dislocation of both the subtalar and tibiotalar joints), this blood supply, along with the artery of the tarsal sinus and the deltoid branches, is significantly disrupted, leading to a high rate of avascular necrosis (AVN).

Question 32

A 55-year-old female presents with progressive flattening of her left foot, medial-sided pain, and difficulty performing a single-leg heel rise. Examination reveals a flexible flatfoot deformity with forefoot abduction (too-many-toes sign). Which of the following procedures is typically included in the surgical reconstruction for this stage of posterior tibial tendon dysfunction?

Explanation

The patient has Stage II adult acquired flatfoot deformity (flexible deformity with inability to perform a single-leg heel rise). The gold standard surgical treatment for Stage II disease typically involves a soft tissue reconstruction, such as transferring the FDL to the navicular to replace the dysfunctional posterior tibial tendon, combined with a bony procedure to correct the biomechanical axis, most commonly a medial displacement calcaneal osteotomy (MDCO). Rigid deformities (Stage III) would require a triple arthrodesis.

Question 33

A 45-year-old runner complains of burning pain and tingling radiating into the plantar aspect of his foot, exacerbated by running and prolonged standing. Examination shows a positive Tinel's sign posterior to the medial malleolus. Which of the following structures is located most anteriorly within the tarsal tunnel?

Explanation

The structures in the tarsal tunnel from anterior to posterior (or medial to lateral) are easily remembered by the mnemonic 'Tom, Dick, And Very Nervous Harry': Tibialis posterior tendon, flexor Digitorum longus tendon, posterior tibial Artery, posterior tibial Vein, tibial Nerve, and flexor Hallucis longus tendon. Therefore, the posterior tibial tendon is the most anterior structure.

Question 34

A 42-year-old obese male undergoes an endoscopic plantar fascia release for recalcitrant plantar fasciitis after 18 months of failed conservative management. The surgeon completely transects the plantar fascia. Which of the following is the most likely biomechanical complication of completely releasing the plantar fascia?

Explanation

The plantar fascia is a critical structure for maintaining the longitudinal arch of the foot through the windlass mechanism. Complete transection of the plantar fascia can lead to a loss of this mechanism, resulting in a decrease in arch height (acquired flatfoot), increased strain on the midfoot ligaments, and lateral column pain or overload (cuboid syndrome or stress fractures). A partial (medial one-third to one-half) release is generally recommended.

Question 35

A 35-year-old recreational basketball player sustains an acute Achilles tendon rupture. He opts for non-operative management with a functional rehabilitation protocol. Compared to traditional cast immobilization, functional rehabilitation for non-operative management of Achilles tendon ruptures has been shown to result in:

Explanation

Recent high-quality studies have demonstrated that non-operative management of acute Achilles tendon ruptures utilizing an early functional rehabilitation protocol (early weight-bearing in a functional brace and early range of motion) yields re-rupture rates equivalent to operative management, while avoiding surgical complications. Compared to traditional prolonged static cast immobilization, functional rehab offers better functional outcomes, less muscle atrophy, and an earlier return to work.

Question 36

A 25-year-old male is brought to the emergency department after a high-speed motorcycle accident. Radiographs and CT scans of the foot and ankle reveal a displaced fracture of the talar neck. The subtalar joint is dislocated, but the tibiotalar and talonavicular joints remain concentrically reduced. Based on the most appropriate classification system for this injury, what is the estimated risk of developing avascular necrosis (AVN) of the talar body?

Explanation

This injury represents a Hawkins Type II talar neck fracture. The Hawkins classification dictates that Type I is a nondisplaced fracture (AVN risk 0-15%); Type II involves a displaced talar neck fracture with subtalar subluxation or dislocation (AVN risk 20-50%); Type III involves dislocation of both the subtalar and tibiotalar joints (AVN risk 50-100%, typically cited around 80%); and Type IV includes subluxation or dislocation of the talonavicular joint in addition to the subtalar and tibiotalar joints (AVN risk approaching 100%). Therefore, a Type II fracture carries a 20% to 50% risk of AVN.

Question 37

A 55-year-old female presents with a progressive, painful flatfoot deformity of her right foot that has failed 6 months of conservative management with custom orthotics. Clinical examination demonstrates a flexible hindfoot valgus and an inability to perform a single-limb heel rise. Radiographs demonstrate advanced collapse of the medial longitudinal arch with 45% uncoverage of the talonavicular joint on the weight-bearing AP view. Which of the following surgical strategies is most appropriate?

Explanation

This patient has Stage IIb Adult Acquired Flatfoot Deformity (posterior tibial tendon dysfunction). Stage II is characterized by a flexible deformity. Stage IIa has minimal forefoot abduction, typically managed with FDL transfer and MDCO. Stage IIb is defined by significant forefoot abduction (>30% talonavicular uncoverage). To adequately address the multiplanar deformity in Stage IIb, a lateral column lengthening (e.g., Evans osteotomy) must be added to the FDL transfer and MDCO to correct the transverse plane deformity (forefoot abduction). A triple arthrodesis is reserved for Stage III (rigid) deformities.

Question 38

A 22-year-old collegiate football player sustains an axial loading injury to a plantarflexed foot. Weight-bearing radiographs reveal a 3.5 mm diastasis between the medial and middle cuneiforms, with no obvious fractures visualized. An MRI confirms a complete, purely ligamentous rupture of the Lisfranc ligament complex. According to recent high-level evidence, which of the following treatments provides the best long-term functional outcome and lowest rate of hardware removal?

Explanation

A purely ligamentous Lisfranc injury is inherently unstable and prone to collapse or post-traumatic arthritis if treated with ORIF alone. Landmark studies (such as those by Ly and Coetzee) have demonstrated that primary arthrodesis of the medial columns (1st, 2nd, and 3rd TMT joints) for purely ligamentous Lisfranc injuries yields superior functional outcomes, a faster return to baseline activities, and avoids the need for planned hardware removal compared to ORIF.

Question 39

A 48-year-old female presents for surgical management of a painful hallux valgus deformity. Clinical examination reveals profound hypermobility of the first tarsometatarsal (TMT) joint in the sagittal plane. Weight-bearing radiographs show a Hallux Valgus Angle (HVA) of 42 degrees and an Intermetatarsal Angle (IMA) of 18 degrees. Which of the following procedures is most strongly indicated?

Explanation

The patient has a severe hallux valgus deformity (HVA >40 degrees, IMA >15 degrees) combined with first TMT joint hypermobility. The Lapidus procedure (first TMT arthrodesis) is the procedure of choice in the setting of first ray hypermobility or significant midfoot instability, as it corrects the primary site of instability and allows for excellent correction of a large IMA. Distal or diaphyseal osteotomies would likely fail or recur due to the unaddressed hypermobility at the TMT joint.

Question 40

Total ankle arthroplasty (TAA) is increasingly utilized for end-stage ankle osteoarthritis. However, stringent patient selection is critical for prosthesis survival. Which of the following is considered an absolute contraindication for primary total ankle arthroplasty?

Explanation

Charcot neuroarthropathy, active infection, absent leg sensation/neurologic compromise, and severe avascular necrosis of the talus (loss of >50% of the talar body) are widely recognized as absolute contraindications for total ankle arthroplasty due to unacceptably high rates of catastrophic failure, loosening, and infection. Subtalar arthritis is actually a relative indication for TAA over arthrodesis to preserve remaining hindfoot motion, and a contralateral ankle arthrodesis often sways surgeons to perform a TAA to prevent bilateral stiffening.

Question 41

A 28-year-old professional skier reports chronic posterolateral ankle pain and a 'snapping' sensation over the lateral malleolus when turning forcefully. Examination reveals subluxation of the peroneal tendons over the distal fibula with active dorsiflexion and eversion. MRI demonstrates a torn superior peroneal retinaculum (SPR) and a convex posterior fibular border. Operative intervention is planned. In addition to primary repair or reconstruction of the SPR, which surgical step is most critical to prevent recurrence?

Explanation

The patient has chronic peroneal tendon subluxation, primarily stabilized by the superior peroneal retinaculum (SPR). An anatomic variant such as a flat or convex retromalleolar fibular groove strongly predisposes to this condition and its recurrence. Therefore, fibular groove deepening is critical alongside SPR repair to ensure a stable anatomic trough for the tendons, significantly lowering the risk of recurrent subluxation.

Question 42

A 62-year-old male with poorly controlled type II diabetes and peripheral neuropathy presents with a globally swollen, erythematous, and warm right foot for the past 3 weeks. He denies any trauma or skin ulcerations. His oral temperature is 37.1 °C, WBC is 8.5 x 10^9/L, and CRP is mildly elevated. Radiographs show soft tissue swelling and early fragmentation of the navicular with subtle periarticular debris, but no focal osteopenia. If the limb is elevated for 10 minutes, the erythema significantly diminishes. What is the most appropriate initial management?

Explanation

This patient is presenting with acute Charcot neuroarthropathy (Eichenholtz Stage 0 or I), characterized by a red, hot, swollen foot in a neuropathic patient. The absence of an ulcer makes osteomyelitis highly unlikely. The 'elevation test' (dependent rubor that resolves with elevation) strongly supports an inflammatory/autonomic etiology (Charcot) rather than infection. The gold standard initial treatment for acute Charcot arthropathy is strict offloading and immobilization using a total contact cast (TCC) to arrest the acute inflammatory phase and prevent further bony collapse.

Question 43

A 20-year-old Division I collegiate basketball player sustains a 5th metatarsal fracture during practice. Radiographs demonstrate a transverse fracture at the metaphyseal-diaphyseal junction extending into the fourth-fifth intermetatarsal facet. There is no evidence of intramedullary sclerosis. To maximize his chances of returning to play this season and minimize the risk of nonunion, which management strategy is most appropriate?

Explanation

The patient has a Zone 2 fracture of the proximal fifth metatarsal, commonly known as a Jones fracture. Because of the precarious blood supply in this vascular watershed area, Jones fractures have a high rate of delayed union or nonunion with conservative management. In elite or highly competitive athletes, early percutaneous intramedullary screw fixation is the treatment of choice. It results in significantly faster clinical and radiographic union times and a quicker return to sports compared to non-operative treatment.

Question 44

During open reduction and internal fixation of a pronation-external rotation (PER) ankle fracture, you suspect an associated syndesmotic injury. The medial clear space was widened preoperatively. After rigid fixation of the fibula, you perform an intraoperative 'hook test' which demonstrates 4 mm of lateral translation of the fibula. You decide to fix the syndesmosis. Which of the following modalities has the highest sensitivity for detecting postoperative syndesmotic malreduction?

Explanation

Standard plain radiographs and 2D intraoperative fluoroscopy are notoriously inaccurate for assessing syndesmotic reduction, missing malreductions in up to 20-30% of cases. Bilateral axial CT imaging (or intraoperative 3D fluoroscopy) is the gold standard and has the highest sensitivity and specificity for evaluating the reduction of the distal tibiofibular syndesmosis, as it allows direct visualization of the fibula within the incisura fibularis.

Question 45

A 42-year-old healthy male suffers an acute, complete mid-substance rupture of his Achilles tendon while playing tennis. He opts for non-operative management. Based on recent prospective randomized controlled trials (e.g., Willits et al.), which rehabilitation protocol has been shown to result in re-rupture rates comparable to surgical repair?

Explanation

High-level evidence, particularly the landmark study by Willits et al., has demonstrated that acute Achilles tendon ruptures treated non-operatively with an early functional rehabilitation protocol (removable brace allowing early protected weight-bearing and early range of motion) yield functional outcomes and re-rupture rates that are statistically comparable to those of operative repair. Prolonged rigid casting (options 0 and 3) leads to tendon elongation, profound calf atrophy, and higher re-rupture rates compared to functional rehab.

Question 46

A 45-year-old female presents with a progressive medial deviation of her great toe 1 year after a distal chevron osteotomy with a lateral soft tissue release for hallux valgus. She complains of pain and difficulty with shoe wear. Examination reveals a flexible hallux varus deformity. Radiographs show a congruent first metatarsophalangeal (MTP) joint with a negative intermetatarsal angle and no evidence of MTP joint arthritis. What is the most appropriate surgical management?

Explanation

This patient has an iatrogenic flexible hallux varus deformity following an overcorrected bunion surgery. For a flexible deformity without degenerative changes, soft tissue reconstruction is indicated. The classic and most reliable procedure is the transfer of the extensor hallucis longus (EHL) (either split or whole) beneath the transverse intermetatarsal ligament into the base of the proximal phalanx, often combined with an MTP joint release. First MTP arthrodesis is reserved for a stiff, arthritic hallux varus or failed soft tissue reconstructions.

Question 47

A 55-year-old female presents with a 2-year history of progressive medial foot pain and flattening of her arch. Examination reveals a flexible hindfoot valgus, a positive 'too many toes' sign, and inability to perform a single-leg heel rise. Weight-bearing radiographs demonstrate uncovering of the talonavicular joint of 40%. Which of the following surgical combinations is most appropriate for this patient?

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible flatfoot, inability to perform a single heel rise, and significant forefoot abduction (talonavicular uncovering > 30%). While Stage IIa (minimal forefoot abduction) can be treated with an FDL transfer and MDCO, Stage IIb requires the addition of a lateral column lengthening (such as an Evans calcaneal osteotomy or calcaneocuboid distraction arthrodesis) to correct the severe forefoot abduction and restore the lateral column length.

Question 48

A 30-year-old male sustains a high-energy motor vehicle collision resulting in a Hawkins Type III talar neck fracture. During the surgical approach for reduction and internal fixation, the surgeon must be meticulous to preserve the remaining blood supply to the talar body. In this specific fracture pattern, which of the following vessels is most likely providing the sole remaining blood supply to the extruded talar body?

Explanation

In a Hawkins Type III fracture, there is a fracture of the talar neck with dislocation of both the subtalar and tibiotalar joints. This displacement systematically disrupts the artery of the tarsal canal, the artery of the sinus tarsi, and the superior neck vessels. The only remaining blood supply to the talar body is often through the deltoid branches of the posterior tibial artery, which enter the medial aspect of the talar body. Preserving the intact medial soft tissues (deltoid ligament) is critical during surgical intervention.

Question 49

A 62-year-old man presents to the clinic to discuss surgical options for end-stage ankle arthritis. He has a complicated medical history and is weighing the risks and benefits of total ankle arthroplasty (TAA) versus ankle arthrodesis. Which of the following conditions is considered an absolute contraindication to total ankle arthroplasty?

Explanation

Absolute contraindications to total ankle arthroplasty (TAA) include active infection, severe peripheral vascular disease, Charcot neuroarthropathy (especially with bone loss), avascular necrosis of the talus affecting > 50% of the talar body, and absent lower extremity sensation. Age < 50, well-controlled prior infection, elevated BMI, and contralateral fusions are considered relative contraindications or factors that require careful patient selection, but not absolute contraindications.

Question 50

When managing a displaced intra-articular calcaneus fracture, surgeons often debate between an extensile lateral approach and a limited sinus tarsi approach. Which of the following is the primary advantage of utilizing the sinus tarsi approach compared to the traditional extensile lateral approach?

Explanation

The primary advantage of the limited sinus tarsi approach is a significantly lower rate of post-operative wound complications and infections compared to the extensile lateral approach. The extensile lateral approach requires a large full-thickness flap that has a known high risk of wound edge necrosis and dehiscence. Studies have shown comparable clinical outcomes and reduction quality for appropriate fracture patterns between the two approaches, but the sinus tarsi approach excels in minimizing soft tissue morbidity.

Question 51

A 22-year-old collegiate basketball player sustains an acute Zone 2 proximal fifth metatarsal fracture (Jones fracture). To minimize the risk of nonunion and facilitate an early return to play, intramedullary screw fixation is planned. To prevent an iatrogenic medial cortical breach of the metatarsal shaft during drilling and screw insertion, what is the ideal entry point?

Explanation

The fifth metatarsal shaft exhibits both a lateral and a plantar bow. When placing a straight intramedullary screw, starting centrally on the tuberosity often results in a medial or plantar cortical breach. To accommodate the natural curvature of the bone and ensure the drill/screw remains within the medullary canal, the ideal starting point is slightly dorsal (high) and medial to the tip of the tuberosity.

Question 52

A 35-year-old male sustains a purely ligamentous Lisfranc injury. After nonoperative management fails to provide a stable arch, surgical intervention is discussed. Compared to primary open reduction and internal fixation (ORIF), recent literature suggests that primary arthrodesis for purely ligamentous Lisfranc injuries provides which of the following advantages?

Explanation

Multiple prospective, randomized studies (e.g., Ly and Coetzee) have demonstrated that primary arthrodesis for purely ligamentous Lisfranc injuries results in fewer subsequent surgeries. Patients undergoing ORIF frequently require a second procedure for hardware removal and have a higher rate of secondary surgeries for post-traumatic midfoot arthritis. Functional outcomes in the primary arthrodesis group are generally equivalent to or better than those in the ORIF group for purely ligamentous injuries.

Question 53

A 42-year-old recreational athlete presents with an acute, closed Achilles tendon rupture. He is evaluating the pros and cons of nonoperative management with a functional rehabilitation protocol versus primary surgical repair. Based on current Level I evidence, what is the most accurate statement regarding the comparison of these two treatment strategies?

Explanation

Historically, nonoperative treatment of Achilles tendon ruptures using prolonged rigid immobilization was associated with higher rerupture rates. However, modern Level I evidence (such as the study by Willits et al.) has shown that when an early functional rehabilitation protocol (early weight-bearing and early ROM in a brace) is utilized, the rerupture rates are statistically similar to those of surgical repair. Nonoperative management avoids the risks of surgical complications, particularly wound breakdown and infection, which are notable concerns in Achilles surgery.

Question 54

A 58-year-old male with long-standing, poorly controlled type 2 diabetes presents with a unilaterally swollen, warm, and erythematous right foot and ankle. He denies any recent trauma or systemic symptoms such as fever. Pedal pulses are bounding. Plain radiographs show no fractures, dislocations, or destructive bone changes. Upon elevating the foot for 10 minutes, the erythema resolves completely. What is the most appropriate initial management?

Explanation

This patient presents with a classic Stage 0 (acute inflammatory) Charcot neuroarthropathy. The key clinical finding is a warm, red, swollen foot with normal plain radiographs, and erythema that resolves upon elevation. This elevation test distinguishes Charcot arthropathy from acute infection (cellulitis/osteomyelitis), where erythema typically persists despite elevation. The gold standard for initial management of acute Charcot is immediate offloading with total contact casting (TCC) and non-weight bearing to prevent progression to fragmentation and deformity (Stage 1).

Question 55

A 60-year-old man undergoes surgical debridement of severe non-insertional Achilles tendinosis. Because more than 50% of the tendon requires excision, an augmentation using a flexor hallucis longus (FHL) tendon transfer is performed. Which of the following is a key biomechanical advantage of using the FHL for Achilles augmentation?

Explanation

The flexor hallucis longus (FHL) is the preferred tendon transfer for augmenting a compromised Achilles tendon because it is an 'in-phase' muscle, meaning it naturally fires during the same phase of the gait cycle (plantar flexion at push-off) as the triceps surae complex. It is also the second strongest plantar flexor of the foot (behind the triceps surae) and its axis of pull closely mimics that of the Achilles tendon. Although harvest does cause some measurable decrease in hallux push-off strength, the clinical deficit is usually well-tolerated.

Question 56

A 24-year-old female presents with a rigid cavovarus foot deformity. Neurological workup confirms Charcot-Marie-Tooth disease. Which of the following muscle imbalances is the primary driver of the plantarflexed first ray in this patient's condition?

Explanation

In Charcot-Marie-Tooth (CMT) disease, the characteristic cavovarus deformity is driven by specific muscle imbalances. The tibialis anterior weakens early, while the peroneus longus is relatively spared. The strong peroneus longus pulls the first metatarsal into plantarflexion, creating a forefoot-driven cavus. Concurrently, the tibialis posterior overpowers the weakened peroneus brevis, leading to varus deformity of the hindfoot.

Question 57

A 35-year-old male sustained a Hawkins Type II talar neck fracture and underwent open reduction and internal fixation. At 8 weeks postoperatively, an AP radiograph of the ankle demonstrates a subchondral radiolucent band in the talar dome. What does this radiographic finding indicate?

Explanation

The subchondral radiolucent band described is the Hawkins sign. It represents subchondral osteopenia secondary to disuse and hyperemia, which indicates that the talar body has an intact vascular supply. Its presence is a strong negative predictor for the development of avascular necrosis (AVN).

Question 58

A 55-year-old male presents with progressive pain and stiffness in his right great toe. Examination reveals pain at the extremes of dorsiflexion, which is limited to 20 degrees. Radiographs demonstrate dorsal osteophytes and mild joint space narrowing (Coughlin and Shurnas Grade 2). Conservative measures, including rigid Morton extensions and NSAIDs, have failed. What is the most appropriate surgical intervention?

Explanation

For Coughlin and Shurnas Grade 1 and 2 hallux rigidus (mild to moderate joint space narrowing, dorsal osteophytes, and pain mainly at extremes of motion), cheilectomy is the surgical treatment of choice. Grade 3 (severe narrowing) and Grade 4 (pain in mid-range of motion) are best treated with arthrodesis.

Question 59

A 52-year-old female presents with a progressive flatfoot deformity. Examination shows a flexible hindfoot valgus and inability to perform a single-leg heel raise. Additionally, there is uncovering of the talonavicular joint (more than 40%) on AP weight-bearing radiographs, indicative of severe forefoot abduction. She has failed prolonged brace management. What combination of procedures is most appropriate?

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible deformity with severe forefoot abduction (talonavicular uncoverage > 30-40%). Management typically involves a soft tissue transfer (FDL to navicular) to replace the diseased posterior tibial tendon, a medial displacement calcaneal osteotomy (MDCO) to correct hindfoot valgus, and a lateral column lengthening (e.g., Evans osteotomy) to correct the severe forefoot abduction. Stage IIa (minimal abduction) can often be treated with FDL transfer and MDCO alone. Rigid deformities (Stage III) require arthrodesis.

Question 60

A 21-year-old collegiate basketball player undergoes intramedullary screw fixation for an acute Zone 2 fifth metatarsal base fracture (Jones fracture) to expedite return to play. Postoperatively, he complains of numbness along the lateral aspect of his foot. Which of the following anatomical structures was most likely injured during the surgical approach?

Explanation

The sural nerve provides sensory innervation to the lateral aspect of the foot. Its lateral dorsal cutaneous branch is at significant risk during the approach for intramedullary screw fixation of the fifth metatarsal. Care must be taken to identify and protect this nerve when establishing the starting point for the guide wire and screw at the base of the fifth metatarsal.

Question 61

A 30-year-old male sustains an ankle fracture-dislocation. Intraoperative stress testing after fixation of the fibula confirms syndesmotic instability. The surgeon opts for dynamic (suture-button) fixation rather than rigid screw fixation. According to current literature, what is the primary advantage of dynamic fixation over static screw fixation for syndesmotic injuries?

Explanation

Suture-button (dynamic) fixation allows for physiologic motion at the syndesmosis while maintaining reduction. Studies have shown it reduces hardware-related complications (such as screw breakage or loosening) and significantly lowers the need for routine hardware removal procedures compared to static screw fixation.

Question 62

A 60-year-old diabetic patient presents with a warm, swollen, and erythematous right foot. He has a plantar ulcer under the first metatarsal head. Which of the following imaging modalities is the most sensitive and specific for differentiating acute Charcot neuroarthropathy from pedal osteomyelitis?

Explanation

Differentiating acute Charcot neuroarthropathy from osteomyelitis is clinically and radiographically challenging. While MRI is highly sensitive, its specificity is reduced in acute Charcot due to widespread marrow edema. A combined leukocyte-marrow scan (Indium-111 WBC combined with Tc-99m sulfur colloid marrow scan) is highly accurate. Osteomyelitis shows increased uptake on the WBC scan with corresponding decreased or normal uptake on the marrow scan (discordant). Charcot arthropathy shows congruent increased uptake on both scans (concordant).

Question 63

A 40-year-old recreational athlete sustains an acute Achilles tendon rupture. After discussing treatment options, the patient opts for nonoperative management utilizing a functional rehabilitation protocol. Compared to traditional nonoperative cast immobilization, what is the primary benefit of utilizing an early functional rehabilitation protocol?

Explanation

High-level evidence demonstrates that nonoperative management utilizing early functional rehabilitation (early weight-bearing in a functional brace with active range of motion) results in re-rupture rates that are comparable to operative management, and significantly lower than traditional nonoperative management with prolonged rigid cast immobilization. Operative management still carries inherent risks of wound complications and sural nerve injury.

Question 64

A professional football player sustains a hyperextension injury to his first metatarsophalangeal (MTP) joint, resulting in a severe turf toe injury. MRI confirms a complete tear of the plantar plate complex. Which of the following is an absolute indication for surgical repair of this injury?

Explanation

Grade 3 turf toe injuries involve a complete tear of the plantar plate complex. Indications for surgical intervention include significant proximal retraction of the sesamoids, intra-articular loose bodies, fracture or traumatic diastasis of a sesamoid, and vertical instability of the MTP joint. Diastasis of a bipartite sesamoid or a true sesamoid fracture combined with a complete plantar plate tear severely disrupts the windlass mechanism and mandates repair in a high-demand athlete.

Question 65

A 45-year-old female runner complains of burning pain and tingling in the plantar aspect of her right foot that worsens with activity and at night. Examination reveals a positive Tinel's sign posterior to the medial malleolus. Compression of which of the following nerves within the fibro-osseous tunnel is responsible for her symptoms?

Explanation

Tarsal tunnel syndrome is a compressive neuropathy of the posterior tibial nerve as it passes through the tarsal tunnel behind the medial malleolus, deep to the flexor retinaculum. The tunnel contains the tibialis posterior tendon, flexor digitorum longus tendon, posterior tibial artery and vein, posterior tibial nerve, and flexor hallucis longus tendon. Compression leads to sensory symptoms along the plantar foot in the distribution of the medial and lateral plantar nerves and calcaneal branches.

Question 66

A 22-year-old female presents with a progressive, bilateral cavovarus foot deformity. She reports frequent ankle sprains and difficulty finding comfortable footwear. Neurological examination suggests a diagnosis of Charcot-Marie-Tooth disease. A Coleman block test is performed, and the hindfoot varus corrects to neutral when the first ray is allowed to drop off the block. Which of the following best describes the primary muscular imbalance responsible for the initial development of this deformity?

Explanation

In Charcot-Marie-Tooth (CMT) disease, the characteristic cavovarus deformity is primarily driven by muscle imbalances. The earliest and most prominent imbalance is the preservation or overactivity of the peroneus longus relative to a weakening tibialis anterior. The strong peroneus longus intensely plantarflexes the first ray, creating a rigid forefoot valgus. During stance, this plantarflexed first ray forces the hindfoot into a compensatory varus alignment (a forefoot-driven hindfoot varus). The Coleman block test demonstrates that the hindfoot is still flexible and corrects when the first ray's deforming force is eliminated. Other common imbalances in CMT include a strong tibialis posterior overpowering a weak peroneus brevis.

Question 67

A 68-year-old male presents with severe, end-stage post-traumatic osteoarthritis of the right ankle. He is interested in joint preservation and inquires about a Total Ankle Arthroplasty (TAA) instead of an ankle arthrodesis. Which of the following conditions is considered an absolute contraindication to performing a primary Total Ankle Arthroplasty in this patient?

Explanation

Total ankle arthroplasty (TAA) has specific indications and contraindications. Absolute contraindications include active infection, severe neuroarthropathy (Charcot), absent lower extremity sensation, inadequate soft-tissue envelope, severe peripheral vascular disease, and extensive avascular necrosis (AVN) of the talus (>50% of the talar body), as the talar component will lack sufficient viable bone for ingrowth and support, leading to early catastrophic failure. Age over 65 is actually an ideal indication for TAA over arthrodesis. Obesity (BMI >30), prior trauma, and adjacent joint arthritis (subtalar arthritis is actually a relative indication for TAA to preserve remaining hindfoot motion) are not absolute contraindications.

Question 68

A 55-year-old woman returns to the clinic 8 months after undergoing a distal chevron osteotomy with a lateral soft-tissue release for a moderate hallux valgus deformity. She now complains of worsening medial forefoot pain and difficulty wearing enclosed shoes. Clinical examination reveals a first metatarsophalangeal (MTP) joint that is deviated medially, and she is unable to actively flex the MTP joint. Which of the following intraoperative technical errors is the most common cause of this specific postoperative complication?

Explanation

The patient has developed iatrogenic hallux varus, a dreaded complication of hallux valgus surgery characterized by medial deviation of the great toe. The most common cause is over-resection of the medial eminence (staking the metatarsal head), which removes the bony buttress for the proximal phalanx. This is frequently exacerbated by excessive lateral release, specifically the excision of the fibular sesamoid, or over-plication of the medial capsule. Inadequate lateral release would result in undercorrection or recurrence of hallux valgus, not hallux varus. Plantar translation or nonunion does not typically drive a coronal plane varus deformity.

Question 69

A 25-year-old professional soccer player sustains an inversion and internal rotation injury to his ankle while pivoting. He has pain over the anterior aspect of the distal tibiofibular syndesmosis. Weight-bearing radiographs of the ankle reveal a normal mortise with no widening of the medial clear space. An MRI demonstrates a complete rupture of the anterior inferior tibiofibular ligament (AITFL) extending 4 cm proximally into the interosseous membrane. The deltoid ligament complex is intact. What is the most appropriate management for this player?

Explanation

This patient has an isolated, stable syndesmotic injury (high ankle sprain) without diastasis. The key finding is the intact deltoid ligament and normal weight-bearing radiographs. Isolated AITFL and interosseous membrane tears, without deep deltoid disruption or dynamic mortise widening, are biomechanically stable. The standard of care is non-operative management consisting of a short period of immobilization or functional bracing, progressive weight-bearing as tolerated, and aggressive physical therapy. Operative fixation is reserved for syndesmotic injuries with associated unstable fractures or frank diastasis (unstable syndesmosis, typically involving deltoid rupture or equivalent).

Question 70

A 60-year-old female presents with a progressive, painful flatfoot deformity. Clinical examination demonstrates a positive 'too many toes' sign, an inability to perform a single-limb heel rise, and a flexible hindfoot that corrects to neutral passively. Radiographs show significant collapse of the medial longitudinal arch and 45% lateral uncovering of the talonavicular joint on the AP view. What is the most appropriate surgical intervention for this specific stage of adult-acquired flatfoot deformity?

Explanation

This patient presents with Stage IIb adult-acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage II signifies a flexible hindfoot deformity. Stage II is further subdivided: IIa has minimal forefoot abduction, while IIb has significant forefoot abduction (typically >30-40% talonavicular uncovering on AP radiographs). For Stage IIa, an FDL transfer + medializing calcaneal osteotomy (MCO) is often sufficient. For Stage IIb, the significant forefoot abduction requires addressing the lateral column; therefore, a lateral column lengthening (e.g., Evans osteotomy) is indicated in addition to the MCO, FDL transfer, and heel cord lengthening. Triple arthrodesis (Option C) is reserved for Stage III (rigid deformity).

Question 71

A 28-year-old male undergoes open reduction and internal fixation for a displaced talar neck fracture sustained in a fall from a height. At his 8-week postoperative follow-up, an AP radiograph of the ankle demonstrates a distinct, continuous subchondral radiolucent band across the dome of the talus. What is the clinical significance of this radiographic finding?

Explanation

The finding described is the Hawkins sign. It appears as a subchondral radiolucent band in the talar dome on an AP or mortise radiograph of the ankle, typically seen 6 to 8 weeks following a talar neck fracture. This radiolucency represents subchondral bone resorption (disuse osteopenia), which can only occur if the bone has an intact blood supply. Therefore, the presence of a positive Hawkins sign is a highly reliable indicator of preserved vascularity to the talar body, effectively ruling out early extensive avascular necrosis (AVN). The absence of this sign does not guarantee AVN, but its presence is a reassuring sign of viability.

Question 72

A 21-year-old Division I collegiate basketball player presents with acute lateral foot pain after landing awkwardly. Radiographs reveal a transverse fracture of the fifth metatarsal located at the metaphyseal-diaphyseal junction, extending into the fourth-fifth intermetatarsal facet articulation. There is no significant sclerosis at the fracture margins. To minimize the risk of nonunion and expedite his return to competitive play, what is the most widely recommended treatment?

Explanation

The patient has sustained an acute Jones fracture (Zone 2 fracture of the proximal fifth metatarsal). This area represents a vascular watershed zone, making these fractures prone to delayed union and nonunion. While non-operative management (strict non-weight-bearing) is acceptable for less active individuals, the standard of care for high-level, elite athletes is early surgical intervention with intramedullary screw fixation. This approach significantly decreases the time to clinical and radiographic union, lowers the rate of nonunion, and allows for a much faster and more predictable return to competitive sports compared to conservative management.

Question 73

Historically, acute Achilles tendon ruptures were treated surgically to minimize re-rupture rates, despite higher rates of soft-tissue complications. Based on high-quality randomized controlled trials (e.g., Willits et al.) utilizing modern early functional rehabilitation protocols, which of the following statements most accurately reflects the current understanding of operative versus non-operative management?

Explanation

Recent high-quality, level I evidence (most notably the RCT by Willits et al.) has dramatically shifted the paradigm for treating acute Achilles tendon ruptures. When an early functional rehabilitation protocol (early weight-bearing and early mobilization in a brace) is employed, there is no statistically or clinically significant difference in the re-rupture rates between operative and non-operative groups. Furthermore, non-operative management avoids surgical complications such as deep infections and wound breakdown. Functional outcomes and strength are also comparable. Thus, non-operative treatment with functional rehab is increasingly favored for acute ruptures.

Question 74

A 38-year-old warehouse worker sustains a crush injury to his foot. Radiographs and a subsequent CT scan demonstrate a highly comminuted, intra-articular fracture-dislocation involving the first, second, and third tarsometatarsal joints (Lisfranc injury). The articular surfaces of the medial and middle cuneiforms are extensively fragmented and impacted. What is the most appropriate definitive surgical management to minimize the need for future procedures?

Explanation

While Open Reduction and Internal Fixation (ORIF) has historically been the standard for bony Lisfranc injuries, primary arthrodesis is strongly indicated in specific scenarios to avoid post-traumatic osteoarthritis and subsequent revision surgery. The classic indications for primary arthrodesis of the medial columns (1st, 2nd, and 3rd TMT joints) in Lisfranc injuries include purely ligamentous injuries and injuries with severe, non-reconstructable intra-articular comminution. Given the extensive fragmentation and impaction of the articular surfaces in this patient, ORIF would almost certainly lead to early joint degeneration. Primary arthrodesis yields better mid- to long-term functional outcomes in this specific highly comminuted pattern.

Question 75

A 12-year-old boy presents with a history of recurrent ankle sprains and a painful, rigid flatfoot. Radiographs demonstrate an 'anteater nose' sign on the lateral view. A CT scan confirms the diagnosis of a calcaneonavicular coalition. After 6 months of failed conservative management including casting, surgical resection is planned. To minimize the risk of coalition recurrence post-resection, which of the following autologous structures is most commonly utilized as interpositional material?

Explanation

The 'anteater nose' sign on a lateral radiograph is pathognomonic for a calcaneonavicular coalition. When conservative management fails, surgical resection of the coalition is indicated. To prevent re-ossification and recurrence of the coalition, interposition of biological material into the resection gap is a standard step. For a calcaneonavicular coalition, the extensor digitorum brevis (EDB) muscle belly is mobilized from its proximal attachment and interposed into the defect. In contrast, for talocalcaneal (middle facet) coalitions, a fat graft or a split portion of the flexor hallucis longus (FHL) tendon is typically used for interposition.

Question 76

A 58-year-old male with a 15-year history of poorly controlled type 2 diabetes presents with a unilaterally swollen, red, and warm right foot. He reports no preceding trauma and denies fevers or chills. On examination, he has bounding pedal pulses and loss of protective sensation to the 5.07 Semmes-Weinstein monofilament. The erythema improves significantly when the leg is elevated for 10 minutes. Radiographs demonstrate early fragmentation and subluxation at the tarsometatarsal joints.

What is the most appropriate initial management for this condition?

Explanation

This patient presents with an acute Eichenholtz stage I Charcot arthropathy. The classic presentation includes a red, hot, swollen foot in a patient with peripheral neuropathy (most commonly diabetic). The distinguishing clinical feature from infection (osteomyelitis or cellulitis) is that the erythema in Charcot arthropathy typically resolves significantly with elevation of the extremity, whereas infectious erythema does not. Radiographs showing early fragmentation and subluxation confirm the diagnosis. The cornerstone of initial management in the acute phase is immobilization and offloading, ideally with total contact casting (TCC), to prevent further deformity and progression. Antibiotics and debridement are inappropriate as this is an inflammatory, not infectious, process. Surgery (ORIF or arthrodesis) is generally reserved for the chronic/coalescent phase if significant instability or non-plantigrade foot deformity persists.

Question 77

A 32-year-old female sustains a purely ligamentous Lisfranc injury following a twisting event while horseback riding. Weight-bearing radiographs reveal 4 mm of diastasis between the medial cuneiform and the base of the second metatarsal, without evidence of osseous avulsions. She undergoes primary arthrodesis of the first, second, and third tarsometatarsal joints. Compared to open reduction and internal fixation (ORIF), what is the expected clinical advantage of primary arthrodesis for this specific injury pattern?

Explanation

Current orthopedic literature (e.g., Ly and Coetzee, Henning et al.) supports primary arthrodesis for purely ligamentous Lisfranc injuries because the ligamentous healing potential is poor compared to osseous injuries. ORIF of purely ligamentous injuries is associated with a high rate of hardware failure, loss of reduction, and subsequent post-traumatic arthritis requiring secondary salvage arthrodesis. Primary arthrodesis significantly decreases the rate of subsequent operations (such as hardware removal and revision fusion) and provides comparable or superior functional outcomes in purely ligamentous patterns. It does not lead to earlier weight-bearing, as fusion still requires extended immobilization to heal.

Question 78

A 21-year-old elite collegiate basketball player sustains a fracture of the fifth metatarsal. Radiographs demonstrate a transverse fracture line located at the metaphyseal-diaphyseal junction, which extends into the fourth-fifth intermetatarsal articulation. To optimize the patient's safe return to play and minimize the risk of nonunion, what is the most appropriate management?

Explanation

The patient has a Zone 2 fracture of the fifth metatarsal, commonly referred to as a Jones fracture. This area represents a vascular watershed zone, predisposing these fractures to delayed union or nonunion. In elite athletes, conservative management (such as casting) is associated with an unacceptably high rate of nonunion and prolonged time away from sports. Intramedullary screw fixation is the gold standard for high-level athletes with Zone 2 fractures, as it provides compression across the fracture site, significantly reduces the nonunion rate, and accelerates the timeline for returning to athletic competition.

Question 79

A 62-year-old man with end-stage post-traumatic ankle osteoarthritis is being evaluated for a total ankle arthroplasty (TAA). Which of the following patient factors is considered an absolute contraindication to performing a TAA?

Explanation

Absolute contraindications to total ankle arthroplasty (TAA) include active infection, severe peripheral vascular disease, inadequate soft tissue envelope, neuroarthropathy (Charcot joint), and significant peripheral neuropathy with loss of protective sensation. Neuropathy results in a lack of joint proprioception and pain feedback, leading to rapid implant loosening, subsidence, and catastrophic failure. Age over 60 is actually an ideal demographic for TAA due to lower functional demands. A BMI of 32 is a relative, but not absolute, contraindication. Prior ORIF and concomitant subtalar arthritis are common in this population and can be managed (e.g., with hardware removal or staged/concurrent subtalar fusion).

Question 80

A 45-year-old female presents with a progressive and painful bunion deformity. Clinical examination demonstrates notable hypermobility in the sagittal plane at the first tarsometatarsal (TMT) joint. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 42 degrees and an Intermetatarsal Angle (IMA) of 18 degrees. Based on these findings, which surgical procedure is most appropriate to address her deformity and prevent recurrence?

Explanation

The patient has a severe hallux valgus deformity (IMA > 15 degrees, HVA > 40 degrees) associated with first TMT joint hypermobility. A first TMT arthrodesis (the Lapidus procedure) is the procedure of choice in this scenario. It provides powerful correction of large intermetatarsal angles and inherently addresses the hypermobility at the TMT joint, which, if left untreated, is a common cause of hallux valgus recurrence. Distal osteotomies (like the Chevron) are typically reserved for mild to moderate deformities (IMA < 13 degrees) without hypermobility. A Keller arthroplasty is generally reserved for elderly, low-demand patients with severe deformity and arthritis.

Question 81

A 28-year-old male is involved in a high-speed motor vehicle collision and sustains a Hawkins Type III talar neck fracture. Which of the following best describes the typical disruption of the blood supply to the talar body in this specific injury pattern?

Explanation

A Hawkins Type III fracture is a talar neck fracture with dislocation of the talar body from both the subtalar joint and the tibiotalar (ankle) joint. The blood supply to the talar body is derived from three main sources: the artery of the tarsal canal (branch of posterior tibial), the artery of the tarsal sinus (anastomosis of branches from dorsalis pedis and peroneal), and the deltoid branches. In a Type III injury, the severe displacement and double dislocation typically rupture all three major sources of extraosseous blood supply (the capsular attachments carrying the dorsalis pedis branches, the artery of the tarsal canal, and the artery of the tarsal sinus), leading to a nearly 100% risk of avascular necrosis (AVN) of the talar body if not promptly reduced.

Question 82

A 40-year-old recreational tennis player sustains an acute Achilles tendon rupture. After a thorough discussion, he elects to undergo non-operative management incorporating an early functional rehabilitation protocol. Compared to acute open surgical repair, which of the following is true regarding his expected clinical outcome?

Explanation

Historically, non-operative treatment of Achilles tendon ruptures using prolonged cast immobilization was associated with a higher re-rupture rate compared to operative repair. However, high-quality modern evidence (e.g., Willits et al.) has demonstrated that when non-operative management is combined with an early, dynamic functional rehabilitation protocol (early weight-bearing in a functional brace), the re-rupture rates are statistically equivalent to operative repair. Furthermore, non-operative management completely avoids surgical complications such as wound breakdown, deep infection, and iatrogenic sural nerve injury.

Question 83

A 14-year-old boy presents with bilateral rigid flatfeet and a history of recurrent ankle sprains. Examination demonstrates severe restriction of subtalar motion and peroneal spasticity. On the lateral weight-bearing radiograph of the foot, a distinct 'C-sign' is identified. What is the most likely diagnosis, and which anatomical structures are fused?

Explanation

The clinical presentation of a rigid flatfoot, peroneal spasticity, and restricted subtalar motion in an adolescent is classic for a tarsal coalition. The 'C-sign' on a lateral radiograph is a radiological hallmark of a talocalcaneal coalition. It is formed by the continuous bony bridge between the talar dome and the sustentaculum tali of the calcaneus, typically indicating a coalition at the middle facet of the subtalar joint. A calcaneonavicular coalition, conversely, is best visualized on a 45-degree internal rotation oblique radiograph and is associated with the 'anteater nose' sign.

Question 84

A 55-year-old female presents with a painful, progressive flatfoot deformity. On examination, she is completely unable to perform a single-leg heel raise on the affected side. Her hindfoot rests in valgus but is manually correctable to neutral. Weight-bearing anteroposterior radiographs demonstrate >40% lateral subluxation (uncovering) of the talonavicular joint. In addition to a flexor digitorum longus (FDL) transfer to the navicular, which of the following osseous procedures is most appropriate?

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible hindfoot valgus deformity and significant forefoot abduction (indicated by >40% talonavicular uncovering on the AP view). An isolated FDL transfer and medial displacement calcaneal osteotomy (MDCO) can address the hindfoot valgus but are insufficient to correct the severe forefoot abduction. Therefore, a lateral column lengthening (e.g., Evans osteotomy or calcaneocuboid distraction arthrodesis) must be added to swing the forefoot medially and restore talonavicular coverage. A triple arthrodesis is reserved for Stage III PTTD, where the deformity has become rigid.

Question 85

A 25-year-old professional soccer player undergoes operative fixation for a syndesmotic injury utilizing a flexible suture-button construct. Compared to traditional rigid syndesmotic screw fixation, what is a recognized clinical or biomechanical advantage of the suture-button construct?

Explanation

Flexible suture-button constructs for syndesmotic injuries provide dynamic stabilization, allowing physiological micromotion at the distal tibiofibular joint during weight-bearing. This mimics the native syndesmosis better than rigid screws. A primary clinical advantage of the suture-button construct is the decreased need for routine implant removal. Traditional syndesmotic screws often require a second surgery for removal due to the risk of screw breakage or patient discomfort during the resumption of physiological motion with weight-bearing. Suture buttons do not promote 'primary bone healing' of the syndesmosis (which is a ligamentous structure) and do not have an inherent effect on medial malleolus bone healing.

Question 86

A 32-year-old male sustained a displaced talar neck fracture treated with open reduction and internal fixation. At 8 weeks postoperatively, an anteroposterior radiograph of the ankle shows a subchondral lucency in the talar dome.

What does this radiographic finding indicate?

Explanation

The subchondral radiolucent band seen in the talar dome 6 to 8 weeks after a talar neck fracture is known as the Hawkins sign. It represents subchondral bone resorption secondary to disuse osteopenia. Because bone resorption requires an active blood supply, the presence of a Hawkins sign indicates intact vascularity to the talar body, forecasting a very low likelihood of avascular necrosis.

Question 87

A 19-year-old male presents with bilateral progressive foot deformities characterized by high arches, claw toes, and varus hindfeet. He reports frequent lateral ankle sprains. The Coleman block test demonstrates a flexible hindfoot. Which of the following best describes the classic muscle imbalance contributing to this patient's deformity?

Explanation

This patient has a classic cavovarus foot deformity, typical of Charcot-Marie-Tooth (CMT) disease. The pathophysiology involves selective muscle weakness. The tibialis anterior and peroneus brevis weaken early. The relatively spared, stronger peroneus longus overpowers the weak tibialis anterior, causing plantarflexion of the first ray (forefoot valgus). Concurrently, the strong tibialis posterior overpowers the weak peroneus brevis, driving the hindfoot into varus.

Question 88

A 65-year-old female with severe post-traumatic ankle osteoarthritis is considering surgical options. She has a history of poorly controlled type 2 diabetes and peripheral neuropathy, lacking protective sensation in her distal extremities. In evaluating her for a total ankle arthroplasty (TAA) versus ankle arthrodesis, which of the following is an absolute contraindication to TAA in this patient?

Explanation

Absolute contraindications to total ankle arthroplasty (TAA) include active infection, severe peripheral vascular disease, inadequate soft-tissue envelope, neuropathic joint disease (Charcot arthropathy), and absent protective sensation. Charcot and lack of sensation predictably lead to catastrophic early failure of the implant. Age over 60 is actually an ideal indication for TAA, as younger, high-demand patients wear out implants faster. Subtalar arthritis may be an indication for a combined procedure or arthrodesis, but not an absolute contraindication to TAA.

Question 89

A 55-year-old female presents with a painful, progressive flatfoot deformity. Examination shows a valgus hindfoot, prominent medial eminence, and 'too many toes' sign laterally. She has 45% uncovering of the talonavicular joint on weight-bearing AP radiographs. She is unable to perform a single-leg heel raise. The hindfoot remains flexible to manual reduction.

Which of the following surgical procedures is most appropriate for this patient?

Explanation

This patient has Stage IIb adult acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage IIb is characterized by a flexible hindfoot with significant forefoot abduction (>40% talonavicular uncovering). Appropriate operative management requires correcting both the hindfoot valgus and the forefoot abduction. This is reliably achieved with a flexor digitorum longus (FDL) transfer, a medializing calcaneal osteotomy, and a lateral column lengthening (e.g., Evans osteotomy). Triple arthrodesis is reserved for rigid (Stage III) deformities.

Question 90

A 22-year-old professional football player sustains a hyperextension injury to his right great toe. MRI demonstrates a complete disruption of the plantar plate with proximal retraction of the sesamoids of 5 mm compared to the contralateral side. What is the most appropriate management for this athlete?

Explanation

This is a Grade 3 turf toe injury (complete tear of the plantar plate complex). While Grade 1 and 2 injuries are generally managed non-operatively, indications for surgical management in high-level competitive athletes include a Grade 3 sprain with >3 mm of proximal sesamoid retraction, intra-articular loose bodies, traumatic hallux valgus, or gross instability. Surgical repair restores the anatomy and tension of the plantar plate to allow return to explosive push-off activities.

Question 91

A 28-year-old female sustains an axial load to a plantarflexed foot. Weight-bearing radiographs show a 4 mm diastasis between the medial and middle cuneiforms and bases of the 1st and 2nd metatarsals. No fractures are identified on computed tomography.

According to current literature, which of the following treatments provides the most predictable long-term functional outcome with the lowest rate of reoperation for this specific injury pattern?

Explanation

The scenario describes a purely ligamentous Lisfranc injury. Multiple studies (most notably by Ly and Coetzee) have demonstrated that primary arthrodesis of the medial columns (1st, 2nd, and 3rd TMT joints) yields superior functional outcomes and significantly lower reoperation rates compared to ORIF for purely ligamentous injuries. ORIF in this setting is associated with high rates of hardware failure, loss of reduction, and painful post-traumatic arthritis requiring salvage arthrodesis.

Question 92

During open reduction and internal fixation of a severe pronation-external rotation (PER-4) ankle fracture, a syndesmotic screw is planned. To optimize anatomic reduction, the surgeon must be aware of the normal anatomy and biomechanics of the distal tibiofibular joint. Which of the following statements is true regarding the distal tibiofibular syndesmosis?

Explanation

The talar dome is trapezoidal in shape, being wider anteriorly than posteriorly. During ankle dorsiflexion, the wider anterior portion of the talus engages the mortise, causing the syndesmosis to widen slightly (about 1-2 mm) and the fibula to externally rotate. The posterior inferior tibiofibular ligament (PITFL) is the strongest ligament. Syndesmotic screws are typically directed 20-30 degrees anteriorly (from posterolateral to anteromedial) to accommodate the normal anatomy of the fibula relative to the tibia.

Question 93

A 19-year-old collegiate basketball player sustains an acute fifth metatarsal fracture. Radiographs show a transverse fracture at the metaphyseal-diaphyseal junction involving the fourth-fifth intermetatarsal articulation. Given the patient's athletic status and the fracture location, which of the following is the most appropriate management?

Explanation

This is a classic Jones fracture (Zone 2), occurring at the metaphyseal-diaphyseal junction extending into the 4th-5th intermetatarsal articulation. Due to the watershed blood supply, these fractures have a high rate of delayed union or nonunion. In high-level competitive athletes, early intramedullary screw fixation is recommended. It significantly decreases the time to union and allows a faster, more predictable return to sport compared to conservative management.

Question 94

A 52-year-old male presents with dorsal foot pain and stiffness of the big toe. Physical examination reveals a palpable dorsal exostosis and restricted dorsiflexion of the first MTP joint. Radiographs confirm joint space narrowing, subchondral sclerosis, and a large dorsal osteophyte (Coughlin and Shurnas Grade 2). Conservative measures have failed. Which of the following surgical interventions is most appropriate for preserving joint motion while relieving symptoms?

Explanation

Hallux rigidus is osteoarthritis of the first MTP joint. For early to moderate stages (Coughlin and Shurnas Grade 1 or 2) where the patient desires preservation of motion and experiences pain primarily from dorsal impingement, a cheilectomy (resection of the dorsal osteophyte and the dorsal 25-30% of the metatarsal head) is the procedure of choice. Arthrodesis is the gold standard for severe disease (Grades 3 and 4) with pain throughout the range of motion.

Question 95

A 58-year-old male with long-standing, poorly controlled diabetes mellitus presents with a swollen, warm, erythematous left foot. He denies trauma and has no open ulcers. Radiographs reveal fragmentation and periosteal reaction around the midfoot.

What is the most definitive imaging modality to differentiate an acute Charcot neuroarthropathy from osteomyelitis in the absence of a skin ulcer?

Explanation

Differentiating acute Charcot arthropathy from osteomyelitis is challenging, as both present with erythema, swelling, and radiographic destruction. While MRI is highly sensitive, it can be poorly specific in the acute phase because both conditions exhibit significant bone marrow edema. The most definitive functional imaging modality to differentiate the two is an Indium-111 labeled WBC scan combined with a Technetium-99m sulfur colloid bone marrow scan. Charcot causes marrow proliferation (matching positive uptake on both scans), whereas osteomyelitis suppresses marrow but accumulates WBCs (spatial mismatch).

Question 96

A 42-year-old woman presents with progressive medial deviation and pain of her great toe 8 months following a bunionectomy. Physical examination reveals a hallux valgus angle of -15 degrees. She actively plantarflexes the interphalangeal joint to compensate for the inability of the metatarsophalangeal (MTP) joint to purchase the ground. Radiographs reveal medial subluxation of the proximal phalanx on the metatarsal head. Which of the following technical errors during the index procedure is the most common cause of this complication?

Explanation

The patient is presenting with iatrogenic hallux varus. The most common technical causes include 'staking' the metatarsal head (resecting the medial eminence past the sagittal groove, which destabilizes the medial sesamoid), excessive medial capsulorrhaphy, and over-release of the lateral collateral ligament. Failure to release the adductor hallucis or inadequate resection would lead to under-correction or recurrence of hallux valgus, not hallux varus.

Question 97

A 48-year-old warehouse worker sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs reveal a 4 mm diastasis between the first and second metatarsal bases without evidence of fracture. MRI confirms a complete tear of the Lisfranc ligament complex. Based on prospective randomized studies comparing operative treatments for purely ligamentous Lisfranc injuries, which of the following is the most significant advantage of primary arthrodesis over open reduction and internal fixation (ORIF)?

Explanation

For purely ligamentous Lisfranc injuries, evidence (such as the landmark prospective trial by Ly and Coetzee) has demonstrated that primary arthrodesis yields superior functional outcomes and a lower rate of subsequent surgeries. ORIF typically mandates a second procedure for hardware removal and has a higher incidence of secondary post-traumatic arthritis requiring salvage arthrodesis compared to primary fusion.

Question 98

A 55-year-old woman undergoes surgical reconstruction for Stage IIB adult acquired flatfoot deformity. The procedure includes a medializing calcaneal osteotomy, lateral column lengthening, flexor digitorum longus (FDL) transfer, and spring ligament repair. Following fixation of the hindfoot, intraoperative assessment using a simulated weight-bearing view reveals a residual forefoot varus with a clinically elevated first ray. Which of the following is the most appropriate next surgical step to achieve a plantigrade foot?

Explanation

In chronic adult acquired flatfoot deformity, the forefoot undergoes compensatory supinatus (varus) to maintain ground contact as the hindfoot falls into valgus. When the hindfoot valgus is surgically corrected, this forefoot deformity often persists as a fixed elevation of the first ray. A Cotton osteotomy (dorsal opening wedge of the medial cuneiform) plantarflexes the medial column, restoring the tripod effect and ensuring a plantigrade foot.

Question 99

A 62-year-old man presents with debilitating end-stage ankle osteoarthritis. He has exhausted all non-operative management options and is inquiring about a total ankle arthroplasty (TAA). Which of the following patient factors is considered an absolute contraindication to TAA?

Explanation

Charcot neuroarthropathy with absent protective sensation is considered an absolute contraindication to total ankle arthroplasty due to poor bone stock and a prohibitively high risk of catastrophic implant failure, subsidence, and ulceration. Conversely, concomitant subtalar or transverse tarsal arthritis is widely considered an indication for TAA to preserve the remaining motion in the hindfoot.

Question 100

A 32-year-old male sustains an acute, closed Achilles tendon rupture while playing tennis. He elects non-operative management. He is placed in a functional rehabilitation protocol incorporating early weight-bearing in a brace. According to current evidence-based literature, how do the outcomes of early functional rehabilitation compare to surgical repair for acute Achilles tendon ruptures?

Explanation

Multiple high-level randomized controlled trials (such as Willits et al.) have demonstrated that non-operative treatment of acute Achilles tendon ruptures using an early functional rehabilitation protocol (incorporating early weight-bearing) achieves functional outcomes and re-rupture rates statistically equivalent to those of surgical repair. Furthermore, the non-operative group entirely avoids surgical complications, such as wound breakdown and sural nerve injury.

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

Orthopedic Foot & Ankle 2026 MCQs: Board Review Questions & Answers (Part 3)

Key Takeaway

Orthopedic Foot & Ankle 2026 MCQs: Board Review Questions & Answers (Part 3)

Chapter Index