ABOS Foot & Ankle MCQs (Set 3): Trauma & Deformities

Question 1

What is the most common malignant tumor of the foot?

Explanation

Whereas chondrosarcoma is the most frequently occurring malignant bone tumor of the foot and synovial sarcoma is the most common soft-tissue foot malignancy, the most common malignant tumor overall is melanoma. It constitutes approximately 25% of lesions found on the lower extremity. Furthermore, 31% of all melanomas arise 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 11-26.

Question 2

A 40-year-old man underwent an ankle arthroscopy 6 months ago for a talus osteochondral defect. He continues to have pain and burning on the lateral portal but states that the pain is now more superficial than his original pain. Examination reveals that he has shooting pain to his medial foot and ankle when his lateral portal is tapped. A previous injection around the lateral portal gave him relief for about 2 weeks. What treatment will best eliminate his pain?

Explanation

The patient clearly has entrapment of the superficial peroneal nerve in the lateral portal. It is most likely only the medial branch by examination. If the nerve is in good condition, it can simply be released. If the nerve is cut or severely thinned, it is better excised and buried. The sural nerve most likely would be caught in a posterior-lateral portal. Jobe MT, Wright PE: Peripheral nerve injuries, in Canale ST (ed): Campbell's Operative Orthopaedics. St Louis, MO, Mosby, 1998, pp 3839-3844.

Question 3

When performing a Weil osteotomy of a lesser metatarsal, the desired angle of the saw cut should be approximately

Explanation

Appropriate orientation of the saw cut when performing a Weil osteotomy is approximately parallel with the plantar surface of the foot. This is done in an effort to minimize plantar displacement of the capital fragment. The removal of additional bone from the osteotomy site either by removing a separate wafer of bone or using a thicker saw blade has also been described to minimize plantar displacement of the distal fragment. Trnka H, 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 4

A patient with diabetic peripheral neuropathy undergoes a partial first ray amputation for a chronic ulcer beneath the first metatarsal head. The insertion of the anterior tibialis is preserved. The patient has 10 degrees of passive dorsiflexion at the ankle and no other foot deformities or ulcers. Which of the following is considered appropriate shoe wear for this patient?

Explanation

The steel shank is a flat 1-inch steel strip placed between layers of the shoe to extend the foot lever and prevent deformity at the toe break seen following a partial first ray amputation. A rocker sole may be added as well to facilitate transition from foot flat to the toe-off phase of gait. Proper shoe fit is important, but "snug" fitting shoes in a patient with peripheral neuropathy and likely fluctuations in volume from intermittent swelling are to be avoided. A custom shoe is an unnecessary expense. The patient has at least 10 degrees of dorsiflexion at the ankle with an intact anterior tibialis muscle; therefore, catching the sole on carpeting should not be a problem. Philbin TM, Leyes M, Sferra JJ, et al: Orthotic and prosthetic devices in partial foot amputations. Foot Ankle Clin 2001;6:215-228.

Question 5

A 32-year-old laborer reports left ankle pain and deformity. History reveals that he sustained a left ankle fracture 2 years ago and was treated with closed reduction and casting. Radiographs are shown in Figures 25a through 25c. What is the most appropriate management?

Explanation

25b 25c Corrective osteotomy of fibular malunions, with appropriate lengthening, even in the presence of early arthritis, has been shown to decrease ankle pain and increase stability. Reduction and bone grafting of the medial malleolar nonunion is also needed. There is no evidence supporting the use of intra-articular steroids or hyaluronic acid in the ankle joint. Lateral talar displacement of even 1 mm has been reproducibly shown to decrease tibiotalar contact by 40% to 42%, causing a predisposition to arthritis. Weber D, Friederich NF, Muller W: Lengthening osteotomy of the fibula for post-traumatic malunion: Indication, technique and results. Int Orthop 1998;22:149-152. Lloyd J, Elsayed S, Hariharan K, et al: Revisiting the concept of talar shift in ankle fractures. Foot Ankle Int 2006;27:793-796. Offierski CM, Graham JD, Hall JH, et al: Later revision of fibular malunion in ankle fractures. Clin Orthop Relat Res 1982;171:145-149.

Question 6

Preservation or reconstruction of which of the following structures is essential to minimize the risk of hallux valgus developing after removal of part or all of the medial sesamoid?

Explanation

Complications of medial sesamoidectomy include stiffness, claw toe, and hallux valgus. Each sesamoid sits within its respective head of the flexor hallucis brevis tendon. Excision of one sesamoid can result in slack in its flexor hallucis brevis tendon; therefore, it is imperative to preserve or repair the flexor hallucis brevis tendon when removing the medial sesamoid. Dedmond BT, Cory JW, McBryde A Jr: The hallucal sesamoid complex. J Am Acad Orthop Surg 2006;14:745-753.

Question 7

In the nonsurgical management of posterior tibial tendon dysfunction with flexible deformity, a common strategy is to prescribe an ankle-foot orthosis or a University of California Biomechanics Laboratory (UCBL) orthosis with medial posting. A high patient satisfaction rating and favorable outcome with this nonsurgical management is most likely in which of the following situations?

Explanation

Most authors recommend an initial trial of nonsurgical management in the treatment of adult-acquired flatfoot deformity such as posterior tibial tendon dysfunction. Chao and associates found that there is high patient satisfaction with ankle-foot orthoses and UCBL-type inserts in elderly patients with a relatively sedentary lifestyle. Alternatively, there was a higher dissatisfaction rate in young active patients, those with balance and ambulation difficulties (Parkinson's, severe arthritis of the hip or knee), and patients with inflammatory systemic disorders. Chao W, Wapner KL, Lee TH, et al: Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int 1996;17:736-741.

Question 8

Figure 26 shows the clinical photograph of a patient who has developed a residual limb ulcer following a traumatic transtibial amputation 2 years ago. What is the preferred treatment to resolve the ulcer?

Explanation

The first step in the treatment of an amputation residual limb (stump) ulcer is local wound care and adjustment of the residual limb-prosthetic interface, as well as adjusting prosthetic alignment. Surgical revision should be undertaken only when prosthetic modification is unsuccessful. Murnaghan JJ, Bowker JH: Musculoskeletal complications, in Smith DG, Michael JW, Bowker JH (eds): Atlas of Amputations and Limb Deficiencies, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 683-700.

Question 9

The spring ligament of the foot connects what two bones?

Explanation

The spring ligament is also known as the calcaneonavicular ligament and connects the calcaneus to the navicular. This ligament supports the talar head and is an important anatomic supporting structure of the medial longitudinal arch of the foot. Choi K, Lee S, Otis JC, et al: Anatomical reconstruction of the spring ligament using peroneus longus tendon graft. Foot Ankle Int 2003;24:430-436.

Question 10

An obese 62-year-old man reports a 10-year history of progressive flatfoot deformity and a 3-month history of a painful callus along the plantar medial midfoot that has not improved with custom shoe wear, pedorthics, and callus care. There is no hindfoot motion, but functional ankle motion remains. He does not have diabetes mellitus. Radiographs are shown in Figures 27a and 27b. What is the best surgical option at this point?

Explanation

27b The deformity is long-standing, the hindfoot is immobile, and the radiographs reveal severe degenerative arthritis involving the entire hindfoot, severe deformity, and talonavicular dislocation. The "exostosis" responsible for the callus is the talar head; resection would severely destabilize the foot. Degenerative arthritis and fixed deformity preclude lateral column lengthening, medial slide calcaneal osteotomy, and talonavicular arthrodesis. Triple arthrodesis is the only viable option. Johnson JE, Yu JR: Arthrodesis techniques in the management of Stage II and III acquired adult flatfoot deformity. Instr Course Lect 2006;55:531-542.

Question 11

A 20-year-old collegiate football player sustains an injury to his left foot 3 weeks before the start of the fall season. Examination reveals localized tenderness over the lateral midfoot and normal foot alignment. Radiographs are shown in Figures 28a through 28c. What is the treatment of choice?

Explanation

28b 28c Due to the relatively high incidence of delayed union and nonunion associated with this mildly displaced Jones-type fracture, and the temporal proximity to his playing season, intramedullary screw fixation is the treatment of choice in this collegiate athlete to best ensure healing and expedite his return to football. If nonsurgical management were elected, application of a non-weight-bearing short leg cast would be appropriate since a higher likelihood of healing is expected with it versus a short leg walking cast. The risk of recurrent fracture of fractures that heal with nonsurgical management has reportedly been high (approximately 30%). Quill GE: Fractures of the proximal fifth metatarsal. Orthop Clin North Am 1995;26:353-361. Torg JS, Balduini FC, Zelko RR, et al: Fractures of the base of the fifth metatarsal distal to the tuberosity: Classification and guidelines for nonsurgical and surgical management. J Bone Joint Surg Am 1984;66:209-214.

Question 12

When the great toe deviates into a valgus position, the action of the abductor hallucis muscle becomes one of

Explanation

The abductor hallucis muscle inserts together with the medial tendon of the flexor hallucis brevis into the medial base of the proximal phalanx of the great toe. When the hallux assumes a valgus position, the action of the abductor becomes one of flexion and pronation of the first metatarsal. Resch S: Functional anatomy and topography of the foot and ankle, in Myerson M (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, vol 1, pp 25-49.

Question 13

When performing a bunionectomy with a release of the lateral soft-tissue structures, the surgeon is cautioned against releasing the conjoined tendon that inserts along the lateral base of the proximal phalanx of the great toe. This conjoined tendon is made up of what two muscles?

Explanation

Owens and Thordardson cautioned surgeons not to release the conjoined tendon from the base of the proximal phalanx of the great toe because of an increased risk of iatrogenic hallux varus. Release of the transverse and oblique heads of the adductor hallucis is largely accomplished by releasing the soft tissue adjacent to the lateral sesamoid, without releasing tissue from the base of the proximal phalanx. The conjoined tendon is made up of the flexor hallucis brevis and the adductor hallucis. Owens S, Thordardson DB: The adductor hallucis revisited. Foot Ankle Int 2001;22:186-191.

Question 14

Figures 29a and 29b show a clinical photograph and radiographs of a patient who sustained an open calcaneus fracture in a motor vehicle accident. The patient received immediate IV antibiotics and an emergent irrigation and debridement. The swelling has subsided by 3 weeks and the medial wound is clean. What do you tell the patient about the likelihood of infection if a formal open reduction and internal fixation via a lateral approach is performed?

Explanation

29b Multiple authors have shown similar infection rates for grade 1 and 2 open medial fractures and closed fractures that have been treated with an extensile lateral approach and open reduction and internal fixation. Patients only need IV antibiotics for 2 to 3 days after surgery. Formal open reduction and internal fixation is not recommended for grade 3 medial wounds and most lateral wounds. Heier KA, Infante AF, Walling AK, et al: Open fractures of the calcaneus: Soft-tissue injury determines outcome. J Bone Joint Surg Am 2003;85:2276-2282.

Question 15

When compared to traditional open repair through a posterior incision, percutaneous Achilles tendon repair clearly results in a reduction of what complication?

Explanation

Prospective studies, including randomized and randomized multicenter reports, have shown that percutaneous or mini-open acute Achilles tendon repair has comparable functional results when compared to traditional open techniques. Calder and Saxby reported one superficial infection out of 46 patients with a mini-open repair; Assal and associates and Cretnik and associates had no wound complications or infections. The other complications have not proved to be less likely with the mini-open or percutaneous technique. Assal M, Jung M, Stern R, et al: Limited open repair of Achilles tendon ruptures: A technique with a new instrument and findings of a prospective multicenter study. J Bone Joint Surg Am 2002;84:161-170. Calder JD, Saxby TS: Early, active rehabilitation following mini-open repair of Achilles tendon rupture: A prospective study. Br J Sports Med 2005;39:857-859.

Question 16

A 24-year-old woman was struck by a mini van in a parking lot and sustained a closed segmental tibia fracture that was treated with an intramedullary nail the following morning. Follow-up examinations reveal a slowly progressive clawing of all five toes, a progressive equinocavovarus contracture, and the patient is unable to perform a single heel rise on the affected limb. At 1 year after surgery, the patient now has a 10-degree equinus contracture that is not relieved with knee flexion. Treatment should now consist of

Explanation

This is an example of a missed deep posterior compartment syndrome that typically presents 6 months after the injury with progressive clawing due to necrosis, scarring, and contracture of the posterior tibial tendon, flexor digitorum longus, and flexor hallucis longus. Treatment consists of debridement of necrotic muscle and scar tissue with corresponding tendon excision. After debridement and posterior capsule release, if the equinus is relieved with knee flexion, a gastrocnemius slide may be performed. Otherwise, the lengthening should be at the level of the Achilles tendon. Bracing will not address the claw toes. Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 212-213. Manoli A II, Smith DG, Hansen ST Jr: Scarred muscle excision for the treatment of established ischemic contracture of the lower extremity. Clin Orthop Relat Res 1993;292:309-314.

Question 17

A 26-year-old man with chronic lateral ankle instability underwent a modified Broström procedure 8 months ago. He reports persistent pain and swelling of the lateral ankle. Examination reveals lateral ankle tenderness and swelling and a negative anterior drawer test. Laboratory studies show a WBC count of 6,500/mm3 and an erythrocyte sedimentation rate of 15 mm/h. Radiographs of the ankle are normal. What is the most likely cause of this problem?

Explanation

Chronic lateral instability is commonly associated with a longitudinal split tear of the peroneus brevis tendon. The interrelationship of lateral ankle instability with superior retinacular laxity and resultant peroneus brevis split can account for persistent lateral ankle pain in this patient. Surgical treatment must identify and correct the underlying tendon pathology and should attempt to repair or debride the peroneus brevis tendon, reconstruct the superior peroneal retinaculum, flatten the posterior edge of the fibula by removing the sharp bony prominence, or deepening the fibular groove, along with addressing lateral ankle ligamentous instability. The laboratory values are not consistent with infection. A negative anterior drawer test confirms stability of the repair. Ankle arthritis is not seen on radiographs and usually takes longer than 3 months to develop. Bonnin M, Tavernier T, Bouysset M: Split lesions of the peroneus brevis tendon in chronic ankle laxity. Am J Sports Med 1997;25:699-703.

Question 18

A 52-year-old woman with a 2-year history of a flexible (stage II) adult-acquired flatfoot deformity has failed to respond to nonsurgical management consisting of immobilization, custom orthotics, nonsteroidal anti-inflammatory drugs, and physical therapy. The patient is unable to perform a single limb heel rise. Weight-bearing radiographs are shown in Figures 30a through 30c. What is the most appropriate surgical correction?

Explanation

30b 30c The patient has an atypical adult flatfoot deformity. The radiographs reveal forefoot abduction, mild loss of calcaneal pitch, and marked plantar flexion sag through the naviculocuneiform joint. The inability to perform a single limb heel rise indicates that the posterior tibial tendon is nonfunctional; however, the deformity remains flexible. In this patient, surgical treatment should include a tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening. Because a substantial portion of the deformity stems from the naviculocuneiform joint in this instance, tendon transfer and lateral column lengthening alone provide insufficient deformity correction. Triple arthrodesis and heel cord lengthening is best reserved for fixed flatfoot deformities. Soft-tissue procedures alone are associated with a high failure rate, as are attempted tendon repairs. Greisberg J, Assal M, Hansen ST Jr, et al: Isolated medial column stabilization improves alignment in adult-acquired flatfoot. Clin Orthop Relat Res 2005;435:197-202.

Question 19

Optimal management of the injury shown in Figure 31 should include which of the following?

Explanation

The radiograph shows a displaced calcaneal beak fracture, a tongue-type fracture variant. The fracture fragment typically includes the insertion point of the Achilles tendon, which places marked tension on the thin overlying soft-tissue envelope and can lead to full-thickness necrosis if not acutely addressed. Cast immobilization does not adequately address the increased soft-tissue tension, as the fragment will be difficult to control. Arthroscopic-assisted techniques or primary arthrodesis are not indicated because calcaneal beak fractures are typically extra-articular. Sanders RW, Clare MP: Fractures of the calcaneus, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 2, pp 2017-2073.

Question 20

A 23-year-old man who was the restrained driver in a car involved in a high-speed motor vehicle accident sustained the closed injury shown in Figures 32a through 32c. Which of the following factors has the greatest impact on the risk of osteonecrosis?

Explanation

32b 32c The incidence of osteonecrosis following displaced talar neck fractures is most related to the extent of initial fracture displacement. With increasing fracture displacement, the tenuous vascular supply to the talar body is more at risk for damage, thereby increasing the risk of osteonecrosis. Although displaced talar neck fractures have historically been considered a surgical emergency, recent studies have shown that the timing of surgical intervention bears no impact on the development of osteonecrosis. While nicotine use has an influence on fracture healing, it has never been shown to be a factor in osteonecrosis, nor has posterior-to-anterior screw fixation or the quality of fracture reduction. Lindvall E, Haidukewych G, Dipasquale T, et al: Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am 2004;86:2229-2234.

Question 21

A 30-year-old woman injured her ankle playing soccer 3 months ago. She now reports popping and pain over the lateral side of her ankle. An MRI scan is shown in Figure 33. What structure needs to be repaired to alleviate the popping?

Explanation

The symptoms and MRI scan indicate dislocated peroneal tendons. In this patient, the structure that needs to be repaired is the superior peroneal retinaculum. If the popping was coming from a torn peroneal tendon, repair would involve the peroneal longus or brevis tendon, but this is not shown in the MRI scan. The anterior talofibular ligament or the calcaneofibular ligament would need to be repaired if the patient had ankle instability due to an ankle sprain. Jones DC: Tendon disorders of the foot and ankle. J Am Acad Orthop Surg 1993;1:87-94.

Question 22

A 35-year-old woman with type 1 diabetes mellitus has been treated for the past 2 years at a wound care center for persistent bilateral fifth metatarsal head ulcers. Management has consisted of shoe wear modifications, treatment with multiple enzymatic ointments, and a fifth metatarsal head resection on the left side. Physical examination reveals intact pulses, minimal ankle dorsiflexion, neutral hindfoot, and a persistent ulcer under the fifth metatarsal heads. What treatment will best help heal the ulcers?

Explanation

The patient likely has a significant Achilles contracture that causes her to always bear more weight on her forefoot. A gastrocnemius recession takes the ankle out of plantar flexion and she will be able to return to a normal gait and reduce the pressures on her forefoot. A forefoot amputation is a salvage option. The other choices are appropriate; however, the patient has had this problem for 2 years and she has already had multiple attempts at shoe wear modification. Laughlin RT, Calhoun JH, Mader JT: The diabetic foot. J Am Acad Orthop Surg 1995;3:218-225.

Question 23

The hallucal sesamoids are held together by which of the following structures?

Explanation

The two sesamoids of the metatarsophalangeal joint are embedded in the tendons of the short flexor of the great toe. They are held together by the intersesamoid ligament and the plantar plate, which inserts on the base of the proximal phalanx of the hallux. The flexor hallucis longus tendon inserts onto the distal phalanx of the great toe. The plantar calcaneonavicular (spring) ligament, by supporting the head of the talus, principally maintains the arch of the foot. The plantar fascia inserts distally onto the skin and to the flexor tendons and transverse metatarsal ligaments at each metatarsophalangeal joint. The intermetatarsal ligament attaches to the base of the second through fifth metatarsals. Lewis WH (ed): Gray's Anatomy of the Human Body, ed 20. Philadelphia, PA, Lea & Febiger, 2000.

Question 24

Figures 34a and 34b show the clinical photograph and a weight-bearing radiograph of a patient with diabetes mellitus who has had recurrent ulcers under the head of the talus that have previously resolved with a series of non-weight-bearing total contact casts. The deformity does not correct passively. Dorsalis pedis and posterior tibial pulses are palpable. The patient is insensate to the Semmes-Weinstein 5.07 (10 gm) monofilament. The ulcer is currently healed. What is the best option to prevent recurrent ulceration and infection?

Explanation

34b This is a nonplantigrade deformity in a patient with a Charcot foot deformity. Longitudinal studies have shown that recurrent ulceration/infection is likely unless the deformity is corrected. Achilles tendon lengthening is advised for simple forefoot ulcers. The current approach to this problem is best managed with surgical correction of the deformity, Achilles tendon lengthening, and therapeutic footwear. Bevan WP, Tomlinson MP: Radiographic measures as a predictor of ulcer formation in diabetic charcot midfoot. Foot Ank Int 2008;29:568-573. Simon SR, Tejwani SG, Wilson DL, et al: Arthrodesis as an early alternative to nonoperative management of Charcot arthropathy of the diabetic foot. J Bone Joint Surg Am 2000;82:939-950.

Question 25

Which of the following conditions precludes performing a tendon transfer?

Explanation

Several conditions must be met before a tendon transfer has the potential to correct a dynamic deformity. If the target joint cannot be passively corrected to neutral, it indicates that a static joint contracture or bony deformity exists that cannot be corrected with a dynamic tendon transfer. While in-phase muscles are best, out-of-phase muscles are often the only muscles available for transfer. Tendon transfer should pull in a straight line to avoid tethering and late failure. Canale ST (ed): Campbell's Operative Orthopaedics, ed 10. St Louis, MO, Mosby, 2003, pp 1283-1287.

Question 26

A 45-year-old man sustains a high-energy closed tibial pilon fracture with severe soft tissue swelling. Spanning external fixation is applied. Which of the following is the most reliable clinical indicator that the soft tissues are ready for definitive open reduction and internal fixation?

Explanation

The appearance of skin wrinkles (the "wrinkle sign") is the most reliable clinical indicator that soft tissue swelling has subsided enough to safely proceed with definitive ORIF in pilon fractures.

Question 27

A 28-year-old athlete undergoes ORIF for a Weber C ankle fracture with syndesmotic instability. A syndesmotic screw is placed. What is the most appropriate recommendation regarding the syndesmotic screw?

Explanation

Current evidence suggests routine removal of syndesmotic screws is not necessary, as functional outcomes are similar whether the screw is retained, removed, or breaks.

Question 28

A 32-year-old male sustains a Hawkins type III talar neck fracture. Which of the following blood vessels provides the primary blood supply to the talar body, placing it at risk for avascular necrosis?

Explanation

The artery of the tarsal canal (a branch of the posterior tibial artery) provides the dominant blood supply to the talar body. Disruption in Hawkins III fractures significantly increases the risk of avascular necrosis.

Question 29

During an extensile lateral approach for a displaced intra-articular calcaneus fracture, the sural nerve is at risk. Where is the sural nerve most vulnerable during this exposure?

Explanation

The sural nerve is most at risk at the apices of the extensile lateral incision, particularly at the corner of the L-shaped flap, and must be protected by creating a full-thickness subperiosteal flap.

Question 30

A 24-year-old football player suffers a purely ligamentous Lisfranc injury. He undergoes surgery. Which of the following has been shown to provide superior functional outcomes for purely ligamentous Lisfranc injuries compared to internal fixation?

Explanation

Primary arthrodesis of the first, second, and third tarsometatarsal joints provides superior functional outcomes and lower revision rates compared to ORIF for purely ligamentous Lisfranc injuries.

Question 31

A 40-year-old recreational basketball player sustains an acute Achilles tendon rupture. If treated non-operatively with a functional rehabilitation protocol, how does the outcome compare to operative treatment?

Explanation

Functional rehabilitation (early weight-bearing and ROM) for non-operative management results in rerupture rates similar to operative treatment, while avoiding surgical complications like infection and nerve injury.

Question 32

A 22-year-old gymnast has chronic lateral ankle instability despite 6 months of dedicated physical therapy. She undergoes a modified Broström procedure. Which structure is typically mobilized and used to reinforce the repair?

Explanation

The modified Broström (Gould modification) involves mobilizing and advancing the inferior extensor retinaculum to reinforce the direct repair of the anterior talofibular and calcaneofibular ligaments.

Question 33

A 55-year-old diabetic patient presents with a warm, swollen, erythematous right foot and ankle. X-rays show periarticular fragmentation and subluxation of the midfoot. What is the most appropriate initial management?

Explanation

The patient is in the acute fragmentation phase (Eichenholtz stage I) of Charcot arthropathy. The mainstay of treatment is strict immobilization and offloading, typically with a total contact cast.

Question 34

A 60-year-old female presents with medial ankle pain and a progressive flatfoot. She is unable to perform a single heel raise. Examination shows a flexible hindfoot valgus and forefoot abduction. What is the most appropriate surgical treatment?

Explanation

For Stage II posterior tibial tendon dysfunction (flexible deformity, inability to perform heel raise), a flexor digitorum longus (FDL) transfer combined with a medial displacement calcaneal osteotomy (MDCO) is the standard treatment.

Question 35

A 16-year-old boy with Charcot-Marie-Tooth disease presents with bilateral cavovarus feet. A Coleman block test is performed, and the hindfoot corrects to neutral. What does this indicate?

Explanation

A flexible hindfoot that corrects to neutral on a Coleman block test indicates that the varus hindfoot is secondary to a rigid plantarflexed first ray, guiding surgical management toward a dorsiflexion osteotomy of the first metatarsal.

Question 36

A 45-year-old woman presents with a symptomatic hallux valgus deformity. Radiographs show a hallux valgus angle of 35 degrees and an intermetatarsal angle of 18 degrees. The first tarsometatarsal joint is hypermobile. Which procedure is most appropriate?

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus with a large intermetatarsal angle (>15 degrees) and clinical first ray hypermobility.

Question 37

A 65-year-old male presents with dorsal foot pain and limited hallux dorsiflexion. Radiographs reveal dorsal osteophytes at the first MTP joint with preserved joint space on the plantar aspect. What is the most appropriate initial surgical option after failed conservative care?

Explanation

For mild-to-moderate hallux rigidus (Coughlin and Shurnas Grade 1 or 2) with dorsal impingement and preserved plantar joint space, a cheilectomy provides excellent pain relief and restores dorsiflexion.

Question 38

A 28-year-old skier sustains an acute inversion injury. He complains of a snapping sensation over the lateral malleolus. Physical exam reveals subluxation of the peroneal tendons over the fibula with resisted dorsiflexion and eversion. What is the primary anatomical lesion?

Explanation

Peroneal tendon subluxation is primarily caused by an injury or avulsion of the superior peroneal retinaculum (SPR) from the posterior lip of the lateral malleolus.

Question 39

A 30-year-old man sustains a medial subtalar dislocation after falling from a height. Closed reduction is attempted but is unsuccessful in the emergency department. What structure is most likely blocking reduction?

Explanation

In a medial subtalar dislocation, the head of the talus can become buttonholed through the extensor retinaculum or the talonavicular joint capsule, blocking closed reduction. The extensor digitorum brevis may also block reduction.

Question 40

A 21-year-old college soccer player sustains a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal. He wishes to return to play as soon as possible. What is the recommended treatment?

Explanation

For competitive athletes with an acute Jones fracture (Zone 2), intramedullary screw fixation is recommended to reduce the risk of nonunion and allow an earlier return to sport.

Question 41

A 25-year-old track athlete complains of vague dorsal midfoot pain. Plain radiographs are normal. An MRI reveals a non-displaced navicular body stress fracture. What is the most appropriate initial management?

Explanation

Non-displaced navicular stress fractures have a high risk of nonunion due to poor blood supply. The standard non-operative management is strict non-weight bearing in a cast for 6 to 8 weeks.

Question 42

A football player presents with severe pain and swelling at the plantar aspect of the first MTP joint after a forced hyperextension injury. MRI confirms a complete rupture of the plantar plate with retraction of the sesamoids. What is the most appropriate treatment?

Explanation

A Grade 3 turf toe injury with a complete rupture of the plantar plate and sesamoid retraction in a competitive athlete often requires surgical repair to restore push-off strength and prevent hallux rigidus.

Question 43

A 35-year-old male sustains a severely displaced intra-articular calcaneus fracture. On examination, he has tense swelling, severe pain out of proportion, and pain with passive toe extension. If a fasciotomy is performed, which compartment of the foot contains the quadratus plantae?

Explanation

The central compartment of the foot contains the quadratus plantae, flexor digitorum brevis, adductor hallucis, and the lumbricals. It is critical to decompress this compartment in foot compartment syndrome.

Question 44

A 45-year-old female twists her ankle. X-rays show an isolated displaced lateral malleolus fracture with a medial clear space of 6 mm on the gravity stress view. What does the widened medial clear space indicate?

Explanation

A medial clear space greater than 4-5 mm on a stress view in the presence of a lateral malleolus fracture indicates a complete rupture of the deltoid ligament (bimalleolar equivalent fracture).

Question 45

A 55-year-old male with post-traumatic end-stage ankle osteoarthritis and a normal BMI is deciding between total ankle arthroplasty (TAA) and ankle arthrodesis. Which of the following is an absolute contraindication to total ankle arthroplasty?

Explanation

Active joint infection, neuropathic (Charcot) arthropathy, severe AVN of the talus, and lacking adequate soft-tissue envelope are absolute contraindications for total ankle arthroplasty.

Question 46

A 45-year-old male sustains a high-energy closed pilon fracture. A spanning external fixator is placed on the day of injury. When planning definitive open reduction and internal fixation (ORIF), which of the following is the most reliable clinical indicator that the soft tissue envelope is ready for surgery?

Explanation

The wrinkle test indicates that tissue edema has subsided enough to allow safe surgical incision and wound closure. Operating before this sign appears significantly increases the risk of wound dehiscence and deep infection.

Question 47

A 45-year-old construction worker falls from a height and sustains a severe pilon fracture, which is treated with a staged open reduction and internal fixation. Two years later, what is the most likely long-term complication this patient will experience?

Explanation

The most common long-term complication following a pilon fracture is post-traumatic ankle arthritis, which can occur in up to 50% of patients due to the severe initial cartilage damage.

Question 48

A 24-year-old athlete sustains an external rotation ankle injury. Radiographs are normal, but weight-bearing causes pain. MRI shows disruption of the anterior inferior tibiofibular ligament (AITFL). During surgical fixation, what is the most appropriate position of the ankle when tightening the syndesmotic screws?

Explanation

Recent studies demonstrate that the ankle should be held in neutral dorsiflexion during syndesmotic fixation to prevent over-compression and malreduction. Historically, maximal dorsiflexion was taught but is no longer the standard.

Question 49

A 35-year-old male sustains an acute Achilles tendon rupture. He opts for nonoperative management utilizing a functional rehabilitation protocol. Compared to standard surgical repair, what is the expected clinical outcome regarding re-rupture and wound complications?

Explanation

Functional rehabilitation protocols for nonoperative management yield an equivalent re-rupture rate to surgical repair while entirely avoiding the surgical risks of wound complications and infection.

Question 50

A 20-year-old track athlete presents with chronic midfoot pain. A CT scan reveals a non-displaced stress fracture of the central third of the navicular. What anatomical factor contributes most to the high risk of nonunion in this specific area?

Explanation

The central third of the navicular is a relative vascular watershed zone between the branches of the dorsalis pedis and medial plantar arteries, strongly predisposing this region to delayed union or nonunion.

Question 51

A 28-year-old football player presents with severe midfoot pain after a hyper-plantarflexion injury. An AP radiograph demonstrates a 'fleck sign' in the first intermetatarsal space. This radiographic sign represents an avulsion fracture at the attachment of a ligament that connects which two bones?

Explanation

The Lisfranc ligament connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. The 'fleck sign' is an avulsion of this critical stabilizing ligament.

Question 52

In the Sanders classification for intra-articular calcaneus fractures, what specific radiographic view is utilized to determine the classification grade, and what anatomical structure dictates it?

Explanation

The Sanders classification relies on the number of intra-articular fracture lines extending through the posterior facet of the calcaneus, best visualized on the widest part of the facet on a coronal CT scan.

Question 53

A 30-year-old male sustains a displaced talar neck fracture with subluxation of the subtalar joint (Hawkins type II). Following ORIF, the presence of the 'Hawkins sign' on AP radiographs at 6 to 8 weeks post-injury indicates what?

Explanation

The Hawkins sign appears as a subchondral radiolucent band in the talar dome. It represents disuse osteopenia (resorption of subchondral bone), which requires intact vascularity, thereby effectively ruling out complete avascular necrosis.

Question 54

A 22-year-old collegiate basketball player sustains an acute, non-displaced fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal (Jones fracture). To minimize time away from sports and decrease the risk of nonunion, which treatment is most appropriate?

Explanation

In high-level athletes, early intramedullary screw fixation for acute Jones fractures is indicated to significantly decrease the risk of nonunion and accelerate the return to competitive sports.

Question 55

A 26-year-old female presents with chronic lateral ankle instability despite 6 months of targeted physical therapy. She undergoes a Broström-Gould procedure. Which anatomical structures are anatomically repaired and advanced during this surgery?

Explanation

The modified Broström-Gould procedure involves direct repair of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL), augmented by mobilizing and advancing the inferior extensor retinaculum over the repair.

Question 56

A 55-year-old female presents with progressive medial ankle pain and a new-onset flatfoot deformity. Examination shows weakness with single-leg heel rise but a flexible hindfoot that corrects to neutral. What is the most appropriate surgical intervention?

Explanation

For Stage II (flexible) adult-acquired flatfoot deformity secondary to posterior tibial tendon dysfunction, a joint-sparing reconstruction using an FDL transfer and a medializing calcaneal osteotomy is the standard of care.

Question 57

A 60-year-old diabetic male presents with a swollen, erythematous, and warm unilateral foot without an open ulcer or signs of systemic infection. Radiographs show osseous fragmentation and joint subluxation at the midfoot. What is the most appropriate initial management?

Explanation

This patient presents with acute Eichenholtz stage I (fragmentation) Charcot arthropathy. The gold standard for initial management is immediate immobilization and offloading, typically via a total contact cast, until the acute inflammatory phase resolves.

Question 58

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 45 degrees and an Intermetatarsal Angle (IMA) of 18 degrees. There is no hypermobility of the first tarsometatarsal joint. Which surgical procedure is most indicated?

Explanation

For severe hallux valgus with an IMA greater than 13 to 15 degrees, a proximal metatarsal osteotomy or Lapidus procedure is necessary to achieve adequate correction. A distal chevron osteotomy cannot provide sufficient translation.

Question 59

A 28-year-old skier reports a painful snapping sensation over the lateral malleolus after a forced dorsiflexion and eversion injury. Examination confirms subluxation of the peroneal tendons with resisted eversion. This condition is primarily caused by an injury to which structure?

Explanation

Acute peroneal tendon subluxation is almost universally caused by a tear or avulsion of the superior peroneal retinaculum (SPR) from its fibular attachment.

Question 60

A 12-year-old boy complains of frequent ankle sprains and has a rigid, painful flatfoot. Oblique radiographs of the foot reveal an elongated anterior process of the calcaneus, commonly known as the 'anteater sign.' This finding points to which diagnosis?

Explanation

The 'anteater sign' seen on 45-degree oblique foot radiographs is a classic indicator of a calcaneonavicular coalition, which frequently presents as a rigid flatfoot in adolescents.

Question 61

A 21-year-old football player sustains a severe hyperextension injury to his great toe. MRI confirms a complete rupture of the plantar plate with significant proximal retraction of the sesamoids. What is the primary indication for surgical repair in this specific turf toe injury?

Explanation

Surgical indications for turf toe injuries (plantar plate ruptures) include Grade III complete tears with gross joint instability, intra-articular loose bodies, or significant proximal retraction of the sesamoids.

Question 62

A 15-year-old female cross-country runner complains of localized, progressive pain in her forefoot over the second metatarsophalangeal joint. Radiographs show flattening, sclerosis, and fragmentation of the second metatarsal head. What is the most likely diagnosis?

Explanation

Freiberg's infraction is avascular necrosis of the metatarsal head, most commonly affecting the second metatarsal in adolescent females. Radiographs classically show flattening and sclerosis of the metatarsal head.

Question 63

A 65-year-old female with long-standing, poorly controlled rheumatoid arthritis presents with severe forefoot pain, significant hallux valgus, and dorsal dislocation of the lesser metatarsophalangeal joints. What is the classic surgical reconstruction for this advanced presentation?

Explanation

The traditional and highly reliable procedure for severe rheumatoid forefoot deformities (Hoffman-Clayton procedure) consists of fusion of the first MTP joint combined with resection arthroplasty of the lesser metatarsal heads.

Question 64

During open reduction and internal fixation of a Weber C ankle fracture, the surgeon performs an intraoperative external rotation stress test (Cotton test) that demonstrates widening of the medial clear space. This finding indicates disruption of the syndesmosis and incompetence of which other critical structure?

Explanation

Widening of the medial clear space upon external rotation stress confirms incompetence of the medial side of the ankle joint, specifically the deltoid ligament complex, accompanying the lateral and syndesmotic injury.

Question 65

A 45-year-old teacher presents with severe heel pain, notably worst during her first steps out of bed in the morning. Examination shows localized tenderness over the medial calcaneal tubercle. She has tried NSAIDs for 2 weeks with minimal relief. What is the next most appropriate step in management?

Explanation

Initial conservative management for plantar fasciitis prioritizes eccentric stretching of the Achilles tendon and plantar fascia, often supplemented with night splinting. Surgical intervention is reserved for refractory cases lasting longer than 6 to 12 months.

Question 66

A 28-year-old man undergoes open reduction and internal fixation for a Hawkins type II talar neck fracture. At his 8-week postoperative visit, a subchondral lucency is visible beneath the talar dome on the anteroposterior radiograph. What is the prognostic significance of this radiographic finding?

Explanation

The Hawkins sign is a subchondral lucency of the talar dome seen 6 to 8 weeks after injury. It represents subchondral osteopenia secondary to hyperemia, confirming intact vascularity to the talar body and virtually ruling out avascular necrosis.

Question 67

When utilizing an extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, which nerve is at the greatest risk of iatrogenic injury during the surgical exposure?

Explanation

The sural nerve is at the highest risk during the extensile lateral approach to the calcaneus. The risk is minimized by creating a full-thickness "no-touch" subperiosteal flap and avoiding excessive tension on the flap apex.

Question 68

A 35-year-old female sustains a purely ligamentous Lisfranc injury. She is an active runner who wishes to return to high-impact activities. Which surgical management strategy is associated with the best mid-to-long-term functional outcomes and the lowest reoperation rate?

Explanation

Recent high-level evidence demonstrates that primary arthrodesis of the medial three tarsometatarsal joints for purely ligamentous Lisfranc injuries yields better functional outcomes and fewer reoperations compared to open reduction and internal fixation.

Question 69

A 15-year-old male with Charcot-Marie-Tooth disease presents with a rigid bilateral pes cavovarus deformity. During examination, a Coleman block test is performed, and the hindfoot varus completely corrects to neutral. This clinical finding indicates that the hindfoot deformity is primarily driven by which of the following?

Explanation

The Coleman block test eliminates the influence of the first ray on hindfoot posture. If the hindfoot varus corrects when the first metatarsal is allowed to drop off the block, the deformity is flexible and driven by a rigid, plantarflexed first ray.

Question 70

A 40-year-old recreational athlete sustains an acute Achilles tendon rupture. In comparing operative repair versus non-operative management utilizing an early functional rehabilitation protocol, current evidence supports which of the following conclusions?

Explanation

Level I evidence indicates that non-operative management utilizing early functional rehabilitation protocols has rerupture rates and functional outcomes equivalent to operative repair, while avoiding surgical site complications.

Question 71

An elite college football player sustains a Zone 2 (Jones) fracture of the proximal fifth metatarsal. To minimize the risk of nonunion and allow the fastest return to play, what is the most appropriate management?

Explanation

Zone 2 fractures (Jones fractures) occur at the metaphyseal-diaphyseal junction, a watershed vascular area prone to nonunion. Intramedullary screw fixation is recommended for high-level athletes to promote reliable healing and expedite return to play.

Question 72

A 45-year-old male falls from a ladder, sustaining a severely comminuted closed pilon fracture. The ankle exhibits severe swelling and early fracture blisters. A spanning external fixator is placed. What is the most appropriate clinical indicator for timing the definitive open reduction and internal fixation?

Explanation

The standard of care for severe pilon fractures is initial temporary external fixation to allow the soft tissue envelope to recover. Definitive ORIF is delayed until the swelling subsides and skin wrinkles appear, usually between 10 and 21 days.

Question 73

When evaluating a trimalleolar ankle fracture, which of the following is currently considered the strongest indication for direct posterior approach and internal fixation of the posterior malleolus?

Explanation

Modern indications for fixing the posterior malleolus have moved away from strict size cutoffs (e.g., 25%). Fixation is indicated for any fragment causing articular incongruity, talar subluxation, or involving intercalary (die-punch) fragments, as it crucially restores syndesmotic stability.

Question 74

A 55-year-old female presents with medial foot pain and progressive flattening of her arch. She is unable to perform a single-leg heel rise. Examination reveals flexible hindfoot valgus and midfoot abduction. Which surgical intervention is most appropriate for this stage of Adult Acquired Flatfoot Deformity (Stage II)?

Explanation

Stage II posterior tibial tendon dysfunction (PTTD) is characterized by a flexible deformity. It is optimally treated with joint-sparing procedures such as an FDL transfer to the navicular combined with a medializing calcaneal osteotomy to correct the hindfoot valgus.

Question 75

A 22-year-old track athlete presents with insidious onset of dorsal midfoot pain. Plain radiographs are negative, but a CT scan reveals an incomplete stress fracture in the dorsal central third of the navicular body. What is the most appropriate initial management?

Explanation

Non-displaced or incomplete navicular stress fractures have a high risk of nonunion due to the avascular central third of the bone. The gold standard initial treatment is strict non-weight-bearing in a cast for 6 to 8 weeks.

Question 76

A professional soccer player sustains a severe hyperdorsiflexion injury to the first metatarsophalangeal (MTP) joint. MRI confirms a Grade 3 "turf toe" with a complete tear of the plantar plate and proximal migration of the sesamoids. What is the recommended treatment?

Explanation

A Grade III turf toe involves a complete rupture of the plantar plate complex. In competitive athletes, surgical repair is indicated to restore push-off strength, alleviate pain, and prevent progressive MTP joint deformity and weakness.

Question 77

A 30-year-old construction worker falls from a roof, landing directly on his feet. He sustains a high-energy ankle injury characterized by severe coronal plane widening of the syndesmosis, an intact fibula, and impaction of the talus into the tibial plafond. What is the standard eponymous term for this injury pattern?

Explanation

A "Logsplitter" injury results from a high-energy axial load that drives the talus upward into the distal tibiofibular joint, causing severe syndesmotic disruption and plafond impaction, frequently without a fibula fracture.

Question 78

During closed reduction of a medial subtalar dislocation in a 25-year-old patient, the joint is successfully reduced in the emergency department. Despite an anatomic reduction and appropriate rehabilitation, what is the most common long-term complication associated with this injury?

Explanation

Medial subtalar dislocations are the most common type and usually amenable to closed reduction. However, due to the high-energy cartilage impaction at the time of injury, post-traumatic subtalar arthritis is the most common long-term complication.

Question 79

During open reduction and internal fixation of a calcaneus fracture via a lateral extensile approach, a screw directed medial to the sustentaculum tali is measured slightly too long. Which anatomical structure is at the greatest risk of being injured or tethered by this prominent screw?

Explanation

The Flexor Hallucis Longus (FHL) tendon courses directly inferior to the sustentaculum tali. Screws that are directed medially and left too long past the sustentacular cortex can easily impale or tether the FHL, leading to fixed flexion of the hallux.

Question 80

When assessing the quality of syndesmotic reduction intraoperatively following fixation of a Weber C ankle fracture, which radiographic measurement is historically considered the most reliable parameter on standard AP and mortise fluoroscopic views?

Explanation

The tibiofibular clear space (normally <5mm on both AP and mortise views) is the most reliable 2D radiographic measure of syndesmotic integrity because it is less dependent on rotation than tibiofibular overlap. However, bilateral CT remains the modern gold standard.

Question 81

A 30-year-old sustains an ankle fracture requiring syndesmotic fixation. Which of the following intraoperative imaging techniques is most sensitive for evaluating syndesmotic reduction?

Explanation

Intraoperative fluoroscopy comparing the injured to the uninjured contralateral ankle is the most accurate radiographic method to assess syndesmotic reduction, significantly reducing malreduction rates compared to standard mortise views alone.

Question 82

A 35-year-old male presents with a closed ankle fracture-dislocation after a fall. Closed reduction in the emergency department is unsuccessful. Radiographs show a posterior fracture-dislocation of the fibula behind the posterior tubercle of the distal tibia. Which of the following is the most likely diagnosis?

Explanation

A Bosworth fracture involves a dislocation of the proximal fibular fragment posterior to the posterior tubercle of the tibia. This anatomical block makes closed reduction virtually impossible and necessitates urgent open reduction.

Question 83

A 45-year-old construction worker falls from a ladder, sustaining a closed, highly comminuted intra-articular distal tibia (pilon) fracture with severe soft tissue swelling and fracture blisters. What is the most appropriate initial management?

Explanation

In high-energy pilon fractures with severe soft tissue compromise, staged management with an initial spanning external fixator allows soft tissue recovery before definitive ORIF. This approach minimizes catastrophic wound complications and infection.

Question 84

Six weeks following open reduction and internal fixation of a Hawkins type II talar neck fracture, an AP radiograph of the ankle reveals a subchondral radiolucent band in the talar dome. What does this radiographic finding indicate?

Explanation

The Hawkins sign is a subchondral radiolucent band seen 6 to 8 weeks post-injury. It represents subchondral atrophy from disuse and confirms intact vascularity to the talar body, effectively excluding avascular necrosis.

Question 85

Which of the following patient profiles is associated with the worst outcomes following open reduction and internal fixation of a displaced intra-articular calcaneus fracture?

Explanation

Smokers, heavy laborers, and patients receiving workers' compensation have significantly poorer clinical outcomes following ORIF of intra-articular calcaneus fractures. Smoking significantly increases the risk of severe wound breakdown.

Question 86

Which of the following is considered an absolute contraindication to a total ankle arthroplasty in a patient with end-stage post-traumatic ankle osteoarthritis?

Explanation

Extensive avascular necrosis (>50% of the talar body) is an absolute contraindication to total ankle arthroplasty. The lack of structural support for the talar component leads to early subsidence and catastrophic implant failure.

Question 87

A 22-year-old professional basketball player sustains an acute, non-displaced fracture of the proximal fifth metatarsal at the metaphyseal-diaphyseal junction (Zone 2). What is the most appropriate treatment to minimize time away from sports and the risk of nonunion?

Explanation

Intramedullary screw fixation is the standard of care for elite athletes with acute Zone 2 (Jones) fractures. It offers higher union rates and faster return to play compared to nonoperative management.

Question 88

A 42-year-old man undergoes percutaneous repair of an acute Achilles tendon rupture. Postoperatively, he complains of numbness and burning pain along the lateral aspect of his foot. Which nerve was most likely injured during the procedure?

Explanation

The sural nerve courses lateral to the Achilles tendon and crosses its lateral border approximately 10 cm proximal to the calcaneal insertion. It is at the highest risk of injury during percutaneous or minimally invasive Achilles repairs.

Question 89

A 35-year-old female sustains a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal joints. Which of the following surgical interventions provides superior functional outcomes and lower revision rates for purely ligamentous injuries?

Explanation

Prospective randomized trials demonstrate that primary arthrodesis of the medial rays in purely ligamentous Lisfranc injuries yields better functional outcomes. It also significantly lowers hardware removal and revision rates compared to ORIF.

Question 90

During the surgical approach for a displaced talar neck fracture, an anteromedial approach is utilized. Which critical vascular structure is at greatest risk of iatrogenic injury during this specific approach, potentially worsening the risk of avascular necrosis?

Explanation

The deltoid branch of the posterior tibial artery supplies the medial body of the talus. Excessive soft tissue stripping during an anteromedial approach puts this critical remaining blood supply at risk, increasing the likelihood of avascular necrosis.

Question 91

A 24-year-old soccer player presents with lateral ankle pain and a popping sensation behind the fibula when circumducting the foot. Radiographs reveal a cortical avulsion off the lateral ridge of the distal fibula. This "fleck sign" indicates an injury to which of the following structures?

Explanation

The "fleck sign" on a mortise or AP radiograph represents an osseous avulsion of the superior peroneal retinaculum from the posterolateral fibula. It is pathognomonic for peroneal tendon dislocation or subluxation.

Question 92

A 14-year-old boy presents with a painful, rigid flatfoot and recurrent ankle sprains. CT imaging confirms a calcaneonavicular coalition. If conservative management fails, which of the following surgical procedures is considered the gold standard?

Explanation

For symptomatic calcaneonavicular coalitions that fail conservative treatment, resection of the coalition with interposition of the extensor digitorum brevis (EDB) muscle or fat graft is the surgical treatment of choice. This prevents recurrence and restores motion.

Question 93

A 55-year-old female presents with stage IIB adult acquired flatfoot deformity. She has a flexible hindfoot but a fixed forefoot supinatus. Along with flexor digitorum longus (FDL) transfer and a medializing calcaneal osteotomy, which additional procedure is required to address the fixed forefoot deformity?

Explanation

In stage II flatfoot deformity with forefoot varus (fixed supinatus) that does not correct with hindfoot realignment, a Cotton osteotomy or a first TMT joint arthrodesis is required. This plantarflexes the first ray and restores the tripod effect of the foot.

Question 94

A 40-year-old male with an uncorrected childhood clubfoot presents with localized medial ankle pain. Weight-bearing radiographs demonstrate varus alignment of the distal tibia and isolated medial tibiotalar joint space narrowing. Hindfoot mobility is preserved. Which of the following is the most appropriate surgical option?

Explanation

A supramalleolar osteotomy is indicated for asymmetric ankle osteoarthritis with a correlative extra-articular deformity. It redistributes weight-bearing forces to the preserved cartilage, delaying the need for fusion or replacement in young, active patients.

Question 95

A 20-year-old track athlete complains of vague dorsal midfoot pain that worsens with sprinting. MRI demonstrates a stress fracture of the tarsal navicular. Which region of the navicular is most susceptible to this injury due to its relative hypovascularity?

Explanation

The central third of the tarsal navicular is a relative watershed area for blood supply. This localized hypovascularity makes it the most common site for navicular stress fractures and nonunions.

Question 96

A 14-year-old female sustains an injury to her ankle while skateboarding. Radiographs reveal a Salter-Harris III fracture of the anterolateral distal tibia. Which ligament is responsible for the avulsion of this fracture fragment?

Explanation

A juvenile Tillaux fracture is a Salter-Harris III fracture of the anterolateral distal tibia epiphysis. The avulsion is caused by the anterior inferior tibiofibular ligament (AITFL) as the distal tibial physis closes from central to anteromedial, leaving the anterolateral aspect open last.

Question 97

A 28-year-old male is involved in a crush injury to his foot. He develops severe pain out of proportion and tense swelling. The decision is made to perform a fasciotomy of the foot. How many distinct fascial compartments are generally recognized in the foot?

Explanation

There are 9 clinically recognized distinct fascial compartments in the foot: medial, lateral, superficial central, deep central (calcaneal), four interosseous compartments, and the dorsal compartment. Release typically requires combined dorsal and medial approaches.

Question 98

A 32-year-old female has persistent ankle pain following a severe sprain 1 year ago. MRI demonstrates a 1.2 cm x 1.0 cm posteromedial osteochondral lesion of the talus with subchondral cystic changes. The cartilage cap appears intact. What is the most appropriate initial surgical management?

Explanation

For an intact cartilage cap with an underlying cystic lesion in the talus, retrograde drilling is an excellent option. It decompresses the cyst and stimulates bone healing while preserving the intact articular cartilage.

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

AAOS Orthopedic Foot & Ankle MCQs (Set 3): Ankle Trauma & Deformities | 2026 Board Review

Key Takeaway

AAOS Orthopedic Foot & Ankle MCQs (Set 3): Ankle Trauma & Deformities | 2026 Board Review

Chapter Index