Foot & Ankle MCQs Part 4: ABOS Board Review 2026

Question 1

A 26-year-old rugby player injured his foot when tackled from behind. Radiographs are seen in Figures 35a through 35c. What is the most appropriate treatment?

Explanation

35b 35c The patient has a ligamentous Lisfranc injury. Diastasis seen between the bases of the second metatarsal and medial cuneiform is pathognomonic for a rupture of the Lisfranc's ligament. This injury is best treated surgically with either open reduction and internal fixation or possibly closed manipulation and percutaneous screw fixation if anatomic alignment can be achieved closed. Pin fixation has been shown to be inferior to screw fixation due to the length of time that fixation is required for adequate ligament healing. Chiodo CP, Myerson MS: Developments and advances in the diagnosis and treatment of injuries of the tarsometatarsal joint. Orthop Clin North Am 2001;32:11-20.

Question 2

A 32-year-old woman sustained a closed calcaneus fracture 2 years ago and was treated nonsurgically. She now reports a 6-month history of progressively worsening pain over the anterior ankle and lateral hindfoot. Climbing stairs and ascending slopes is particularly difficult for her. Bracing and intra-articular corticosteroid injections have not provided sufficient relief. Figure 36 shows a weight-bearing lateral radiograph. What is the most appropriate surgical option?

Explanation

Intra-articular fractures of the calcaneus often include depression of the posterior facet of the subtalar joint. This can lead to dorsiflexion of the talus because of diminished height posteriorly. In a weight-bearing position, the dorsal surface of the talar neck can impinge against the distal tibia, causing anterior ankle pain. In addition, posttraumatic arthritis of the subtalar joint typically occurs after a calcaneus fracture. The patient's symptoms are consistent with both anterior ankle impingement and subtalar degenerative arthritis. The Bohler angle, approximately 15 degrees, confirms depression of the posterior facet. Distraction subtalar arthrodesis with a corticocancellous bone block autograft will improve talar declination, decrease anterior impingement, and address the subtalar degenerative arthritis simultaneously. Rammelt S, Grass R, Zawadski T, et al: Foot function after subtalar distraction bone-block arthrodesis: A prospective study. J Bone Joint Surg Br 2004;86:659-668.

Question 3

A 42-year-old woman who observes traditional Muslim practices is seen in your office accompanied by her physician husband to discuss possible elective bunion correction. In considering the treatment of this patient, what is one of the most important considerations?

Explanation

In considering faith-based issues regarding treatment of this patient, the presence of her husband for the office visit would imply an agreement with her decision to have surgery. It also may facilitate her examination. Her role as caregiver, dietary concerns, and cleansing rituals are less important considerations with an outpatient-based procedure. Privacy concerns remain paramount to Muslim women, which include limited exposure during examination, during surgery, and in subsequent follow-up visits.

Question 4

A 35-year-old female runner reports progressive vague aching pain involving her midfoot. Her pain is most notable when running. She denies specific injury. Examination reveals minimal swelling and localized tenderness over the dorsal medial midfoot and navicular. Radiographs and an MRI scan are shown in Figures 37a through 37c. What is the most appropriate management?

Explanation

37b 37c A high index of suspicion is required to identify a possible navicular stress fracture, especially in runners. High pain tolerance in the competitive athlete and often minimal swelling contribute to frequent delays in diagnosis. Localized tenderness over the dorsal navicular (so-called "N spot") in a running athlete should alert the treating physician. In this patient, the radiographs are negative and the MRI scan shows marrow edema within the navicular. This could represent a stress reaction, stress fracture, or osteonecrosis. Appropriate management should include non-weight-bearing immobilization and obtaining a CT scan to determine if a fracture is present. Early surgical treatment may be considered but only if a fracture is identified. Lee A, Anderson R: Stress fractures of the tarsal navicular. Foot Ankle Clin 2004;9:85-104.

Question 5

A 47-year-old woman underwent a bunionectomy and hallux valgus correction a few years ago. She now has the complication shown in Figures 38a and 38b. She has no pain with motion of the metatarsophalangeal or interphalangeal joints. What is the best reconstructive option in this setting?

Explanation

38b The patient has a flexible hallux varus that is a complication of the bunion surgery. With joints that are not arthritic and still flexible, a medial release is necessary to realign the joint. The extensor hallucis longus split transfer helps maintain position and still preserve motion at the interphalangeal joint level. Arthrodesis is a salvage procedure. Soft-tissue releases alone are most likely inadequate. Excision of the lateral sesamoid is contraindicated because that further compromises the forces resisting hallux varus. Phalangeal osteotomy would not address the medial subluxation at the metatarsophalangeal joint. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 27-32.

Question 6

A 43-year-old man reports a 3-year history of progressively worsening pain in the first metatarsophalangeal joint that is aggravated by activity. Larger shoes, intra-articular corticosteroid injections, and a Morton's extension pedorthic have failed to provide relief. Motion is limited to 10 degrees of dorsiflexion, and the "grind test" is positive. An AP radiograph is shown in Figure 39. What is the most appropriate surgical treatment?

Explanation

Stage III hallux rigidus comprises end-stage degenerative arthritis with loss of cartilage from the phalanx and metatarsal. Therefore, cheilectomy, osteotomy, and resection arthroplasty are inadequate. Resection arthroplasty results in diminished propulsion and transfer metatarsalgia. Resurfacing implant hemiarthroplasty remains unproven for earlier stages of hallux rigidus, but is not appropriate when there is cartilage loss from the base of the proximal phalanx. First metatarsophalangeal arthrodesis has proven to be a very reliable and functional treatment of end-stage hallux rigidus. Gibson JN, Thomson CE: Arthrodesis or total replacement arthroplasty for hallux rigidus: A randomized controlled trial. Foot Ankle Int 2005;26:680-690.

Question 7

A 12-year-old girl who plays softball has chronic lateral hindfoot aching pain that is aggravated by weight-bearing activity. She reports that the pain has recurred after initial improvement with cast immobilization, and it continues to limit her overall level of activity. Radiographs are seen in Figures 40a through 40c. What is the most appropriate surgical treatment?

Explanation

40b 40c The patient has a calcaneonavicular tarsal coalition. Symptoms of calcaneonavicular coalitions typically are seen between the ages of 10 and 14 years. The cause of pain has not been clearly established. It has been postulated that the coalition stiffens with maturity and microfractures can result, producing pain. Resection of a calcaneonavicular coalition generally has been associated with a satisfactory result. Soft-tissue interposition, most commonly using the extensor digitorum brevis muscle, appears to be helpful. A hindfoot arthrodesis (usually triple) would be reserved if coalition resection proves to be unsuccessful. Achilles tendon lengthening and orthotic support, as well as debridement of the sinus tarsi, are not expected to result in a satisfactory outcome. The patient does not have a flatfoot deformity. Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 757-765.

Question 8

A 38-year-old man underwent a transtibial amputation for chronic posttraumatic foot and ankle pain and chronic calcaneal osteomyelitis. Postoperative radiographs are seen in Figures 41a and 41b. What is the proposed purpose of the surgical modification seen in the radiographs?

Explanation

41b The Ertl modification of a below-knee amputation has been proposed to create a more stable "platform" to aid in transferring the load of weight bearing between the residual limb and the prosthetic socket. It is felt that a stable platform allows total contact loading over an enlarged stable surface area. Early studies have suggested that this modification may enhance the patient's perceived functional outcome. Pinzur MS, Pinto MA, Saltzman M, et al: Health-related quality of life in patients with transtibial amputation and reconstruction with bone bridging of the distal tibia and fibula. Foot Ankle Int 2006;27:907-912.

Question 9

Figures 42a through 42c show the clinical photographs and radiograph of a patient with diabetes mellitus who lives independently. The patient was admitted to the hospital late yesterday afternoon with clinical signs of sepsis. Parenteral antibiotic therapy resolved the sepsis, and blood glucose levels are now well controlled. The patient has no palpable pulses. The ankle-brachial index is 0.70. Laboratory studies show a WBC count of 8,500/mm3, a serum albumin of 1.9 g/dL, and a total lymphocyte count of 1,500/mm3. What treatment has the best potential to optimize his survival and independence?

Explanation

42b 42c The patient was admitted to the hospital with sepsis. The sepsis has resolved, leaving the patient with a negative nitrogen balance. Now that the patient is stable, metabolic support should be used to optimize his nutrition. If the serum albumin can be increased to 2.5 g/dL, he has an excellent potential to heal an amputation at the Syme ankle disarticulation level; a level that will optimize his functional independence. Pinzur MS, Stuck RR, Sage R, et al: Syme ankle disarticulation in patients with diabetes. J Bone Joint Surg Am 2003;85:1667-1672.

Question 10

A toddler is brought in by his parents for evaluation of gait problems. Birth history and neurologic examination are unremarkable. After evaluating femoral torsion, tibial torsion, and foot contour, the diagnosis is excessive internal tibial torsion. The parents should be advised to expect which of the following outcomes?

Explanation

Excessive internal tibial torsion is a common cause of intoeing in toddlers. In most children, this resolves spontaneously by 3 to 4 years of age. Intoeing in elementary age children is usually the result of excessive femoral anteversion. Studies have shown that active intervention (casting, splinting, and shoe modifications) has no demonstrable effect on the natural history or resolution of tibial torsion. Surgery is rarely indicated in adolescents with severe internal tibial torsion that has not resolved and is resulting in cosmetic and functional problems. Canale ST, Beaty JH: Operative Pediatric Orthopaedics. St Louis, MO, Mosby Year Book, 1991, pp 357-385.

Question 11

Arthrodesis of which of the following joints has the greatest cumulative effect on midfoot/hindfoot motion?

Explanation

Arthrodesis of the talonavicular joint eliminates almost all hindfoot motion. Arthrodesis of the subtalar joint eliminates 74% of talonavicular motion and 44% of calcaneocuboid motion. Arthrodesis of the calcaneocuboid joint eliminates 33% of talonavicular motion and 8% of subtalar motion. Arthrodesis of the naviculocuneiform or cuboid-fifth metatarsal joint has limited effect on hindfoot motion. Astion DJ, Deland JT, Otis JC, et al: Motion of the hindfoot after simulated arthrodesis. J Bone Joint Surg Am 1997;79:241-246.

Question 12

A 51-year-old man sustained an open fracture of his tibia in Korea 42 years ago. An infection developed and it was resolved with surgical treatment. For the past 6 months, an ulcer with mild drainage has developed over the medial tibia. The ulcer is small and there is minimal erythema at the ulcer site. A radiograph and MRI scan are shown in Figures 43a and Figure 43b. Initial cultures show Staphylococcus aureus susceptible to the most appropriate antibiotics. Laboratory studies show an erythrocyte sedimentation rate of 70 mm/h. What is the most appropriate surgical treatment at this time?

Explanation

43b The patient has chronic tibial osteomyelitis that is due to low virulent bacteria. The history and studies do not suggest the need for an amputation or a free-flap procedure. This is a localized tibial infection that is in a healed bone; there is no need to resect the entire area of the tibia bone around the infection. The most appropriate treatment is curettage, debridement of nonviable bone, and placement of absorbable antibiotic beads, followed by a course of IV antibiotics from 1 to 4 weeks and a 6-week course of oral antibiotics. Studies have shown that in cases of localized osteomyelitis that are of low virulence, as little as 1 week of IV antibiotics followed by 6 weeks of oral antibiotics is successful. Patzakis MJ, Zalavras CG: Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: Current management concepts. J Am Acad Orthop Surg 2005;13:417-427.

Question 13

Which of the following best describes the relationship of the anterior tibial artery and dorsalis pedis artery to the extensor hallucis longus (EHL) tendon as they progress from the level of the ankle to the dorsum of the foot?

Explanation

At the ankle level, the anterior tibial artery lies medial to the EHL tendon. The artery becomes the dorsalis pedis after crossing onto the dorsum of the foot. At this point, the artery lies lateral to the tendon. 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 14

A 42-year-old man reports a 12-month history of a painful fusiform swelling of the Achilles tendon. Physical therapy, heel lifts, and anti-inflammatory drugs have failed to provide relief. MRI scans are shown in Figures 44a and 44b. What is the treatment of choice?

Explanation

44b The area of the tendon degeneration is greater than 50% of the width so a supplemental tendon transfer is needed. Debridement and repair alone do not provide adequate strength. Injection risks tendon rupture. Brisement is indicated for peritendinitis, not tendinosis. Nonsurgical management is unlikely to be of benefit after 12 months. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 94-95.

Question 15

A 35-year-old man is seen for evaluation of his left ankle following multiple previous ankle sprains and frequent episodes of the ankle giving way. Examination reveals marked laxity about the lateral ankle with associated tenderness along the peroneal tendons. Physical therapy, anti-inflammatory drugs, and supportive bracing have failed to provide relief. An MRI scan shows peroneal tenosynovitis and a possible tear. He elects to undergo a peroneal tendon repair and lateral ligament reconstruction. Which of the following best describes the structure labeled "A" in Figure 45?

Explanation

The structure labeled "A" is a peroneus quartus, a supernumary muscle arising most commonly from the peroneus brevis. The presence of peroneus quartus is not uncommon, with an incidence of up to 21%, and is associated with lateral ankle pain and peroneal tendon symptoms, theoretically as a result of mass effect within the peroneal tendon sheath. Zammit J, Singh D: The peroneus quartus muscle: Anatomy and clinical relevance. J Bone Joint Surg Br 2003;85:1134-1137.

Question 16

You are asked to evaluate the patient whose current clinical photographs are shown in Figures 46a and 46b following aortic valve replacement 9 days ago. He is currently taking anticoagulation medication. He has no systemic signs of sepsis. What is the best management?

Explanation

46b These lesions are emboli related to the cardiac surgery, and the patient is already on anticoagulation medication. The foot reveals no signs consistent with gangrene or infection. Unless the patient shows local or systemic signs of sepsis, the best management is observation. It is unlikely that formal debridement will be necessary. Bowker JH, Pfeiffer MA (eds): The Diabetic Foot. St Louis, MO, Mosby, 2001, pp 219-260.

Question 17

A 48-year-old woman with a history of a spinal cord injury as a teenager, has unilateral weakness in the left lower extremity. She has used an ankle-foot orthosis for many years without difficulty but recently has had a recurrent painful callus beneath the great toe that has been recalcitrant to nonsurgical management. Examination reveals intact sensation with an intractable plantar keratosis (IPK) beneath the first metatarsal head. Motor examination reveals no active ankle or great toe dorsiflexion, and 4/5 plantar flexion strength at the ankle and great toe. Passive ankle dorsiflexion is 10 degrees, whereas passive plantar flexion is 40 degrees. Passive great toe dorsiflexion is 30 degrees and plantar flexion is 10 degrees. Foot alignment on standing is normal. Radiographs are shown in Figures 47a and 47b with a marker beneath the IPK. Based on her request for surgical treatment, what is the most appropriate procedure?

Explanation

47b Passive dorsiflexion is adequate to accommodate standing erect without excessive pressure, and a gastrocnemius recession may lead to more instability. Complete excision of the medial sesamoid could lead to an iatrogenic hallux valgus deformity. She does not have a cock-up toe deformity; therefore, a flexor hallucis longus tendon transfer is not warranted. There is no significant foot deformity; therefore, a dorsiflexion osteotomy is not warranted. The appropriate procedure is planing of the plantar half of the medial sesamoid, thereby preserving its function while diminishing the excessive pressure. Grace DL: Sesamoid problems. Foot Ankle Clin 2000;5:609-627. Mizel MS, Miller RA, Scioli MW (ed): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 135-150.

Question 18

The cavovarus deformity associated with Charcot-Marie-Tooth (CMT) disease is caused by which of the following?

Explanation

The most common inherited neuromuscular disease seen by orthopaedic surgeons is CMT, which is an inherited autosomal-dominant disease. It is more commonly seen in men due to the nature of the inheritance. Identification of cavus deformity in the foot of a child should arouse suspicion. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 135-143. Charcot-Marie-Tooth Disease (CMT) Penn State Hershey Medical Center. www.hmc.psu.edu/healthinfo/c/cmt.htm

Question 19

When performing a gastrocnemius recession, what structure should be protected?

Explanation

When performing a gastrocnemius slide at the tendinous portion of the gastrocnemius insertion, the sural nerve and saphenous vein, which tend to run midline posterior at this level, must be protected and retracted laterally. An anatomic study of the sural nerve at this level localized the nerve superficial to the deep fascia overlying the gastrocnemius in 42.5% of the cases; deep to the superficial fascia in 57.5% of the cases, and directly applied to the gastrocnemius tendon in 12.5% of cases. Pinney SJ, Sangeorzan BJ, Hanen ST Jr: Surgical anatomy of the gastrocnemius resection (Strayer procedure). Foot Ankle Int 2004;25:247-250.

Question 20

A 59-year-old woman underwent open reduction and internal fixation (ORIF) of her ankle 6 months ago, with subsequent hardware removal 3 months later. She now reports persistent, diffuse ankle pain, swelling, and limited range of motion. Figure 48 shows an oblique radiograph of the ankle. What is the next most appropriate step in management?

Explanation

The radiographs demonstrate persistent widening of the medial clear space with an ossicle. This represents soft-tissue interposition-scar tissue, the deltoid ligament, or the posterior tibialis tendon. Physical therapy will not improve the symptomatic malalignment. Hardware removal would be indicated for pain localized to the lateral fibula. Repeat syndesmotic screw fixation alone will not reduce the malalignment. Deltoid ligament repair may be necessary but will need to be combined with debridement of the medial ankle and syndesmosis, as well as repeat placement of one or more syndesmotic screws to maintain the reduction. Weening B, Bhandari M: Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma 2005;19:102-108.

Question 21

A farmer is seen in the emergency department after falling out of a hay loft onto the barn floor below. He is unable to bear weight. Exploration of a 0.5 cm laceration over the anterior tibia reveals bone. Radiographs reveal oblique displaced midshaft tibial and fibular fractures. Based on these findings, what is the most appropriate antibiotic prophylaxis?

Explanation

A farm injury is automatically considered a grade III (Gustillo classification) injury regardless of size, energy, or additional soft-tissue injury due to the likelihood of substantial contamination. Antibiotic recommendations for grade III injuries include a first- or second-generation cephalosporin with an aminoglycoside or fluoroquinolone within 3 hours of injury, with penicillin added for farm injuries. Okike K, Bhattacharyya T: Trends in the management of open fractures: A critical analysis. J Bone Joint Surg Am 2006;88:2739-2748.

Question 22

A 66-year-old patient with type 1 diabetes mellitus has a deep, nonhealing ulcer under the first metatarsal head and a necrotic tip of the great toe. He has been under the direction of a wound care clinic for 4 months, and has had orthotics and shoe wear changes. What objective findings are indicative of the patient's ability to heal the wound postoperatively?

Explanation

Absolute toe pressures greater than 40 to 50 mm Hg are a good sign of healing potential. An ABI of greater than 0.45 favors healing, but indices greater than 1 are falsely positive due to calcifications in the vessels. Normal albumin is an overall indication of nutritional status. A transcutaneous oxygen level should be greater than 40 mm Hg for healing. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 113-122.

Question 23

Which of the following have been found to affect the rate of perioperative infections or wound complication rates in foot and ankle surgery?

Explanation

Clinical studies have shown that smoking cessation for 4 weeks reduces the risk of infection to the level of nonsmokers. Adverse effects on wound healing caused by chemotherapy used to treat rheumatoid arthritis has not been borne out in the literature. Bibbo C, Anderson RB, Davis WH, et al: The influence of rheumatoid chemotherapy, age, and presence of rheumatoid nodules on postoperative complications in rheumatoid foot and ankle surgery: Analysis of 725 procedures in 104 patients. Foot Ankle Int 2003;24:40-44. Bibbo C, Goldberg JW: Infections and healing complications after elective orthopaedic foot and ankle surgery during tumor necrosis factor-alpha inhibition therapy. Foot Ankle Int 2004;25:331-335.

Question 24

Intrinsic muscles of the foot act on the toes by

Explanation

Intrinsic muscles of the foot function to flex the metatarsophalangeal joints and extend the interphalangeal joints. Myerson MS, Shereff MJ: The pathologic anatomy of claw and hammertoes. J Bone Joint Surg Am 1989;71:45-49.

Question 25

A 23-year-old woman with a history of bilateral recurrent ankle sprains, progressive cavovarus feet, and a family history of high arches and foot deformities is seen for evaluation. Management consisting of bracing and physical therapy has been poorly tolerated. Heel varus is partially corrected with a Coleman block. There are thick calluses under the first metatarsal heads. Sensation to touch and Weinstein monofilament is normal. Tibialis anterior and peroneus brevis are weak but present. What is the most appropriate management?

Explanation

The history and presentation are consistent with type I Charcot-Marie-Tooth (CMT), the most common form of hereditary peripheral motor sensory neuropathy. Type I CMT is the most common, occurring in 50% of patients with CMT, and is characterized by marked slowing of motor neuron velocities, and inconsistent slowing of sensory neuron velocities. Peroneus longus to brevis transfer is indicated to release the overpull of the peroneus longus, and restore the eversion and dorsiflexion function of the peroneus brevis. A lateralizing calcaneal osteotomy with proximal translation is indicated to correct heel varus given that the Coleman block only allows for partial correction of heel varus. Proximal translation of the posterior tuber corrects for the increased calcaneal dorsiflexion, improving the lever arm for the triceps surae. A medial column closing wedge osteotomy is often required to correct a rigid, or semirigid plantar flexed first ray to allow for a balanced, plantigrade foot. Triple arthrodesis is indicated for rigid, arthritic hindfoot deformities. Transfer of the posterior tibial tendon to the tibialis anterior is not indicated since it is an out-of-phase transfer. Transfer of the posterior tibial tendon, when performed, should be to the lateral aspect of the foot. A medializing calcaneal osteotomy would accentuate the heel varus. There is no indication for Botox in CMT; Botox injection of the calf would further weaken push-off during gait. Bracing of a progressive semirigid or rigid deformity is not recommended. Younger AS, Hansen ST Jr: Adult cavovarus foot. J Am Acad Orthop Surg 2005;13:302-315. Sammarco GJ, Taylor R: Cavovarus foot treated with combined calcaneus and metatarsal ostetotomies. Foot Ankle Int 2001;22:19-30.

Question 26

A 35-year-old male sustains a purely ligamentous Lisfranc injury after a fall from a horse. Radiographs reveal diastasis between the medial and middle cuneiforms with proximal migration of the second metatarsal.

What is the most appropriate surgical management for this specific injury pattern to minimize the need for revision surgery?

Explanation

Primary arthrodesis of the medial 2 or 3 rays is the treatment of choice for purely ligamentous Lisfranc injuries. Studies demonstrate improved functional outcomes and lower revision rates compared to ORIF for purely ligamentous variants.

Question 27

A 40-year-old female presents with a painful bunion. Clinical examination reveals hypermobility of the first tarsometatarsal (TMT) joint. Radiographs show a hallux valgus angle of 38 degrees and an intermetatarsal angle (IMA) of 18 degrees. What is the most appropriate surgical intervention?

Explanation

A Lapidus procedure (1st TMT arthrodesis) is indicated for moderate-to-severe hallux valgus (IMA > 15 degrees) combined with first ray hypermobility. It corrects the deformity at the apex and stabilizes the medial column.

Question 28

A 28-year-old male sustained a Hawkins Type II talar neck fracture and underwent open reduction and internal fixation. At his 8-week postoperative visit, a subchondral lucency is visible in the talar dome on the AP mortise radiograph. What does this radiographic finding indicate?

Explanation

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

Question 29

A 31-year-old recreational basketball player presents with an acute mid-substance Achilles tendon rupture. After discussing operative and non-operative management, he elects for non-operative treatment. Which of the following rehabilitation protocols provides re-rupture rates most comparable to surgical repair?

Explanation

Recent high-level evidence shows that non-operative management with early functional mobilization and weight-bearing protocols yields re-rupture rates equivalent to surgical repair, while avoiding surgical wound complications.

Question 30

A 21-year-old collegiate basketball player complains of lateral foot pain. Radiographs show a transverse fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal.

What is the best treatment option to minimize time lost from play?

Explanation

Zone 2 fifth metatarsal fractures (Jones fractures) in elite or competitive athletes are best treated with intramedullary screw fixation to ensure a faster and more predictable return to play and to lower the risk of nonunion.

Question 31

A 55-year-old female presents with worsening medial ankle pain and a progressively flattening arch. On examination, she is unable to perform a single-leg heel rise. Weight-bearing radiographs demonstrate >50% talonavicular uncoverage and an abnormal talo-first metatarsal angle. Which surgical strategy is most appropriate?

Explanation

This is a Stage IIb adult acquired flatfoot deformity (flexible, >50% talonavicular uncoverage). Management typically requires a FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening to correct the severe forefoot abduction.

Question 32

A 60-year-old diabetic male presents with a red, hot, and swollen right foot. He has bounding pedal pulses and a loss of protective sensation. Laboratory tests show normal WBC and a mildly elevated ESR. Radiographs show fragmentation of the midfoot joints. What is the most appropriate initial management?

Explanation

The clinical presentation is classic for acute Charcot neuroarthropathy (Eichenholtz stage I). The standard initial treatment is offloading via total contact casting to prevent further deformity until the acute inflammatory phase resolves.

Question 33

A 22-year-old track athlete complains of vague, chronic dorsal midfoot pain that worsens with sprinting. Plain radiographs are negative, but an MRI reveals a high T2 signal and an incomplete fracture line in the central third of the navicular. What is the recommended initial management?

Explanation

Tarsal navicular stress fractures carry a high risk of nonunion due to a relatively avascular central third. Initial conservative management for incomplete fractures requires strict non-weight-bearing in a cast for 6 to 8 weeks.

Question 34

A 48-year-old man presents with chronic insertional Achilles tendinopathy and a large Haglund deformity. Non-operative management has failed. During surgery, aggressive debridement of the calcific tendinosis requires removal of 60% of the Achilles tendon insertion. What additional procedure is indicated?

Explanation

When >50% of the Achilles tendon insertion is debrided during surgery for insertional Achilles tendinopathy, an FHL tendon transfer is indicated to augment plantarflexion strength and revascularize the repair site.

Question 35

A patient with Charcot-Marie-Tooth disease presents with a symptomatic cavovarus foot. A Coleman block test is performed by placing the patient's heel and lateral forefoot on a block while allowing the first metatarsal to drop. The hindfoot varus corrects to neutral. What does this test signify?

Explanation

The Coleman block test distinguishes between fixed and flexible hindfoot varus. If the varus corrects when the first metatarsal is allowed to drop, the deformity is forefoot-driven (flexible hindfoot), and a dorsiflexion osteotomy of the 1st metatarsal is indicated.

Question 36

A 62-year-old male is considering surgical options for end-stage ankle osteoarthritis. Which of the following is an absolute contraindication to a total ankle arthroplasty (TAA)?

Explanation

Absolute contraindications to total ankle arthroplasty include active infection, severe peripheral neuropathy/Charcot neuroarthropathy, absent limb sensation, and avascular necrosis of >50% of the talar body.

Question 37

A 32-year-old construction worker sustained a displaced, intra-articular calcaneus fracture.

You are planning an open reduction and internal fixation via an extensile lateral approach. Which of the following factors poses the highest risk for postoperative wound edge necrosis and infection?

Explanation

Current tobacco smoking significantly increases the risk of wound complications, including skin slough and deep infection, particularly with the extensile lateral approach for calcaneus fractures.

Question 38

A 50-year-old female presents with dorsal midfoot pain localized to the first metatarsophalangeal (MTP) joint. Radiographs show mild to moderate joint space narrowing with a large dorsal osteophyte, consistent with Grade 2 hallux rigidus. She has failed conservative management. What is the most appropriate surgical treatment?

Explanation

For early to moderate hallux rigidus (Coughlin and Shurnas Grades 1 and 2) with dorsal impingement and preserved plantar cartilage, dorsal cheilectomy is the surgical treatment of choice and preserves joint motion.

Question 39

A 25-year-old skier presents with lateral ankle pain and swelling after catching an edge, forcibly dorsiflexing and everting the foot. He reports a snapping sensation posterior to the lateral malleolus. Radiographs reveal a small cortical avulsion fracture off the posterolateral margin of the distal fibula. What is the most likely diagnosis?

Explanation

The 'fleck sign' (avulsion fracture off the posterolateral fibula) is pathognomonic for a superior peroneal retinaculum injury, resulting in subluxation or dislocation of the peroneal tendons.

Question 40

A collegiate football player sustains a high-energy hyperdorsiflexion injury to his great toe. MRI reveals a complete rupture of the plantar plate at the first metatarsophalangeal joint with proximal retraction of the sesamoids. What is the most appropriate management?

Explanation

This describes a Grade 3 turf toe injury with sesamoid retraction. Given the high demands of the athlete and complete instability of the complex, surgical repair of the plantar plate is indicated.

Question 41

A 30-year-old male presents with persistent medial ankle pain 6 months after an inversion injury. An MRI shows an osteochondral lesion of the medial talar dome measuring 1.1 cm in diameter, without subchondral cysts. What is the most appropriate primary surgical intervention?

Explanation

For symptomatic osteochondral lesions of the talus (OLTs) smaller than 1.5 cm^2 that fail conservative treatment, arthroscopic bone marrow stimulation (microfracture or drilling) is the standard initial surgical treatment.

Question 42

A 45-year-old female presents with burning pain and numbness on the plantar aspect of her foot. Symptoms are worse with prolonged standing. She has a positive Tinel's sign posterior to the medial malleolus. What imaging modality is most useful to identify the etiology in this patient?

Explanation

The patient has tarsal tunnel syndrome. Because up to 80% of tarsal tunnel syndrome cases are caused by a space-occupying lesion (e.g., ganglion cyst, lipoma, or varicosities), an MRI is the most useful imaging modality.

Question 43

A 40-year-old male falls from a ladder and sustains a severely displaced intra-articular distal tibia (Pilon) fracture with severe soft tissue swelling and fracture blisters. What is the most widely accepted initial management strategy?

Explanation

Due to high complication rates associated with early surgery through compromised soft tissues, high-energy Pilon fractures are best managed with a staged protocol: initial spanning external fixation followed by delayed ORIF (typically at 10-21 days).

Question 44

A 24-year-old male sustains a pronation-external rotation ankle injury with a frank syndesmotic diastasis. He undergoes stabilization with a flexible suture-button device instead of traditional syndesmotic screws. Which of the following is an expected advantage of the suture-button device?

Explanation

Dynamic (suture-button) fixation for syndesmotic injuries demonstrates similar functional outcomes to rigid screw fixation but is associated with significantly lower rates of symptomatic hardware requiring secondary removal.

Question 45

A 55-year-old female presents with a 6-month history of a 'pebble in my shoe' sensation and burning pain in her 3rd web space. Compression of the forefoot produces a palpable click and exacerbates the pain. She has not improved after shoe modifications and corticosteroid injections. If surgery is performed, which of the following is critical to prevent recurrence?

Explanation

For a Morton's neuroma that fails conservative care, operative excision is indicated. It is critical to resect the nerve well proximal to the deep transverse metatarsal ligament to ensure the cut nerve stump retracts into soft muscle tissue, avoiding a painful stump neuroma.

Question 46

A 55-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. She is able to perform a single heel rise, though it is painful and weak. On examination, she has a positive too-many-toes sign and flexible hindfoot valgus. Forefoot abduction is present and uncovers >40% of the talar head. What is the most appropriate surgical management?

Explanation

Stage IIb posterior tibial tendon dysfunction (PTTD) is characterized by a flexible deformity with significant forefoot abduction (>40% talonavicular uncoverage). This requires a lateral column lengthening in addition to FDL transfer and medial displacement calcaneal osteotomy.

Question 47

A 45-year-old roofer sustained a closed, displaced intra-articular calcaneus fracture treated with ORIF via an extensile lateral approach 1 year ago. He complains of lateral ankle pain with walking. Examination reveals tenderness inferior to the lateral malleolus and pain with resisted foot eversion. Subtalar motion is well-preserved and painless. What is the most likely cause of his current symptoms?

Explanation

Lateral wall blowout or prominent hardware post-calcaneus fracture ORIF can cause subfibular impingement of the peroneal tendons. This typically presents with lateral ankle pain and pain on resisted eversion, while painless subtalar motion rules against subtalar arthritis.

Question 48

A 32-year-old recreational athlete sustains an acute Achilles tendon rupture and opts for nonoperative management. Which of the following rehabilitation protocols has been shown to result in re-rupture rates most comparable to surgical repair?

Explanation

Functional rehabilitation with early weight-bearing in a functional orthosis decreases re-rupture rates in nonoperatively managed Achilles tendon ruptures. This approach yields outcomes and re-rupture rates comparable to operative management without the surgical risks.

Question 49

A 24-year-old collegiate football player sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial and middle cuneiforms.

What is the most appropriate surgical management?

Explanation

Purely ligamentous Lisfranc injuries have a high rate of hardware failure and loss of reduction with ORIF. Primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) is preferred for athletes to ensure a more reliable return to play and prevent post-traumatic arthritis.

Question 50

A 30-year-old man presents with a Hawkins type III talar neck fracture following a motor vehicle collision. Which of the following is the most significant predictor of avascular necrosis (AVN) of the talar body in this patient?

Explanation

The risk of AVN in talar neck fractures is most directly correlated with the degree of initial displacement and disruption of the blood supply. This severity is categorized by the Hawkins classification system; timing of fixation does not significantly alter the AVN rate.

Question 51

A 19-year-old track athlete complains of vague dorsal midfoot pain that worsens with sprinting. Radiographs are negative. MRI reveals a stress fracture of the tarsal navicular in the central third, without a completed fracture line. What is the most appropriate initial management?

Explanation

The central third of the tarsal navicular is a watershed vascular area making it highly prone to nonunion. Incomplete stress fractures should be treated strictly non-weight-bearing in a cast for 6-8 weeks.

Question 52

A 21-year-old professional basketball player sustains an acute, non-displaced fracture of the base of the fifth metatarsal at the metaphyseal-diaphyseal junction. He wishes to return to play as soon as possible. What is the recommended treatment?

Explanation

A true Jones fracture occurs at the metaphyseal-diaphyseal junction where blood supply is tenuous. In elite athletes, intramedullary screw fixation is recommended to minimize nonunion risk and allow for an accelerated return to play.

Question 53

Which of the following is true regarding the operative versus nonoperative management of acute Achilles tendon ruptures according to high-level clinical evidence?

Explanation

Recent level 1 evidence shows no significant difference in re-rupture rates between operative and nonoperative treatment when a strict early functional rehabilitation protocol is employed. Operative treatment carries a slightly higher risk of soft-tissue complications and nerve injury.

Question 54

A 25-year-old sustains a closed, high-energy hyperdorsiflexion injury to the foot. Radiographs show a talar neck fracture with subtalar subluxation, but the ankle joint remains perfectly intact.

What is the Hawkins classification and approximate risk of avascular necrosis (AVN) for this fracture?

Explanation

This is a Hawkins Type II fracture, defined by a talar neck fracture with subluxation or dislocation of the subtalar joint while the ankle joint remains intact. The risk of AVN for a Hawkins II fracture is approximately 20% to 50%.

Question 55

A 22-year-old collegiate football player sustains a pure ligamentous Lisfranc injury. Weight-bearing radiographs show 3 mm of widening between the medial cuneiform and the base of the second metatarsal. What is the most appropriate surgical management for this athlete?

Explanation

Primary arthrodesis is the preferred surgical treatment over ORIF for purely ligamentous Lisfranc injuries, particularly in athletes. Arthrodesis yields better mid- to long-term functional outcomes and significantly lowers the rates of hardware failure and revision surgery.

Question 56

A 55-year-old man presents with dorsal midfoot pain during gait. Examination shows a painful block at 20 degrees of passive first MTP dorsiflexion, but preserved and painless plantarflexion.

Radiographs reveal dorsal osteophytes with joint space narrowing limited to the dorsal half of the joint. What is the most appropriate surgical treatment?

Explanation

The patient has Grade II hallux rigidus characterized by preserved plantarflexion and pain primarily at the extremes of dorsiflexion due to impingement. Cheilectomy (resection of dorsal osteophytes and the dorsal third of the metatarsal head) has a high success rate for this specific stage.

Question 57

A 25-year-old male sustains a high-energy motor vehicle collision resulting in a displaced talar neck fracture with subluxation of the subtalar joint. The tibiotalar joint remains concentrically reduced. According to the Hawkins classification, what is the estimated risk of avascular necrosis (AVN) of the talar body?

Explanation

A Hawkins Type II fracture involves a talar neck fracture with subtalar subluxation or dislocation, carrying an AVN risk of 20-50%. Type I has a <10% risk, Type III has a >75% risk, and Type IV approaches 100%.

Question 58

A 65-year-old female presents with severe, activity-limiting post-traumatic ankle osteoarthritis. Radiographs demonstrate bone-on-bone tibiotalar arthritis and moderate subtalar osteoarthritis. She has a well-aligned hindfoot. What is the primary advantage of total ankle arthroplasty (TAA) over ankle arthrodesis in this specific patient?

Explanation

TAA is favored in patients with adjacent joint arthritis (like subtalar OA) because it preserves tibiotalar motion. This reduces compensatory stresses on already degenerative neighboring joints, whereas arthrodesis accelerates adjacent arthritic progression.

Question 59

A 55-year-old male complains of progressive right big toe pain. Examination reveals a rigid first metatarsophalangeal (MTP) joint with less than 10 degrees of dorsiflexion and severe pain in the midrange of motion. Radiographs show joint space obliteration and large dorsal osteophytes (Coughlin and Shurnas Grade 3). What is the most reliable surgical option for long-term pain relief?

Explanation

First MTP arthrodesis is the gold standard for advanced hallux rigidus (Grade 3 and 4) presenting with pain in the midrange of motion. Cheilectomy is indicated for early stages where pain is primarily at terminal dorsiflexion.

Question 60

A 48-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. Examination reveals she is unable to perform a single-limb heel rise. Weight-bearing radiographs demonstrate uncovering of the talar head of 45% on the AP view (forefoot abduction) and plantarflexion of the talus on the lateral view. Which of the following surgical strategies is most appropriate for this Stage IIb deformity?

Explanation

Stage IIb adult acquired flatfoot deformity includes flexible hindfoot valgus with significant forefoot abduction (>30% talonavicular uncoverage). This requires a lateral column lengthening (e.g., Evans osteotomy) in addition to FDL transfer and MDCO.

Question 61

A 24-year-old competitive skier presents with lateral ankle pain and a snapping sensation behind the lateral malleolus after catching an edge. On examination, resisted eversion with the ankle in dorsiflexion reproduces the snapping. Which anatomic structure is most likely attenuated or torn?

Explanation

The superior peroneal retinaculum (SPR) is the primary restraint to subluxation of the peroneal tendons. Injury to the SPR allows the tendons to subluxate or dislocate anteriorly over the fibula during active dorsiflexion and eversion.

Question 62

A 58-year-old man with poorly controlled type 2 diabetes presents with an acutely swollen, erythematous, and warm left foot. He denies trauma. Radiographs reveal no fractures or subluxations. Serum inflammatory markers are mildly elevated, but he is afebrile. What is the most appropriate initial management?

Explanation

This patient presents with Eichenholtz stage 0 acute Charcot neuroarthropathy. The gold standard treatment to prevent progressive deformity and joint destruction is immediate immobilization with a total contact cast and offloading.

Question 63

A 22-year-old man presents with progressive bilateral high arched feet and frequent lateral ankle sprains. A Coleman block test is performed, which completely corrects the hindfoot varus alignment. This finding indicates that the primary driver of his hindfoot deformity is:

Explanation

The Coleman block test evaluates hindfoot flexibility in a cavovarus foot. If the hindfoot corrects to neutral or valgus when the first ray is offloaded, the deformity is primarily driven by a rigid plantarflexed first ray caused by peroneus longus overpull.

Question 64

A 22-year-old collegiate football player complains of midfoot pain after an axial load was applied to his plantarflexed foot. Plain radiographs are normal, but a weight-bearing CT scan demonstrates a 2.5 mm diastasis between the first and second metatarsal bases. What is the most appropriate definitive management?

Explanation

Subtle Lisfranc injuries in high-level athletes with greater than 2 mm of diastasis are best treated surgically with ORIF or dorsal bridge plating. This restores anatomic alignment and stability, whereas primary arthrodesis is generally reserved for purely ligamentous injuries in older or non-athletic patients, or delayed presentations.

Question 65

A 19-year-old college soccer player presents with an acute 5th metatarsal base fracture located at the metaphyseal-diaphyseal junction. To minimize the risk of nonunion and expedite return to play, what is the most appropriate management?

Explanation

Zone 2 (Jones) fractures in elite or competitive athletes are best treated with early intramedullary screw fixation. Operative treatment significantly decreases the rate of delayed union or nonunion and allows for a much faster return to play compared to non-operative casting.

Question 66

A 34-year-old man sustains a displaced talar neck fracture with subluxation of the subtalar joint (Hawkins Type II). Which of the following radiographic findings at 8 weeks post-injury indicates a favorable prognosis regarding osteonecrosis of the talus?

Explanation

The Hawkins sign, which is subchondral radiolucency of the talar dome seen on the AP or mortise view at 6 to 8 weeks, indicates intact vascularity and active bone resorption. Its presence is a highly reliable predictor that avascular necrosis (AVN) will not occur.

Question 67

A 45-year-old woman complains of medial eminence pain. Radiographs demonstrate a hallux valgus angle of 45 degrees and an intermetatarsal angle of 18 degrees.

Clinical examination reveals hypermobility at the first tarsometatarsal (TMT) joint. Which procedure is most appropriate?

Explanation

A first TMT arthrodesis (Lapidus procedure) is indicated for patients with a severe hallux valgus deformity (IMA > 15 degrees) combined with first ray hypermobility. It definitively corrects the deformity while stabilizing the incompetent medial column.

Question 68

A 55-year-old male with poorly controlled diabetes mellitus presents with a red, hot, swollen foot without systemic signs of infection. Radiographs show periarticular debris, fragmentation, and subluxation of the midfoot. MRI is negative for osteomyelitis. What is the most appropriate initial management?

Explanation

This clinical picture represents the acute phase (Eichenholtz Stage I - fragmentation) of Charcot neuroarthropathy. The gold standard for initial management is strict immobilization using a total contact cast to prevent further structural collapse until the acute inflammatory phase resolves.

Question 69

A 28-year-old man with a history of frequent ankle sprains presents with bilateral foot deformities. A Coleman block test is performed, and the hindfoot varus corrects to neutral when the first metatarsal drops off the block.

What does this clinical finding dictate regarding surgical correction?

Explanation

The Coleman block test distinguishes a flexible forefoot-driven hindfoot varus from a rigid hindfoot varus. If the varus corrects when the first ray is allowed to drop off the block, the primary deforming force is a plantarflexed first ray, which should be addressed with a first metatarsal dorsiflexion osteotomy.

Question 70

A 48-year-old woman reports medial ankle pain and the inability to perform a single-leg heel rise. Examination reveals a flexible flatfoot with a positive "too many toes" sign. Nonoperative management has failed. What is the most appropriate surgical intervention?

Explanation

This patient has a Stage II (flexible) adult acquired flatfoot deformity secondary to posterior tibial tendon dysfunction. The standard joint-sparing surgical treatment is an FDL transfer to the navicular combined with a medializing calcaneal osteotomy.

Question 71

A 65-year-old active man with severe post-traumatic ankle arthritis desires surgical intervention after failing conservative care.

He has minimal coronal plane deformity. Which of the following is considered an absolute contraindication to total ankle arthroplasty (TAA)?

Explanation

Active Charcot neuroarthropathy, active infection, and severe avascular necrosis of the talus with poor bone stock are absolute contraindications for a total ankle arthroplasty. Concomitant subtalar arthritis is actually a relative indication for TAA to preserve the remaining hindfoot motion.

Question 72

A 14-year-old boy presents with a history of frequent ankle sprains and a rigid, painful flatfoot. Oblique radiographs of the foot demonstrate an "anteater nose" sign.

Which of the following is the most likely diagnosis?

Explanation

The "anteater sign" is an elongated anterior process of the calcaneus seen on a 45-degree oblique radiograph, which is pathognomonic for a calcaneonavicular coalition. Talocalcaneal coalitions are typically identified by a "C-sign" on the lateral view or middle facet irregularity on CT.

Question 73

A 52-year-old runner complains of chronic posterior heel pain. Imaging reveals insertional Achilles tendinopathy with a large Haglund deformity and 30% degeneration of the distal tendon. Nonoperative management has failed over the last 8 months. Which surgical approach is most appropriate?

Explanation

Insertional Achilles tendinopathy with a prominent Haglund deformity is surgically treated via a central tendon splitting approach, retrocalcaneal exostectomy, and debridement. Direct repair/reattachment is indicated when less than 50% of the tendon is compromised, whereas an FHL transfer is added for defects >50%.

Question 74

A 24-year-old wide receiver sustains a severe hyperextension injury to his first MTP joint. MRI reveals a complete rupture of the plantar plate with proximal retraction of the sesamoids. Which of the following best establishes the indication for operative intervention in this scenario?

Explanation

Grade 3 turf toe injuries involve complete tearing of the plantar plate-sesamoid complex with proximal migration of the sesamoids. Surgical repair is indicated in high-level athletes to restore push-off strength and prevent chronic instability.

Question 75

A 50-year-old man presents with pain and stiffness in the great toe. Radiographs show dorsal joint space narrowing and a prominent dorsal osteophyte (Coughlin and Shurnas Grade 2 hallux rigidus). The plantar joint space is relatively preserved. What is the preferred surgical option after failing conservative care?

Explanation

Cheilectomy, which entails excision of the dorsal osteophyte and the dorsal 30% of the metatarsal head, is the gold standard surgical treatment for early-to-moderate hallux rigidus (Grades 1 and 2). Arthrodesis is reserved for end-stage diffuse joint space loss (Grades 3 and 4).

Question 76

A 42-year-old woman complains of a "pebble in her shoe" sensation and burning pain radiating to the third and fourth toes. Examination reveals a painful, palpable click when the metatarsal heads are squeezed together while applying plantar pressure to the webspace. What is the most appropriate initial management?

Explanation

The clinical presentation is classic for a Morton's neuroma in the 3rd webspace, complete with a positive Mulder's click. First-line management should always be nonoperative, primarily utilizing shoe wear modifications (wide toe-box) and a metatarsal pad, prior to considering surgical excision.

Question 77

A 45-year-old male presents with acute posterior ankle pain after playing tennis. Clinical exam reveals a positive Thompson test. An MRI is obtained as seen in Figure 17.

Which of the following physical examination findings is most specific for this condition?

Explanation

A positive Matles test (increased resting ankle dorsiflexion when prone with knees flexed 90 degrees) and positive Thompson test are highly specific for Achilles tendon ruptures. Active plantarflexion may remain intact due to the recruitment of accessory flexors like the tibialis posterior.

Question 78

A 22-year-old collegiate football player sustains a hyperextension injury to his great toe. He has diffuse swelling, ecchymosis, and inability to bear weight. MRI shows a complete tear of the plantar plate with proximal retraction of the sesamoids. What is the most appropriate management?

Explanation

This is a Grade 3 Turf Toe injury with complete disruption of the plantar plate and proximal sesamoid retraction. Surgical repair is indicated in high-level athletes to restore push-off strength and prevent chronic instability.

Question 79

A 56-year-old diabetic patient presents with a red, hot, swollen foot without systemic signs of infection. Radiographs show fragmentation of the navicular and cuneiforms with subluxation of the midfoot. Which Eichenholtz stage does this represent, and what is the best initial management?

Explanation

Eichenholtz Stage 1 (development/fragmentation) is characterized by acute inflammation, osteopenia, fragmentation, and subluxation. The gold standard initial treatment for acute Charcot arthropathy is offloading with a total contact cast.

Question 80

A 30-year-old equestrian presents after falling from her horse with her foot caught in the stirrup. She has severe midfoot pain and plantar ecchymosis. Radiographs are shown in Figure 43.

The primary deforming force causing lateral displacement of the lesser metatarsals is mediated by which structure?

Explanation

In a Lisfranc injury, lateral displacement of the lesser metatarsal bases is primarily driven by the unopposed pull of the peroneus brevis. It inserts on the base of the 5th metatarsal and acts as the main deforming force when the midfoot ligaments are disrupted.

Question 81

A 38-year-old roofer sustains a displaced intra-articular calcaneus fracture. An extensile lateral approach is planned. Which of the following is the most significant risk factor for wound complications following this procedure?

Explanation

Smoking is the single greatest modifiable risk factor for wound edge necrosis and infection following an extensile lateral approach for calcaneus fractures. Surgery should generally be delayed 10-14 days until the "wrinkle sign" appears to decrease swelling and complication rates.

Question 82

A 62-year-old woman complains of progressive medial foot pain and flattening of her arch. On examination, she has a "too many toes" sign and cannot perform a single-limb heel rise. Radiographs demonstrate a flexible pes planus deformity without degenerative changes in the subtalar or talonavicular joints. What is the most appropriate surgical treatment?

Explanation

Stage II adult-acquired flatfoot deformity involves a flexible hindfoot without arthritis. Appropriate surgical management includes a flexor digitorum longus (FDL) transfer to replace the diseased posterior tibial tendon, combined with a medial displacement calcaneal osteotomy to correct the valgus.

Question 83

A 24-year-old hockey player sustains an external rotation injury to his right ankle. Figure 45 demonstrates his intraoperative stress radiograph after fibular fixation.

Which ligament provides the greatest resistance to lateral displacement of the fibula in the distal tibiofibular syndesmosis?

Explanation

The posterior inferior tibiofibular ligament (PITFL) is the strongest component of the syndesmotic complex. Biomechanical studies show it contributes approximately 42% of the resistance to lateral fibular displacement.

Question 84

A 31-year-old male sustains a Hawkins type III talar neck fracture following a motor vehicle collision. Which of the following vascular supplies is completely disrupted in this injury pattern?

Explanation

A Hawkins type III fracture involves subluxation or dislocation of both the subtalar and tibiotalar joints. This typically disrupts all three major sources of blood supply to the talar body, resulting in a nearly 100% risk of avascular necrosis.

Question 85

A 19-year-old basketball player presents with chronic lateral foot pain. Radiographs reveal a fracture at the proximal diaphyseal junction of the 5th metatarsal, distal to the 4th-5th intermetatarsal articulation, with cortical thickening and a narrow medullary canal. What is the most appropriate definitive management for optimal return to sport?

Explanation

This represents a Zone 3 stress fracture of the proximal 5th metatarsal diaphyseal junction. In high-level athletes, intramedullary screw fixation is recommended to minimize nonunion risk and expedite return to play.

Question 86

A 55-year-old man presents with dorsal midfoot pain and limited great toe dorsiflexion. Figure 46 demonstrates his standing lateral radiograph.

He has failed orthotics and NSAIDs. He wishes to maintain joint motion. What is the most appropriate surgical intervention?

Explanation

For early to moderate hallux rigidus (Coughlin and Shurnas grades 1 or 2) in patients wishing to preserve motion, a dorsal cheilectomy is the procedure of choice. It involves resection of the dorsal osteophyte and up to 30% of the dorsal metatarsal head.

Question 87

A 28-year-old female presents with deep ankle pain and catching 1 year after a severe ankle sprain. MRI demonstrates a 1.2 cm osteochondral lesion on the posteromedial talar dome with intact overlying cartilage. What is the most appropriate initial surgical approach?

Explanation

For an intact osteochondral lesion of the talus (especially with underlying subchondral cysts), retrograde drilling promotes revascularization and healing. This technique avoids breaching the intact overlying articular cartilage.

Question 88

A 40-year-old woman complains of burning pain in the plantar aspect of her forefoot, radiating into the third and fourth toes. Symptoms worsen with tight shoes. A Mulder's click is present. If nonoperative management fails, excision of the neuroma is planned. Which structure must be transected to adequately expose and resect the neuroma from a dorsal approach?

Explanation

Morton's neuroma most commonly occurs in the third web space. A dorsal surgical approach requires transection of the deep transverse metatarsal ligament to access the neurovascular bundle, which lies plantar to it.

Question 89

A 16-year-old female ballet dancer presents with pain and swelling over the dorsal aspect of her second metatarsophalangeal joint. Radiographs reveal flattening and sclerosis of the second metatarsal head. Which of the following describes the underlying pathophysiology?

Explanation

Freiberg's infraction is an osteochondrosis or avascular necrosis of the metatarsal head, most commonly affecting the second metatarsal in adolescent females. Repetitive microtrauma is believed to compromise the fragile blood supply to the epiphysis.

Question 90

A 52-year-old man presents with burning pain and tingling over the plantar aspect of his foot that worsens at night. Tinel's sign is positive posterior to the medial malleolus. EMG confirms entrapment of the posterior tibial nerve. Which structure forms the roof of the anatomical space where this compression occurs?

Explanation

Tarsal tunnel syndrome is a compression neuropathy of the posterior tibial nerve. The tarsal tunnel is bordered medially by the flexor retinaculum (lanciniate ligament), laterally by the calcaneus and talus, and anteriorly by the medial malleolus.

Question 91

A 65-year-old man with end-stage post-traumatic ankle osteoarthritis desires surgical intervention. Which of the following is considered an absolute contraindication to total ankle arthroplasty?

Explanation

Active deep infection, active Charcot arthropathy, severe uncorrectable malalignment, and inadequate soft tissue coverage are absolute contraindications to total ankle arthroplasty. Concomitant hindfoot arthritis is actually a relative indication for TAA to preserve remaining joint motion.

Question 92

A 21-year-old male cross-country runner presents with vague midfoot pain. Plain radiographs are normal, but an MRI demonstrates a stress fracture in the central third of the navicular body without displacement. What is the recommended management?

Explanation

Nondisplaced navicular stress fractures have a high risk of nonunion due to the avascular zone in the central third of the bone. The standard of care is strict non-weight-bearing cast immobilization for 6-8 weeks.

Question 93

A 14-year-old boy presents with progressive bilateral foot deformities, characterized by high arches, claw toes, and a "peek-a-boo" heel sign. Neurological exam reveals absent ankle reflexes and decreased sensation in a stocking distribution. What is the primary muscle imbalance driving the hindfoot varus in this condition?

Explanation

In Charcot-Marie-Tooth (CMT) disease, the hindfoot varus is primarily driven by a strong, preserved tibialis posterior overpowering a weak peroneus brevis. The forefoot plantarflexion (cavus) is driven by a strong peroneus longus overpowering a weak tibialis anterior.

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

Orthopedic Foot & Ankle MCQs (Part 4): ABOS & AAOS Board Review 2026

Key Takeaway

Orthopedic Foot & Ankle MCQs (Part 4): ABOS & AAOS Board Review 2026

Chapter Index