Orthopedic Foot And Ank Review | Dr Hutaif Foot & Ankle -...

Question 1

A 45-year-old female presents with a painful bunion. Radiographs demonstrate a hallux valgus angle (HVA) of 35 degrees and an intermetatarsal angle (IMA) of 16 degrees. Clinical examination reveals profound hypermobility at the first tarsometatarsal (TMT) joint. What is the most appropriate surgical treatment?

Explanation

The Lapidus procedure (first TMT joint arthrodesis) is indicated for moderate to severe hallux valgus associated with first TMT joint hypermobility. It stabilizes the medial column and corrects the IMA effectively.

Question 2

A 60-year-old male complains of severe pain and stiffness in his right big toe. Examination reveals significantly limited dorsiflexion and pain at the extremes of motion. Radiographs demonstrate large dorsal osteophytes and near-complete joint space narrowing of the first MTP joint, consistent with Grade 3 hallux rigidus. Which of the following is considered the gold standard surgical treatment?

Explanation

First MTP joint arthrodesis is the gold standard for severe (Grade 3 or 4) hallux rigidus. It provides excellent, reliable pain relief and maintains functional outcomes for daily activities and moderate exercise.

Question 3

When comparing early functional rehabilitation protocols to traditional cast immobilization for acute Achilles tendon ruptures treated nonoperatively, which of the following statements is most accurate?

Explanation

High-level evidence demonstrates that utilizing early functional rehabilitation protocols for nonoperatively managed Achilles tendon ruptures reduces re-rupture rates to levels equivalent to operative treatment, while avoiding surgical complications.

Question 4

A 55-year-old female presents with a progressive flatfoot deformity. She is unable to perform a single-limb heel rise on the affected side. Radiographs demonstrate talonavicular uncoverage of 40% and a Meary's angle of 15 degrees apex plantar. The hindfoot deformity is correctable passively. Which stage of posterior tibial tendon dysfunction (PTTD) does this represent?

Explanation

Stage IIb PTTD involves a flexible flatfoot with significant forefoot abduction (talonavicular uncoverage >30%). Stage IIa is flexible without significant forefoot abduction. Stage III indicates a rigid hindfoot deformity, and Stage IV involves ankle valgus tilt or arthritis.

Question 5

A 22-year-old athlete requires surgical intervention for chronic lateral ankle instability after failing 6 months of physical therapy. A modified Broström procedure with a Gould modification is performed. What specific structure is mobilized and advanced to augment the primary ligament repair in the Gould modification?

Explanation

The Gould modification of the Broström procedure involves the proximal advancement of the lateral portion of the inferior extensor retinaculum over the repaired anterior talofibular and calcaneofibular ligaments to reinforce the repair and limit inversion.

Question 6

A 30-year-old male has an osteochondral lesion of the medial talar dome measuring 1.2 cm x 1.0 cm. He has failed 6 months of conservative management. What is the most appropriate initial surgical treatment?

Explanation

Arthroscopic bone marrow stimulation (microfracture) is the recommended primary surgical treatment for osteochondral lesions of the talus that are <1.5 cm^2 in area. Procedures like OATS or ACI are reserved for larger lesions, cystic lesions, or lesions that have failed primary microfracture.

Question 7

In the evaluation of an intra-articular calcaneus fracture, the Sanders classification is utilized. What specific anatomical finding defines a Sanders Type III fracture?

Explanation

The Sanders classification is based on coronal CT images of the posterior facet. Type I: non-displaced. Type II: 1 fracture line (2 articular fragments). Type III: 2 fracture lines (3 articular fragments). Type IV: highly comminuted (4 or more fragments).

Question 8

A patient sustained a Hawkins Type III talar neck fracture following a high-energy motor vehicle accident. What does this classification imply regarding the displacement of the talus?

Explanation

The Hawkins classification describes talar neck fractures. Type I is undisplaced. Type II involves subtalar subluxation or dislocation. Type III involves dislocation of both the subtalar and tibiotalar joints. Type IV involves dislocation of the subtalar, tibiotalar, and talonavicular joints.

Question 9

During the radiographic evaluation of a suspected midfoot injury, what finding is considered pathognomonic for a Lisfranc injury?

Explanation

The "fleck sign" represents a bony avulsion of the Lisfranc ligament from the base of the second metatarsal. When present on an AP or oblique radiograph, it is considered pathognomonic for a Lisfranc ligament injury.

Question 10

A 60-year-old diabetic male presents with a warm, swollen, erythematous foot. His pedal pulses are bounding. Radiographs demonstrate periarticular fragmentation, subluxation, and bony debris at the tarsometatarsal joints. Which stage of the Eichenholtz classification does this clinical and radiographic picture represent?

Explanation

Eichenholtz Stage I is the developmental or fragmentation stage of Charcot arthropathy. It is characterized clinically by a hot, swollen foot and radiographically by active bone resorption, fragmentation, joint subluxation, and debris formation.

Question 11

When evaluating a patient with a hindfoot cavovarus deformity, the Coleman block test is performed. If the hindfoot varus corrects to neutral when the first metatarsal is allowed to drop off the block, what is the primary biomechanical driver of the varus deformity?

Explanation

The Coleman block test evaluates hindfoot flexibility in a cavovarus foot. Allowing the first ray to drop off the block removes the forefoot pronation effect. If the hindfoot varus corrects, the deformity is flexible and primarily driven by a rigidly plantarflexed first ray.

Question 12

A 24-year-old elite collegiate basketball player suffers a Zone 2 proximal fifth metatarsal fracture. To minimize the risk of nonunion and expedite his return to play, what is the recommended treatment?

Explanation

Zone 2 fractures (Jones fractures) occur at the metaphyseal-diaphyseal junction, a watershed vascular area prone to nonunion. In elite athletes, early intramedullary screw fixation is highly recommended to reduce the nonunion rate and allow a faster return to competitive play.

Question 13

Surgical release of the plantar fascia for recalcitrant plantar fasciitis involves releasing only the medial one-third to one-half of the fascia. Releasing the entire plantar fascia significantly increases the biomechanical risk of developing which of the following complications?

Explanation

Complete release of the plantar fascia disrupts the windlass mechanism, decreasing arch height. Biomechanically, this transfers significant stress to the lateral column of the foot, frequently leading to iatrogenic lateral column overload, lateral foot pain, and cuboid syndrome.

Question 14

A patient is diagnosed with a Morton's neuroma based on a positive Mulder's click and burning forefoot pain. Anatomically, which intermetatarsal web space is most commonly affected by this condition?

Explanation

Morton's neuroma is a compressive perineural fibrosis of the common plantar digital nerve. It most frequently occurs in the third intermetatarsal web space, followed by the second web space.

Question 15

In the context of Tarsal Tunnel Syndrome, compression of the tibial nerve occurs deep to the flexor retinaculum. The first branch of the lateral plantar nerve, which can become entrapped and cause symptoms mimicking severe chronic heel pain, is anatomically known as:

Explanation

The first branch of the lateral plantar nerve is commonly referred to as Baxter's nerve. It courses anterior to the medial calcaneal tuberosity and deep to the abductor hallucis. Entrapment here can cause chronic heel pain that mimics or coexists with plantar fasciitis.

Question 16

A 45-year-old male presents with posterior heel pain. MRI confirms severe insertional Achilles tendinosis with a Haglund's deformity. Surgical debridement is planned. If the debridement requires detachment of greater than 50% of the Achilles tendon insertion, what is the most appropriate adjunct procedure?

Explanation

When surgical debridement for insertional Achilles tendinopathy requires detachment of >50% of the tendon insertion to remove the diseased tissue and bone spur, an FHL tendon transfer is indicated to augment plantarflexion power and provide a well-vascularized tissue bed for healing.

Question 17

During the operative fixation of a pronation-external rotation ankle fracture, the syndesmosis is evaluated fluoroscopically. Which radiographic parameter on a standard AP or mortise view is the most reliable indicator of syndesmotic widening?

Explanation

A tibiofibular clear space of greater than 5mm, measured 1cm proximal to the joint line on either an AP or mortise view, is the most reliable and rotationally independent radiographic indicator of syndesmotic injury.

Question 18

When managing a highly comminuted distal tibia pilon fracture (AO/OTA 43-C3) with significant soft tissue injury, standard protocol involves a staged approach (spanning external fixation followed by delayed ORIF). What is the primary rationale for this delay?

Explanation

The primary reason for employing a staged protocol in pilon fractures is to allow the massive soft tissue swelling to resolve (often taking 10-21 days). Attempting early definitive ORIF through a compromised soft tissue envelope carries an unacceptably high risk of wound dehiscence and deep infection.

Question 19

A professional wide receiver sustains a severe hyperextension injury to his first MTP joint (Turf Toe). MRI reveals a complete rupture of the plantar plate with proximal retraction of the sesamoid apparatus. What is the most appropriate management?

Explanation

A Grade 3 turf toe injury, characterized by a complete tear of the plantar plate complex and proximal migration of the sesamoids, typically requires surgical repair in high-level athletes to restore the anatomic stability and push-off strength of the first MTP joint.

Question 20

A 20-year-old collegiate dancer presents with localized, recalcitrant pain directly plantar to the first metatarsal head. Imaging demonstrates a fragmented and nonunited tibial sesamoid. After 6 months of failed conservative management, what is the surgical treatment of choice?

Explanation

For a painful, nonunited tibial sesamoid that has failed conservative treatment, isolated excision of the tibial sesamoid is indicated. It is critical to meticulously repair the plantar plate and the abductor hallucis tendon defect to prevent a postoperative iatrogenic hallux valgus deformity.

Question 21

A 60-year-old female presents with progressive flattening of her left foot. Examination reveals a flexible hindfoot valgus and inability to perform a single-limb heel rise. Radiographs show >40% talonavicular uncoverage on the AP view. What procedure is indicated in addition to flexor digitorum longus (FDL) transfer and medializing calcaneal osteotomy to address the specific deformity seen on the AP radiograph?

Explanation

The patient has Stage IIb adult-acquired flatfoot deformity, characterized by significant forefoot abduction, which corresponds to >30-40% talonavicular uncoverage on the AP radiograph. This requires a lateral column lengthening (e.g., Evans osteotomy) in addition to an FDL transfer and medializing calcaneal osteotomy to structurally correct the abduction. A Cotton osteotomy is used to correct residual forefoot supination.

Question 22

A 22-year-old man presents with a right cavovarus foot deformity. On the Coleman block test, the hindfoot varus corrects to neutral when the lateral border of the foot is placed on the block while the first metatarsal is allowed to drop off. What is the primary driver of this patient's hindfoot deformity?

Explanation

The Coleman block test differentiates between a flexible and rigid hindfoot varus in the setting of a cavovarus foot. By allowing the first ray to drop off the block, the test eliminates the effect of the forefoot on the hindfoot. If the hindfoot corrects to neutral, the deformity is flexible and primarily driven by a rigidly plantarflexed first ray (forefoot-driven hindfoot varus).

Question 23

A 25-year-old male athlete presents with deep ankle pain 6 months after an inversion injury. MRI reveals a 1.2 cm^2 osteochondral lesion of the medial talar dome with intact overlying cartilage. He has failed non-operative management. What is the most appropriate next step in treatment?

Explanation

For primary osteochondral lesions of the talus (OCLT) that are < 1.5 cm^2, arthroscopic marrow stimulation (e.g., microfracture or drilling) is the gold standard surgical treatment, providing success rates typically exceeding 80%. OATS or ACI are generally reserved for larger lesions (> 1.5 cm^2), cystic lesions, or secondary lesions that have failed primary marrow stimulation.

Question 24

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs show a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and hypermobility at the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention?

Explanation

The patient has a severe hallux valgus deformity (HVA >40, IMA >13) combined with hypermobility of the first TMT joint. The Lapidus procedure (first TMT arthrodesis) is specifically indicated for hallux valgus associated with first ray hypermobility or first TMT arthritis. It stabilizes the medial column while effectively allowing for correction of large intermetatarsal angles.

Question 25

A 58-year-old man complains of dorsal forefoot pain with push-off during walking. Examination reveals restricted first MTP joint dorsiflexion, with pain at the extremes of motion. Radiographs demonstrate a dorsal osteophyte, joint space narrowing, but preservation of the plantar joint space (Coughlin and Shurnas Grade 2). What is the initial surgical procedure of choice if conservative care fails?

Explanation

Coughlin and Shurnas Grade 2 hallux rigidus involves moderate joint space narrowing, dorsal osteophytes, and pain mainly at the extremes of dorsiflexion. Cheilectomy (removal of the dorsal osteophyte and the dorsal 25-30% of the metatarsal head) is the surgical treatment of choice for early to moderate (Grade 1 and 2) hallux rigidus when conservative measures fail. Arthrodesis is definitively preferred for Grade 3 and 4.

Question 26

A 50-year-old overweight male presents with posterior heel pain. Examination reveals a tender, bulbous enlargement at the Achilles insertion. Radiographs show a large dorsal calcaneal exostosis (Haglund's deformity) and intratendinous calcification. Non-operative management for 6 months has failed. MRI shows tendinosis involving 60% of the tendon width at the insertion. What is the most appropriate surgical management?

Explanation

In insertional Achilles tendinopathy with extensive degeneration (>50% of the tendon width) and a large Haglund's deformity, open debridement and exostectomy are required. Because more than 50% of the tendon must be detached and debrided, augmentation with a Flexor Hallucis Longus (FHL) tendon transfer is indicated to restore plantarflexion strength and provide vascularized tissue to enhance healing.

Question 27

A 28-year-old soccer player sustains a twisting injury to his ankle. Radiographs show a spiral fracture of the proximal third of the fibula. An external rotation stress view shows widening of the medial clear space to 6 mm. Which of the following structures is most likely to be completely disrupted?

Explanation

The scenario describes a Maisonneuve fracture, which involves a proximal fibula fracture associated with a syndesmotic disruption and a medial injury (either a medial malleolus fracture or deltoid ligament rupture). The widened medial clear space on stress views confirms instability due to deltoid ligament rupture, and the force transmission through the interosseous membrane implies disruption of the tibiofibular syndesmosis.

Question 28

A 40-year-old construction worker falls from a ladder, sustaining a closed, displaced intra-articular calcaneus fracture. The primary fracture line on the coronal CT scan divides the posterior facet into two pieces. Which of the following describes a Sanders Type II fracture?

Explanation

The Sanders classification for intra-articular calcaneus fractures is based on the number of fracture lines through the posterior facet on coronal CT slices. Type I is non-displaced. Type II has one fracture line (creating two articular fragments). Type III has two fracture lines (three fragments). Type IV is highly comminuted (four or more fragments).

Question 29

A 30-year-old involved in a motor vehicle collision sustains a Hawkins Type III talar neck fracture. What does this classification imply regarding the displacement and the blood supply to the talar body?

Explanation

The Hawkins classification evaluates talar neck fractures and predicts the risk of avascular necrosis (AVN). Type I: non-displaced (0-10% AVN risk). Type II: subtalar dislocation or subluxation (20-50% AVN risk). Type III: subtalar and tibiotalar dislocation (nearly 100% AVN risk). Type IV (added by Canale): subtalar, tibiotalar, and talonavicular dislocation (also near 100% AVN risk).

Question 30

A 22-year-old offensive lineman sustains an axial load to a plantarflexed foot. Weight-bearing radiographs demonstrate a 3 mm diastasis between the bases of the first and second metatarsals without any visible fractures. What is the recommended definitive treatment for this pure ligamentous injury in a high-level athlete?

Explanation

Purely ligamentous Lisfranc injuries have a high rate of poor outcomes and post-traumatic arthritis when treated with ORIF. Recent literature supports primary arthrodesis of the medial column (first, second, and often third TMT joints) for pure ligamentous injuries, especially in athletes, to facilitate a reliable return to sport and avoid the need for hardware removal and treatment of late arthritis.

Question 31

A 24-year-old professional football player hyperextends his great toe on artificial turf. He has severe pain, 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

The patient has a Grade III turf toe injury (complete tear of the plantar plate/capsule complex) with proximal retraction of the sesamoids. Surgical repair is indicated for Grade III injuries with significant instability, sesamoid retraction, or intra-articular loose bodies. This is particularly true in professional athletes to restore push-off strength and prevent hallux rigidus or clawing.

Question 32

A 60-year-old diabetic patient presents with a warm, swollen, erythematous left foot. Radiographs reveal fragmentation and periarticular debris around the midfoot, with subluxation of the tarsometatarsal joints. Skin is intact. Inflammatory markers are mildly elevated. What is the appropriate initial management?

Explanation

The patient is in the acute fragmentation phase (Eichenholtz stage I) of Charcot arthropathy. The hallmark of initial treatment for acute Charcot is offloading and immobilization, most effectively achieved with a total contact cast. Surgery in the acute inflammatory phase is generally contraindicated due to poor bone quality and high failure rates, unless there is severe impending ulceration or instability that cannot be managed conservatively.

Question 33

A 26-year-old skier presents with a snapping sensation at the posterolateral ankle. Examination reveals the peroneal tendons dislocating anteriorly over the lateral malleolus with resisted dorsiflexion and eversion. Conservative treatment has failed. Surgical exploration reveals a shallow fibular groove and an incompetent superior peroneal retinaculum (SPR). What is the standard surgical procedure?

Explanation

Recurrent peroneal tendon subluxation is caused by incompetence of the superior peroneal retinaculum (SPR), often associated with a shallow fibular retromalleolar groove. The gold standard surgical treatment involves deepening the fibular groove and repairing or tightening (reefing) the SPR over the tendons.

Question 34

A 45-year-old woman complains of sharp, burning pain in the plantar aspect of her forefoot, radiating to the third and fourth toes. Symptoms worsen with tight shoes. A Mulder's click is positive. The most likely diagnosis involves entrapment of a nerve beneath which of the following structures?

Explanation

Morton's neuroma most commonly occurs in the third web space. It is a compressive neuropathy of the common digital nerve as it passes under the deep transverse metatarsal ligament. Treatment options include wide shoe wear, metatarsal pads, steroid injections, and, if conservative measures fail, surgical excision of the neuroma and release of the deep transverse metatarsal ligament.

Question 35

A 14-year-old boy presents with frequent ankle sprains and a rigid flatfoot. Radiographs show a "C-sign" on the lateral view and an irregular subtalar joint. Which type of tarsal coalition does this patient most likely have, and which imaging modality is best to confirm it?

Explanation

A talocalcaneal (subtalar) coalition often presents with a rigid flatfoot and peroneal spasticity. The "C-sign" on a lateral radiograph is formed by the medial outline of the talar dome and the posteroinferior outline of the sustentaculum tali, strongly suggesting a talocalcaneal coalition (most often involving the middle facet). A CT scan is the gold standard for defining the location, extent, and joint involvement of the coalition.

Question 36

A 21-year-old collegiate basketball player sustains a fracture of the fifth metatarsal base. Radiographs show a transverse fracture at the metaphyseal-diaphyseal junction extending into the intermetatarsal (4-5) articulation. This is a Zone 2 injury. To minimize the risk of nonunion and allow early return to play, what is the best treatment?

Explanation

The scenario describes a Jones fracture (Zone 2 fracture of the 5th metatarsal base). Because of the watershed blood supply in this area, these fractures have a high risk of delayed union or nonunion. In a high-level athlete, early intramedullary screw fixation is recommended to decrease nonunion rates and expedite return to play compared to non-operative treatment.

Question 37

A 20-year-old male track athlete complains of vague, aching pain in the dorsal midfoot that is worse with sprinting. Radiographs are negative. An MRI reveals a linear signal abnormality in the central third of the navicular. CT scan confirms an incomplete sagittal fracture. What is the most appropriate initial treatment?

Explanation

Navicular stress fractures typically occur in the relatively avascular central third of the bone. For incomplete or non-displaced fractures, the gold standard initial treatment is strict non-weight-bearing in a cast for 6 weeks. Weight-bearing in a boot leads to unacceptably high rates of delayed union and nonunion. If conservative treatment fails, or if the fracture is displaced, ORIF (usually with screws) is indicated.

Question 38

A 45-year-old active man presents with asymmetric anterior ankle pain. Radiographs demonstrate asymmetric narrowing of the medial ankle joint space with a varus tibial plafond angle. The lateral joint space is preserved. Hindfoot motion is normal. What is the primary rationale for performing a supramalleolar osteotomy in this patient?

Explanation

A supramalleolar osteotomy (SMO) is a joint-preserving procedure indicated for asymmetric ankle arthritis with coronal plane deformity (e.g., varus ankle arthritis). By correcting the tibial deformity, the mechanical axis is shifted away from the worn, arthritic side (medial) toward the side with preserved cartilage (lateral), thereby reducing pain and potentially delaying the need for ankle arthroplasty or arthrodesis.

Question 39

In a high-energy tibial pilon fracture, CT imaging is routinely obtained for preoperative planning. The classic three-fragment pattern involves a medial fragment, a posterior fragment, and an anterolateral fragment. The anterolateral fragment is typically attached to which of the following ligaments?

Explanation

In a classic pilon fracture, the distal tibia breaks into three main fragments based on their ligamentous attachments. The anterolateral (Chaput) fragment remains attached to the fibula via the anterior inferior tibiofibular ligament (AITFL). The posterior (Volkmann) fragment is attached to the PITFL. The medial malleolar fragment is attached to the deltoid ligament.

Question 40

A 55-year-old diabetic male presents with an ulcer under his first metatarsal head and a swollen foot. It is critical to differentiate osteomyelitis from acute Charcot arthropathy. On MRI, which finding is most specific for osteomyelitis over acute Charcot neuroarthropathy?

Explanation

Both acute Charcot arthropathy and osteomyelitis can present with bone marrow edema, soft tissue swelling, and joint effusions on MRI. However, the presence of a sinus tract extending from a skin ulcer down to the bone, or replacement of marrow fat with fluid signal on T1 images near an ulcer (often called the 'ghost sign'), is highly specific for osteomyelitis. Charcot changes are typically periarticular and centered around the midfoot (TMT joints), while osteomyelitis occurs contiguous to an ulcer, often at pressure points like the metatarsal heads.

Question 41

A 55-year-old female presents with medial ankle pain and a progressively flattening arch. She has pain with single-limb heel rise but is able to perform it weakly. Passively, her hindfoot corrects to neutral. What is the most appropriate surgical intervention if conservative management fails?

Explanation

This presentation is consistent with Stage II posterior tibial tendon dysfunction (flexible deformity). Standard surgical treatment includes a soft tissue reconstruction (FDL transfer) combined with an extra-articular bony procedure (medial displacement calcaneal osteotomy) and often a gastroc recession.

Question 42

A 28-year-old male sustains a Hawkins Type III talar neck fracture following a motor vehicle collision. Which of the following best describes the disruption of blood supply and the associated risk of avascular necrosis (AVN)?

Explanation

A Hawkins Type III fracture involves subluxation or dislocation of both the subtalar and tibiotalar joints. This disrupts all three major blood supplies to the talus, leading to a nearly 100% risk of AVN.

Question 43

A 22-year-old football player sustains an axial load to a plantarflexed foot. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the first and second metatarsals. What is the most appropriate definitive management?

Explanation

In a young athlete with an acute, primarily ligamentous or bony Lisfranc injury, open reduction and internal fixation (ORIF) is generally preferred to restore exact anatomy. Primary arthrodesis is often reserved for non-athletes, delayed presentations, or severe intra-articular comminution.

Question 44

A 62-year-old male undergoes surgical debridement for severe insertional Achilles tendinopathy. During the procedure, 60% of the tendon insertion is resected to remove calcifications and degenerative tissue. What is the most appropriate next step in management?

Explanation

When more than 50% of the Achilles tendon insertion requires debridement, augmentation is indicated to prevent catastrophic failure. FHL transfer is the gold standard due to its strength, line of pull, and matched phase of firing.

Question 45

A 19-year-old collegiate basketball 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

Zone II (Jones) fractures have a high rate of nonunion due to watershed blood supply. In elite or competitive athletes, early intramedullary screw fixation is recommended to reduce nonunion risk and expedite safe return to play.

Question 46

A 58-year-old poorly controlled diabetic presents with a red, hot, swollen unilateral foot. Radiographs show periarticular fragmentation and debris at the midfoot. Which of the following tests is most specific for differentiating acute Charcot neuroarthropathy from osteomyelitis?

Explanation

Differentiating acute Charcot from osteomyelitis is challenging. A combined Indium-111 tagged WBC scan and Technetium-99m sulfur colloid bone marrow scan has the highest specificity for diagnosing osteomyelitis in the setting of Charcot arthropathy.

Question 47

A 24-year-old marathon runner presents with vague dorsal midfoot pain. A CT scan confirms an incomplete, non-displaced stress fracture of the tarsal navicular in the sagittal plane. What is the most appropriate initial management?

Explanation

Non-displaced, incomplete navicular stress fractures are initially treated with strict non-weight-bearing in a cast for 6 to 8 weeks. Operative fixation is indicated for displaced fractures or failure of conservative management.

Question 48

A 72-year-old thin female with rheumatoid arthritis and low functional demands presents with severe, bone-on-bone ankle osteoarthritis. She has preserved subtalar and midfoot motion. What is the primary advantage of total ankle arthroplasty (TAA) over ankle arthrodesis in this patient?

Explanation

TAA is an excellent option for older, lower-demand patients, particularly those with inflammatory arthritis. The primary advantage of TAA over arthrodesis is the preservation of tibiotalar motion, which protects the adjacent hindfoot and midfoot joints from accelerated degeneration.

Question 49

A professional football player sustains a hyperdorsiflexion injury to the 1st MTP joint. Clinical examination reveals absent push-off strength and a positive Lachman test of the MTP joint. MRI shows a complete disruption of the plantar plate with proximal retraction of the sesamoids. What is the most appropriate management?

Explanation

This represents a Grade 3 turf toe injury with complete plantar plate disruption and sesamoid retraction. In a professional athlete, primary surgical repair is indicated to restore push-off strength and joint stability.

Question 50

A 16-year-old male presents with bilateral progressive cavovarus feet. Examination shows weak tibialis anterior and peroneus brevis muscles, with a strong peroneus longus and tibialis posterior. A Coleman block test normalizes the hindfoot varus. What is the primary driver of this patient's deformity?

Explanation

Charcot-Marie-Tooth disease causes a classic pattern of muscle imbalance. An overactive peroneus longus plantarflexes the first ray, driving the forefoot into pronation and forcing the hindfoot into a compensatory flexible varus alignment (corrects on Coleman block test).

Question 51

A 35-year-old roofer falls 15 feet, sustaining a closed, displaced intra-articular calcaneus fracture (Sanders Type III). He is scheduled for ORIF via an extensile lateral approach. Which of the following patient factors is the strongest contraindication to this surgical approach?

Explanation

Active smoking dramatically increases the risk of catastrophic wound complications (necrosis, infection) following an extensile lateral approach to the calcaneus. Many surgeons consider heavy active smoking a strict contraindication to this specific approach.

Question 52

A 25-year-old female presents with persistent ankle pain 6 months after an inversion sprain. MRI reveals an anterolateral osteochondral lesion of the talus (OCLT) measuring 0.8 cm squared. The cartilage is intact but soft on probing during arthroscopy. What is the most appropriate surgical treatment?

Explanation

For symptomatic primary OCLTs smaller than 1.5 cm squared, arthroscopic bone marrow stimulation (microfracture) is the gold standard first-line surgical treatment. Larger lesions or microfracture failures are typically treated with structural grafting.

Question 53

A 25-year-old male presents with severe midfoot pain after a football injury. He states another player fell on his heel while his foot was plantarflexed. Radiographs reveal a widening of the space between the 1st and 2nd metatarsal bases with a small osseous fragment visible in the interspace.

What is the most likely mechanism of this injury?

Explanation

Lisfranc injuries classically occur due to an axial load applied to a plantarflexed foot. The "fleck sign" seen on radiographs is pathognomonic, representing an avulsion of the Lisfranc ligament from the base of the second metatarsal.

Question 54

A 14-year-old male presents with recurrent ankle sprains and a rigid, painful flatfoot. A lateral weight-bearing radiograph demonstrates a continuous, C-shaped bony contour extending from the talar dome to the sustentaculum tali. What is the most likely diagnosis and appropriate initial management?

Explanation

A rigid flatfoot with a "C-sign" on a lateral radiograph is classic for a talocalcaneal (middle facet) coalition. Initial nonoperative management focuses on reducing inflammation and pain through a trial of short leg cast immobilization.

Question 55

A 55-year-old female presents with Stage IIB adult-acquired flatfoot deformity. Clinical exam demonstrates a flexible hindfoot valgus and significant forefoot abduction (too many toes sign). Radiographs show greater than 30% uncovering of the talonavicular joint. Which of the following procedures is essential to correct her deformity in addition to a flexor digitorum longus transfer and medial displacement calcaneal osteotomy?

Explanation

Stage IIB flatfoot is characterized by substantial forefoot abduction due to talonavicular uncoverage (>30%). A lateral column lengthening (e.g., Evans osteotomy) is necessary to restore the lateral column length and correct the abduction deformity.

Question 56

A 60-year-old male with poorly controlled diabetes presents with a red, hot, swollen right foot. There are no open ulcers or portals of entry. Radiographs show fragmentation and debris at the tarsometatarsal joints. What is the most appropriate initial management?

Explanation

The patient has acute (Eichenholtz Stage I) Charcot arthropathy, which presents similarly to an infection but lacks an ulcer. The gold standard initial treatment is offloading with total contact casting (TCC) to halt progression during the acute inflammatory phase.

Question 57

A surgeon is performing a minimally invasive percutaneous repair of an acute Achilles tendon rupture. Which nerve is at the highest risk of iatrogenic injury during this procedure, and in what anatomical zone?

Explanation

The sural nerve crosses from lateral to medial across the Achilles tendon approximately 9-12 cm proximal to the calcaneal insertion. Percutaneous or minimally invasive repairs place the nerve at significant risk in the proximal-lateral zone of the repair.

Question 58

A 25-year-old male presents with chronic ankle pain. MRI reveals an anterolateral osteochondral lesion of the talus (OLT) measuring 1.1 cm squared. He has failed 6 months of conservative management. What is the most appropriate primary surgical treatment?

Explanation

For primary, non-cystic osteochondral lesions of the talus smaller than 1.5 cm squared, arthroscopic bone marrow stimulation (microfracture) is the first-line surgical treatment. Larger or previously failed lesions often require structural grafting like OATS.

Question 59

A 35-year-old construction worker sustains a Sanders type III calcaneus fracture after a fall from a ladder. The surgeon elects to use an extensile lateral approach for open reduction and internal fixation. Which structure is elevated within the full-thickness subperiosteal flap and must be protected?

Explanation

The extensile lateral approach to the calcaneus requires developing a full-thickness subperiosteal flap "down to bone" to minimize skin necrosis. The sural nerve is housed within this flap and is protected by retracting the entire flap "no-touch" using K-wires in the talus.

Question 60

A 22-year-old elite collegiate basketball player sustains a Zone 2 fracture of the proximal fifth metatarsal. To minimize nonunion risk and expedite return to play, what is the treatment of choice?

Explanation

Zone 2 fractures (Jones fractures) have high rates of nonunion due to a watershed blood supply area. In high-level athletes, early intramedullary screw fixation is recommended to significantly reduce nonunion risk and allow for a faster return to sport.

Question 61

During open reduction and internal fixation of a pronation-external rotation ankle fracture, the surgeon is evaluating the syndesmosis. What intraoperative step provides the most reliable assessment to ensure anatomic reduction of the syndesmosis?

Explanation

Malreduction of the syndesmosis is common when relying solely on fluoroscopy. Direct open visualization of the anterior syndesmosis (AITFL and incisura fibularis) provides the most reliable confirmation of anatomic reduction.

Question 62

A 40-year-old female complains of burning pain in her third webspace, exacerbated by wearing narrow shoes. Examination reveals a painful click when compressing the metatarsal heads (Mulder's sign). The pathogenesis of this condition involves perineural fibrosis caused by compression against which structure?

Explanation

Morton's neuroma is a perineural fibrosis of the common digital nerve. It is caused by mechanical entrapment and compression of the nerve against the deep transverse metatarsal ligament during the toe-off phase of gait.

Question 63

A 65-year-old female with end-stage post-traumatic ankle arthritis desires a total ankle arthroplasty (TAA). Which of the following conditions is considered an absolute contraindication for TAA?

Explanation

Absolute contraindications for total ankle arthroplasty include active infection, inadequate soft-tissue envelope, severe peripheral vascular disease, and Charcot neuroarthropathy. Neuropathy with loss of protective sensation results in premature implant failure and profound complications.

Question 64

When performing a Scarf osteotomy for correction of moderate to severe hallux valgus, which of the following is a unique and recognized complication specific to the geometry of this osteotomy?

Explanation

The Scarf osteotomy is a versatile Z-step diaphyseal osteotomy. "Troughing" is a unique complication where the hard cortical edge of one fragment collapses into the cancellous medullary canal of the other, leading to loss of fixation and elevation of the metatarsal head.

Question 65

A 30-year-old male sustains a Hawkins Type III talar neck fracture following a high-energy motor vehicle collision. What is the approximate risk of avascular necrosis (AVN) for this injury, and what is the primary arterial supply to the talar body?

Explanation

Hawkins Type III fractures (talar neck fracture with subtalar and tibiotalar dislocation) disrupt multiple blood supplies, resulting in an 80-100% rate of AVN. The primary blood supply to the talar body is the artery of the tarsal canal, a branch of the posterior tibial artery.

Question 66

A competitive skier presents with lateral ankle pain and a snapping sensation behind the lateral malleolus after a sudden dorsiflexion and inversion injury. Radiographs show a small "fleck sign" avulsed from the posterolateral fibula. What is the primary stabilizing structure injured in this condition?

Explanation

The scenario describes peroneal tendon subluxation or dislocation. The mechanism typically causes attenuation or avulsion (fleck sign) of the superior peroneal retinaculum, which is the primary restraint to peroneal tendon displacement from the fibular groove.

Question 67

A 45-year-old male with chronic, recalcitrant plantar fasciitis undergoes an open complete release of the plantar fascia after failing 12 months of conservative care. What is a recognized biomechanical complication of releasing the entire plantar fascia?

Explanation

Releasing more than 50% of the plantar fascia can result in loss of the windlass mechanism, leading to longitudinal arch collapse. This shift in biomechanics commonly results in lateral column overload and subsequent lateral midfoot pain.

Question 68

A 55-year-old diabetic male has a chronic, full-thickness neuropathic ulcer beneath the first metatarsal head. The ulcer probes to bone. No retained hardware is present. Which imaging modality provides the highest sensitivity and specificity for diagnosing osteomyelitis in this setting?

Explanation

MRI is the modality of choice, offering the highest sensitivity and specificity for detecting osteomyelitis in the diabetic foot. It excels at demonstrating bone marrow edema and differentiating between soft tissue infection and true bone infection.

Question 69

A 22-year-old football player sustains an external rotation injury to his ankle and has a positive squeeze test. He is diagnosed with an acute syndesmotic sprain. Which ligament is considered the strongest component of the inferior tibiofibular syndesmotic complex?

Explanation

The posterior inferior tibiofibular ligament (PITFL) is anatomically the strongest component of the syndesmosis. It contributes the most significant resistance to posterior translation and diastasis of the distal fibula.

Question 70

A 28-year-old male with Charcot-Marie-Tooth disease presents with a progressive cavovarus foot deformity. A Coleman block test is performed, and the hindfoot corrects from a varus to a neutral position. What does this test signify about the primary driver of his deformity?

Explanation

The Coleman block test evaluates hindfoot flexibility in cavovarus deformities. Correction to neutral indicates that the hindfoot varus is flexible and compensatory, driven primarily by a plantarflexed first ray acting as a "kickstand."

Question 71

A 24-year-old professional athlete hyperextends his great toe on artificial turf. MRI confirms a Grade 3 turf toe injury with proximal migration of the sesamoids. Complete disruption of which structure is characteristic of this grade of injury?

Explanation

Turf toe is a forced hyperextension injury of the first MTP joint. A Grade 3 injury involves a complete tear of the plantar plate and the capsuloligamentous complex, which causes the sesamoids to retract proximally.

Question 72

A 20-year-old female track athlete complains of vague, aching midfoot pain that worsens with running. CT imaging demonstrates a partial, non-displaced dorsal cortical stress fracture in the central third of the navicular. What is the most appropriate initial management?

Explanation

Navicular stress fractures occur in the relatively avascular central third of the bone, making them prone to nonunion. The standard of care for partial, non-displaced fractures is strict non-weight bearing in a cast for 6 to 8 weeks.

Question 73

A 28-year-old male presents with bilateral cavovarus feet. A Coleman block test is performed, and the hindfoot corrects to a neutral alignment. Which of the following is the most appropriate primary osseous surgical procedure?

Explanation

A flexible hindfoot varus that corrects with a Coleman block test is primarily driven by a rigidly plantarflexed first ray. A dorsiflexion closing wedge osteotomy of the first metatarsal addresses the primary apex of deformity. A lateralizing calcaneal osteotomy would be indicated if the hindfoot deformity was rigid.