Question 1

While he is working, an industrial worker sustains a puncture wound to the plantar aspect of his foot. He suspects the wound was caused by a sharp protruding nail that penetrated his sneaker. The most likely organism to be responsible for a subsequent infection is:

Explanation

Although one must be concerned about the possibility of a Pseudomonas infection, the most common organism following puncture injury is staphylococcus aureus. Unless in the setting of diabetes or immune compromise, anaerobic infection rarely occurs.

Question 2

A 54-year-old woman sustained an injury to her knee 16 months ago. She describes the injury as a dislocation, and she was treated with ligament reconstruction. She has plantarflexion and inversion strength, absent ankle dorsiflexion, and weak eversion. She desires an improvement in the function of the ankle and the ability to comfortably ambulate. The ideal treatment for her is:

Explanation

Following peroneal nerve injury, varying degrees of plantarflexion weakness may be present. In the patient with an intact and strong posterior tibial muscle, an intramembranous transfer to the dorsum of the foot may yield positive results with possible active dorsiflexion. Although neurolysis or nerve graft may be considered for selected patients, it is unlikely to yield a satisfactory result at this time following injury.

Question 3

A 61-year-old man has been treated for type I diabetes for 6 years and presents for evaluation and treatment of an ulcer on the plantar aspect of the forefoot. The ulcer has been present for 4 weeks. The ulcer does not appear infected, claw toe deformities are present, and a posterior tibial pulse is palpable. An important screening test for this patient is:

Explanation

Although vascular evaluation of all patients with diabetes is important, this patient has a neuropathic plantar ulcer and it is important to assess the extent of neuropathy. The Semmes-Weinstein monofilament is a first-rate screening tool.

Question 4

The most common complication following medial subtalar dislocation with incarceration of the talus in the extensor brevis muscle is:

Explanation

A medial peritalar dislocation is easy to reduce even when the head of the talus is incarcerated in the extensor brevis muscle. Following reduction, stiffness and arthritis of the subtalar joint occurs. Ankle arthritis and tarsal tunnel syndrome may occur following lateral subtalar dislocation.

Question 5

A patient sustained a fracture of the calcaneus 9 months ago. The fracture was treated with non-weight bearing and cast immobilization. The patient experiences constant pain and is unable to work. On examination, he has limited inversion, eversion motion of the foot, and lateral foot pain. Radiographs are presented. The recommended treatment is:

Explanation

In the presence of stiffness of the subtalar joint, physical therapy modalities are unlikely to improve the foot function. For the young active worker, an early subtalar arthrodesis is the most reliable procedure to return him to work and an active lifestyle. A triple arthrodesis is contraindicated in the absence of painful transverse tarsal arthritis.

Question 6

A 44-year-old woman presents with chronic pain in the region of the forefoot. She is unable to wear a shoe with a heel and she has pain in the region of the second toe. On examination, she has swelling of the second toe and painful inflammation of the metatarsophalangeal joint. A clinical picture of her foot is presented. Your initial treatment consists of:

Explanation

This patient has idiopathic synovitis of the second metatarsophalangeal (MP) joint. This may be associated with hallux valgus or a long second metatarsal, leading to attritional changes in the volar plate and secondary instability of the MP joint. Immobilization of the toe with limitation of dorsiflexion is required. Although cortisone injection may be effective, toe support must be the initial form of treatment. Orthopedic Prometric Exam Question

Question 7

The most reliable clinical finding of an acute compartment syndrome of the foot is:

Explanation

The most reliable clinical finding of an acute compartment syndrome of the foot is pain upon passive dorsiflexion of the toes. Decreased sensation does not occur commonly and is a late finding, along with changes in perfusion to the foot.

Question 8

A 9-year-old girl presents for treatment of a calcaneus deformity of the foot that has progressively worsened over the past 3 years. She has a history of poliomyelitis. Upon examination, she has poor plantarflexion, neutral varus and valgus of the hindfoot, and strong dorsiflexion. The preferred treatment for this deformity is:

Explanation

A calcaneus deformity is ideally treated with posterior transfer of the anterior tibial tendon to the calcaneus. In the presence of calcaneovalgus deformity (which is not present in this child), posterior transfer to the fibula is a better procedure to prevent continued valgus deformity of the ankle.

Question 9

A 54-year-old woman presents for treatment of leg weakness. She is unable to walk up stairs. She recalls an injury to her ankle while playing tennis 1 year ago. Upon examination, she has poor plantarflexion strength, but excellent dorsiflexion and inversion strength. A magnetic resonance image of her leg is presented. The recommended treatment is:

Explanation

This patient sustained a rupture of the Achilles tendon that went untreated for 1 year. She has symptomatic weak plantarflexion that may be improved by tendon transfer. Achilles repair is not possible due to the size of the defect. Although transfer of the peroneus brevis muscle or the flexor digitorum longus muscle has been described for correction of plantarflexion weakness, the flexor hallucis longus muscle is stronger and a better transfer.

Question 10

A 19-year-old collegiate lacrosse player presents for treatment of acute pain along the lateral aspect of the foot. The pain developed during a preseason game 1 week ago. A radiograph is presented. The treatment that will return the athlete to playing competitively with the least likelihood of complications is:

Explanation

To rapidly return the competitive athlete to full function, percutaneous screw fixation of an acute fracture or a stress fracture of the fifth metatarsal at the Orthopedic Prometric Exam Question

junction of the metaphysis and diaphysis is preferred treatment. Although nonoperative treatment is associated with fracture healing, the limited function and requirement for immobilization, and possibly limited weight bearing, makes this alternative less appealing in the athlete.

Question 11

A 19-year-old woman presents for treatment of a painful hallux valgus deformity. In addition to the foot deformity, she has spastic hemiplegic cerebral palsy. A clinical picture of her foot is presented. The recommended treatment is:

Explanation

In patients with spasticity, arthrodesis of the hallux metatarsophalangeal joint is the only reliable means of controlling the hallux and preventing recurrent deformity.

Question 12

The most common complication of arthrodesis of the proximal interphalangeal (PIP) joint is:

Explanation

With arthrodesis of the proximal interphalangeal joint (PIP), the long flexor tendon that remains intact flexes the toe at the metatarsophalangeal (MP) joint and also at the distal interphalangeal (DIP) joint, thus the development of a mallet toe deformity.

Question 13

A 59-year-old woman presents for treatment of a painful hallux valgus deformity. She has a prominent bunion, normal motion of the hallux metatarsophalangeal (MP) joint, and painful callosity under the second MP joint. Radiographs of the foot are presented. The recommended treatment is:

Explanation

This patient has probable instability of the metatarsocuneiform joint manifested by the overload phenomenon of the second metatarsal. Although this is not a sufficient indication for performing an arthrodesis of the metatarsocuneiform joint (modified Lapidus procedure), other findings of second metatarsal overload, including thickening of the cortex of the second metatarsal and instability of the first metatatarsocuneiform joint, should be looked for in addition to hypermobility of the first ray.

Question 14

In surgical correction of the adult acquired flatfoot deformity, a medial translational calcaneal osteotomy is often performed in conjunction with additional soft tissue correction medially. One of the proposed biomechanical effects of the osteotomy associated with improvement in the arch of the foot is:

Explanation

The medial shift of the calcaneus effectively moves the Achilles tendon, thereby increasing the medial torque on the subtalar joint. The valgus deforming force of the Achilles on the heel is neutralized. The plantar fascia is lengthened, not tightened, by the medial shift of the calcaneus.

Question 15

One year ago, a patient underwent a triple arthrodesis for management of a severe foot deformity. Although the deformity of her foot is notably improved since the surgery, she has not walked comfortably and the pain is worse than it had been prior to surgery. Upon clinical examination, she is noted to have a fixed supination deformity of the forefoot and callosity under the base of the fifth metatarsal. The recommended management of this problem is:

Explanation

This patient underwent a triple arthrodesis that resulted in malunion as demonstrated by the location of the callosity and the fixed forefoot deformity. A calcaneus osteotomy will not correct the midfoot deformity. Nonoperative treatment will not be sufficient in long-term management.

Question 16

A 28-year-old woman presents for treatment of pain and swelling in the foot. She had twisted her ankle 2 months ago and her initial treatment consisted of limited activity, crutches, and immobilization. Because she has not been able to wean off the crutches, she has pain in the foot radiating to the ankle and distal lateral leg. She has constant pain in the foot and the swelling appears worse than at the time of her injury. C linically, there are multiple areas of tenderness in the foot and ankle that appear swollen and sensitive to examination. The study that would be most helpful to clarify this diagnosis is:

Explanation

This patient appears to have an acute sympathetically mediated pain syndrome. Previously referred to as reflex sympathetic dystrophy, it is essential to make an early diagnosis and initiate treatment. While a lumbar sympathetic block has both diagnostic and therapeutic value, a bone scan is an excellent imaging study for screening and diagnostic purposes in this patient.

Question 17

A 52-year-old man presents for evaluation and treatment of a painful flatfoot deformity. While playing tennis 2 years ago, he felt a tearing sensation in his foot and ankle. Since that time, he notes that the arch of his foot has become progressively flatter. Upon examination, he has a flatfoot inability to perform a single heel rise and weak inversion strength. He desires to have this deformity corrected. At surgery, the posterior tibial tendon is grossly normal in appearance. The most likely source of his deformity is:

Explanation

A rupture of the spring ligament, the talonavicular capsule, or the deltoid ligament should be looked for in the patient with an acquired flatfoot following trauma. Intratendinous tear of the posterior tibial tendon is also possible.

Question 18

A 27-year-old man sustained an injury to his foot 2 Â½ years ago when a forklift crushed his foot. He sustained a fracture dislocation of the midfoot and was treated with open reduction and internal fixation. His current complaints are burning in the foot associated with numbness over the dorsal foot surface. On examination, he has severe focal sensitivity over the dorsal foot, particularly in the first web space radiating proximally to the ankle. Radiographs demonstrate mild arthritis and anatomic reduction of the tarsometatarsal and midfoot joints. The prognosis for relief of his foot pain at this stage is:

Explanation

This patient sustained a crush injury to the foot, and although the dislocation was apparently treated with anatomic reduction, he experiences focal neuritis. It is unlikely that he has a sympathetically mediated pain syndrome, although this should always be considered. The outcome, regardless of treatment, must be guarded for this post-traumatic crush syndrome.

Question 19

A 34-year-old woman presents for treatment of pain in the hallux. She notes pain upon weight bearing and wearing high-heel shoes. Upon examination, the range of motion of the hallux metatarsophalangeal (MP) joint is 10° dorsiflexion and 30° plantarflexion, with pain upon passive dorsiflexion. Radiographs demonstrate osteophytes over the dorsal surface of the metatarsal head, maintenance of the joint space, and a metatarsal declination angle of 10°. The first metatarsal is elevated above the second metatarsal at the level of the metatarsal neck by 4 mm. The ideal procedure to correct this problem and alleviate pain is:

Explanation

This patient has mild hallux rigidus with a normal alignment of the first metatarsal. The average elevation of the first metatarsal above the second metatarsal at the level of the metatarsal neck is 7.5 mm, thus, 4 mm is within normal limits. Arthrodesis is not indicated for mild rigidus and osteotomy is indicated only for severe elevation of the first metatarsal. C heilectomy combined with osteotomy of the proximal phalanx (the Moberg osteotomy) is the preferred procedure.

Question 20

A patient experienced a nondisplaced fracture of the medial and middle cuneiforms. His nonoperative treatment consisted of cast immobilization for 2 weeks with no weight bearing permitted, followed by ambulation as tolerated. He presents for treatment 1 week later with severe swelling in the foot, stiffness of the toes, and limited motion of the hindfoot. The fracture of the cuneiforms appears healed. The ideal management of the stiffness and swelling of the foot is:

Explanation

Patients who develop swelling of the foot and ankle following trauma and surgery can be effectively treated with application of an intermittent foot pump device. The bladder of the foot pump can be inserted into either a removable boot or cast, or applied to the foot in combination with other methods of rehabilitation. The foot pump is an effective device for decreasing swelling of the foot in association with acute trauma.

Question 21

A 31-year-old woman presents for treatment of pain in the hallux. She has been experiencing the pain for 2 years. She notes limited motion of the hallux with pain in the joint, particularly when wearing high-heel shoes. She is unable to toe off with running activities. Upon examination, the motion in the hallux metatarsophalangeal (MP) joint is limited in dorsiflexion and radiographs demonstrate mild arthritis of the joint. She requests surgery to correct this disorder. The recommended treatment is:

Explanation

Cheilectomy is the ideal treatment for correction of mild hallux rigidus. Although elevation of the first metatarsal rarely occurs (metatarsus primus elevatus) as the cause for hallux rigidus, osteotomy of the metatarsal should not be used as the treatment for correction of hallux rigidus with normal alignment of the first metatarsal.

Question 22

A 17-year-old woman presents for evaluation of a painful hallux valgus deformity. She is unable to wear shoes comfortably, has pain with athletic and daily activities, and notices that the deformity is gradually worsening. Upon clinical examination, she has generalized ligamentous laxity, with motion of the hallux metatarsophalangeal (MP) joint 75° dorsiflexion and 25° plantarflexion. Motion of the first metatarsal is approximately 8° to 10° of combined dorsiflexion and plantarflexion. There is no pain to range of motion of these joints. The hallux valgus angle is 28° and the 1-2 intermetatarsal angle is 12°. The recommended treatment is:

Explanation

This adolescent has symptomatic hallux valgus, and surgery is warranted. The motion at the metatarsophalangeal and talometatarsal joints is normal, and there is no evidence of hypermobility despite her generalized ligamentous laxity. Therefore, the modified Lapidus procedure is not indicated. With this deformity, a distal metatarsal osteotomy is ideal.

Question 23

An 82-year-old woman presents for treatment of a painful second toe deformity. The toe is subluxated at the metatarsophalangeal (MP) joint, and a fixed claw toe deformity is present. Despite severe hallux valgus, and the hallux under riding the second toe, the hallux and bunion are not symptomatic. The procedure that will ideally correct this deformity is:

Explanation

This elderly patient has a symptomatic second toe deformity only, and surgery to the hallux should be avoided if possible. This is a common clinical problem, and although patients do not readily accept amputation of the toe, it is the preferred procedure because it does not involve reconstruction of the hallux. C orrection of the second toe without amputation will not work unless the hallux deformity is addressed.

Question 24

A 19-year-old woman had previously been treated for hallux valgus deformity with resection of the medial eminence only. She now presents with severe recurrent deformity of the hallux, with pain. There is neither pain nor crepitus upon range of motion of the hallux metatarsophalangeal (MP) joint. The procedure that will successfully correct the deformity of the hallux and the first metatarsal and maintain motion at the MP joint is:

Explanation

This patient has recurrent hallux valgus with a marked increase in the distal metatarsal articular angle (DMAA). C orrection of this increased DMAA is essential to obtain motion at the metatarsophalangeal joint, and can only be accomplished with a closing wedge type of osteotomy distally. Although a distal biplanar osteotomy may be sufficient, in view of the magnitude of the deformity, a double first metatarsal osteotomy is preferred.

Question 25

A 63-year-old woman who underwent attempted correction of a hallux valgus deformity 3 years previously presents to the office. She has pain in the hallux from dorsal abutment of the hallux on the shoe. There is no pain in the lesser toes or metatarsals. The recommended procedure to alleviate the irritation of the hallux is:

Orthopedic Prometric Exam Question

Explanation

This patient had previously undergone resection arthroplasty (Keller) for correction. A common complication of this procedure is a cock-up toe deformity due to insufficiency of the short flexors. This can be corrected with lengthening of the extensor hallucis. If the latter procedure fails, then an arthrodesis can be performed.

Question 26

A 66-year-old woman has experienced the gradual onset of a flatfoot deformity over the past 10 years. She notes that the condition is bilateral, although worse on one side. Presented are clinical and radiographic images of her condition. This is associated with pain upon ambulation and difficulty with shoe wear. The most likely cause of this flatfoot deformity is:

Explanation

Although posterior tibial tendon insufficiency is a more common cause of adult acquired flatfoot, in this patient the associated clinical and radiographic deformity makes the diagnosis of tarsometatarsal arthritis more likely.

Question 27

A 66-year-old woman has experienced the gradual onset of a flatfoot deformity over the past 10 years. She notes that the condition is bilateral, although worse on one side. Presented are clinical and radiographic images of her condition. This is associated with pain upon ambulation and difficulty with shoe wear. The most likely cause of this flatfoot deformity is tarsometatarsal arthritis. The initial recommended treatment is:

Explanation

The initial treatment of idiopathic tarsometatarsal arthritis in the adult is through foot support, shoe modifications, and orthoses. Tarsometatarsal arthrodesis may be required if these treatments fail. Orthopedic Prometric Exam Question

Question 28

Many materials are used in the production of orthotic arch supports. Plastizote is a material commonly used either alone or in combination. The problem with this material is:

Explanation

Plastizote is a remarkably forgiving material and accommodates well to the foot shape. It is soft, and it loses resilience or sponginess after 6 months. Therefore, plastizote is commonly used in combination with other materials for orthotic support, particularly for the patient with neuropathy.

Question 29

A 35-year-old man has experienced ankle pain for 7 years. It is associated with giving way and progressive deformity of the foot. He notices that the foot is rolling inward and is becoming flatter. The cause of his condition is:

Explanation

This patient presents with ankle instability and progressively worsening flatfoot, with the hindfoot in valgus. Although a rare condition, this is caused by a talonavicular tarsal coalition, with increasing stress on the ankle likely.

Question 30

A 14-year-old boy presents for treatment of a painful foot, which has been present for 2 years. He has limited his athletic activities. He has similar symptoms in the opposite foot, although not as severe. On clinical examination, the alignment and appearance of the foot are normal; motion of the foot and ankle is good; and some discomfort is present in the sinus tarsi. Standard radiographs, of which the lateral view is presented, include anteroposterior, lateral, and oblique views. Because the diagnosis is unclear, more imaging studies are required. The next study to obtain is:

Explanation

The radiograph demonstrates changes in the subtalar joint suggestive of a middle facet coalition. Note the sclerosis of the joint surface. Although a computed axial tomography scan may be helpful, standard axial views of the subtalar joint (Harris) taken in the plane of the joint are usually diagnostic of tarsal coalition. Motion of the subtalar joint may be normal in the adolescent with a tarsal coalition.

Question 31

The radiograph of a 22-year-old woman with ankle pain and instability is presented. She has noted this problem for 10 years, and it appears to be worsening. The opposite ankle is not symptomatic. She has not had any previous treatment for foot or ankle problems. The cause of this ankle deformity is most likely to be associated with which of the following conditions:

Explanation

This patient has a ball and socket ankle, which results from limited motion of the hindfoot during early childhood, either from extensive tarsal coalition, premature hindfoot arthrodesis, or trauma. The condition most commonly associated with a ball and socket ankle is a form of hemimelia of the fibula with lateral ray deficiencies and associated tarsal coalition of which the latter is usually extensive.

Question 32

The sustentaculum tali is the anatomic roof of which tendon:

Explanation

The sustentaculum tali forms an arch under which the flexor hallucis longus passes. This is of anatomic significance when resecting middle facet tarsal coalition and performing subtalar arthrodesis.

Question 33

The nerve most likely to be at risk during surgical exposure when performing a triple arthrodesis is the:

Explanation

The sural nerve has a variable path in the distal leg, but lies immediately adjacent to the peroneal tendons on the lateral side of the foot. The lateral incision used to expose the subtalar and calcaneocuboid joints is adjacent to this nerve.

Question 34

A 55-year-old man presents for treatment of pain in the Achilles tendon. This has been present for 2 years, but has suddenly become much worse. The pain is approximately 6 cm proximal to the insertion. He is unable to push off during walking and has pain when ascending stairs. C linical examination reveals thickening of the tendon, weakness of the gastrocnemius-soleus, and pain upon squeezing the Achilles tendon. The magnetic resonance image is shown. The diagnosis is:

Explanation

The widening and thickening over a length of the tendon noted clinically and on magnetic resonance image (MRI) is diagnostic of chronic degenerative tendinosis. While paratendinitis may be present simultaneously, limited MRI changes are noted in this condition. Rupture of the tendon may occur and patients with chronic tendinosis should recognize the potential for tendon rupture. Orthopedic Prometric Exam Question

Question 35

A patient presents for surgical correction of a ruptured Achilles tendon. He recalls injuring his ankle 1 year previously, but did not seek any medical treatment at that time. You plan to repair the tendon, and at surgery, a gap between the tendon ends is noted (Slide). The following procedure is not consistent with an acceptable outcome:

Explanation

End-to-end repair of a chronic rupture of the Achilles tendon may not be considered if the gap is greater than 2 cm. Equinus positioning is never acceptable. Although each of the other alternatives above may be considered, each has its proponents and potential disadvantages.

Question 36

You are commencing a repair of an acute rupture of the Achilles tendon that occurred 8 days previously in a 32-year-old recreational tennis player. Fibrillation of the tendon ends is noted. The following is most important to maximize the ultimate outcome of the repair:

Explanation

Repair of the Achilles tendon at its normal resting length is critical. The frayed tendon ends should not be excised, since this will force a repair with the foot in equinus. The resting tension of the repair can be compared with the position of the opposite limb that should be prepared into the operative field.

Question 37

A 17-year-old patient presents for evaluation and treatment of pain in the back of her ankle. She is a ballet dancer and has noticed that for the past year, she is unable to assume the pointe position without pain. Upon clinical examination she has full range of motion, excellent strength, normal toe function, and pain with pressure in the posterior ankle. The cause of her pain is:

Explanation

Posterior ankle impingement is common in ballet dancers. When in the pointe position, maximum plantar flexion of the ankle is present, and pain may occur from impingement in the posterior ankle. Flexor hallucis tendonitis may cause posterior ankle pain, but there is no evidence for this condition here.

Question 38

The structure that lies immediately medial to the bone prominence in the posterior ankle shown is the:

Explanation

The os trigonum presented in the radiograph may be the cause of posterior ankle impingement. The flexor hallucis longus lies immediately medial to the os and must be protected during excision of this bone.

Question 39

A 43-year-old construction worker sustained a work-related injury to his foot 7 months ago. He was initially treated with cast immobilization and limited weight bearing. He has lateral foot pain and inability to walk comfortably. He has limited walking endurance. Upon examination, pain is present laterally along the course of the peroneal tendons, and no motion of the subtalar joint is present. The recommendation is:

Explanation

A worker who sustains a calcaneus fracture must be returned to the work force as soon as possible. Although these alternatives for treatment may be considered in the patient with limited activity and low demands, the longer the time from injury to salvage surgery with arthrodesis, the less likely it is that the injured worker will ever return to gainful employment. Therefore, subtalar arthrodesis should be performed.

Question 40

The structure on the side of the metatarsophalangeal joint of the second toe which is marked by the pointer is the:

Explanation

The structure is the volar plate ligament. This ligament may assume a pathologic role in claw toe deformity and instability of the metatarsophalangeal joint.

Question 41

A 21-year-old man presents for evaluation of high arches, which have been present his entire life. C urrently, he is experiencing some discomfort with running activities. His brother and mother have high arches. He does not recall any trauma as a child, or any other pertinent childhood musculoskeletal problems. C linical examination reveals a rigid deformity bilaterally. The most common cause for his high arches is:

Explanation

The most common cause of familial cavovarus foot deformity is hereditary sensorimotor neuropathy (C harcot-Marie-Tooth disease). This is an autosomal dominant condition with variable penetrance. Idiopathic cavus foot is common, but not familial, nor is it associated with this extensive deformity.

Question 42

A 21-year-old man presents for evaluation of high arches, which have been present his entire life. C urrently, he is experiencing some discomfort with running activities. His brother and mother have high arches. He does not recall any trauma as a child, or any other pertinent childhood musculoskeletal problems. C linical examination reveals a rigid deformity bilaterally. What structure is responsible for plantarflexion of the first metatarsal:

Orthopedic Prometric Exam Question

Explanation

The peroneus longus passes under the cuboid to function as a plantar flexor of the first metatarsal. It is a primary deforming force in the development of the cavus foot.

Question 43

A 22-year-old patient presents for treatment of a painful foot deformity. On examination, a flexible cavovarus deformity is present. The patient has good dorsiflexion foot strength, and eversion strength is weak. A possible tendon transfer that can be used to correct this deformity is:

Explanation

Transfer of the strong peroneus longus to the weak peroneus brevis tendon can be considered to improve function and strength of the cavus foot. Posterior tibial tendon transfer is not indicated because dorsiflexion strength is good. Transfer of the anterior tibial tendon is not indicated, although it is contributing to the midfoot varus.

Question 44

A 56-year-old man presents for treatment of chronic ankle pain. He has noted long-standing pain associated with activities since early adulthood. He does not have any other pertinent musculoskeletal history. C linical and radiographic examinations reveal ankle arthritis. A probable cause for this arthritis and deformity is:

Orthopedic Prometric Exam Question

Explanation

The varus ankle deformity indicates either a chronic hindfoot varus and hindfoot cavus, or chronic recurrent instability of the ankle. If associated with rotatory instability, anterior impingement and eventual arthritis will occur.

Question 45

When performing fasciotomy of the foot for acute compartment syndrome, the muscle specifically decompressed through medial fasciotomy is:

Explanation

Knowledge of the anatomy and pathophysiology of compartment syndrome of the foot is important to plan adequate and correct treatment. The exact number of compartments is not as relevant as the location and ability to decompress the compartment through fasciotomy. The medial compartment contains the abductor hallucis and the flexor hallucis brevis muscles. The quadrates plantae is more posteriorly located and considered to be in a separate calcaneal compartment.

Question 46

This muscle group demonstrates electrical activity at the time of heel strike:

Explanation

The anterior muscle compartment, in particular, the anterior tibialis, is active during heel strike, to maintain foot dorsiflexion, and prevent foot drop during heel strike.

Question 47

A 7-year-old boy presents with bilateral high arches. His parents report that they are having difficulty finding shoes that comfortably fit him. The patient denies any foot pain. The father had similar problems with his feet and was diagnosed with a mild neurologic condition. On exam, the child has bilateral pes cavus with a supple hindfoot. Treatment of the feet at this time should consist of:

Explanation

The child has a supple deformity secondary to C harcot-Marie-Tooth disease that will progress if untreated. Soft tissue procedures, which may consist of claw toe correction, plantar release, and possibly tendon transfer, are recommended for children younger than 8 years old who have a supple hindfoot. The calcaneal osteotomy is reserved for patients with a rigid hindfoot. Triple arthrodesis is a salvage procedure reserved for a fixed, painful foot in older children. Bracing and observation are not preferred options due to the progressive nature of the disease, and the lack of ability to apply corrective forces to the foot in cavus.

Question 48

A 50-year-old woman presents with pain in the second toe. She describes this as burning and notes swelling of the toe for the past month. Upon examination, there appears to be instability of the toe with a positive dorsal subluxation stress test. The anatomic structure which is responsible for this patientâ s symptoms is:

Explanation

This patient describes swelling of the toe, which is not associated with an interdigital neuroma. The pain, swelling, and clinical findings suggest a rupture of the plantar plate with early instability and second metatarsophalangeal synovitis.

Question 49

A 15-year-old boy presents with a 2-year history of pain in the foot associated with a sense stiffness and of giving way of the ankle. Upon examination, pain in the sinus tarsi, slightly decreased subtalar motion, and normal ankle motion with no apparent instability are noted. A lateral foot radiograph is presented. The next radiograph to obtain is:

Explanation

This child presents with symptoms suggestive of a tarsal coalition. There is stiffness, and symptoms of ankle discomfort or instability. On the lateral radiograph, there is consolidation of trabeculation under the posterior facet in the shape of a â C â , a typical finding of a middle facet coalition, which should be investigated further with an axial view of the subtalar joint (Harris).

Question 50

Which ancillary test is not helpful in the diagnosis of C harcot-Marie-Tooth disease (C MT):

Explanation

Charcot-Marie-Tooth disease (C MT) is a neuropathic process resulting in muscle atrophy, therefore, muscle enzyme studies will not be helpful. Electromyography (EMG) will confirm the diagnosis by displaying increased amplitude and duration of signals, both of which are indicative of a neuropathic process. Nerve conduction velocity (NC V) will also confirm the diagnosis by displaying decreased motor and sensory conduction velocities. Nerve biopsy can be helpful by showing loss of myelinated fibers and fibrosis. Muscle biopsy will show diffuse atrophy, fibrosis, and adipose tissue within muscle.

Question 51

A 6-year-old child sustains a completely displaced supracondylar humerus fracture. After closed reduction and percutaneous pinning, the fracture heals. However, at 1-year follow-up, the child has a noticeable cubitus varus deformity. What is the most common cause of this specific deformity?

Explanation

Cubitus varus is the most common long-term complication of supracondylar humerus fractures. It is almost exclusively caused by malunion, specifically from inadequate correction of medial comminution and internal rotation malalignment.

Question 52

A 28-year-old man sustains a vertically oriented, displaced femoral neck fracture (Pauwels type III) after a motor vehicle collision. Which of the following fixation constructs provides the greatest biomechanical stability for this specific fracture pattern?

Explanation

Pauwels type III fractures are subject to high vertical shear forces. A sliding hip screw (fixed-angle device) with an anti-rotation screw provides superior biomechanical stability against shear stress compared to parallel cancellous screws.

Question 53

A 22-year-old female soccer player undergoes anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone (BTB) autograft. Which of the following is the most frequent complication specific to this graft choice compared to hamstring autografts?

Explanation

Bone-patellar tendon-bone (BTB) autografts offer excellent bone-to-bone healing but are significantly associated with a higher incidence of anterior knee pain and kneeling pain compared to hamstring autografts.

Question 54

A 35-year-old carpenter sustains a volar laceration over the proximal phalanx of his index finger, resulting in an inability to flex both the DIP and PIP joints. This injury is classified as occurring in which flexor tendon zone?

Explanation

Zone II extends from the A1 pulley to the insertion of the flexor digitorum superficialis (FDS). Injuries here often involve both the FDP and FDS tendons within the tight fibro-osseous sheath.

Question 55

A 45-year-old man presents with sudden severe lower back pain, bilateral sciatica, saddle anesthesia, and urinary retention. MRI reveals a massive L4-L5 central disc herniation. To maximize the chance of full neurological recovery, surgical decompression should ideally be performed within what timeframe?

Explanation

Cauda equina syndrome is a surgical emergency. Decompression within 48 hours of symptom onset is strongly associated with significantly better outcomes for bladder, bowel, and sexual function recovery.

Question 56

A 15-year-old boy presents with progressive knee pain and swelling for 2 months. Radiographs of the distal femur show a mixed lytic and blastic lesion, cortical destruction, and a Codman triangle. After staging, what is the most appropriate next step in management?

Explanation

The clinical and radiographic findings are classic for osteosarcoma. The standard of care involves neoadjuvant chemotherapy, followed by wide surgical resection (limb salvage), and subsequent adjuvant chemotherapy.

Question 57

Following a primary total hip arthroplasty via a posterior approach, a patient experiences recurrent posterior dislocations. Radiographs demonstrate an acetabular cup with 5 degrees of retroversion and 45 degrees of inclination. What is the most appropriate surgical intervention?

Explanation

Normal acetabular cup positioning targets 15-20 degrees of anteversion. A retroverted cup significantly predisposes to posterior dislocation and requires revision to correct the anteversion.

Question 58

A 40-year-old recreational athlete sustains an acute Achilles tendon rupture and opts for non-operative management. What functional protocol has been shown to result in re-rupture rates comparable to surgical repair?

Explanation

High-level evidence demonstrates that non-operative management utilizing early functional rehabilitation and functional bracing yields re-rupture rates similar to operative management, while avoiding surgical complications.

Question 59

A diaphyseal tibial fracture is treated with a rigid locked intramedullary nail. Which type of bone healing predominantly occurs in this scenario?

Explanation

Intramedullary nailing provides relative stability rather than absolute stability. This biomechanical environment promotes secondary bone healing through the formation of a soft and hard fracture callus.

Question 60

A 13-year-old obese boy presents with a 3-week history of right groin pain and an obligatory external rotation of the hip when the hip is flexed. What is the most appropriate initial treatment?

Explanation

The presentation is classic for a slipped capital femoral epiphysis (SCFE). The standard of care is immediate in situ pinning with a single, centrally placed cannulated screw to prevent further slippage.

Question 61

A hemodynamically unstable 30-year-old man is brought in after a motorcycle accident. Pelvic radiograph shows a pubic symphysis diastasis of 4 cm and widening of the sacroiliac joints. After initiating massive transfusion protocols, what is the most appropriate immediate orthopedic intervention?

Explanation

In a hemodynamically unstable patient with an anteroposterior compression (APC) pelvic ring injury, the immediate priority is closing the pelvic volume using a pelvic binder to tamponade venous bleeding.

Question 62

A 65-year-old man presents with chronic shoulder pain and pseudoparalysis. MRI reveals a massive, retracted tear of the supraspinatus and infraspinatus tendons with severe fatty infiltration (Goutallier stage 4). What is the most appropriate surgical treatment?

Explanation

In an older patient with an irreparable rotator cuff tear (indicated by Goutallier stage 4 fatty infiltration) and pseudoparalysis, a reverse total shoulder arthroplasty reliably provides pain relief and restores function.

Question 63

A 70-year-old woman presents with worsening clumsiness in her hands, difficulty buttoning her shirt, and a broad-based gait. Physical examination reveals a positive Hoffmann's sign bilaterally and lower extremity hyperreflexia. What is the most likely diagnosis?

Explanation

Hand clumsiness, gait disturbances, and upper motor neuron signs (Hoffmann's sign, hyperreflexia) are hallmark signs of cervical spondylotic myelopathy, typically caused by degenerative cervical canal narrowing.

Question 64

A 25-year-old athlete presents with midfoot pain after an axial load to a plantarflexed foot. On an anteroposterior radiograph of the foot, which alignment abnormality is most indicative of a Lisfranc injury?

Explanation

A Lisfranc injury involves the tarsometatarsal joint complex. The classic radiographic hallmark is a disruption of normal alignment where the medial border of the second metatarsal base fails to align with the medial border of the middle cuneiform.

Question 65

A 4-year-old boy presents with refusal to bear weight on his right leg. He has a temperature of 38.8°C (101.8°F), an ESR of 50 mm/hr, and a WBC count of 14,000/mm³. Based on Kocher's criteria, what is the approximate probability that this child has septic arthritis of the hip?

Explanation

Kocher's criteria include non-weight-bearing, fever >38.5°C, ESR >40, and WBC >12,000. With all 4 criteria present, the predicted probability of septic arthritis is approximately 99%.

Question 66

A 13-year-old obese boy presents with left thigh pain and an obligatory external rotation of the hip during flexion. Radiographs confirm a slipped capital femoral epiphysis (SCFE). Which of the following is the most significant risk factor for the development of chondrolysis in this patient?

Explanation

Unrecognized intra-articular hardware penetration is a well-documented and highly significant risk factor for chondrolysis following SCFE fixation. Proper fluoroscopic evaluation using the approach-withdrawal technique is crucial to avoid this complication.

Question 67

A 35-year-old man sustains a high-energy Schatzker VI tibial plateau fracture.

Twelve hours post-admission, he develops severe pain out of proportion to the injury, exacerbated by passive stretch of his toes. His pedal pulses are palpable. What is the most appropriate next step in management?

Explanation

Severe pain out of proportion and pain with passive stretch in the setting of a high-energy tibial plateau fracture are classic signs of acute compartment syndrome. Intact pulses do not rule out compartment syndrome, and immediate fasciotomy is the definitive treatment to prevent irreversible muscle necrosis.

Question 68

A 55-year-old active man undergoes a total hip arthroplasty. The surgeon opts for a highly cross-linked polyethylene (HXLPE) liner. Which of the following best describes the mechanical trade-off associated with the increased cross-linking of the polyethylene?

Explanation

Highly cross-linked polyethylene undergoes irradiation to increase wear resistance by forming cross-links between polymer chains. However, this process decreases bulk mechanical properties such as fatigue strength, fracture toughness, and yield strength.

Question 69

A 68-year-old woman presents with bilateral lower extremity pain that worsens when walking and improves when she leans forward on a shopping cart. She has a history of hypertension and osteoarthritis. Which of the following physical examination findings best differentiates her condition from vascular claudication?

Explanation

Neurogenic claudication is characterized by pain relief with lumbar flexion (sitting or leaning forward) and a normal vascular exam. In contrast, vascular claudication is relieved simply by standing still and is typically associated with diminished pulses or abnormal ABI.

Question 70

A 22-year-old male falls on an outstretched hand and presents with anatomic snuffbox tenderness. Radiographs show a displaced fracture of the proximal pole of the scaphoid.

If left untreated, which of the following represents the typical progression of arthritic changes in the wrist?

Explanation

Scaphoid nonunion advanced collapse (SNAC) begins with arthritis at the radial styloid-scaphoid articulation. It then progresses to the scaphocapitate joint, and finally the capitolunate joint, characteristically sparing the radiolunate joint.

Question 71

A 19-year-old soccer player sustains a twisting injury to her knee. Radiographs reveal an avulsion fracture of the anterolateral proximal tibia (Segond fracture). Which of the following examination findings is most likely to be present?

Explanation

A Segond fracture is an avulsion of the anterolateral ligament complex and is highly correlated with an anterior cruciate ligament (ACL) tear. Therefore, the patient is likely to have a positive pivot shift test, which assesses anterolateral rotatory instability.

Question 72

A 58-year-old man with a 15-year history of poorly controlled diabetes presents with a red, hot, swollen right foot. There are no open ulcers, and radiographs show fragmentation, periarticular debris, and subluxation of the tarsometatarsal joints. His WBC count is normal. What is the most appropriate initial management?

Explanation

The patient is presenting with acute Eichenholtz Stage I (fragmentation) Charcot arthropathy, characterized by a red, hot, swollen foot without infection. The standard of care for acute Charcot is rigid immobilization and offloading, most effectively achieved with a total contact cast.

Question 73

A 14-year-old boy presents with progressive knee pain. Radiographs demonstrate a destructive metaphyseal lesion of the distal femur with a sunburst periosteal reaction.

Biopsy confirms high-grade osteosarcoma. Which of the following factors is the most important prognostic indicator for his long-term survival?

Explanation

In high-grade extremity osteosarcoma, the most significant prognostic factor for survival is the histologic response to neoadjuvant chemotherapy. Greater than 90% tumor necrosis is considered a good response and correlates with improved long-term outcomes.

Question 74

A 42-year-old man is brought to the trauma bay after a motorcycle collision. He is hypotensive with a mechanically unstable pelvis. The trauma team decides to apply a pelvic binder. To be maximally effective in reducing pelvic volume, where should the binder be centered?

Explanation

To effectively reduce pelvic volume and stabilize the pelvic ring in the acute trauma setting, a pelvic binder must be centered directly over the greater trochanters. Placing it over the iliac crests is a common error and can paradoxically widen certain pelvic ring injuries.

Question 75

A 66-year-old woman presents with right knee pain 3 years after a total knee arthroplasty. Her ESR is 45 mm/hr and CRP is 22 mg/L. Joint aspiration yields synovial fluid with a WBC count of 4,500 cells/uL with 85% polymorphonuclear leukocytes. Which of the following tests would provide the highest specificity for confirming a periprosthetic joint infection (PJI)?

Explanation

Alpha-defensin is an antimicrobial peptide released by neutrophils in response to infection and has very high sensitivity and specificity for diagnosing periprosthetic joint infection. Gram stain, while specific, has notably low sensitivity for PJI.

Question 76

A 6-week-old female infant is undergoing treatment for developmental dysplasia of the hip (DDH) with a Pavlik harness. During a follow-up visit, the mother notes that the infant is no longer actively extending her knee on the affected side. What is the most appropriate next step in management?

Explanation

The infant is demonstrating signs of a femoral nerve palsy, a known complication of hyperflexion in a Pavlik harness. The most appropriate immediate management is to loosen the anterior straps or temporarily remove the harness until nerve function recovers.

Question 77

A 32-year-old carpenter sustains a small puncture wound to his left index finger. Two days later, he presents with uniform swelling of the digit, flexed resting posture, and excruciating pain with passive extension.

Which of the following is the fourth Kanavel sign typically seen in this condition?

Explanation

The four classic Kanavel signs of acute suppurative flexor tenosynovitis are fusiform swelling, flexed resting posture, pain with passive extension, and tenderness along the flexor tendon sheath. Erythema, crepitus, and purulence are not considered part of the four classic signs.

Question 78

A 35-year-old man is involved in a high-speed motor vehicle collision. Radiographs and CT of the cervical spine reveal a unilateral facet dislocation at C5-C6. He is neurologically intact. MRI shows a large, extruded disc herniation posterior to the C5 vertebral body. What is the most appropriate next step in management?

Explanation

In a patient with a cervical facet dislocation and a significant anterior disc herniation, performing closed reduction or posterior reduction first can push the disc material into the spinal cord, causing neurologic deficit. An anterior approach (ACDF) should be performed first to remove the disc safely.

Question 79

A 12-year-old obese boy presents with a stable slipped capital femoral epiphysis (SCFE) of the left hip. The surgeon plans in situ fixation with a single partially threaded cannulated screw. To avoid the most common complication leading to chondrolysis, which of the following is the most sensitive intraoperative imaging technique to ensure the screw has not penetrated the joint?

Explanation

The approach-withdrawal technique using live fluoroscopy while rotating the hip is the most sensitive method to detect unrecognized screw penetration in SCFE fixation. Standard orthogonal views possess blind spots that can obscure a prominent screw tip.

Question 80

A patient sustains a severe laceration to the proximal forearm, completely transecting the median nerve. However, clinical examination reveals intact intrinsic function of the hand typically supplied by the ulnar nerve, and unexpectedly, intact thenar muscle function. Which of the following anatomical anomalies best explains this physical examination finding?

Explanation

The Martin-Gruber anastomosis is a communication between the median and ulnar nerves in the forearm. It typically carries motor fibers from the median nerve to the ulnar nerve, preserving thenar and intrinsic muscle function despite a proximal median nerve injury.

Question 81

A 65-year-old man who underwent a metal-on-metal total hip arthroplasty 8 years ago presents with groin pain and a palpable mass. Serum cobalt and chromium levels are significantly elevated. Aspiration yields sterile, cloudy fluid. Histopathology of the periprosthetic tissue is most likely to show which of the following?

Explanation

Adverse local tissue reaction (ALTR) or ALVAL in metal-on-metal hips is a delayed-type hypersensitivity reaction. Histologically, it classically presents with a perivascular lymphocytic infiltrate and macrophages laden with dark metallic debris.

Question 82

A 22-year-old soccer player sustains a twisting injury to his knee. Radiographs demonstrate an avulsion fracture of the anterolateral tibial plateau (Segond fracture). Which of the following structures is most likely injured in association with this radiographic finding?

Explanation

A Segond fracture is an avulsion of the anterolateral capsular complex from the proximal lateral tibia. It is considered a pathognomonic radiographic sign of an anterior cruciate ligament (ACL) tear.

Question 83

A 78-year-old woman with a history of severe osteoporosis presents with a displaced intracapsular femoral neck fracture (Garden IV). She is an independent community ambulator but suffers from mild Alzheimer's dementia. Which of the following is the most appropriate surgical treatment?

Explanation

In an elderly ambulator with a displaced femoral neck fracture and cognitive impairment, hemiarthroplasty is generally preferred. Total hip arthroplasty carries a significantly higher dislocation risk in patients with dementia, and internal fixation has unacceptably high failure rates in elderly displaced fractures.

Question 84

A 28-year-old construction worker drops a heavy beam on his midfoot. Radiographs reveal widening of the space between the bases of the first and second metatarsals. What is the anatomical path of the intact Lisfranc ligament?

Explanation

The Lisfranc ligament connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is a critical stabilizer of the midfoot arch, given the absence of an intermetatarsal ligament between the first and second metatarsals.

Question 85

A 15-year-old boy presents with progressive pain and swelling in his distal femur. Radiographs reveal a mixed lytic and sclerotic lesion with cortical destruction and a "sunburst" periosteal reaction. Biopsy confirms high-grade osteosarcoma. What is the most important prognostic factor for his overall survival?

Explanation

The percentage of tumor necrosis following neoadjuvant chemotherapy is the most reliable prognostic indicator for patients with high-grade osteosarcoma. Achieving greater than 90% necrosis is strongly associated with improved long-term survival.

Question 86

During the process of secondary bone healing, which of the following mechanical and biological environments most strongly promotes the differentiation of mesenchymal stem cells into chondrocytes, leading to endochondral ossification?

Explanation

Secondary bone healing involves callus formation via endochondral ossification. A relatively low oxygen (hypoxic) environment combined with moderate cyclic mechanical strain promotes the differentiation of mesenchymal stem cells into chondrocytes to form a cartilaginous callus.

Question 87

A 65-year-old woman complains of neurogenic claudication and low back pain. Upright lateral radiographs show a grade I degenerative spondylolisthesis at L4-L5. Which of the following anatomical features is most characteristic of degenerative spondylolisthesis compared to isthmic spondylolisthesis?

Explanation

Degenerative spondylolisthesis most commonly occurs at L4-L5 and is associated with sagittally oriented facet joints, which fail to resist anterior shear forces. Isthmic spondylolisthesis typically involves a pars interarticularis defect and is most common at L5-S1.

Orthopedic Prometric Exam Preparation MCQs - Part 1

Orthopedic Prometric Exam Preparation MCQs - Part 2

Orthopedic Prometric Exam Preparation MCQs - Part 2

Chapter Index