Question 1

A 67-year-old woman sustained a cerebrovascular accident 18 months previously, and has problems with ambulation. She notes that the ankle buckles with ground contact. Upon examination, she ambulates with slight circumduction of one limb, and heel varus is present during the swing and heel strike phases of gait. The procedure that would stabilize her foot during ground contact is:

Explanation

A patient with persistent hindfoot varus during ground contact has an overactive anterior tibialis, which will cause a sense of instability upon heel strike. This can be effectively treated with a split anterior tibial tendon transfer, transferring half of the tendon more laterally to the lateral cuneiform or cuboid.

Question 2

A 19-year-old man presents for treatment in the emergency department following a motorcycle accident. He sustained an isolated injury to his foot and ankle. The recommended treatment is:

Explanation

The prognosis following fracture dislocation of the navicular is not good regardless of treatment. Although one may be tempted to perform an open reduction and immediate primary talonavicular arthrodesis, this is not Orthopedic Prometric Exam Question

necessary. Following open reduction and internal fixation, arthritis of the talonavicular joint may occur.

Question 3

A 23-year-old man sustains an injury to his foot when falling off a ladder. The foot is grossly twisted inward, and the talonavicular joint is dislocated with the talar head penetrating through the extensor brevis muscle. The dislocation is reduced. The likelihood of this resulting in avascular necrosis of the talus is:

Explanation

Medial peritalar dislocation does not result in avascular necrosis of the talus. The development of subtalar arthritis is more likely.

Question 4

A 53-year-old diabetic patient presents with an ulcer on the plantar aspect of the foot that has been present for 2 years. There is mild serous drainage; bone is not exposed. The recommended treatment is:

Explanation

This is a typical chronic plantar neuropathic ulcer. There is no evidence of acute infection by appearance, and therefore, no cultures or antibiotic therapy is required. Debridement of the ulcer margin only is useful followed by application of a total contact cast. Split thickness skin grafting is never indicated on the plantar foot surface in the setting of neuropathic ulceration. Orthopedic Prometric Exam Question

Question 5

Which of the following is not a feature of the foot deformity in C harcot- Marie-Tooth disease (C MT):

Explanation

Hindfoot varus develops to counter forefoot pronation due to weakness of evertors with preservation of inverter muscle strength. The first metatarsal plantarflexes relative to the other metatarsals, leading to pronation of the forefoot. Plantarflexion of the first metatarsal occurs as part of the windlass mechanism as the intrinsics and plantar fascia contract. As the intrinsics weaken, the toe extensors pull the metatarsophalangeal (MTP) joint into hyperextension as part of the claw toe deformity. When the MTP joint hyperextends, the strength of the long toe flexors pulls the interphalangeal joint into flexion contributing to the claw toe deformity.

Question 6

A 32-year-old woman was treated surgically for ankle instability 2 years ago. She notes that her ankle is stable, but over the past year, she has noted progressive difficulty with the use of her big toe. She finds that her toe no longer touches the ground. This is confirmed upon pedobarograph testing, because there is no contact between the first metatarsal and the ground, which is an abnormal finding compared to her opposite foot. The appearance of the foot is presented. The probable cause for this is:

Explanation

The primary function of the peroneus longus is to depress or plantarflex the first metatarsal and oppose the effect of the anterior tibialis on the base of Orthopedic Prometric Exam Question

the first metatarsal. The peroneus longus is no longer functioning, and first metatarsus elevatus is present.

Question 7

A 26-year-old woman presents for treatment of painful forefoot deformity. Hallux valgus is present, with a 35Â° angle, and arthritis of the metatarsophalangeal (MP) joint. The second and third lesser toe MP joints are dislocated with juxta-articular erosions of the fourth metatarsal head noted. The ideal surgical treatment is:

Explanation

For the patient with rheumatoid arthritis, stabilization of the hallux metatarsophalangeal joint is necessary, and a combination bunionectomy and metatarsal osteotomy is unlikely to succeed in the long-term when arthritis is present. Although shortening osteotomies of the lesser toe metatarsals may be considered to reduce the joint dislocations, this procedure has not yet been reported with long-term follow-up. Silastic joint replacement is not a procedure with long-term benefit, and is not indicated for the lesser toes.

Question 8

A 20-year-old collegiate football player sustains an injury to his big toe during a scrimmage game. He was pushing off when another player fell on his foot, resulting in the hallux being hyperextended. Two days later he has pain and swelling in the joint, limited motion, and normal radiographs. The recommended treatment is:

Explanation

This is a typical turf toe injury caused by hyperextension of the hallux, and injury to the plantar plate. This injury may result in marked disability if not correctly treated, and the joint must be rested, although cast and boot immobilization is not necessary. Injection is not indicated, and taping of the toe will alleviate pain and permit ambulation.

Question 9

A 43-year-old patient presents with pain in the hallux metatarsophalangeal (MP) joint. Motion is limited in dorsiflexion and to some extent in plantarflexion, and mild arthritis is radiographically evident. If a cheilectomy is performed on this patient, what is the primary goal of the procedure in the management of hallux rigidus:

Explanation

The goal of cheilectomy is to decrease pain. Although motion may increase, this must not be the goal of surgery because the motion may only be minimally increased. Some patients improve motion markedly after cheilectomy, but this should not be the focus of treatment or promised to the patient.

Question 10

The most common complication after resection of a plantar fibromatosis is:

Explanation

The most common complication after resection of plantar fibromatosis is recurrence. Although other complications (nerve injury and wound dehiscence) do occur, they occur less frequently. The most reliable treatment for plantar fibromatosis is observation and shoe wear modification if the lesion is painful.

Question 11

A 24-year-old man presents for treatment of a painful fifth toe deformity. He had the deformity for 10 years and notes that it is getting progressively worse. On examination, a claw toe deformity is present. There is 90° of fixed hyperextension of the metatarsophalangeal joint, 70° of flexion at the interphalangeal joint, and a painful corn on the distal tip of the phalanx. The patient would like surgical correction. Which procedure is most likely to give him relief of pain and correction of deformity:

Explanation

Correction of a fixed claw fifth toe deformity is not an easy procedure. The customary procedures used for correction of other lesser toe deformities are not always successful. In this patient, PIP arthroplasty or arthrodesis alone will not correct this deformity. The deformity requires a subtotal or complete proximal phalangectomy. Although this procedure corrects the deformity, patients must know that they will inevitably have a floppy fifth toe.

Question 12

A 22-year-old collegiate basketball player presents for treatment of a stress fracture of the base of the fifth metatarsal at the junction of the metaphysis and diaphysis. The fracture was treated operatively, and the patient returned to playing basketball. Three months later, it was apparent that a repeat fracture was present. The fracture was treated with screw removal and a repeat screw fixation. Four months later, after a successful basketball season, he sustained a repeat stress fracture of the metatarsal. On examination, he has a mild cavovarus foot configuration with normal ankle range of motion. Inversion is 15Â° and eversion is 5Â°. The base of the fifth metatarsal is prominent. The most likely cause for the repeat fracture is:

Explanation

The most common cause of recurrent injury to the fifth metatarsal is unrecognized varus heel deformity. Surgeons must also check for ankle instability, which may be present in this patient. A varus heel, ankle instability, and injury to the fifth metatarsal are associated with recurrent deformity.

Question 13

Which statement regarding the peroneal tendon(s) is incorrect:

Explanation

The peroneus brevis tendon plantarflexes and everts the foot and ankle. The peroneus longus tendon plantarflexes the foot, is a mild evertor of the foot, and plantarflexes the first metatarsal. The peroneus brevis tendon is prone to tears or splits at the level of the distal fibula and lies anterior to the peroneus longus tendon at this level.

Question 14

A 41-year-old patient presents for treatment of a joint depression calcaneus fracture. A Sanders type IIA fracture is visible on a computerized tomography scan. After appropriate counseling, the patient elects nonoperative treatment. What is the most common complication of this injury that may subsequently occur in this patient:

Explanation

Subtalar arthritis occurs when a calcaneus fracture is treated nonoperatively; however, impingement of the fibula against the widened calcaneus will more frequently cause symptoms. Soft tissue problems, including tarsal tunnel syndrome, peroneal tendonitis, and sural neuritis, occur less frequently.

Question 15

A patient presents for treatment of a painful ankle 2 years after a hindfoot injury. He was treated nonsurgically for a calcaneus fracture that occurred when he fell. His symptoms include anterior ankle pain, weakness during pushing off, and pain along the lateral aspect of the hindfoot. On examination, he has pain to palpation at the tip of the fibula, absent inversion and eversion, 20Â° of plantarflexion, and no dorsiflexion. Plantarflexion strength appears adequate, and there is no compromise of the forefoot flexor function. The recommended surgical procedure is:

Explanation

This patient sustained a joint depression calcaneus fracture with a loss of the talar declination angle. He has limited dorsiflexion that is characteristic of a negative talar declination angle. This decreases the fulcrum of the Achilles tendon and weakens pushoff strength. An in situ subtalar arthrodesis may correct the subtalar joint pain but will not address the decreased height of the hindfoot and the negative talar declination angle. The negative talar declination angle can only be corrected by inserting a tricortical bone graft into the subtalar joint.

Question 16

A patient presents for treatment of painful toes 1 year after open reduction and internal fixation of a calcaneus fracture. He notes difficulty with shoe wear and pain on ambulation. On examination, there are fixed claw toe deformities of the second, third, and fourth toes that are painful. The most likely cause of the toe deformities is:

Explanation

Claw toe deformities after calcaneus fracture occur as a result of untreated compartment syndrome. C ompartment syndrome occurs as a result of intrinsic muscle atrophy or fibrosis of the short flexor muscles followed by fixed toe deformity.

Question 17

A 56-year-old patient sustained an ankle fracture 3 years ago that was treated with closed reduction and cast immobilization. Since the injury, she has experienced pain upon ambulation and ankle stiffness. On examination, the range of motion of the ankle is 5Â° of dorsiflexion and 30Â° of plantarflexion. C repitus with motion is not present, but the patient does experience severe pain. A radiograph is presented (Slide). The recommended procedure to alleviate the patientâ s pain and improve function is:

Orthopedic Prometric Exam Question

Explanation

The arthritis in this joint is not severe, but there is joint malalignment associated with a short and externally rotated fibula. Joint malalignment is correctable with a lengthening and rotational (internal) osteotomy of the fibula with bone graft. Joint debridement, either open or arthroscopic, is not effective in the management of posttraumatic ankle arthritis. Arthrodesis and arthroplasty are not necessary at this stage.

Question 18

A 43-year-old construction worker presents for treatment of ankle pain. The patient recounts a fall from a height that caused an ankle fracture 2 years ago. The fracture was treated with closed reduction and cast immobilization for 5 months. He experiences pain upon ambulation and is unable to work. On examination, the range of ankle motion is 5Â° dorsiflexion and 20Â° plantarflexion. There is no crepitus with motion, but severe pain is present. A radiograph is presented (Slide 1). The recommended procedure to alleviate pain and improve function is:

Explanation

The arthritis in this joint is not severe, but there is joint malalignment associated with a short and externally rotated fibula and a marked valgus tibiotalar deformity. Although arthrodesis or total ankle replacement may be considered as treatment for some patients, this patient is not a good candidate for these procedures because he does not have severe arthritis. The deformity must be corrected with an osteotomy of the tibia and fibula. Although an opening wedge osteotomy may be considered, a closing wedge procedure is easier to perform and has a higher rate of healing. Orthopedic Prometric Exam Question

Question 19

A 29-year-old patient has had pain in her foot for 1 year. She twisted her ankle and was treated for a sprain with a brace and therapy. She has persistent pain in her foot and pain on ambulation. On examination, slight pes planus is present, pain is noted on manipulation of the foot, and there is tenderness in the midfoot and hindfoot. A radiograph is presented (Slide). The most likely cause of the pain is:

Explanation

Slight abduction of the tarsometatarsal joints is noted, along with arthritis of the medial and middle columns of the midfoot. This likely resulted from a tear of the ligament between the base of the second metatarsal and the medial cuneiform (Lisfranc ligament).

Question 20

A 53-year-old man presents with a swollen foot. He does not recall any injury to the foot, and he has minimal pain. He does not have any pertinent medical history. The clinical and radiographic appearance of the foot is presented (Slide 1 and Slide 2). Based upon the information, the recommended treatment of this injury is:

Explanation

Patients with neuropathy may present for the first time with a neuropathic dislocation (C harcot neuroarthropathy) even before the cause of the neuropathy is diagnosed. The recommended treatment of an acute neuropathic midfoot dislocation is open reduction and primary arthrodesis. Although ORIF without arthrodesis may be considered, recurrent deformity frequently occurs.

Question 21

A 49-year-old woman has had swelling in the posterior aspect of the ankle for 5 years (Slide). The pain is focal and does not radiate. She notes that pain is worse with activity, exercise, and shoe wear. Which of the following is not an acceptable treatment for this patient:

Orthopedic Prometric Exam Question

Explanation

Insertional Achilles tendinopathy is aggravated by a hard heel counter on the shoe, a flat shoe, or exercise without stretching. Therapy modalities are effective for treatment of this condition. If patients do not respond to nonoperative measures, then surgery with debridement of the Achilles tendon and posterior calcaneus may be required. Osteotomy of the calcaneus (as opposed to ostectomy) is not an effective treatment.

Question 22

This slide (the arrow is pointing in the direction of the pathology) illustrates which of the following conditions of the Achilles tendon:

Explanation

This ultrasound is a longitudinal section of the Achilles tendon demonstrating acute rupture. Note the defect in continuity of the tendon below the skin surface. No tendon defects are noted in paratendinitis and tendinosis.

Question 23

Which of the statements regarding paratendinitis of the Achilles tendon is true:

Orthopedic Prometric Exam Question

Explanation

Paratendinitis of the Achilles tendon is commonly associated with runners who hyperpronate. Paratendinitis of the Achilles tendon is amenable to stretching, physical therapy treatments, and an orthotic support that controls rapid pronation during the flat foot phase of gait. Although the condition can become chronic and require surgery, it does not lead to or predispose to a degenerative rupture.

Question 24

A 65-year-old woman presents for treatment of a painful flatfoot condition. On examination, the hindfoot is in marked valgus and a rupture of the posterior tibial tendon is noted. The recommended treatment is a transfer of the flexor digitorum longus tendon and a medial translational osteotomy of the calcaneus. The rationale for the osteotomy includes all of the following except:

Explanation

A medial translational osteotomy of the calcaneus shifts the axis of the Achilles tendon insertion medial to the axis of the subtalar joint. In doing so, the lateralizing force of the gastrocnemius on the heel is lessened and the medial tendon shift augments the strength of the flexor digitorum longus transfer and improves the mechanical efficiency of the foot by altering the ground reaction forces.

Question 25

Which of the following muscles has the largest cross-sectional diameter:

Explanation

Following the muscles of the gastrocnemius soleus muscle group, the flexor hallucis longus is the most powerful flexor of the ankle. The flexor hallucis longus is almost twice as strong as the flexor digitorum longus. These are important factors when planning tendon transfers in the foot and ankle.

Question 26

After surgery to the hallux, a patient complains of burning and numbness along the medial aspect of the first metatarsal. The numbness extends from the medial cuneiform distally to the midportion of the first metatarsal and junction of the plantar and dorsal skin. The nerve involved with the pain is the:

Explanation

The branches of the various sensory nerves of the foot are important to understand. The normal and aberrant topographic anatomy is important in any foot surgery, and management of posttraumatic neuritis is contingent upon an understanding of the anatomy.

Question 27

The most common complication after resection arthroplasty (Keller) of the base of the hallucal proximal phalanx for correction of hallux valgus is:

Explanation

Resection of the base of the hallucal proximal phalanx detaches the volar plate and the medial and lateral head of the flexor brevis tendon. This leads to weakening of plantarflexion strength and dorsal contracture. The weakness may also lead to lateral overload, metatarsalgia, and stress fracture.

Question 28

A patient sustains a fracture of the anterior process of the calcaneus. What ligament is responsible for avulsion of this bone:

Explanation

The bifurcate ligament extends from the anterior process of the calcaneus to the cuboid and navicular. In certain plantarflexion and inversion injuries of the hindfoot, the ligament, which is strong, will avulse the anterior process of the calcaneus.

Question 29

The ball and socket ankle deformity shown (Slide) is associated with all of the following except:

Explanation

A ball and socket ankle deformity is caused by limited motion of the peritalar joints, particularly the subtalar and talonavicular joints, during childhood. For example, a talonavicular coalition limits inversion and eversion, and the tibiotalar joint compensates for this loss by increasing motion in the horizontal plane. As motion is increased in the horizontal plane, the medial and lateral edges of the tibiotalar articulation round off and the ball and socket joint develops.

Question 30

A patient wants a below the knee amputation. As an alternative, you recommend a Syme amputation. What is the most relevant factor that would contraindicate performing a Syme amputation:

Explanation

Although the Syme amputation was once popular because it allowed patients to ambulate for short distances (e.g., around their house) without using a prosthesis, surgeons now perform more below the knee amputations because of newer prosthetic designs. The Syme procedure still remains in our surgical armamentarium. The only factor listed in the answer choices that may preclude amputation at this level is peripheral vascular disease. A more important factor that would contraindicate performing a Syme amputation is perfusion to the heel pad.

Question 31

Which of the following statements regarding a fracture of the junction of the proximal metaphyseal and diaphyseal portion of the fifth metatarsal is false:

Explanation

The fracture of the junction of the proximal metaphyseal and diaphyseal portion of the fifth metatarsal, otherwise known as the Jones fracture, causes complications with bone healing. The fracture is caused by a plantarflexion inversion twist of the foot and ankle and needs prompt treatment because nonunion rates are high with this type of fracture.

Question 32

A foot is maximally dorsiflexed during this point of the gait cycle:

Explanation

During gait, a foot is dorsiflexed during midswing and foot flat. During midswing, the anterior tibial muscle maintains the foot in a dorsiflexed position to facilitate a smooth heelstrike. This is an active dorsiflexion of the foot and ankle. The maximum dorsiflexion of the foot, however, is passive and occurs as the leg moves forward over the foot during foot flat at midstance.

Question 33

Which of the following structures is disrupted in patients with an acute medial subtalar dislocation:

Explanation

As the foot and the subtalar joint move medially, the subtalar ligaments and the ligaments on the lateral aspect of the ankle are disrupted. The talocalcaneal, or interosseous, ligament is the only ligament that is vulnerable in an acute medial subtalar dislocation.

Question 34

An 8-year-old soccer player has had bilateral heel pain for 3 months. He has no constitutional complaints. Isolated tenderness to the posterior aspect of his calcaneal tuberosity is present. Recommended treatment is:

Explanation

Posterior heel pain in a child is common. This scenario describes an apophysitis of the insertion of the Achilles tendon, referred to as Sever disease. The condition is self-limited and responds well to stretching of the Achilles tendon, temporary limitation of activities, and ice applied to the heel after exercise.

Question 35

A 26-year-old recreational volleyball player presents with complaints of recurrent right ankle instability. She has undergone 3 months of peroneal strengthening and proprioceptive training without success. She has tried and failed ankle bracing. She has a positive anterior drawer finding on examination, and her hindfoot is in neutral alignment. The recommended surgical plan is:

Explanation

In an athlete, unless there are unusual anatomic and physical findings, the appropriate ankle reconstruction is an anatomic repair of the ligaments as originally described by Brostrum. Procedures that use the peroneal tendon or tendon grafts should be used in circumstances when a high demand is put on the ankle (e.g., if the patient is heavy or if generalized ligamentous laxity is present).

Question 36

A 65-year-old woman presents with pain along the posteromedial aspect of her right ankle. She has a clinical deformity of her foot with loss of normal arch height. Her hindfoot is in valgus but is passively correctable to neutral. She has weakness with inversion and cannot perform a single stance heel raise. She has not had any form of treatment. Recommended treatment includes:

Explanation

Although there is the likelihood that this patient may ultimately require surgery, the nonoperative management of posterior tibial tendon rupture is important. The success rate of bracing is variable, but bracing must be used as the first line of treatment for a patient as described above.

Question 37

After counseling a 22-year-old patient who is scheduled to undergo a triple arthrodesis, he wants to know the risk that he will develop ankle arthritis. You tell him:

Explanation

Ankle arthritis commonly occurs following a triple arthrodesis. In a recent study by Pell and colleagues, the incidence of ankle arthritis in 134 patients who underwent a triple arthrodesis with a 5.6-year mean follow-up was 53%. Although not all of these patients are symptomatic, this is a problem.

Question 38

A 57-year-old woman presents for treatment of a painful flatfoot deformity. She says that her foot has been painful for 4 years, but she does not recall any injury to the foot. The opposite foot is not bothersome. Upon examination, she has pain in the midfoot and hindfoot. Resisted inversion is strong and painful. She is able to perform a single and repetitive heel rise test. The most likely diagnosis is:

Explanation

Osteoarthritis of the tarsometatarsal joints in the adult is common. Patients are usually 50 to 60 years old, and the condition typically presents with pain in the midfoot and becomes progressively worse over time. The posterior tibial tendon is not torn, but as the foot becomes flatter and the forefoot more abducted there may be secondary stretching or tearing of the posterior tibial tendon.

Question 39

Which clinical examination is likely to confirm a suspected rupture of the posterior tibial tendon:

Explanation

The anterior tibial tendon can compensate for a weak posterior tibial tendon. The primary function of the anterior tibial tendon is dorsiflexion, although the tendon may also invert the foot, particularly against resistance in the presence of a ruptured posterior tibial tendon. To prevent the anterior tibial tendon from inverting the foot, position the foot in plantarflexion and abduction to begin with when testing resistance to inversion.

Question 40

The most reliable indication of an interdigital neuroma in the second web space is:

Explanation

A click when compressing the forefoot (referred to as a positive Mulder sign) is not diagnostic of a neuroma and is present due to an enlarged intermetatarsal bursa. The sensation of pain and burning is varied, and some patients report only a vague numbness. Magnetic resonance imaging can have a false positive and false negative result; therefore, it must not be relied upon for diagnosis. The most reliable finding on physical examination is pain on compression of the affected web space.

Question 41

A 68-year-old patient presents for evaluation of ankle pain. He is unable to walk more than 10 minutes without pain and stiffness. He has been treated with anti-inflammatory medication, intra-articular injection of steroid, and an ankle foot orthosis. He has 35Â° of clinical motion associated with crepitus and pain and there is no motion in the subtalar joint. Radiographs demonstrate large osteophytes in the anterior ankle, no joint space, and mild osteophytes of the talonavicular joint. The recommended surgical treatment is:

Explanation

A patient with good range of motion of the ankle associated with poor subtalar motion and ankle arthritis is a candidate for a total ankle replacement. Although ankle arthrodesis may be considered, in the presence of a stiff subtalar joint, osteophytes of the talonavicular joint, and good ankle motion, this procedure is likely to lead to a high incidence of peritalar arthritis and pain.

Question 42

A 21-year-old recreational athlete presents for treatment of ankle weakness. She notes that she trips frequently, that the ankle feels unstable, particularly on uneven ground surfaces, and that she has experienced frequent sprains. On examination, the ankle appears to be unstable and radiographs demonstrate no instability on stress testing. The most likely diagnosis is:

Explanation

This patient has subtalar instability. When there is no instability demonstrated on radiographic stress testing despite a history of recurrent ankle sprains, the subtalar joint must be assessed.

Question 43

The symptoms of a tarsal tunnel syndrome may become aggravated by:

Explanation

Pronation of the foot places increased stretch on the tibial nerve. This motion has important implications for treatment because the pronated flatfoot should be supported with an orthotic arch support in patients with symptoms of a tarsal tunnel syndrome.

Question 44

A 56-year-old woman presents for evaluation and treatment of a painful hallux. She notes the pain over the dorsal surface of the hallux metatarsophalangeal (MP) joint and on the plantar aspect of the hallux interphalangeal (IP) joint. C linically, there is no range of motion in dorsiflexion of the hallux MP joint, pain upon attempted movement of the MP joint, and 20° of extension of the hallux IP joint. Radiographs demonstrate arthritis of the hallux MP joint and normal alignment of the first metatarsal. The surgical procedure that is likely to cause further mechanical problems for this patient is:

Explanation

This patient has end stage arthritis and rigidus of the hallux MP joint. Hyperextension of the IP joint is already present. If arthrodesis of the MP joint were performed, then further load and instability of the IP joint would occur.

Question 45

A 38-year-old woman presents for evaluation of painful hallux rigidus. Her clinical and radiographic images are shown (Slide 1 and Slide 2). Based upon her presentation, what is the likelihood that first metatarsus elevatus is responsible for her clinical condition:

Explanation

Surgeons cannot assume that an elevated first metatarsal is responsible for causing hallux rigidus. On a lateral radiograph, there may be notable elevation of the first metatarsal (as present in this patient), but the elevation may be a secondary result of the limited motion of the hallux metatarsophalangeal joint. Studies have demonstrated that there is no difference in the elevation of the first metatatarsal in patients with hallux rigidus.

Question 46

The patient shown in Slide 1 and Slide 2 underwent surgical correction of painful hallux rigidus. The purpose of the procedure on the hallux was:

Explanation

The osteotomy of the proximal phalanx of the hallux (the Moberg osteotomy) is designed to elevate the hallux off the ground. The procedure does not improve the range of motion of the MP joint, but it increases the available motion of the hallux in toe off.

Question 47

Of the proximal first metatarsal osteotomies listed below, which has the least stability for dorsiflexion load:

Explanation

The crescentic osteotomy is inferior on mechanical testing to the other proximal first metatarsal osteotomies. This must be considered when planning correction of deformity associated with hallux valgus, particularly in a patient with osteopenia.

Question 48

A 54-year-old patient presents for correction of painful hallux valgus. She has a prominent medial eminence, pain on pressure over the metatarsophalangeal (MP) joint, increased elevation of the first metatarsal, and painful callosity under the second metatarsal. The recommended procedure is:

Explanation

This patient has typical findings of hypermobility of the first metatarsal. The increased pressure under the second metatarsal head may be the result of elevation of the first metatarsal or dysfunction of the windlass mechanism that depresses the first metatarsal upon toe off. Hypermobility of the first ray associated with hallux valgus is successfully treated with arthrodesis of the metatarsocuneiform joint or the modified Lapidus procedure.

Question 49

This patient was treated for metatarsalgia with an oblique osteotomy of the metatarsal head and neck (Weil osteotomy). Although the symptoms of metatarsalgia dissipated, she has continued complaints about the position of the toe (Slide 1 and Slide

Explanation

Following an oblique osteotomy of the metatarsal head and neck (Weil osteotomy), the interosseous tendons shift dorsal to the axis of the metatarsal head. Instead of functioning as strong plantarflexors of the MP joint, they may now function as dorsiflexors, leading to the elevation of the toe off the ground and dorsal contracture.

Question 50

The strongest plantarflexor of the metatarsophalangeal (MP) joint of the lesser toes is the:

Explanation

Although the short flexor tendon plantarflexes the MP joint of the lesser toes, the interosseous tendons are stronger. When intrinsic atrophy or dysfunction of the forefoot is present, an intrinsic minus deformity occurs. The long flexor tendon does not flex the MP joint.

Question 51

A 35-year-old male sustains an axial load injury to a plantarflexed foot. Radiographs reveal widening of the space between the first and second metatarsals. A "fleck sign" is also noted. The primary ligament injured in this condition originates from and inserts into which of the following structures?

Explanation

The Lisfranc ligament is a critical stabilizing structure of the midfoot. It traverses from the medial cuneiform to the base of the second metatarsal. A "fleck sign" represents a bony avulsion of this exact ligament.

Question 52

A 45-year-old female presents after a high-speed motor vehicle collision with a Schatzker IV tibial plateau fracture. Which of the following neurovascular structures is at the highest risk of injury in this specific fracture pattern?

Explanation

A Schatzker IV fracture involves the medial tibial plateau and is typically the result of high-energy trauma. Due to the high energy and valgus deforming forces, there is a significantly increased risk of popliteal artery injury and compartment syndrome.

Question 53

A 65-year-old male complains of worsening clumsiness in his hands and difficulty buttoning his shirts over the last 6 months. Examination reveals a positive Hoffman's sign bilaterally and hyperreflexia in the lower extremities. What is the most appropriate next step in management?

Explanation

The clinical presentation is classic for cervical spondylotic myelopathy, indicated by upper extremity clumsiness and upper motor neuron signs (Hoffman's, hyperreflexia). MRI of the cervical spine is the gold standard imaging modality to evaluate for cord compression.

Question 54

A 13-year-old obese male presents with a 3-week history of groin pain and a limp. On examination, there is obligatory external rotation of the hip during passive hip flexion. The pathology of this condition occurs primarily through which zone of the physis?

Explanation

The patient has a slipped capital femoral epiphysis (SCFE), characterized by groin pain and obligatory external rotation during hip flexion. The mechanical failure and slippage occur through the hypertrophic zone of the physis.

Question 55

A 70-year-old female presents with recurrent posterior dislocations following a primary total hip arthroplasty. Radiographic evaluation shows the acetabular component is placed in 10 degrees of anteversion and 30 degrees of inclination. What is the most appropriate surgical intervention?

Explanation

The target safe zone for an acetabular component is typically 15-20 degrees of anteversion and 40-45 degrees of inclination. The cup is under-anteverted (retroverted relative to ideal), predisposing the patient to posterior dislocation, and requires revision to increase anteversion.

Question 56

A 22-year-old female soccer player sustains a non-contact pivoting injury to her knee, hearing a loud "pop." Radiographs show an elliptic bone fragment avulsed from the lateral tibial plateau (Segond fracture). This fracture represents an avulsion of which structure?

Explanation

A Segond fracture is a pathognomonic radiographic sign for an anterior cruciate ligament (ACL) tear. It represents an avulsion of the anterolateral ligament (ALL) and lateral capsular structures from the proximal anterolateral tibia.

Question 57

A 24-year-old male falls on an outstretched hand and presents with anatomic snuffbox tenderness. Initial standard radiographs of the wrist are negative for fracture. What is the most appropriate next step in management to definitively rule out a fracture?

Explanation

In cases of suspected scaphoid fractures with negative initial radiographs, MRI is highly sensitive and specific for detecting occult fractures. Alternatively, immobilization and repeat radiographs at 10-14 days can be performed.

Question 58

A 30-year-old male sustains a completely displaced femoral neck fracture (Pauwels type III) following a fall from a height. He is neurovascularly intact. What is the most appropriate definitive treatment?

Explanation

In young adults, every effort should be made to preserve the native femoral head. Displaced femoral neck fractures require urgent closed or open reduction and internal fixation (CRIF/ORIF) to minimize the risk of avascular necrosis and nonunion.

Question 59

A 40-year-old construction worker undergoes ORIF of a displaced intra-articular calcaneus fracture via an extensile lateral approach. The most common wound complication associated with this approach is necrosis of the flap apex. Which artery primarily supplies this flap?

Explanation

The extensile lateral approach to the calcaneus relies on the blood supply from the lateral calcaneal artery. Proper full-thickness flap creation (no-touch technique) is essential to prevent apical wound necrosis.

Question 60

A 6-month-old female is referred for asymmetric thigh folds and limited hip abduction. Which imaging modality is most appropriate to evaluate for developmental dysplasia of the hip (DDH) at this age?

Explanation

While ultrasound is the modality of choice for infants under 4 to 6 months, plain AP pelvis radiographs become more reliable at 6 months of age. This is due to the progressive ossification of the femoral head (ossific nucleus).

Question 61

A 15-year-old male presents with worsening distal femur pain. Radiographs reveal a mixed lytic/sclerotic lesion with a "sunburst" periosteal reaction. Staging studies are performed. What is the most common site of metastasis for this primary bone tumor?

Explanation

The clinical and radiographic presentation is classic for osteosarcoma. The lungs are the most common site of initial metastasis for osteosarcoma, making chest CT a critical component of staging.

Question 62

A 68-year-old male is 5 years post-primary total knee arthroplasty and presents with a swollen, painful knee. Aspirate reveals 65,000 WBC/hpf with 95% polymorphonuclear cells. What is the most widely accepted surgical treatment for this chronic periprosthetic joint infection?

Explanation

A late, chronic periprosthetic joint infection (>4 weeks post-op) requires explantation of the implants. A two-stage revision arthroplasty (antibiotic spacer followed by delayed reimplantation) is the gold standard for eradicating the infection.

Question 63

A 28-year-old male sustains an open midshaft tibia fracture. There is a 12 cm laceration with severe periosteal stripping, and the wound cannot be closed primarily, requiring a rotational muscle flap for coverage. What is the correct Gustilo-Anderson classification?

Explanation

Gustilo-Anderson Type IIIB fractures involve extensive soft-tissue injury with periosteal stripping and bone exposure, requiring a local or free flap for coverage. Type IIIC would involve an arterial injury requiring repair.

Question 64

A 72-year-old female presents with bilateral leg pain and heaviness that worsens with walking and improves when leaning over a shopping cart. At which spinal level does the pathology causing this condition most frequently occur?

Explanation

The patient's symptoms describe neurogenic claudication secondary to lumbar spinal stenosis. The L4-L5 level is the most common site for degenerative lumbar spinal stenosis and degenerative spondylolisthesis.

Question 65

A closed tibia fracture is treated with a long leg cast. The fracture heals primarily through callus formation. This type of bone healing relies fundamentally on which cellular process?

Explanation

Secondary bone healing (callus formation), typically seen with cast immobilization or relative stability, occurs mainly via endochondral ossification. In this process, a cartilage model is initially formed and subsequently replaced by bone.

Question 66

A 25-year-old male presents with recurrent anterior shoulder instability. Advanced imaging reveals 25% anterior glenoid bone loss and a large, engaging Hill-Sachs lesion. Which surgical procedure is most appropriate to prevent recurrence?

Explanation

Critical glenoid bone loss (>20-25%) combined with an engaging Hill-Sachs lesion is a strict contraindication to isolated soft-tissue (Bankart) repair. A bony augmentation procedure, such as the Latarjet (coracoid transfer), is required to restore stability.

Question 67

A 42-year-old man presents in hemorrhagic shock following a severe crush injury to his pelvis. Pelvic radiograph shows a 4 cm pubic symphysis diastasis with disruption of the sacroiliac joints. Following 1L of crystalloid fluid, his blood pressure remains 75/40 mmHg. The most appropriate immediate next step in management is:

Explanation

The initial management of a mechanically unstable pelvic ring injury in a hemodynamically unstable patient is closing the pelvic volume with a binder or sheet. This facilitates tamponade of venous bleeding and bony stabilization prior to potential angiography or surgery.

Question 68

A 12-year-old boy presents with left hip pain and an obligate external rotation of the hip with flexion. Radiographs confirm a mild left slipped capital femoral epiphysis (SCFE). Which of the following is the strongest indication for prophylactic pinning of the contralateral asymptomatic hip?

Explanation

Prophylactic pinning of the contralateral hip in SCFE is strongly recommended for patients with underlying endocrinopathies, radiation therapy, or renal failure. These systemic conditions present an exceptionally high risk for bilateral involvement.

Question 69

A 55-year-old man with poorly controlled diabetes presents with a swollen, warm, and erythematous right foot. Radiographs reveal prominent bone fragmentation, subluxation at the tarsometatarsal joints, and joint debris.

According to the Eichenholtz classification, what is the current stage and most appropriate management?

Explanation

The clinical and radiographic presentation describes Eichenholtz Stage 1 (Developmental/Fragmentation), characterized by debris, fragmentation, and subluxation. The mainstay of treatment during this active phase is offloading and immobilization, typically with a total contact cast.

Question 70

A 62-year-old woman undergoes an uncomplicated total hip arthroplasty using a ceramic-on-ceramic bearing surface. Two years postoperatively, she complains of an audible 'squeaking' sound from her hip during walking. What surgical factor is most strongly associated with this phenomenon?

Explanation

Squeaking in ceramic-on-ceramic THA is heavily associated with component malposition, specifically acetabular cup retroversion or excessive anteversion/inclination. This leads to edge loading, disruption of fluid film lubrication, and subsequent stripe wear.

Question 71

A 68-year-old man presents with deteriorating handwriting and frequent falls. Examination reveals hyperreflexia in both lower extremities and a positive Hoffmann's sign. He exhibits the 'finger escape sign' when asked to hold his fingers extended and adducted. This sign is most commonly associated with compression of which of the following spinal cord tracts?

Explanation

The finger escape sign (inability to maintain the ulnar digits in adduction/extension) is a specific sign of cervical myelopathy. It indicates upper motor neuron dysfunction resulting from compression of the descending corticospinal tract.

Question 72

A 28-year-old carpenter sustains a laceration over the volar aspect of the proximal phalanx of his index finger. Examination reveals the inability to actively flex the proximal and distal interphalangeal joints. This injury occurred in which flexor tendon zone, and what is the optimal timing for primary repair?

Explanation

Lacerations over the proximal phalanx fall within Zone II ('No Man\'s Land'), involving both FDS and FDP tendons. Primary repair is typically indicated within the first 1 to 2 weeks to optimize functional outcomes and prevent tendon retraction.

Question 73

A 22-year-old female soccer player undergoes anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone (BPTB) autograft. Compared to the native ACL, what is the ultimate tensile load of a 10 mm wide BPTB graft?

Explanation

The ultimate tensile load of a 10 mm BPTB autograft is approximately 2977 N, which is roughly 138-160% of the native ACL (which is around 2160 N). This high initial strength makes it an excellent choice for demanding athletic patients.

Question 74

A 15-year-old boy is diagnosed with a conventional high-grade intramedullary osteosarcoma of the distal femur. He undergoes neoadjuvant chemotherapy followed by wide surgical resection. Which of the following is the most important prognostic factor for his overall survival?

Explanation

The histologic response to neoadjuvant chemotherapy, defined by the percentage of tumor necrosis in the resected specimen (Huvos grading), is the single most significant prognostic indicator for overall survival in osteosarcoma.

Question 75

A 31-year-old man falls from a height and sustains a displaced fracture of the talar neck with subluxation of the subtalar joint, but the tibiotalar joint remains congruous.

According to the Hawkins classification, what is the expected rate of avascular necrosis (AVN) of the talar body for this injury?

Explanation

This describes a Hawkins Type II talar neck fracture, involving subtalar subluxation or dislocation with a normal tibiotalar joint. The reported incidence of AVN for Type II fractures ranges from 20% to 50%.

Question 76

A 45-year-old man undergoes open reduction and internal fixation of a transverse radial shaft fracture using a dynamic compression plate providing absolute stability. Which of the following histologic processes predominantly characterizes the bone healing in this scenario?

Explanation

Rigid internal fixation providing absolute stability and anatomic reduction bypasses callus formation. It relies on primary (direct) bone healing via osteoclast cutting cones that cross the fracture gap, followed directly by osteoblastic bone deposition.

Question 77

A 2-week-old infant is being treated for idiopathic congenital talipes equinovarus using the Ponseti method. After sequential correction of the cavus, adductus, and varus deformities over several weeks, the foot remains in significant equinus. What is the next appropriate step in management?

Explanation

In the Ponseti method, after correcting cavus, adductus, and varus, residual equinus deformity requires a percutaneous Achilles tenotomy prior to the final cast. Forceful dorsiflexion against a tight Achilles must be avoided as it causes a rocker-bottom deformity.

Question 78

A 24-year-old man falls onto an outstretched hand and complains of anatomic snuffbox tenderness. MRI confirms a nondisplaced fracture of the proximal pole of the scaphoid. What is the primary arterial supply to the proximal pole of the scaphoid that places it at high risk for nonunion and avascular necrosis?

Explanation

The scaphoid has a retrograde blood supply. The dorsal carpal branch of the radial artery enters the dorsal ridge at the distal pole and waist, leaving the proximal pole entirely dependent on this retrograde flow.

Question 79

A 70-year-old woman who underwent a primary total knee arthroplasty 4 years ago presents with a sudden inability to actively extend her knee after a fall. Radiographs reveal a normal-appearing prosthesis but superior displacement of the patella. What is the most appropriate surgical management for this acute injury?

Explanation

An acute patellar tendon rupture following a TKA necessitates surgical repair. However, primary repair alone carries a prohibitively high failure rate; therefore, augmentation with autograft, allograft (extensor mechanism allograft), or synthetic mesh is the standard of care.

Question 80

A 35-year-old male presents to the emergency department after a high-speed motor vehicle collision. Radiographs demonstrate a butterfly fragment of the pubic rami and widening of the sacroiliac joint. During the secondary survey, blood is noted at the urethral meatus. What is the most appropriate next step in management?

Explanation

Blood at the urethral meatus is a classic sign of a possible urethral tear in the setting of pelvic trauma. A retrograde urethrogram must be performed prior to any attempt at Foley catheter placement to avoid converting a partial tear into a complete transection.

Question 81

A 16-year-old female soccer player sustains a non-contact pivoting injury to her knee. MRI confirms an isolated rupture of the anterior cruciate ligament (ACL). Which of the following anatomic factors is most strongly associated with an increased risk for this specific injury pattern?

Explanation

An increased posterior tibial slope is a recognized anatomic risk factor for non-contact ACL tears due to increased anterior tibial translation under axial load. A narrow intercondylar notch and increased Q angle also predispose patients to ACL injuries.

Question 82

A 65-year-old woman undergoes a primary total hip arthroplasty via a posterior approach. Six weeks postoperatively, she presents to the emergency department with a posterior dislocation that occurred while rising from a low toilet seat. Which of the following component positions is most likely responsible for this instability?

Explanation

Decreased femoral anteversion (or retroversion) of the femoral component strongly predisposes a THA to posterior dislocation, particularly during hip flexion and internal rotation. Excessive acetabular anteversion typically leads to anterior instability.

Question 83

A 13-year-old obese male presents with a 4-week history of right groin pain and a worsening limp. Physical examination reveals an obligate external rotation of the hip during passive flexion. Radiographs demonstrate posterior and inferior displacement of the proximal femoral epiphysis. What is the standard of care for this condition?

Explanation

The standard of care for a stable Slipped Capital Femoral Epiphysis (SCFE) is in situ fixation, typically utilizing a single cannulated screw. Attempting a closed reduction significantly increases the risk of avascular necrosis of the femoral head.

Question 84

A 22-year-old man falls on an outstretched hand and complains of severe radial-sided wrist pain. Examination reveals marked tenderness within the anatomic snuffbox.

Initial PA and lateral radiographs are interpreted as negative. What is the most appropriate initial management?

Explanation

Occult scaphoid fractures may not be visible on initial plain radiographs immediately following an injury. Applying a thumb spica splint and reassessing with follow-up radiographs or an MRI in 10-14 days prevents displaced nonunions of potentially hidden fractures.

Question 85

A 15-year-old boy presents with severe knee pain that awakens him at night. Plain radiographs reveal a mixed lytic and sclerotic lesion in the distal femoral metaphysis with a prominent 'sunburst' periosteal reaction. Core biopsy confirms high-grade intramedullary osteosarcoma. What is the standard sequence of treatment?

Explanation

The current standard of care for high-grade intramedullary osteosarcoma includes neoadjuvant chemotherapy, wide surgical resection (limb salvage if possible), and adjuvant chemotherapy. Osteosarcoma is generally radioresistant, making radiation therapy a non-primary modality.

Question 86

A 70-year-old man complains of dropping objects and difficulty buttoning his shirts, along with a stiff, broad-based gait. Physical examination demonstrates a positive Hoffmann sign bilaterally, hyperreflexia in the lower extremities, and an inverted supinator reflex. What is the most likely diagnosis?

Explanation

The combination of hand clumsiness, gait disturbances, and upper motor neuron signs (such as a positive Hoffmann sign and hyperreflexia) strongly indicates cervical spondylotic myelopathy. It is the most common cause of spinal cord dysfunction in individuals over 55.

Question 87

A 28-year-old man sustains a closed tibial shaft fracture during a football tackle. Twelve hours post-injury, he develops excruciating leg pain that is out of proportion to the injury and unrelieved by intravenous opioids. His pain is exacerbated by passive stretch of the hallux. Pulses are palpable. What is the definitive treatment?

Explanation

Pain out of proportion to the injury and pain with passive stretch are the earliest and most reliable clinical indicators of acute compartment syndrome. The definitive treatment is emergent surgical decompression via a four-compartment fasciotomy; palpable pulses do not rule out the condition.

Question 88

A 55-year-old man with a 15-year history of poorly controlled type 2 diabetes presents with a swollen, warm, and erythematous right foot. He denies fever, chills, or any open wounds. Plain radiographs show midfoot osteopenia and early subluxation of the tarsometatarsal joints. Inflammatory markers are only mildly elevated. What is the most appropriate initial management?

Explanation

The clinical presentation describes the acute (Eichenholtz stage I) phase of Charcot neuroarthropathy. The gold standard for initial management is immediate offloading and immobilization using a total contact cast to arrest the progression of bone destruction and deformity.

Question 89

A basic science researcher is studying the mechanics of fracture healing.

Under conditions of absolute stability, such as rigid compression plating where the fracture site experiences less than 2% interfragmentary strain, which biological process predominantly dictates bone healing?

Explanation

Absolute stability yielding less than 2% strain suppresses callus formation and permits primary bone healing. This process occurs directly via osteoclastic cutting cones crossing the fracture gap, closely followed by osteoblasts laying down new lamellar bone.

Orthopedic Prometric Exam Preparation MCQs - Part 1

Orthopedic Prometric Exam Preparation MCQs - Part 3

Orthopedic Prometric Exam Preparation MCQs - Part 3

Chapter Index