Orthopedics Hyperguide Review | Dr Hutaif General Ortho -...

Question 1High Yield

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 2High Yield

Figure 1
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 3High Yield

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 4High Yield

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 5High Yield

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 6High Yield

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 7High Yield

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 8High Yield

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 10Â° dorsiflexion and 30Â° 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 10Â°. 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 9High Yield

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 10High Yield

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

C heilectomy 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 11High Yield

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 75Â° dorsiflexion and 25Â° plantarflexion. Motion of the first metatarsal is approximately 8Â° to 10Â° of combined dorsiflexion and plantarflexion. There is no pain to range of motion of these joints. The hallux valgus angle is 28Â° and the 1-2 intermetatarsal angle is 12Â°. 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 12High Yield

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 13High Yield

Figure 1
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 14High Yield

Figure 1
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:

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 15High Yield

Figure 1 Figure 2
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 16High Yield

Slide 1 Slide 2
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.

Question 17High Yield

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 18High Yield

Figure 1
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 19High Yield

Figure 1
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 20High Yield

Figure 1
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 21High Yield

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 22High Yield

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 23High Yield

Slide 1
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.

Question 24High Yield

Slide 1
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 25High Yield

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 26High Yield

Slide 1
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 27High Yield

Figure 1
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 28High Yield

Slide 1
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 29High Yield

Slide 1
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 30High Yield

Figure 1
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 31High Yield

Figure 1
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:

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 32High Yield

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 33High Yield

Figure 1 Figure 2
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:

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 34High Yield

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 quadratus plantae is more posteriorly located and considered to be in a separate calcaneal compartment.

Question 35High Yield

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 36High Yield

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 âmildâ 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 37High Yield

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 patientâs 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 38High Yield

Figure 1
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 âC â, a typical finding of a middle facet coalition, which should be investigated further with an axial view of the subtalar joint (Harris).

Question 39High Yield

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

Explanation

C harcot-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.

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Orthopedics Hyperguide Review | Dr Hutaif General Ortho -...

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