A 38-year-old female with a grade IIIB open tibia fracture is scheduled to undergo definitive fixation and subsequent flap coverage with the orthopaedic and plastic surgery teams. She is met in the pre-operative area by the surgical intern and paperw

The surgical intern must be present because he brought the patient to the operating room

A 43-year-old man who works as a plumber has a painful stiff elbow in his dominant arm. He notes that while he recalls no single event of injury, he thinks the many years of pulling wrenches and soldering pipes have resulted in his problem. He report

Osteophyte resection and capsular release

A 75-year-old woman began a walking program 2 months after undergoing right total knee arthroplasty. She had to stop the program after 4 weeks because of hindfoot pain and ankle swelling. Radiographs are shown in Figures 42a and 42b. What is the most

Insufficiency fracture of the calcaneus

An inverted radial reflex is associated with

spinal cord compression with myelopathy.

He reports that he had no problems with the knee until 6 weeks ago when he noted the gradual onset of pain following a colonoscopy. Examination reveals a painful, swollen knee. Knee aspiration reveals a WBC count of 40,000/mm3. Management should cons

two-stage resection arthroplasty and reimplantation.

A 70-year-old man underwent primary total knee arthroplasty 3 months ago. Figures 7a and 7b show the radiograph and clinical photograph following incision and drainage of the wound 1 week ago. Aspiration of the joint reveals methicillin-sensitive Sta

Delayed exchange reimplantation

A 25-year-old farm worker sustained a grade III open fracture of the midshaft of the left tibia after falling from a ladder. Which of the following antibiotic regimens is best for this patient?

Synthetic penicillin and aminoglycoside

Orthopedic Foot Review Quiz With Answers | Dr Hutaif

Question 1

Which of the following arteries provides the dominant blood supply to the body of the talus, rendering it susceptible to avascular necrosis following a talar neck fracture?

Explanation

The artery of the tarsal canal is a branch of the posterior tibial artery and provides the dominant blood supply to the talar body. It forms an anastomotic sling with the artery of the tarsal sinus (branch of the dorsalis pedis/anterior tibial artery). Disruption of the artery of the tarsal canal in talar neck fractures is the primary reason for the high incidence of avascular necrosis.

Question 2

A 25-year-old professional football player sustains a hyperplantarflexion injury to his foot. Radiographs demonstrate diastasis between the medial cuneiform and the base of the second metatarsal. The primary stabilizing ligament disrupted in this injury connects which two structures?

Explanation

The Lisfranc ligament is an interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the largest and most critical primary stabilizer of the tarsometatarsal joint complex, as there is no direct ligamentous connection between the bases of the first and second metatarsals.

Question 3

When comparing operative to nonoperative management of acute Achilles tendon ruptures utilizing an early functional rehabilitation protocol, current evidence indicates which of the following regarding clinical outcomes?

Explanation

Recent high-quality randomized controlled trials and meta-analyses have demonstrated that when an early functional rehabilitation protocol (early weight-bearing and mobilization) is utilized, there is no significant difference in the re-rupture rates between operative and nonoperative management of acute Achilles tendon ruptures. Operative management does, however, carry higher risks of wound complications and sural nerve injury.

Question 4

Which of the following is the most reliable radiographic parameter on plain films to diagnose a syndesmotic injury requiring surgical fixation in an acute rotational ankle fracture?

Explanation

In the setting of a suspected syndesmotic injury (e.g., Weber B or C fractures), medial clear space widening greater than 4 mm on a gravity stress or weight-bearing view is the most reliable radiographic predictor of deep deltoid and syndesmotic instability requiring fixation. Simple measurements of tibiofibular overlap or clear space on static non-stress views are less sensitive and specific due to rotational variations.

Question 5

A 55-year-old female presents with medial foot pain and a progressive flatfoot deformity. Examination reveals a flexible flatfoot, an inability to perform a single-leg heel raise, and correctable hindfoot valgus. According to the Johnson and Strom classification for posterior tibial tendon dysfunction, what stage represents her condition?

Explanation

The Johnson and Strom classification (modified by Myerson) categorizes Adult Acquired Flatfoot Deformity. Stage I features tenosynovitis with mild pain but no deformity. Stage II features a flexible flatfoot deformity, unable to perform a single-leg heel raise. Stage III is a rigid, non-correctable flatfoot deformity. Stage IV includes rigid ankle valgus with deltoid ligament compromise.

Question 6

A 45-year-old female with severe hallux valgus has a Hallux Valgus Angle (HVA) of 48 degrees, an Intermetatarsal Angle (IMA) of 20 degrees, and significant hypermobility of the first tarsometatarsal (TMT) joint. Which surgical procedure is most indicated to correct her deformity?

Explanation

The Lapidus procedure consists of a fusion of the first tarsometatarsal (TMT) joint. It is highly indicated for severe hallux valgus (IMA > 15-20 degrees) combined with clinical hypermobility of the first ray. Distal osteotomies (like the Chevron) cannot adequately correct an IMA of 20 degrees. The Scarf is a diaphyseal osteotomy but does not specifically address TMT hypermobility as reliably as a Lapidus fusion.

Question 7

A 60-year-old male with long-standing diabetes presents with a swollen, erythematous, and warm foot but no systemic signs of infection. Radiographs reveal joint fragmentation, periarticular debris, and subluxation of the midfoot joints. According to the Eichenholtz classification of Charcot arthropathy, what is the current stage of this disease process?

Explanation

Eichenholtz Stage I is the developmental or fragmentation stage, characterized clinically by an acute, swollen, erythematous foot. Radiographically, it shows joint effusion, subchondral osteopenia, fragmentation, joint subluxation/dislocation, and bony debris. Stage II (Coalescence) shows absorption of debris and early fusion. Stage III (Consolidation) shows remodeling and stable deformity.

Question 8

A 22-year-old elite collegiate basketball player sustains a fifth metatarsal fracture. Radiographs show a transverse fracture at the metaphyseal-diaphyseal junction extending into the fourth-fifth intermetatarsal articulation. He wishes to return to play as rapidly and safely as possible. What is the standard of care?

Explanation

This is a classic Zone 2 (Jones) fracture. Due to the watershed blood supply in this region, there is a high risk of nonunion or delayed union. In high-level athletes who desire early return to sport, intramedullary screw fixation is the gold standard, demonstrating faster time to union and earlier return to play compared to nonoperative management.

Question 9

A 19-year-old track athlete presents with insidious onset dorsal midfoot pain. MRI confirms a non-displaced stress fracture of the tarsal navicular. What is the most appropriate initial management?

Explanation

Navicular stress fractures occur in the relatively avascular central third of the bone. For non-displaced navicular stress fractures, strict non-weight-bearing in a short leg cast for 6 to 8 weeks is the most appropriate initial management. Weight-bearing treatments have unacceptably high rates of nonunion or delayed union. Surgery is reserved for displaced fractures or failure of strict conservative care.

Question 10

Operative intervention for an acute 'turf toe' injury is most clearly indicated in which of the following scenarios?

Explanation

Turf toe is a sprain of the first metatarsophalangeal (MTP) joint plantar plate. Grade III injuries involve a complete tear of the plantar plate. Indications for surgery include a Grade III tear with proximal migration of the sesamoids, large intra-articular bony avulsion, traumatic bunion deformity, or progressive instability. Grades I and II are treated nonoperatively.

Question 11

A 14-year-old male with Charcot-Marie-Tooth disease presents with a significant bilateral cavovarus foot deformity. The Coleman block test is performed during the physical examination. This test is primarily used to evaluate which of the following?

Explanation

The Coleman block test evaluates whether the hindfoot varus in a cavovarus foot is flexible (driven by a plantarflexed first ray) or fixed. A block is placed under the lateral foot, allowing the first ray to drop off. If the hindfoot varus corrects to neutral or valgus, the deformity is flexible and primarily forefoot-driven, dictating surgical interventions that address the first ray (e.g., dorsiflexion osteotomy) rather than needing a corrective hindfoot osteotomy.

Question 12

During open reduction and internal fixation of a displaced intra-articular calcaneus fracture utilizing an extensile lateral approach, which nerve is at the highest risk for iatrogenic injury or inclusion in the surgical incision?

Explanation

The sural nerve courses posterior to the lateral malleolus and along the lateral aspect of the hindfoot and midfoot. During the standard extensile lateral approach to the calcaneus, the sural nerve is highly vulnerable to injury, traction, or entrapment in the surgical scar. Care must be taken to create full-thickness flaps to protect it.

Question 13

A 62-year-old male presents with severe hallux rigidus (Coughlin and Shurnas Grade 3) and pain with daily activities. He does not engage in running or high-impact sports. Radiographs demonstrate severe joint space narrowing and large dorsal osteophytes. What is the gold standard surgical intervention for this patient?

Explanation

For advanced (Grade 3 or 4) hallux rigidus with diffuse joint degeneration, the gold standard treatment is first MTP joint arthrodesis. It provides reliable pain relief and durability. Cheilectomy is indicated for Grade 1 or 2 hallux rigidus where arthritis is confined to the dorsal aspect of the joint. Keller arthroplasty and silicone implants carry higher risks of failure and transfer metatarsalgia.

Question 14

Which of the following conditions is considered an absolute contraindication for a primary Total Ankle Arthroplasty (TAA)?

Explanation

Absolute contraindications for Total Ankle Arthroplasty (TAA) include active infection, severe peripheral neuropathy/Charcot neuroarthropathy, avascular necrosis of a significant portion of the talar body, and poor soft tissue envelope or vascular compromise. Rheumatoid arthritis and older age are often considered excellent indications for TAA over arthrodesis.

Question 15

A 35-year-old female presents with burning pain in the third webspace of her foot, consistent with a Morton's neuroma. This common digital nerve in the third webspace is classically formed by communicating branches from which two nerves?

Explanation

Morton's neuroma most commonly occurs in the third intermetatarsal space. The common digital nerve in this space is uniquely formed by communicating branches from both the medial and lateral plantar nerves, making it relatively thicker and more prone to mechanical tethering and compression under the transverse intermetatarsal ligament.

Question 16

A 26-year-old male has persistent deep ankle pain 8 months after a severe inversion sprain. MRI demonstrates a 1.2 cm x 1.0 cm osteochondral lesion of the medial talar dome with intact overlying cartilage. He has failed exhaustive conservative management. What is the most appropriate first-line surgical intervention?

Explanation

For primary, symptomatic osteochondral lesions of the talus (OLT) that are relatively small (< 1.5 cm^2 or < 15 mm in diameter) and have failed conservative management, arthroscopic debridement and bone marrow stimulation (microfracture) is the gold standard first-line surgical treatment. OATS or allografts are reserved for larger lesions (> 1.5 cm^2), cystic lesions, or revision surgery.

Question 17

A 45-year-old distance runner presents with chronic heel pain. It is maximal on the plantar-medial aspect of the heel and radiates distally along the lateral border of the foot. The pain is not worse with the first step in the morning but worsens after prolonged activity. Entrapment of Baxter's nerve is suspected. Baxter's nerve is the first branch of which nerve?

Explanation

Baxter's nerve is the first branch of the lateral plantar nerve. It courses deep to the abductor hallucis muscle and supplies motor innervation to the abductor digiti minimi. Entrapment of Baxter's nerve can cause chronic heel pain that mimics, or coexists with, plantar fasciitis but often includes radiating pain and possible hypotrophy of the abductor digiti minimi on MRI.

Question 18

A 28-year-old soccer player experiences a snapping sensation behind the lateral malleolus when abruptly changing directions. On physical examination, resisted eversion of the foot with the ankle in dorsiflexion reproduces the snapping and pain. Injury to which of the following structures is most likely responsible for this clinical presentation?

Explanation

The clinical presentation describes peroneal tendon subluxation or dislocation. The primary restraint to peroneal tendon subluxation is the superior peroneal retinaculum (SPR). Injury to the SPR, often occurring with forced dorsiflexion and eversion, leads to the tendons snapping out of the retromalleolar groove.

Question 19

In the management of high-energy distal tibia pilon fractures (OTA/AO 43C), what is the primary rationale for utilizing a staged protocol consisting of immediate spanning external fixation followed by delayed definitive open reduction and internal fixation (ORIF)?

Explanation

High-energy pilon fractures are associated with massive soft tissue swelling and injury. Historically, immediate ORIF led to catastrophic wound necrosis and deep infection rates over 30%. The staged protocol (span and scan) allows the soft tissue envelope to recover (usually 10-21 days) before definitive surgical approaches, drastically lowering the rate of wound complications and deep infection.

Question 20

A 12-year-old boy presents with a history of recurrent ankle sprains. Examination reveals a rigid, flat arch and severe pain when attempting to invert the heel. CT scan confirms a calcaneonavicular coalition. During the physical exam, which of the following findings is most characteristically associated with this condition?

Explanation

Tarsal coalitions (most commonly calcaneonavicular or talocalcaneal) restrict the normal motion of the hindfoot joints. The hallmark physical exam finding is a rigid flatfoot with significantly decreased or completely absent subtalar range of motion. The hindfoot fails to invert during the single-leg heel raise, and forced inversion elicits pain.

Question 21

A 22-year-old elite runner presents with insidious onset dorsal midfoot pain. CT scan demonstrates a dorsal cortical break in the navicular that does not propagate into the plantar cortex. Which of the following best describes the blood supply of the tarsal navicular that predisposes to this specific injury pattern?

Explanation

The tarsal navicular receives its blood supply from radial branches of the dorsalis pedis artery dorsally and the medial plantar artery plantarly. This creates a central avascular 'watershed' zone in the middle third of the bone, heavily predisposing it to stress fractures and nonunions, particularly in running athletes.

Question 22

A patient presents with a painful, flexible hallux varus deformity 1 year after bunion surgery. Review of the previous operative note reveals an aggressive medial eminence resection and a complete fibular sesamoidectomy. Which of the following tendon transfers is most appropriate for dynamic correction of this flexible deformity?

Explanation

Iatrogenic hallux varus is often caused by over-resection of the medial eminence, excessive lateral release, or fibular sesamoidectomy. For a flexible deformity, a dynamic tendon transfer is indicated. The extensor hallucis brevis (EHB) tendon is detached proximally, passed deep to the deep transverse metatarsal ligament, and attached to the lateral aspect of the proximal phalanx to recreate the lateral stabilizing force.

Question 23

A 13-year-old boy presents with frequent ankle sprains and rigid flatfeet. Radiographs reveal a continuous osseous bridge between the calcaneus and the navicular on the oblique view. Which of the following radiographic signs is most commonly associated with this specific type of tarsal coalition?

Explanation

The patient has a calcaneonavicular coalition, which is best seen on a 45-degree internal rotation oblique radiograph. On a lateral radiograph, the anterior process of the calcaneus appears elongated, resembling an anteater's nose ('anteater sign'). The 'C-sign' is classically associated with talocalcaneal coalitions.

Question 24

A 28-year-old male sustains a Hawkins Type III talar neck fracture following a high-speed motor vehicle collision. Which of the following best describes the expected rate of avascular necrosis (AVN) of the talar body associated with this injury pattern?

Explanation

Hawkins Type III talar neck fractures involve displacement of the talar body with subluxation or dislocation from both the subtalar and tibiotalar joints. This disrupts all three major sources of blood supply (artery of the tarsal canal, deltoid branches, and dorsalis pedis branches), resulting in a high AVN rate historically reported between 70% and 100%.

Question 25

During a percutaneous repair of an acute Achilles tendon rupture using a standard passing jig, the patient develops neuropathic pain and numbness along the lateral border of the foot postoperatively. Which of the following structures was most likely injured during the proximal lateral suture passage?

Explanation

The sural nerve crosses from the midline to the lateral side of the Achilles tendon approximately 10 cm proximal to its insertion on the calcaneus. It is at significant risk during percutaneous Achilles tendon repairs, especially when placing proximal lateral locking sutures.

Question 26

A 65-year-old woman presents with a painful, severe flatfoot deformity. Examination reveals a rigid deformity that is not passively correctable to neutral, and she cannot perform a single-limb heel rise. Radiographs demonstrate advanced degenerative changes in the subtalar and talonavicular joints. What is the most appropriate definitive surgical management?

Explanation

The patient has Stage III Adult Acquired Flatfoot Deformity (Posterior Tibial Tendon Dysfunction), characterized by a rigid deformity and hindfoot arthrosis. Joint-sparing osteotomies and tendon transfers (Stages I and II) are no longer appropriate. A triple arthrodesis (subtalar, talonavicular, and calcaneocuboid) is the gold standard for restoring a plantigrade foot and eliminating arthritic pain.

Question 27

When utilizing an extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, the full-thickness flap must be elevated in a subperiosteal plane. Which of the following vascular structures must be preserved within the flap to ensure adequate soft tissue healing and prevent necrosis?

Explanation

The lateral calcaneal artery, a branch of the peroneal artery, provides the primary blood supply to the corner of the extensile lateral flap used in calcaneus fracture ORIF. The flap must be elevated full-thickness (subperiosteal) to protect this vessel and minimize the risk of wound edge necrosis.

Question 28

A 21-year-old collegiate basketball player sustains an acute Zone 2 fracture of the proximal fifth metatarsal (Jones fracture). He wishes to return to play as soon as safely possible. What is the recommended treatment to minimize the risk of nonunion and allow early return to sports?

Explanation

Zone 2 (Jones) fractures occur at the metaphyseal-diaphyseal junction and are prone to nonunion due to a watershed blood supply. While nonoperative management can be used in the general population, elite athletes have an unacceptably high risk of delayed union/nonunion and prolonged return to play. Intramedullary screw fixation is the gold standard for high-level athletes to ensure early and reliable return to sport.

Question 29

The syndesmotic ligamentous complex provides crucial stability to the distal tibiofibular articulation. Biomechanical studies indicate that which of the following ligaments provides the greatest resistance to lateral displacement of the fibula?

Explanation

The posterior inferior tibiofibular ligament (PITFL) provides the strongest resistance to lateral displacement of the fibula (approximately 42%), followed by the AITFL (approx. 35%), the interosseous ligament (22%), and the transverse tibiofibular ligament.

Question 30

A 45-year-old marathon runner presents with chronic, recalcitrant heel pain. Clinical examination reveals maximal tenderness at the medial aspect of the calcaneal tuberosity. MRI demonstrates fatty atrophy of the abductor digiti minimi muscle. Entrapment of which of the following nerves is the most likely cause of these findings?

Explanation

Baxter's nerve is the first branch of the lateral plantar nerve. It supplies motor innervation to the abductor digiti minimi. Entrapment typically occurs between the deep fascia of the abductor hallucis and the medial margin of the quadratus plantae, leading to chronic heel pain and isolated fatty atrophy of the abductor digiti minimi on MRI.

Question 31

A 55-year-old poorly controlled diabetic male presents with a markedly swollen, erythematous, and warm foot. Radiographs demonstrate periarticular bone fragmentation, subluxation, and soft tissue swelling at the tarsometatarsal joints. Based on the Eichenholtz classification, what is the appropriate stage and recommended initial management?

Explanation

The patient is in Eichenholtz Stage 1 (Development/Fragmentation) of Charcot arthropathy, characterized by clinical inflammation and radiographic evidence of osteopenia, fragmentation, and joint subluxation/dislocation. The standard of care during the acute phase (Stage 1) is offloading and immobilization, most commonly via total contact casting. Surgery is generally contraindicated during the acute inflammatory phase.

Question 32

A 50-year-old male presents with dorsal first metatarsophalangeal (MTP) joint pain. Examination shows restricted MTP dorsiflexion with pain only at the extremes of motion. Radiographs reveal dorsal osteophytes with preserved joint space and no central cartilage loss. What is the most appropriate surgical treatment if nonoperative measures fail?

Explanation

This patient has early-stage hallux rigidus (Coughlin and Shurnas Grade 1 or 2) with preserved joint space and pain primarily on terminal dorsiflexion due to impingement. Dorsal cheilectomy (excision of dorsal osteophytes and the dorsal third of the metatarsal head) is highly effective for these grades. First MTP arthrodesis is reserved for advanced disease (Grade 3 or 4) with significant cartilage loss.

Question 33

A 40-year-old female complains of burning pain in her forefoot, specifically radiating to her third and fourth toes. She reports the pain worsens when wearing narrow-toed shoes. Excision of a suspected Morton's neuroma is planned. Between which metatarsal heads is this lesion most commonly located, and which nerve is predominantly affected?

Explanation

Morton's neuroma is a perineural fibrosis most frequently found in the third web space. The nerve involved is the third common digital nerve, which is uniquely formed by communicating branches from both the medial and lateral plantar nerves, making it thicker and more prone to tethering and compression under the deep transverse metatarsal ligament.

Question 34

A 26-year-old skier presents with posterolateral ankle pain and a snapping sensation behind the lateral malleolus. Ultrasound confirms anterior subluxation of the peroneal tendons out of the retromalleolar groove during active ankle dorsiflexion and eversion. Which anatomical structure is primarily incompetent in this condition?

Explanation

The superior peroneal retinaculum (SPR) is the primary restraint against anterior subluxation of the peroneal tendons. Injury or avulsion of the SPR from the fibula (often accompanied by a 'fleck sign' on radiographs) leads to dynamic subluxation of the tendons over the lateral malleolus.

Question 35

A 24-year-old football lineman sustains an axial load to a plantarflexed foot. Non-weight-bearing radiographs appear normal, but a weight-bearing AP radiograph reveals a 3 mm diastasis between the medial cuneiform and the base of the second metatarsal. Which of the following is the most appropriate management?

Explanation

This represents a subtle but unstable Lisfranc injury. Diastasis greater than 2 mm on weight-bearing views indicates frank instability. Nonoperative management leads to midfoot collapse and arthritis. The standard of care is anatomic restoration via Open Reduction Internal Fixation (ORIF) or primary arthrodesis (often preferred for purely ligamentous injuries).

Question 36

A 28-year-old professional football player suffers a hyperextension injury to his great toe. Physical examination reveals marked tenderness over the plantar aspect of the first MTP joint and weakness of active plantarflexion of the hallux. An MRI demonstrates a complete rupture of the plantar plate with proximal retraction of the sesamoids. What is the most appropriate treatment?

Explanation

This is a Grade III turf toe injury (complete tear of the plantar plate/capsuloligamentous complex) with proximal sesamoid migration. In a high-demand professional athlete, surgical repair is indicated to restore the push-off strength and anatomy of the first MTP joint, preventing chronic instability, weakness, and hallux rigidus.

Question 37

A 15-year-old female dancer presents with pain and swelling over the dorsal aspect of her forefoot. Radiographs show flattening, sclerosis, and fragmentation of the second metatarsal head. What is the most likely diagnosis?

Explanation

Freiberg's infraction is avascular necrosis of a metatarsal head, most commonly affecting the second metatarsal in adolescent females. Repetitive microtrauma, especially in activities like dance, disrupts the tenuous blood supply to the epiphysis, leading to collapse and fragmentation.

Question 38

A 42-year-old woman presents with lateral foot pain after an inversion injury. Radiographs show an extra-articular fracture through the tuberosity of the fifth metatarsal. Which structures are primarily responsible for the deforming force associated with this specific avulsion fracture?

Explanation

Zone 1 fractures of the fifth metatarsal are avulsion fractures of the tuberosity. The mechanism involves an inversion injury where the peroneus brevis tendon and the lateral cord of the plantar fascia exert a strong pulling force, avulsing the proximal tip of the bone. The peroneus longus passes under the cuboid to insert on the first metatarsal and medial cuneiform.

Question 39

A 30-year-old male sustains a severe crush injury to the foot. The surgeon is concerned about foot compartment syndrome and prepares to measure compartment pressures. How many distinct osseofascial compartments are classically described in the foot?

Explanation

There are classically 9 distinct compartments in the foot: the medial, lateral, superficial central, calcaneal (deep central), and 4 interosseous compartments. Accurate knowledge is essential when performing fasciotomies for compartment syndrome of the foot, typically requiring a dual dorsal approach and sometimes a medial approach to decompress fully.

Question 40

A 62-year-old male with symptomatic end-stage osteoarthritis of the right ankle is being evaluated for surgical intervention. Which of the following is considered an absolute contraindication to Total Ankle Arthroplasty (TAA) in this patient?

Explanation

Severe peripheral neuropathy, lack of protective sensation, and Charcot arthropathy are absolute contraindications to Total Ankle Arthroplasty due to the extremely high risk of implant loosening, progressive deformity, and failure. Concomitant subtalar arthritis is actually an indication for TAA over arthrodesis to preserve remaining hindfoot motion. Mild varus can be corrected concurrently.

Question 41

A 14-year-old boy presents with a rigid flatfoot and recurrent ankle sprains. Radiographs show a continuous C-shaped bony outline involving the medial talar dome and the posteroinferior aspect of the sustentaculum tali. Which of the following is true regarding this patient's condition?

Explanation

The 'C-sign' on a lateral radiograph is formed by the continuous outline of the medial talar dome and the posteroinferior aspect of the sustentaculum tali, strongly indicating a talocalcaneal coalition. Calcaneonavicular coalitions are best seen on a 45-degree internal oblique radiograph. Talocalcaneal coalitions typically present with a rigid pes planovalgus deformity. Resection is generally reserved for coalitions involving less than 50% of the posterior facet.

Question 42

A 28-year-old female presents with a progressive cavovarus foot deformity. A Coleman block test is performed by placing a block under the lateral aspect of her foot, allowing the first metatarsal to drop off. Upon doing so, her hindfoot varus corrects to a neutral alignment. This finding indicates:

Explanation

The Coleman block test differentiates between a flexible (forefoot-driven) and a fixed hindfoot varus. When the hindfoot corrects to neutral after allowing the plantarflexed first ray to drop off the block, it confirms that the hindfoot varus is flexible and driven by the forefoot pathology (typically a plantarflexed first ray driven by an overpowering peroneus longus relative to a weak tibialis anterior).

Question 43

A 55-year-old male with poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm right foot. He denies trauma. Pulses are palpable. Radiographs reveal prominent periarticular debris, fragmentation of the tarsal bones, and joint subluxation without consolidation. According to the Eichenholtz classification, what stage of Charcot arthropathy is this, and what is the optimal initial management?

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation), characterized clinically by a red, hot, swollen foot and radiographically by osteopenia, fragmentation, joint subluxation, and debris. The cornerstone of treatment in Stage I is offloading and immobilization, most effectively achieved with a total contact cast (TCC) to prevent further deformity while the acute inflammatory process resolves.

Question 44

Which of the following conditions is considered a strict, absolute contraindication for a Total Ankle Arthroplasty (TAA)?

Explanation

Absolute contraindications for Total Ankle Arthroplasty (TAA) include active infection, severe neuroarthropathy (Charcot disease), absent plantar sensation, avascular necrosis involving >50% of the talar body, and severe uncorrectable malalignment. Concomitant subtalar arthritis is actually often an indication for TAA rather than arthrodesis to preserve remaining hindfoot motion.

Question 45

A 42-year-old weekend warrior sustains an acute Achilles tendon rupture during a tennis match. Non-operative management is chosen utilizing functional rehabilitation. Compared to traditional open surgical repair, which of the following outcomes is most closely associated with non-operative management utilizing an accelerated functional rehabilitation protocol?

Explanation

Modern high-quality randomized controlled trials (e.g., Willits et al.) have consistently demonstrated that non-operative management using an accelerated, functional rehabilitation protocol with early weight-bearing and motion yields rerupture rates comparable to surgical repair, while effectively avoiding the surgical risks of wound complications, infection, and iatrogenic nerve injury.

Question 46

A 25-year-old skier presents with posterolateral ankle pain after catching an edge. Examination reveals snapping of the peroneal tendons over the lateral malleolus with resisted dorsiflexion and eversion. Surgical exploration demonstrates that the superior peroneal retinaculum is avulsed along with a small fleck of bone from the lateral malleolus. According to the Eckert and Davis classification, what grade is this injury?

Explanation

The Eckert and Davis classification describes superior peroneal retinaculum (SPR) injuries: Grade I is elevation of the SPR with the periosteum; Grade II is a tear of the fibrocartilaginous ridge; Grade III is an avulsion of the SPR with a bony fragment from the lateral malleolus. Grade IV (added by Oden) is a complete tear of the SPR from its posterior attachment.

Question 47

A 16-year-old female gymnast complains of insidious onset pain in her forefoot. Examination reveals tenderness over the dorsal aspect of the second metatarsophalangeal joint. Radiographs display sclerosis, flattening, and early fragmentation of the second metatarsal head. What is the most likely underlying pathophysiology of her condition?

Explanation

Freiberg's infraction is an avascular necrosis of a metatarsal head, most commonly the second metatarsal. It is generally thought to be caused by repetitive microtrauma and subsequent vascular compromise. It frequently affects adolescent females, especially those involved in high-stress forefoot activities like gymnastics or dance.

Question 48

A professional football player sustains a severe forced hyperextension injury to his first metatarsophalangeal (MTP) joint. MRI confirms a complete tear of the plantar plate with significant retraction of the sesamoids proximal to the MTP joint line. Which of the following is the most appropriate management strategy to optimize his return to elite play?

Explanation

This represents a Grade III turf toe injury (complete tear of the plantar plate capsule-ligamentous complex). In high-demand athletes, especially when accompanied by sesamoid retraction, frank joint instability, or a massive tear of the capsular structures, surgical repair is indicated to restore functional push-off strength and joint stability.

Question 49

A 22-year-old collegiate athlete sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial and middle cuneiforms. Based on comparative literature regarding purely ligamentous Lisfranc injuries in adults, which procedure provides the most predictable long-term functional outcome and lowest rate of revision surgery?

Explanation

Several pivotal studies, notably by Coetzee and Ly, have demonstrated that for purely ligamentous Lisfranc injuries, primary arthrodesis of the medial columns (1st, 2nd, and 3rd TMT joints) yields significantly better functional outcomes and lower revision rates compared to ORIF, which often leads to hardware failure, loss of reduction, or progressive post-traumatic arthritis requiring salvage arthrodesis.

Question 50

A 20-year-old collegiate track athlete presents with insidious onset dorsal midfoot pain. A CT scan confirms a non-displaced stress fracture of the tarsal navicular. Which specific anatomic region of the navicular is most prone to stress fractures due to its precarious blood supply?

Explanation

The central third of the tarsal navicular is a relative 'watershed' area with a tenuous vascular supply, making it highly susceptible to stress fractures, delayed union, and nonunion. Initial management for a non-displaced fracture in this specific zone typically involves strict non-weight bearing cast immobilization for a minimum of 6 weeks.

Question 51

A 19-year-old collegiate basketball player sustains a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal. Which of the following factors most strongly supports the indication for early intramedullary screw fixation rather than conservative management?

Explanation

A fracture strictly at the metaphyseal-diaphyseal junction is a Zone II (Jones) fracture. Because of the watershed blood supply in this region, these fractures are notorious for a high rate of delayed union or nonunion. Early intramedullary screw fixation is highly recommended for elite and high-demand athletes to minimize the risk of nonunion and dramatically expedite their return to play.

Question 52

An extensile lateral approach is utilized for the open reduction and internal fixation of a highly comminuted, displaced intra-articular calcaneus fracture. During the surgical exposure, a full-thickness subperiosteal flap is created. Which nerve is most at risk of iatrogenic injury if the vertical or horizontal limbs of the incision are improperly placed too anteriorly or dorsally over the lateral hindfoot?

Explanation

The sural nerve courses posterior to the lateral malleolus and travels along the lateral aspect of the foot. It is highly vulnerable to transection or traction injury during the extensile lateral approach for calcaneus fractures, particularly when creating the vertical and horizontal limbs of the L-shaped incision. The horizontal limb must be carefully placed in line with the glabrous junction to minimize this specific risk.

Question 53

Six weeks following open reduction and internal fixation of a Hawkins type II talar neck fracture, an anteroposterior radiograph of the ankle demonstrates a distinct subchondral radiolucent band in the talar dome. This radiographic finding most accurately indicates:

Explanation

The Hawkins sign is a subchondral radiolucent band seen in the talar dome typically 6 to 8 weeks post-injury. It represents localized subchondral osteopenia secondary to active bone resorption, a process that physiologically requires an intact, functioning blood supply. Therefore, the presence of the Hawkins sign is a reliable indicator that vascularity to the talar body is preserved, effectively ruling out total avascular necrosis.

Question 54

A patient develops a severe compartment syndrome of the foot following a heavy crush injury. Surgical fasciotomy is planned using a standard dual dorsal incision technique. Based on anatomic consensus, how many distinct osseofascial compartments are recognized in the human foot?

Explanation

The foot contains 9 classically recognized osseofascial compartments: 4 interosseous, 3 central (superficial, shallow, deep), 1 medial, and 1 lateral compartment. Fasciotomy is typically achieved via two dorsal longitudinal incisions (one placed medial to the 2nd metatarsal, one lateral to the 4th metatarsal), with an optional medial incision utilized to ensure complete release of the deep central structures if necessary.

Question 55

A 58-year-old male presents with severe pain and stiffness in his right great toe, notably worsening at both extremes of dorsiflexion and plantarflexion. Radiographs reveal advanced dorsal osteophyte formation, near complete obliteration of the MTP joint space, and multiple subchondral cysts (Coughlin and Shurnas Grade 3). He has failed extensive conservative management. What is the gold standard surgical treatment?

Explanation

For advanced hallux rigidus (Coughlin and Shurnas Grade 3 or 4), where the joint space is obliterated and pain occurs throughout the entire range of motion, the gold standard surgical treatment providing the most reliable pain relief and predictable functional improvement is first MTP joint arthrodesis. Cheilectomy is indicated for early-stage disease (Grades 1 and 2) with preserved joint space and pain primarily at terminal dorsiflexion.

Question 56

A 45-year-old female with a history of chronic, worsening midfoot pain presents with a severe, progressive flatfoot deformity. Radiographs show a unique comma-shaped deformity of the tarsal navicular characterized by fragmentation, lateral collapse, and medial protrusion. Which of the following diagnoses best describes this specific pathologic entity?

Explanation

Muller-Weiss disease is a spontaneous osteonecrosis of the adult tarsal navicular. It classically presents bilaterally in middle-aged females. Radiographically, the navicular appears 'comma-shaped' due to lateral collapse, often resulting in a paradoxical planovarus deformity. In contrast, Kohler disease refers to osteonecrosis of the navicular occurring in early childhood.

Question 57

A 52-year-old obese female presents with a progressive, painful flatfoot. She is unable to perform a single-leg heel raise. Upon examination, her hindfoot valgus deformity is fully flexible. Weight-bearing radiographs demonstrate an AP talonavicular coverage angle of 45 degrees, consistent with greater than 30% uncovering of the talar head. Which of the following surgical interventions is most appropriate for this specific stage of Posterior Tibial Tendon Dysfunction (PTTD)?

Explanation

This is a Stage IIb PTTD (Johnson and Strom/Myerson classification), characterized by a flexible deformity with severe forefoot abduction (>30% talonavicular uncovering). Management requires FDL transfer and a medial displacement calcaneal osteotomy (MDCO) to address the tendon insufficiency and hindfoot valgus, PLUS a lateral column lengthening (e.g., Evans osteotomy) to adequately correct the severe forefoot abduction component.

Question 58

A 40-year-old long-distance runner experiences refractory heel pain despite 6 months of conservative treatment, including stretching, custom orthotics, and night splints. He describes a radiating, burning pain over the medial heel that worsens considerably following a long run. Examination reveals maximal tenderness at the medial aspect of the heel, just distal to the medial malleolus, without pinpoint tenderness at the medial calcaneal tubercle. Entrapment of which specific nerve is the most likely cause?

Explanation

The first branch of the lateral plantar nerve (Baxter's nerve) can become entrapped between the deep fascia of the abductor hallucis and the medial margin of the quadratus plantae. It often mimics severe plantar fasciitis but typically presents with radiating, burning neurological pain. Tenderness is slightly more proximal and medial along the nerve's course, rather than directly at the plantar medial calcaneal tubercle.

Question 59

During the operative fixation of a Weber C ankle fracture, an intraoperative 'Cotton test' is performed to critically assess the stability of the syndesmosis. Which of the following describes the correct maneuver for executing this test?

Explanation

The intraoperative Cotton test involves securely placing a bone hook or clamp around the distal fibula and applying a direct lateral and posterior pull (away from the tibia) while visualizing the syndesmosis dynamically under fluoroscopy. Asymmetric widening of the syndesmotic space (tibiofibular clear space) during this maneuver strongly indicates syndesmotic instability requiring operative fixation.

Question 60

A 24-year-old professional ballerina complains of chronic posterior ankle pain selectively triggered by rising onto her toes (en pointe). MRI reveals a prominent os trigonum with intense surrounding marrow edema and fluid within the flexor hallucis longus (FHL) tendon sheath. She opts for open surgical excision via a posteromedial approach. Which critical neurovascular structure is at highest risk during this specific surgical approach?

Explanation

The posteromedial surgical approach to the posterior ankle and os trigonum carries a significantly high risk to the structures contained within the tarsal tunnel, specifically the posterior tibial artery and the tibial nerve (along with its calcaneal branches). Because of this risk, an os trigonum excision is most often performed via a posterolateral open approach or via posterior endoscopy to safely avoid these critical medial neurovascular structures.

Question 61

A 50-year-old female presents with symptomatic hallux valgus. Radiographs show a hallux valgus angle (HVA) of 35 degrees, an intermetatarsal angle (IMA) of 16 degrees, and clinical examination reveals a hypermobile first tarsometatarsal joint. Which surgical procedure is most appropriate?

Explanation

The Lapidus procedure (first tarsometatarsal arthrodesis) is indicated for moderate to severe hallux valgus associated with first ray hypermobility. Distal osteotomies are insufficient for an IMA greater than 13 degrees combined with significant instability.

Question 62

A 45-year-old woman presents with a painful, flexible flatfoot. Clinical exam reveals weakness in single-leg heel rise but a passively correctable hindfoot valgus deformity. Which of the following is the most appropriate surgical intervention if conservative measures fail?

Explanation

Stage II adult-acquired flatfoot deformity involves a flexible deformity with posterior tibial tendon insufficiency. Joint-sparing procedures like an FDL transfer combined with a medializing calcaneal osteotomy are the standard surgical treatment.

Question 63

A 22-year-old male with Charcot-Marie-Tooth disease presents with bilateral cavovarus foot deformities. A Coleman block test demonstrates that the hindfoot varus corrects to neutral when the first ray is allowed to drop off the block. What does this indicate?

Explanation

The Coleman block test evaluates hindfoot flexibility in cavovarus feet. If the hindfoot corrects when the plantarflexed first ray is accommodated, the hindfoot is flexible, meaning treatment should focus on restoring forefoot alignment (e.g., dorsiflexing first metatarsal osteotomy).

Question 64

Three years following nonoperative treatment of a displaced intra-articular calcaneus fracture, a patient complains of severe lateral heel pain and difficulty walking on uneven ground. Radiographs show loss of Bohler's angle and subtalar arthritis. What is the most likely cause of the lateral heel pain?

Explanation

Lateral wall blow-out in calcaneus fractures often leads to subfibular impingement and secondary peroneal tendon irritation. In the setting of subtalar arthritis, this late complication typically requires subtalar fusion and lateral wall exostectomy.

Question 65

A 24-year-old elite basketball player sustains an acute Zone 2 fracture of the proximal fifth metatarsal. Which of the following describes the most appropriate management to minimize the risk of nonunion and allow early return to play?

Explanation

Zone 2 fractures (Jones fractures) have a higher risk of nonunion due to a vascular watershed area. Intramedullary screw fixation is recommended for high-level athletes to decrease nonunion risk and expedite return to sport.

Question 66

A 19-year-old track athlete experiences vague dorsal midfoot pain. A CT scan reveals an incomplete, non-displaced stress fracture of the tarsal navicular. What is the recommended initial treatment?

Explanation

Non-displaced navicular stress fractures should initially be treated with strict non-weight-bearing in a cast for 6 to 8 weeks. Weight-bearing modalities have an unacceptably high rate of delayed union or frank nonunion.

Question 67

Six weeks following open reduction and internal fixation of a Hawkins Type II talar neck fracture, an AP radiograph of the ankle reveals a subchondral radiolucent line in the talar dome. What is the clinical significance of this finding?

Explanation

The Hawkins sign is a subchondral radiolucency observed in the talar dome 6-8 weeks post-injury, representing subchondral bone resorption secondary to an intact blood supply. It is a highly reliable indicator that avascular necrosis is unlikely to occur.

Question 68

A 55-year-old diabetic male presents with an acutely swollen, erythematous, and warm foot with a bounding dorsalis pedis pulse. Radiographs show fragmentation and periarticular debris around the midfoot. What is the most appropriate initial management?

Explanation

The patient is presenting in the acute, fragmentation phase (Eichenholtz stage I) of Charcot arthropathy. The gold standard of initial treatment is offloading with a total contact cast to prevent further deformity until the active phase resolves.

Question 69

A 28-year-old male undergoes ankle arthroscopy for a symptomatic osteochondral lesion of the medial talar dome. The lesion measures 120 square millimeters. What is the most appropriate surgical treatment?

Explanation

Arthroscopic bone marrow stimulation (microfracture) is highly successful and remains the first-line treatment for primary osteochondral lesions of the talus smaller than 150 square millimeters. Larger or cystic lesions may require an autograft or allograft transfer.

Question 70

A 42-year-old runner complains of chronic, recalcitrant heel pain that radiates into the medial plantar arch. MRI reveals isolated atrophy of the abductor digiti minimi muscle. Entrapment of which of the following nerves is the most likely cause?

Explanation

The first branch of the lateral plantar nerve (Baxter's nerve) innervates the abductor digiti minimi. Entrapment of this nerve causes chronic heel pain and isolated muscle atrophy visible on MRI.

Question 71

A 60-year-old male with chronic insertional Achilles tendinopathy undergoes surgical debridement. During the procedure, 60% of the Achilles tendon insertion is detached to remove the degenerative tissue and Haglund's deformity. What is the most appropriate next step?

Explanation

When more than 50% of the Achilles tendon insertion is compromised or detached during debridement, tendon augmentation is indicated. The flexor hallucis longus (FHL) is the preferred transfer due to its proximity, strength, and in-phase firing.

Question 72

A 25-year-old football player sustains a hyperdorsiflexion injury to his great toe. Exam reveals profound ecchymosis, swelling, and gross instability of the first metatarsophalangeal joint with absent push-off strength. MRI confirms a complete tear of the plantar plate and sesamoid complex. What is the most appropriate treatment?

Explanation

A Grade 3 turf toe injury involves a complete tear of the plantar plate complex with gross instability. In high-level competitive athletes, surgical repair is indicated to restore push-off strength and joint stability.

Question 73

A 50-year-old male presents with painful, limited dorsiflexion of the right hallux. Radiographs reveal advanced narrowing of the 1st MTP joint, large dorsal osteophytes, and less than 50% of the joint space remaining (Coughlin and Shurnas Grade 3). What is the most reliable surgical option for long-term pain relief?

Explanation

First MTP joint arthrodesis is the gold standard for advanced hallux rigidus (Grade 3 and 4), providing the most reliable long-term pain relief and functional improvement. Cheilectomy is generally reserved for Grade 1 or 2 disease with preserved joint space.

Question 74

A 26-year-old skier presents with lateral ankle pain and a snapping sensation behind the lateral malleolus. On examination, active ankle dorsiflexion and eversion reproduce the snapping. Which anatomic structure is most likely incompetent?

Explanation

Peroneal tendon subluxation is caused by an injury to the superior peroneal retinaculum (SPR), often occurring during forceful dorsiflexion and eversion. Surgical repair of the SPR with or without fibular groove deepening is usually required for symptomatic cases.

Question 75

In the operative management of a purely ligamentous Lisfranc injury, current literature suggests which of the following regarding primary arthrodesis compared to open reduction and internal fixation (ORIF)?

Explanation

Studies have shown that primary arthrodesis for purely ligamentous Lisfranc injuries provides comparable or superior functional outcomes and a significantly lower reoperation rate compared to ORIF, which often requires routine hardware removal and may fail.

Question 76

During an ankle fracture ORIF, the surgeon performs an intraoperative Cotton test and notes widening of the medial clear space and tibiofibular clear space. Which of the following is the most appropriate management?

Explanation

A positive Cotton test indicates syndesmotic instability after fibular fixation. This requires stabilization using either syndesmotic screws or a dynamic suture-button construct to restore the tibiofibular relationship.

Question 77

A 22-year-old collegiate basketball player sustains a fracture of the proximal fifth metatarsal. Radiographs show a fracture line at the metaphyseal-diaphyseal junction extending into the fourth-fifth intermetatarsal articulation. To minimize the risk of nonunion and allow early return to play, which of the following is the most appropriate surgical treatment?

Explanation

This is a Zone 2 (Jones) fracture, which is prone to nonunion due to watershed vascularity. In high-level athletes, intramedullary screw fixation is recommended for faster return to play and higher union rates compared to nonoperative management.

Question 78

A 58-year-old male with long-standing, poorly controlled type 2 diabetes presents with a unilaterally swollen, red, and warm foot. Radiographs demonstrate fragmentation of the midfoot with subluxation, but no skin ulceration. Inflammatory markers are mildly elevated. What is the most appropriate initial management?

Explanation

The patient is in Eichenholtz Stage I (developmental/acute) of Charcot arthropathy, characterized by fragmentation and joint subluxation. The mainstay of acute treatment to prevent further deformity is strict immobilization with a total contact cast and offloading.

Question 79

A 55-year-old female presents with progressive flattening of her left foot. Examination reveals a flexible hindfoot valgus, inability to perform a single-leg heel rise, and forefoot abduction that uncovers >40% of the talar head. Which of the following surgical strategies is most appropriate?

Explanation

This presentation describes Stage IIb posterior tibial tendon dysfunction (PTTD), marked by a flexible deformity with significant forefoot abduction. Treatment requires an FDL transfer combined with a lateral column lengthening (e.g., Evans osteotomy) to correct the forefoot abduction.

Question 80

A patient sustains a talar neck fracture. Routine follow-up radiographs at 8 weeks demonstrate a subchondral radiolucent band in the dome of the talus. This radiographic finding indicates which of the following?

Explanation

This describes the Hawkins sign, which is subchondral radiolucency secondary to localized disuse osteopenia. Its presence indicates intact vascular supply to the talar body, effectively ruling out avascular necrosis.

Question 81

A 45-year-old runner presents with chronic, severe heel pain refractory to conservative management, including corticosteroid injections. Pain is maximal at the medial aspect of the heel and radiates distally. Examination reveals tenderness over the first branch of the lateral plantar nerve. This nerve provides motor innervation to which of the following muscles?

Explanation

The first branch of the lateral plantar nerve (Baxter's nerve) courses between the abductor hallucis and quadratus plantae, providing motor innervation to the abductor digiti minimi. Entrapment can mimic or coexist with plantar fasciitis.

Question 82

During evaluation of a patient with a severe cavovarus foot deformity, the examiner places the patient's foot on a 1-inch block with the first metatarsal hanging freely off the medial edge. The hindfoot varus corrects to neutral. What does this test signify?

Explanation

The Coleman block test distinguishes between forefoot-driven and hindfoot-driven varus. Correction of hindfoot varus when the first ray is dropped indicates a flexible hindfoot driven by a rigid plantarflexed first ray.

Question 83

A 38-year-old female presents with symptomatic hallux valgus. Radiographs show a hallux valgus angle (HVA) of 35 degrees, an intermetatarsal angle (IMA) of 16 degrees, and significant hypermobility at the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate?

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for moderate to severe hallux valgus, particularly when accompanied by first ray hypermobility. It provides powerful correction of the IMA and stabilizes the medial column.

Question 84

A 24-year-old professional American football player sustains a hyperextension injury to his first metatarsophalangeal (MTP) joint. Clinical exam reveals marked swelling, ecchymosis, and frank instability of the first MTP joint with proximal migration of the sesamoids on radiographs. What is the most appropriate management?

Explanation

This is a Grade III turf toe injury characterized by a complete tear of the plantar plate and sesamoid complex with frank instability. In a competitive athlete, operative repair of the plantar plate and stabilization of the sesamoids is indicated.

Question 85

When utilizing the Ponseti method for the correction of idiopathic clubfoot, what is the first component of the deformity that must be addressed?

Explanation

The Ponseti method follows the CAVE sequence: Cavus, Adductus, Varus, Equinus. The cavus is corrected first by elevating the first ray (supinating the forefoot) to align it with the supinated hindfoot.

Question 86

A 65-year-old patient with end-stage post-traumatic ankle osteoarthritis undergoes a tibiotalar arthrodesis. To optimize the patient's postoperative gait, the ankle should be fused in which of the following positions?

Explanation

Optimal positioning for ankle arthrodesis is neutral dorsiflexion (0 degrees), 5 degrees of hindfoot valgus, and 5 to 10 degrees of external rotation (to match the contralateral limb). Plantarflexion or varus positioning leads to poor gait and adjacent joint arthritis.

Question 87

A 21-year-old track athlete is diagnosed with a navicular stress fracture. Which area of the navicular is most susceptible to this injury due to its watershed blood supply?

Explanation

Navicular stress fractures typically occur in the central one-third of the bone. This area is relatively avascular (a watershed zone) between the medial and lateral vascular supplies, predisposing it to delayed healing and nonunion.

Question 88

A 30-year-old skier sustains an acute dorsiflexion and inversion injury. He complains of posterolateral ankle pain and a snapping sensation behind the lateral malleolus. Disruption of which of the following structures is the primary cause of his symptoms?

Explanation

The patient has peroneal tendon subluxation. The primary restraint to peroneal tendon subluxation is the superior peroneal retinaculum (SPR), which often avulses from the posterolateral fibular margin during the injury.

Question 89

A 40-year-old laborer sustains a purely ligamentous, unstable Lisfranc injury. Based on high-level evidence, which of the following surgical treatments yields the best long-term clinical outcomes and functional scores for purely ligamentous midfoot injuries?

Explanation

Current evidence demonstrates that primary arthrodesis of the medial columns (1st, 2nd, and 3rd TMT joints) leads to better functional outcomes and lower reoperation rates than ORIF for purely ligamentous Lisfranc injuries.

Question 90

Osteochondral lesions of the talus (OCLT) typically present in distinct locations based on the mechanism of injury. A lesion located on the posteromedial aspect of the talar dome is classically associated with which mechanism?

Explanation

Posteromedial talar dome lesions are classically caused by a plantarflexion and inversion injury. They are typically deeper, larger, and less likely to displace compared to anterolateral lesions (which are caused by dorsiflexion and inversion).

Question 91

A 55-year-old male undergoes surgical treatment for severe insertional Achilles tendinopathy with a prominent Haglund's deformity. During debridement of the degenerative tendinosis, 60% of the Achilles tendon insertion is detached. What is the recommended concurrent surgical step?

Explanation

When more than 50% of the Achilles tendon insertion must be detached to adequately debride insertional tendinopathy, augmentation with a Flexor Hallucis Longus (FHL) tendon transfer is recommended to restore strength and prevent rupture.

Question 92

A 60-year-old female presents with severe pain and stiffness in her great toe. Radiographs demonstrate complete loss of joint space at the first MTP joint, extensive dorsal osteophytes, and subchondral cysts. She wishes to maintain an active lifestyle involving hiking. What is the gold standard surgical treatment?

Explanation

This patient has Grade III/IV hallux rigidus. The gold standard surgical procedure for advanced, symptomatic hallux rigidus, especially in active patients, is a first MTP joint arthrodesis, providing reliable pain relief and durability.

Question 93

A 45-year-old male sustains a high-energy closed tibial pilon fracture with severe soft tissue compromise (Tscherne Grade III). What is the standard staged protocol for managing this injury?

Explanation

High-energy pilon fractures with severe soft-tissue injury are managed with a staged approach: immediate spanning external fixation to restore length/alignment, allowing the soft tissue envelope to recover (often 10-21 days) before definitive ORIF.

Question 94

A 15-year-old female dancer presents with pain in her forefoot. Radiographs show sclerosis and flattening of the second metatarsal head. Conservative treatment has failed. What surgical procedure is designed to rotate the plantar viable cartilage dorsally to articulate with the proximal phalanx?

Explanation

This presentation describes Freiberg's infraction. A dorsal closing wedge osteotomy of the metatarsal neck directs the necrotic dorsal articular cartilage away from the joint while bringing the healthy plantar cartilage into articulation.

Question 95

A 12-year-old boy presents with frequent ankle sprains and a rigid, flat foot. Examination reveals peroneal spasticity and restricted subtalar motion. Which radiographic view is best suited to confirm the presence of a calcaneonavicular coalition?

Explanation

The 45-degree internal oblique radiograph of the foot is the standard view to identify a calcaneonavicular coalition, classically demonstrating the "anteater sign." The Harris axial view is utilized to evaluate talocalcaneal coalitions.

Question 96

During a lateral extensile approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, the full-thickness subperiosteal flap is created. Which nerve is most at risk and must be protected in the superior/posterior aspect of the incision?

Explanation

The sural nerve courses posterior to the lateral malleolus and along the lateral aspect of the hindfoot. It is highly vulnerable during the vertical limb and corner-creation of the lateral extensile approach to the calcaneus.

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