Question 1

Which of the following procedures is not indicated as part of the reconstruction of the cavovarus hindfoot:

Explanation

All of the above tendon transfers may be used as part of a reconstruction of the cavus foot except the anterior tibial tendon. The imbalance between the anterior tibial tendon and the peroneus longus tendons are responsible for the cavovarus deformity.

Question 2

Transfer of the extensor hallucis longus tendon to the first metatarsal and arthrodesis of the hallux interphalangeal joint is indicated for which of the following deformities:

Explanation

Correction of the claw hallux and first metatarsal equinus deformity may be accomplished by transfer of the extensor hallucis longus tendon and arthrodesis of the hallux interphalangeal joint. Once the deformity of the forefoot is fixed (e.g., following a compartment syndrome), the extensor hallucis longus tendon can no longer dorsiflex the first metatarsal. Although C harcot-Marie- Tooth disease is often associated with a cavus foot, the transfer is not indicated when a planovalgus foot is present.

Question 3

A 43-year-old diabetic patient has had an ulcer on the plantar aspect of her foot for 9 months. She has no systemic symptoms. There is minimal drainage from the ulcer, and she has no pain in the foot. Initial management of this patient must include:

Explanation

This neuropathic ulcer is stable. There is minimal drainage and no clinical findings to suggest an active infection. C ulture of the ulcer yields multiple nonpathogenic organisms and antibiotic therapy is not indicated. Treatment is initiated with either a total contact cast or a total contact walker boot.C orrect Answer: A total contact cast

Question 4

The primary cause for the deformity shown (Slide) is:

Explanation

Overplication of the medial capsule, overcorrection of the metatarsal osteotomy, and excessive lateral soft tissue release can lead to a hallux varus deformity. The most likely cause, however, is interference with the varus- valgus balance of the hallux as a result of a fibular sesamoidectomy.

Question 5

A patient had a fixed deformity of the hallux interphalangeal (IP) joint (Slide) for 3 years following forefoot surgery. She complains of pain over the distal aspect of the hallux where rubbing occurs on the shoe. On examination, the hallux is flexible at the metatarsophalangeal (MP) and IP joints, there is no crepitus of the MP joint, and radiographs demonstrate normal alignment of the first metatarsal. The recommended procedure for correcting this deformity is:

Orthopedic Prometric Exam Question

Explanation

anchor Arthrodesis and resection arthroplasty of the hallux MP joint are indicated in the presence of arthritis of the hallux MP joint. A tendon transfer is preferred, and the extensor hallucis brevis tendon is an effective transfer. Use of the extensor hallucis longus tendon with arthrodesis of the hallux IP joint is indicated when there is a fixed deformity of the hallux IP joint.

Question 6

A 33-year-old recreational athlete presents for treatment of chronic ankle pain. He recalls multiple ankle sprains that occurred 10 years ago. He has not undergone any surgical treatment. On examination, his ankle is stable, there is no crepitus on range of motion, and pain is present to palpation of the posterior ankle. A computerized axial tomography is presented (Slide). The surgical procedure most consistent with a rapid recovery and predictable outcome is:

Explanation

Ankle arthrodesis must be used as a salvage procedure for failed management of the osteochondral lesion of the talus. Although osteoarticular autograft is a popular procedure, the results are variable and unpredictable, particularly in posteromedial lesions. Ankle arthroscopy with transarticular drilling is the most predictable procedure with expected satisfactory results in approximately 80% of patients. Orthopedic Prometric Exam Question

Question 7

A 52-year-old man presents for treatment of acute pain in the forefoot. He notes that the onset of pain started 24 hours ago, and he is unable to walk. Examination of the hallux (Slide) is uncomfortable. The recommended treatment for this condition is:

Explanation

This patient presents with a classic acute gout attack. Although the hallux is in severe valgus, it is unlikely that this is the cause of the joint pain. Note the swelling of the hallux and the shiny skin from the acute inflammation. These clinical findings are typical of gout. Intra-articular injection of steroids is effective treatment and can be combined with oral anti-inflammatory agents.

Question 8

A 43-year-old patient presents for treatment of a chronically painful ankle. He notes pain with ambulation, is unable to exercise, and has had marked swelling of the ankle for the last 6 months. When walking, he notes continued instability of the ankle. Examination of the ankle is unremarkable with the exception of swelling. A plain radiograph and intraoperative photograph are shown (Slide 1 and Slide 2). The most likely cause for this condition is:

Orthopedic Prometric Exam Question

Explanation

The appearance of the synovium is typical of pigmented villonodular synovitis. Staining of the synovium is characteristic. It is unlikely that a 43- year-old man will present with rheumatoid arthritis, although synovitis may appear similar. Recurrent ankle sprains cause a nonspecific synovitis that is not pigmented.

Question 9

A patient sustains a crush injury when heavy farm equipment rolls over his foot. He presents to the emergency department 4 hours later with pain and swelling in the foot. Radiographic examination is normal. You examine him for a compartment syndrome. The intracompartmental pressure in the interosseous compartment is 20 mm Hg. The next phase of management may include all of the following except:

Explanation

Fasciotomy of the foot is not indicated when pressures are less than 20 mm Hg. All of the alternatives are reasonable forms of treatment including application of an intermittent foot pump device that has been demonstrated to decrease compartment pressures of the foot. If pressures were more than 30 mm Hg, then a fasciotomy may be indicated.

Question 10

A 61-year-old woman presents for treatment of a painful ankle. She reports that 4 years ago, she sustained a fracture of her ankle that was treated with cast immobilization. She has experienced progressively worsening pain over the past 2 years. On examination, she has good range of motion of the ankle with crepitus and pain. Radiographs are presented (Slide 1 and Slide 2). All of the following are acceptable forms of surgical correction except:

Orthopedic Prometric Exam Question

Explanation

Each of the alternatives presented is reasonable except for ankle arthroscopy because it has a limited role in the management of posttraumatic arthritis of the ankle. In this patient, there is a possibility to salvage the ankle before arthrodesis or joint replacement with an osteotomy of the tibia and or the fibula. Both have a definite role in management of ankle deformity and arthritis. A closing wedge osteotomy of the tibia was performed in this patient, and she remains asymptomatic 4 years later (Slide 3 and Slide 4).

Question 11

This patient developed a peripheral neuropathy of uncertain etiology. She has a partial peroneal nerve palsy with lack of extensor function of the hallux. She repeatedly stubs and catches the hallux when walking. Upon examination, she has good strength of the extensor digitorum longus tendon, as well as the anterior tibial tendon. Flexor strength of the foot is intact. All of the following are acceptable surgical alternatives except:

Explanation

When arthrodesis of the hallux MP joint is performed, it stabilizes the MP joint and continued flexion of the hallux with recurrent deformity occurs because the hallux interphalangel joint is not controlled with MP arthrodesis. All of the other procedures are satisfactory alternatives.

Question 12

A 28-year-old professional athlete presents for treatment of foot pain following an inversion injury to her ankle. She has been immobilized in a short leg walker boot for 1 month with minimal relief of symptoms. On examination, pain is present in the sinus tarsi. The patientâ s ankle is not painful or unstable. Radiographs demonstrate a calcaneonavicular coalition. Recommended treatment includes:

Explanation

When a tarsal coalition becomes symptomatic in an adult, surgery becomes necessary. Initial immobilization may be attempted, although prolonged immobilization in an athlete is not ideal. Manipulation of the foot will exacerbate the pain, and therapy is not indicated. If arthrodesis of the hindfoot is performed for treatment of a calcaneonavicular coalition, then a triple arthrodesis is performed. Excision of the adult calcaneonavicular coalition is the preferred treatment.

Question 13

A 43-year-old woman presents for treatment of pain in her forefoot that has been present for 1 year. The pain is localized to the second toe and radiates out to the tip of the toe with activities. When the patient wears high heel shoes, the pain is associated with numbness and burning of the toe. Your initial treatment consists of:

Explanation

This patient has typical symptoms of an interdigital neuroma, most likely involving the second web space. The likelihood of resolution of pain with nonsurgical treatment is good despite the duration of symptoms. Treatment can be initiated with a wide shoe, an orthotic arch support, or an injection of corticosteroid into the affected web space.

Question 14

A 62-year-old man presents for treatment of ankle pain. He suffered a fibular fracture 7 months ago while hiking in the mountains. He was treated with a short leg walking cast. On examination, he has pain on range of motion of the ankle, pain over the distal fibula, and no instability or crepitus to range of motion of the ankle. Pain is present on external rotation of the foot under the leg. Radiographs of the ankle demonstrate a healed fibular fracture with 7 mm of shortening and slight external rotation. There is a 7Â° valgus tilt of the tibiotalar joint and a widening of the medial clear space. The joint space laterally appears slightly narrowed. Recommended treatment includes:

Explanation

This patient has a malunion of the fibula that does not appear to be associated with ankle arthritis, despite the radiographic changes. The valgus tilt of the ankle joint is common with shortening of the fibula and does not imply arthritis. Therefore, arthrodesis and ankle replacement are not indicated. Lengthening osteotomy of the fibular combined with excision of the medial joint scar is ideal to realign the tibiotalar joint. Although ankle arthroscopy may be performed in conjunction with the fibular osteotomy, it is not sufficient treatment.

Question 15

The most common complication following operative treatment of an acute rupture of the Achilles tendon is:

Explanation

Although all of the above complications may occur following repair of an acute Achilles rupture, improper tensioning of the repair and stretching of the repair occur most commonly. This is due to a number of factors including the position of the foot during the repair, incorrect tensioning of the repair, and premature unprotected dorsiflexion of the foot following surgery. When suturing the tendon ends, the sutures must be inserted correctly and not into the frayed tendon ends, which will lead to incorrect tension on the repair. It is preferable to position the foot in slight equinus during the repair.

Question 16

A 67-year-old obese patient presents for treatment of ankle pain. Twenty- five years ago, he underwent a total ankle replacement. He was asymptomatic for 15 years, and his symptoms have become intolerable. He has limited ankle motion, associated with pain in the ankle. His radiograph is presented (Slide). Which of the following is the preferred surgical procedure:

Orthopedic Prometric Exam Question

Explanation

Removal of the implant is necessary but will not be sufficient to alleviate pain from arthritis. In this obese patient, an arthrodesis is necessary. An extended hindfoot arthrodesis is only necessary when pain and arthritis are present in joints adjacent to the ankle. An ankle arthrodesis with interposition graft is sufficient.

Question 17

A 53-year-old woman presents for treatment of recurrent symptoms following excision of a third web space interdigital neuroma. She was asymptomatic for 6 months following surgery. On examination, pain is present in the third web space and reproduced with compression of the forefoot. The likelihood of a good result following revision surgery is:

Explanation

The reported results following revision surgery following recurrence of symptoms after excision of an interdigital neuroma are poor. In a large series, Stamatis and Myerson reported less than a 50% good outcome following revision surgery.

Question 18

A patient presents for treatment of a dislocated second metatarsophalangeal joint. Radiographs demonstrate the dislocation. In addition to soft tissue balancing, you perform an oblique shortening osteotomy of the second metatarsal head (Weil). The most common complication following this osteotomy is:

Explanation

The Weil osteotomy is a good procedure to correct deformity about the lesser metatarsophalangeal joint but is associated with potential complications, the most common of which is elevation of the second toe. As a result of shortening and plantar shifting of the metatarsal, the intrinsic muscles shift dorsally and can function as a dorsiflexor of the metatarsophalangeal joint.

Question 19

A 26-year-old professional football player presents for evaluation of ankle pain. He was playing in a match 2 days ago and felt a pop in his ankle. On examination, the peroneal tendon is felt to subluxate anterior to the fibula. Magnetic resonance imaging confirms a tear of the superior peroneal retinaculum. Recommended treatment includes:

Explanation

An acute dislocation of the peroneal tendon must be repaired. The results of immobilization are not predictable and, in a professional athlete, the added potential for failure with nonoperative treatment must be considered. With a rupture of the superior peroneal retinaculum likely to be the cause of the dislocation, the peroneal tendon should be repaired. When repair of an acute dislocation is performed, it should not be necessary to deepen the fibular groove.

Question 20

A patient presents for treatment of a painful hallux. The pain is over the dorsal surface of the hallux metatarsophalangeal joint and is worsened with plantar flexion of the toe. The passive range of motion is 30Â° of dorsiflexion and 10Â° of plantarflexion. The radiographs confirm the presence of mild arthritis of the metatarsophalangeal joint, with dorsal osteophytes on the metatarsal head. Which of the following procedures is most likely to be associated with a long-term satisfactory outcome:

Explanation

The pain present in plantarflexion is common and associated with friction of the capsule against the dorsal osteophytes. This patient has noted only mild arthritis of the metatarsophalangeal joint. An arthrodesis is not a necessary treatment, although it is a reasonable alternative. Implant and interposition arthroplasty are alternatives for the treatment of arthritis of the metatarsophalangeal joint but preferably only when the condition is advanced.

Question 21

This patient is a 17-year-old athlete who presents for treatment of a feeling of giving way of the ankle. The inversion clinical stress is demonstrated below (Slide). Which statement concerning the image presented below is correct:

Explanation

Although some laxity may be present in this patient, it is impossible to determine whether this is present in the ankle or the subtalar joint based upon this clinical test. Simple inversion stress without simultaneously palpating the lateral shoulder of the talus cannot indicate the presence or the type of instability. An anterior drawer that is positive and, in particular, is associated with a vacuum phenomenon in the anterolateral ankle is more diagnostic of ankle instability.

Question 22

What structure is held in between the forceps in this photograph (Slide):

Explanation

The extensor retinaculum is an important structure in maintaining and possibly augmenting the stability of the lateral ankle and subtalar joint. The inferior root of the extensor retinaculum inserts in the floor of the sinus tarsi, improving stability of the subtalar joint. This structure can be used to augment a repair of ankle instability.

Question 23

A 37-year-old woman injured her ankle 17 weeks ago when stepping off a sidewalk. She has experienced pain in the ankle since that time, and no treatment has yet been initiated. Presented is a view of the ankle performed with external rotation stress (Slide). The recommended treatment at this time is:

Explanation

This unstable ankle is associated with a complete disruption of the syndesmosis. With the information available, it is not likely that a high fibular fracture is present. One has to assume that the injury is limited to the syndesmosis. Although the deltoid ligament may be torn, one cannot determine this until the time of surgery. At surgery, if the mortise reduces well following insertion of screw(s), then the deltoid is left alone. If the talus does not reduce, then there may be deltoid tissue that needs to be removed before the reduction can be accomplished.

Question 24

A 42-year-old male patient presents with a history of repeated giving way of his ankle. He notes that this has been present for 1 year. He does not experience any pain, even with the episodic bouts of the ankle buckling. On examination, the ankle range of motion is normal, no pain is elicited, and there is no crepitus. A stress radiograph (Slide 1) and a lateral weight- bearing radiograph (Slide 2) are presented. The patient does not want to undergo surgery, but he needs to know the possibility of problems with his ankle in the future. The patient should be advised that:

Orthopedic Prometric Exam Question

Explanation

Ankle arthritis is rarely idiopathic. In the United States, the most common source of ankle arthritis is following trauma, usually of a major nature. Repetitive ankle injury, particularly when associated with recurrent instability and a varus or cavus foot, will likely lead to the development of ankle arthritis. Patients should be counseled that recurrent instability of the ankle, particularly when osteophytes are already present, frequently leads to arthritis.

Question 25

A 73-year-old woman states that she has been tripping over her right foot for the past year (Slide). She walks with a limp, and she states that her foot â slapsâ the ground. On examination, weakness in which muscle is likely present:

Explanation

This patient presents with a typical rupture of the anterior tibial tendon. She reports a drop foot, commonly perceived by the patient as a slapping sensation of the foot when attempting to lift the foot up as the heel contacts the ground. Note the slight extension of the hallux, indicating chronic overuse in an attempt to provide accessory dorsiflexion of the ankle.

Question 26

A 76-year-old man has experienced aching in the anterior aspect of his ankle for 6 months. He felt a sudden onset of soreness 6 months ago. Since then, he has noted weakness of the foot. He walks with a limp, and the foot hits the ground during the heel contact phase of gait. On examination there is a mobile subcutaneous mass in the anterior ankle. The patientâ s magnetic resonance image (MRI) is presented (Slide). Which of the following is the most accurate diagnosis:

Orthopedic Prometric Exam Question

Explanation

This MRI presents the typical appearance of an anterior tibial tendon rupture. There is no continuity of the tendon distally, and the retracted tendon end has formed a scar palpable as a subcutaneous mass. The clinical history of the weakness associated with a drop foot gait is characteristic of the tendon rupture.

Question 27

A 23-year-old carpenter fell off a roof 4 weeks ago. He has pain in the ankle and a deformity. The lateral radiograph is presented (Slide). Which of the following treatments is most likely to return this patient to work with a functioning foot and ankle:

Explanation

The calcaneus fracture is associated with subluxation of the subtalar joint, giving the appearance of injury to the talus and calcaneus. The true extent of the injury cannot be determined without a computed tomography scan; however, the question is not as to the outcome of treatment, but the ability to return this patient to his occupation. At 4 weeks following injury, while open reduction internal fixation of the fracture is possible, anatomic reduction may be difficult. The most likely means of returning this patient to work is Orthopedic Prometric Exam Question

with early arthrodesis, which should be combined with an open reduction internal fixation of the calcaneus.

Question 28

A patient underwent an arthrodesis of the hallux metatarsophalangeal joint for correction of painful arthritis (Slide 1 and Slide 2). She remains symptomatic and cannot walk without pain. The most likely cause for her pain is:

Explanation

The ideal position for arthrodesis of the hallux metatarsophalangeal joint is in 5° of valgus, 10° of dorsiflexion relative to the ground, and neutral rotation. Although the hallux is short and may be associated with painful metatarsalgia, the most likely cause of pain is abutment of the hallux against the shoe because it was fused in varus.

Question 29

A 53-year-old woman presents for treatment of painful toe and metatarsal deformities (Slide). She underwent surgery to the hallux 2 years ago for correction of arthritis of the hallux metatarsophalangeal joint. Pain in the joint persists. She has no systemic disease, and the opposite foot is normal. What is the ideal surgical correction for her forefoot:

Orthopedic Prometric Exam Question

Explanation

Resection of the lesser metatarsal heads is an operation that is commonly performed for patients with rheumatoid arthritis; however, this may also be performed for patients with debilitating metatarsalgia in the absence of systemic disease. Capsulotomy and tendon lengthening will not correct the alignment of the lesser toes or address the metatarsalgia. Revision of the resection arthroplasty will not address the metatarsalgia, and recurrent deformity of the hallux is likely. Shortening osteotomies of the metatarsal will decompress the joint, realign the toes, and decrease the metatarsalgia, particularly if performed in conjunction with metatarsophalangeal arthrodesis. A lengthening bone block fusion is not necessary.

Question 30

A 17-year-old patient presents with pain in the second toe. Pain becomes worse with exercise and has been present for 6 months. On examination, swelling is present around the metatarsophalangeal joint, and pain is present over the joint and upon squeezing the forefoot. Radiographic evaluation demonstrates a lucency in the second metatarsal head. The most likely cause of this condition is:

Explanation

This patient has the typical features of Freibergs osteochondrosis of the second metatarsal head. There is swelling present, which is not noted in association with a neuroma, even though the clinical findings may be similar. Synovitis is common but not associated with radiographic changes.

Question 31

An 11-year-old girl presents with chronic foot pain. Her mother notes that her daughter has had flatfeet since birth, but the condition is worsening. The patient has aching in her foot, the arch of her foot, and her leg with walking and activities. She has been treated for 3 years with various orthotic arch supports. The foot is mobile and flexible on examination. Radiographs (Slide 1 and Slide 2) and a photograph (Slide 3) of her foot are presented. Which of the following surgical treatment alternatives is unacceptable in this patient:

Explanation

This patient has a flexible flatfoot deformity associated with a painful accessory navicular. No clinical or radiographic findings of a tarsal coalition are present. In addition to excision of the accessory navicular and advancement of the posterior tibial tendon, either a subtalar arthroerisis or an osteotomy of the calcaneus may be necessary.C orrect Answer: Excision of a middle facet tarsal coalition Orthopedic Prometric Exam Question

Question 32

A 12-year-old girl was successfully treated for a flexible flatfoot deformity on the left foot. A clinical photograph (Slide 1) of her foot and a lateral radiograph (Slide 2) are presented. What is the purpose of the implant noted under the talus in the radiograph:

Explanation

The subtalar arthroerisis, as demonstrated in the radiograph, is used to control eversion of the subtalar joint during the foot flat phase of gait. A subtalar arthroerisis limits excessive eversion but does not restrict subtalar Orthopedic Prometric Exam Question

motion further. This procedure is indicated for a patient who has a flexible flatfoot deformity and can be used either as the sole or an adjunctive procedure for correction.

Question 33

The patient presented (Slide 1 and Slide 2) has a hereditary sensory motor neuropathy. Based upon the photographs, a surgeon should be able to determine the pattern of muscle weakness. Weakness in which muscle is most likely the cause of this deformity:

Explanation

Although the anterior tibial muscle is weak, the cavus is the predominant deformity of this condition, caused by weakness of the peroneus brevis. The peroneus longus is functioning and is responsible for the plantarflexion of the first metatarsal.

Question 34

You are planning a tendon transfer to help correct deformity in a patient with hereditary sensory motor neuropathy. Which of the following muscles will be used for the transfer based upon the clinical appearance of the foot (Slide 1 and Slide 2):

Explanation

The posterior tibial tendon transfer is a commonly performed surgery for correction of cavus foot deformity associated with weakness of the anterior tibial muscle and varying degrees of drop foot deformity. The removal of the force of the posterior tibial tendon adds to the correction of the deformity of the foot by balancing the absent peroneus brevis. Although the extensor hallucis longus can be used as a tendon transfer, it will not be the primary muscle used or sufficient to correct deformity.

Question 35

Which combination of muscle weakness is typically associated with hereditary sensory motor neuropathy:

Explanation

The peroneus brevis is usually the first muscle to atrophy. Varying patterns of loss of the other muscles of the lower extremity include the anterior tibial and, in particular, the intrinsic foot muscles. Weakness in these muscles accounts for the cavus and the claw foot deformities noted in patients with hereditary sensory motor neuropathy.

Question 36

A 42-year-old man with diabetes presents for treatment of a swollen foot (Slide). He does not recall the onset of swelling, and he states that his foot is not painful. On examination, the foot is hot to touch and swollen. Upon radiographic examination, no deformities are evident. Which of the following treatment options should be used next:

Explanation

This patient presents with an acute neuroarthropathy. The acute painless swelling, associated with warmth and absence of radiographic findings, is typical of the acute phase of a Charcot process. A short leg cast or a boot to immobilize the foot is ideal, and no weight bearing should be permitted until the acute phase of this neuroarthropathy has subsided.

Question 37

A 29-year-old woman presents for treatment of a swollen foot. Although her foot is not painful, it has been swollen for 2 weeks. The patient walks into the office without any assistive device. On examination, the foot is swollen and warm. The patient does not have protective sensation in the foot, and she denies a history of diabetes and does not have a clinically relevant medical history. A radiograph of her foot is presented (Slide). Which of the following tests will be most helpful in determining the etiology of her condition:

Orthopedic Prometric Exam Question

Explanation

This patient most likely has diabetes. Patients may present for the first time with an acute neuroarthropathy of the foot as a result of diabetes, even without a clinical history of the disease. Although the sedimentation rate will likely be elevated, it will not help in the diagnosis. Infection is not a likely consideration in this patient.

Question 38

A patient with diabetes and severe peripheral neuropathy has been treated for a C harcot ankle deformity for 9 months (Slide 1, Slide 2, and Slide 3). An ankle foot orthosis has been used for 4 months. No skin breakdown occurred in the brace. Swelling is present but has decreased over the past month. Ankle range of motion is limited, and crepitus is present upon examination of the ankle. Which surgical procedure is most consistent with the future treatment of this patient:

Orthopedic Prometric Exam Question

Explanation

The indication for surgery is intractable deformity, which is refractory to all forms of bracing. By refractory, one implies that skin breakdown or imminent infection is present. If surgery were performed, then it would consist of a tibiotalocalcaneal arthrodesis. There are no indications for this surgery in this patient. Once the neuropathic process has reached a stable point, a deformity is not likely to progress.

Question 39

An 83-year-old woman presents for treatment of a painful second toe deformity. The hallux, the bunion, and the third toe are not painful. A fixed crossover toe deformity is present (Slide), with a dislocation of the second metatarsophalangeal joint noted radiographically. Which procedure is likely to give the patient rapid pain relief:

Explanation

In this age group, amputation of the second toe is a reasonable treatment. It is not possible to correct the second toe deformity without correction of the hallux, either by arthrodesis or arthroplasty at the metatarsophalangeal joint. The hallux is asymptomatic, which is common in this age group, and the simplest treatment is to amputate the toe.C orrect Answer: Amputation of the second toe at the metatarsophalangeal joint Orthopedic Prometric Exam Question

Question 40

A 60-year-old man experiences pain under the lesser metatarsal heads. Prominence of the metatarsal heads under the second, third, and fourth metatarsal is noted, as well as associated fixed claw toe deformities (Slide). The etiology of the foot pain is:

Explanation

The cause of claw toe deformity is not idiopathic. C law toe deformity is a common deformity in adults, particularly in women as a result of lack of use of the intrinsic muscles of the foot, leading to an imbalance between the extrinsic and intrinsic muscles in the foot. As the intrinsic muscle atrophies, the long extensor and flexor tendons cause the deformity (as presented in this patient), with resulting metatarsalgia. Orthopedic Prometric Exam Question

Question 41

A patient presents with a claw toe deformity (Slide). What is the strongest flexor of the metatarsophalangeal joint, which in this patient is not functioning adequately:

Explanation

Although the long and short flexor tendons have some effect albeit indirect on the flexion of the metatarsophalangeal joint, the flexor that acts directly on the joint is the interosseous muscle. Intrinsic atrophy will lead to claw toe deformity.

Question 42

A 54-year-old woman presents for treatment of an ulcer (Slide). She has diabetes, no protective sensation, and slight deformity of the foot. There is no inflammation of the foot and no purulent drainage. Slight serous oozing is present daily. Initial evaluation and treatment should consist of:

Explanation

Ambulatory treatment for a patient with diabetes is always the preferable treatment. In this patient, there is no evidence of infection. Unless drainage is purulent and the ulcer is in contact with bone, there should be minimal concern for infection. Reconstruction of a Charcot deformity of the midfoot is only indicated following repeated failure of nonoperative treatments.

Question 43

A 63-year-old patient underwent a triple arthrodesis for correction of flatfoot deformity. He presents with continued ankle pain, as well as a hindfoot valgus deformity. The ankle deformity is flexible, and the joint can be reduced. All of the following are reasonable surgical alternatives as a single or staged procedure with the exception of:

Explanation

Repair of a chronically torn deltoid ligament is not sufficient to correct this type of deformity. The ligament has degenerated, and the quality of the ligament is insufficient. Each of the other alternatives is reasonable either performed as the sole or adjunctive procedure.C orrect Answer: Deltoid ligament repair

Question 44

A 34-year-old patient presents for treatment of painful ankle arthritis. Deformity of the ankle is present with posttraumatic arthritis and 20° of varus deformity as a result of erosion of the distal tibial plafond. There is minimal motion of the subtalar joint, and the forefoot is plantigrade. You plan an ankle arthrodesis. In addition to the position of the ankle arthrodesis, what additional procedure should you consider:

Explanation

This patient has a fixed deformity of the ankle, as well as the hindfoot. The subtalar joint has adapted to the varus position of the ankle but is stiff. Following the ankle arthrodesis, which has to be performed by bringing the ankle into a few degrees of varus, the forefoot will not be able to compensate for the fixed changes that have taken place in the hindfoot. To keep the forefoot plantigrade, a dorsal wedge osteotomy of the first metatarsal should be performed to keep the foot plantigrade.

Question 45

A 26-year-old woman presents for treatment of ankle arthritis following trauma. She is an active individual despite her arthritis. On examination, her foot is fixed in equinus, no ankle motion is present, and the motion in the subtalar joint is normal. Ankle arthritis is noted radiographically. In a preoperative discussion, she states the desire to have as mobile a foot as possible, wear high heel shoes, and participate in realistic exercise activities. You perform an ankle arthrodesis. What is the ideal position for the arthrodesis:

Explanation

Regardless of patient activities, desire for shoe wear, and age, the ankle must be fused in a standard position of neutral dorsiflexion and slight valgus. This is important because any deviation of this position, particularly in equinus, will increase th likelihood of arthritis in the talonavicular and subtalar joint.

Question 46

A 22-year-old man has experienced pain in his foot and ankle for 10 years. His radiographs are presented (Slide 1 and Slide 2). The foot is flexible, and pain is present in the sinus tarsi and along the medial border of the foot. With the subtalar joint held in a reduced neutral position, the forefoot is in 15° of supination. You attempt orthotic arch supports and when these do not alleviate his pain, a brace is suggested. He refuses to wear a brace. You plan an osteotomy of the calcaneus with lengthening bone graft at the neck of the calcaneus (lateral column lengthening). The most common complication following this procedure is:

Orthopedic Prometric Exam Question

Explanation

This patient demonstrates the common finding of fixed forefoot varus associated with a flexible flatfoot deformity. It is likely that a gastrocnemius contracture is also present, but this is not always the case. Arthritis of the calcaneocuboid joint rarely occurs following a lengthening calcaneal osteotomy in an adult. C orrection of the forefoot varus is best accomplished with an opening wedge osteotomy of the medial cuneiform. Arthrodesis of the first tarsometatarsal joint may be performed in selected patients with noted instability at this joint.C orrect Answer: Elevation of the first metatarsal

Question 47

A 44-year-old obese man presents for treatment of acute ankle pain. He does not have a history of trauma or a systemic history of note. His opposite foot has had multiple episodes of acute pain in the past, lasting from 3 to 5 days. On examination, the ankle is warm, swollen, and exquisitely tender to palpation and any range of motion (Slide1, Slide 2, and Slide 3). Concerned about the source of pain, you aspirate the joint and send the sample for analysis. You expect to find:

Explanation

This patient most likely has an acute attack of gout. The prior episodes of foot pain and the sudden onset lasting 5 days for each bout is characteristic. The ankle is not a common location for gout (the most frequent site is the hallux metatarsophalangeal joint). The treatment should consist of injection of a corticosteroid into the joint and administration of appropriate oral anti-inflammatory medication. Orthopedic Prometric Exam Question

Question 48

This patient presents for treatment of a painful hallux varus deformity following correction of hallux valgus deformity (Slide). All of the following procedures may be acceptable surgical alternatives for correction of deformity with the exception of:

Explanation

The extensor hallucis longus or the extensor hallucis brevis (rarely the abductor hallucis) may be used as a tendon transfer for correction. Arthrodesis of the hallux interphalangeal joint may be performed for Orthopedic Prometric Exam Question

correction of a fixed claw deformity of the interphalangeal joint, usually in conjunction with a tendon transfer. Arthrodesis of the metatarsophalangeal joint is a reasonable alternative provided there is no fixed deformity of the interphalangeal joint present and when arthritis or fixed deformity of the metatarsophalangeal joint is present.C orrect Answer: First metatarsal osteotomy

Question 49

Which of the following is true concerning Achilles tendon ruptures:

Explanation

Important points to remember about Achilles tendon ruptures: A. Most common in middle-aged men B. Often intermittent sports activity C . Left more than right D. Often the tendon is abnormal (degenerative) E. Mechanism 1. Sudden forced plantarflexion 2. Unexpected dorsiflexion 3. Violent dorsiflexion of the plantar flexed foot Factors which may make the patient more prone to rupture: A. Steroids B. Fluoroquinolones

Question 50

Which of the following is true concerning the repair of acute Achilles tendon ruptures:

Explanation

This meta-analysis showed: Operative versus nonoperative (pooled rates): Rerupture Operative 3.5% (6/173) (relative risk 0.27) Nonoperative 12.6% (23/183) Complications (adhesions, infection, disturbed sensibility) Operative 34.1% (59/173) (relative risk 10.60) Nonoperative 2.7% (5/183) Infection Operative 4.0% (7/173) (relative risk 4.89) Nonoperative 0%

Question 51

A 55-year-old diabetic patient presents with a warm, swollen, erythematous foot without an open wound. Radiographs show fragmentation of the navicular and cuneiforms. Which of the following is the most appropriate initial management?

Explanation

Acute Charcot arthropathy (Eichenholtz stage 1) is characterized by a warm, swollen foot and radiographic fragmentation. Initial management is immediate offloading with a total contact cast to prevent further mechanical deformity.

Question 52

A 40-year-old man sustains a high-energy varus directed force to his knee resulting in a medial tibial plateau fracture.

Which of the following associated neurovascular injuries is most frequently seen with this specific high-energy fracture pattern compared to lateral plateau injuries?

Explanation

Schatzker IV (medial tibial plateau) fractures typically result from high-energy trauma and represent knee dislocation equivalents. They have a significantly higher association with popliteal artery injuries and peroneal nerve palsies than lateral plateau fractures.

Question 53

Which of the following is an accepted indication for prophylactic in situ pinning of the contralateral asymptomatic hip in a patient presenting with an acute slipped capital femoral epiphysis (SCFE)?

Explanation

Prophylactic pinning of the contralateral hip in SCFE is highly recommended for patients with endocrinopathies (like hypothyroidism or renal osteodystrophy) or prior radiation therapy. These patients have an exceptionally high risk of bilateral involvement.

Question 54

A 65-year-old man presents with bilateral leg pain exacerbated by walking and relieved by sitting and leaning forward. He reports that riding a stationary bicycle does not provoke his symptoms. What is the most likely pathophysiological mechanism of his symptoms?

Explanation

The patient's symptoms are classic for neurogenic claudication caused by lumbar spinal stenosis. Central canal narrowing is frequently due to facet arthropathy and hypertrophy of the ligamentum flavum, and symptoms are relieved by lumbar flexion (e.g., leaning forward, cycling).

Question 55

A 32-year-old manual laborer presents with dorsal wrist pain and decreased grip strength. Radiographs reveal sclerosis and early fragmentation of the lunate, with negative ulnar variance, but no carpal collapse.

What is the most appropriate surgical intervention?

Explanation

In Lichtman Stage II or IIIA Kienbock's disease with negative ulnar variance, a joint-leveling procedure such as a radial shortening osteotomy is indicated. This unloads the lunate and helps prevent further carpal collapse.

Question 56

During an anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone (BPTB) autograft, the surgeon must be aware that this graft has a higher incidence of which of the following postoperative complications compared to a hamstring autograft?

Explanation

BPTB autografts are historically associated with a higher incidence of anterior knee pain and donor site morbidity (e.g., patellar tendonitis, kneeling pain) compared to hamstring autografts. However, they demonstrate excellent fixation and incorporation rates.

Question 57

Which of the following bearing surface combinations in total hip arthroplasty historically demonstrates the lowest volumetric wear rate?

Explanation

Ceramic-on-ceramic bearing surfaces demonstrate the lowest volumetric wear rates in total hip arthroplasty. This makes them a durable option for young, active patients, though they carry risks of squeaking and catastrophic fracture.

Question 58

Bone morphogenetic protein-2 (BMP-2) and BMP-7 promote bone healing primarily through which of the following molecular intracellular pathways?

Explanation

BMPs bind to serine/threonine kinase receptors on mesenchymal stem cells, phosphorylating intracellular SMAD proteins (SMAD 1/5/8). These proteins then translocate to the nucleus to induce osteogenic gene transcription.

Question 59

According to the Ponseti method for the treatment of idiopathic clubfoot, what is the correct sequence of deformity correction?

Explanation

The Ponseti method sequentially corrects the CAVE deformities: Cavus (by elevating the first ray), Adductus, Varus, and finally Equinus. Equinus correction frequently requires a percutaneous Achilles tenotomy.

Question 60

A 28-year-old motorcyclist is brought to the ED after a collision. Pelvic radiographs show a symphyseal diastasis of 3.5 cm and widening of the anterior sacroiliac joints bilaterally.

Which ligamentous structures are completely ruptured in this injury?

Explanation

In an Anteroposterior Compression (APC) Type II injury, pubic symphysis diastasis exceeds 2.5 cm. There is rupture of the anterior SI, sacrotuberous, and sacrospinous ligaments, while the posterior SI ligaments remain intact providing vertical stability.

Question 61

In a patient diagnosed with high-grade conventional intramedullary osteosarcoma, which of the following represents the most significant prognostic factor for long-term survival?

Explanation

The degree of tumor necrosis following neoadjuvant chemotherapy (histologic response) is the single most important prognostic factor for overall survival in patients with high-grade osteosarcoma. Greater than 90% necrosis denotes a favorable response.

Question 62

During a posterior-stabilized total knee arthroplasty, the surgeon notes that the knee is tight in flexion and well-balanced in extension. Which of the following maneuvers is most appropriate to balance the knee?

Explanation

A tight flexion gap with a balanced extension gap requires reducing the anteroposterior dimension of the femur. Downsizing the femoral component (and optionally increasing the posterior tibial slope) addresses the tight flexion gap without altering extension.

Question 63

A 30-year-old man sustains a closed tibial shaft fracture. Twelve hours later, he complains of severe leg pain out of proportion to the injury. Which of the following physical examination findings is the most sensitive early clinical indicator of acute compartment syndrome?

Explanation

Pain with passive stretch of the muscles traversing the involved compartment is considered the most sensitive and reliable early clinical sign of acute compartment syndrome. Pulselessness and paralysis are late, often irreversible signs.

Question 64

A 58-year-old woman presents with clumsiness of her hands, frequent tripping, and a sensation of electric shocks shooting down her spine upon neck flexion (Lhermitte's sign). Physical examination reveals a positive Hoffmann's sign bilaterally. What is the most appropriate next step in diagnosis?

Explanation

The patient's presentation of clumsiness, gait disturbance, Lhermitte's sign, and positive Hoffmann's sign are classic for cervical spondylotic myelopathy. An MRI of the cervical spine is the gold standard imaging modality for evaluating spinal cord compression.

Question 65

A 24-year-old carpenter suffers a laceration over the volar aspect of his proximal phalanx of the index finger, resulting in an inability to flex both the PIP and DIP joints.

Which of the following accurately describes the anatomical flexor tendon zone of this injury?

Explanation

Flexor tendon Zone II (historically known as 'no man's land') extends from the A1 pulley (distal palmar crease) to the insertion of the FDS at the middle phalanx. Lacerations here typically involve both the FDS and FDP tendons.

Question 66

A 22-year-old overhead athlete sustains an acute anterior shoulder dislocation. After reduction, an MRI arthrogram reveals an avulsion of the anterior-inferior labrum along with the anterior band of the inferior glenohumeral ligament (IGHL). What is the specific name of this lesion?

Explanation

A classic Bankart lesion is defined as an anteroinferior detachment of the labrum and the attached inferior glenohumeral ligament from the glenoid rim. It is the essential soft-tissue lesion in recurrent anterior shoulder instability.

Question 67

In evaluating an ankle fracture for syndesmotic instability, which radiographic parameter on a standard AP or mortise view is most indicative of a syndesmotic injury?

Explanation

A tibiofibular clear space greater than 6 mm on the AP or mortise radiograph is the most reliable parameter indicating diastasis and syndesmotic ligament injury. It is measured 1 cm proximal to the plafond.

Question 68

A 4-week-old female infant is diagnosed with developmental dysplasia of the hip (DDH) and placed in a Pavlik harness. Two weeks later, she presents with decreased active extension of her knee, though she still kicks her foot. What complication has most likely occurred?

Explanation

Femoral nerve palsy is a known complication of extreme hyperflexion in a Pavlik harness, presenting as an inability to actively extend the knee. The harness should be adjusted to decrease the degree of hip flexion or temporarily discontinued.

Question 69

A 6-year-old child sustains a completely displaced extension-type supracondylar fracture of the humerus. Examination reveals inability to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger. Which nerve is most likely injured?

Explanation

The anterior interosseous nerve (AIN) is the most commonly injured nerve in extension-type supracondylar humerus fractures. It innervates the flexor pollicis longus and flexor digitorum profundus to the index and middle fingers.

Question 70

A 3-month-old girl has a persistent dislocated hip after 4 weeks of Pavlik harness treatment for developmental dysplasia of the hip. What is the most appropriate next step in management?

Explanation

Continuing a Pavlik harness in a persistently dislocated hip beyond 3 to 4 weeks risks 'Pavlik disease' (acetabular damage and avascular necrosis). The harness should be abandoned and the child scheduled for closed reduction and spica casting.

Question 71

A 45-year-old man presents with a Schatzker type II tibial plateau fracture. Which of the following surgical approaches is most commonly utilized for open reduction and internal fixation of this injury?

Explanation

A Schatzker type II fracture is a split-depression of the lateral tibial plateau. The anterolateral approach provides optimal visualization for elevating the depressed articular segment and applying a lateral buttress plate.

Question 72

During an ACL reconstruction using a bone-patellar tendon-bone autograft, the surgeon notes a minor mismatch between the graft length and the tunnel length, leading to graft protrusion from the femoral tunnel. Which maneuver is best to resolve a minor (2-3 mm) mismatch?

Explanation

Rotating the bone-patellar tendon-bone graft 180 degrees effectively shortens the functional length of the graft by 2 to 3 mm. This is a classic, simple technique to address minor graft-tunnel mismatch.

Question 73

A 35-year-old male presents with severe lower back pain, saddle anesthesia, and acute urinary retention. MRI reveals a massive L4-L5 disc herniation. What is the most critical prognostic factor for neurological recovery?

Explanation

Cauda equina syndrome is a surgical emergency. The time to surgical decompression, ideally within 24 to 48 hours, is the most critical prognostic factor for restoring bladder and bowel function.

Question 74

A 25-year-old carpenter lacerates his volar index finger at the level of the proximal phalanx, cutting both the FDS and FDP tendons. This injury corresponds to which flexor tendon zone?

Explanation

Zone II, historically known as "no man's land," extends from the A1 pulley to the distal insertion of the FDS. Injuries here are notoriously difficult to treat due to the risk of adhesions between the closely opposed FDS and FDP tendons.

Question 75

A 72-year-old female presents with chronic shoulder pain and pseudoparalysis. Radiographs show superior migration of the humeral head and an acromiohumeral interval of 3 mm. Which treatment provides the best predictable outcomes for this specific condition?

Explanation

The patient has rotator cuff tear arthropathy. Reverse total shoulder arthroplasty (RTSA) is the treatment of choice because it establishes a stable center of rotation, allowing the deltoid muscle to efficiently elevate the arm.

Question 76

An obese 13-year-old boy presents with right knee pain and a limp. Examination shows obligatory external rotation of the right hip during passive flexion. What is the most appropriate definitive management?

Explanation

The presentation is classic for a Slipped Capital Femoral Epiphysis (SCFE). The standard of care is in situ stabilization with a single, partially threaded cannulated screw to prevent further slippage.

Question 77

A 55-year-old diabetic patient presents with a swollen, erythematous, and warm left foot. There are no open ulcers. Radiographs show soft tissue swelling but no acute fractures. What is the most appropriate initial management?

Explanation

This presentation is highly suspicious for acute Charcot neuroarthropathy (Eichenholtz stage 0). Total contact casting is the initial treatment of choice to offload the foot, decrease inflammation, and prevent severe deformity.

Question 78

A biopsy of a destructive, lytic bone lesion in the diaphysis of the femur of a 15-year-old boy shows sheets of uniform, small round blue cells. Cytogenetic analysis reveals a t(11;22) translocation. What is the most likely diagnosis?

Explanation

Ewing sarcoma is classically characterized by small round blue cells on histology and the t(11;22) chromosomal translocation, which results in the EWS-FLI1 fusion protein.

Question 79

A 28-year-old male sustains a closed tibia fracture. Hours later, he develops severe pain out of proportion to the injury. Intracompartmental pressure testing is performed. Which measurement is generally considered the threshold indicating the need for emergent fasciotomy?

Explanation

A delta pressure (diastolic blood pressure minus compartment pressure) of less than 30 mmHg is highly sensitive for compartment syndrome. This value is widely accepted as an absolute indication for emergent fasciotomy.

Question 80

According to the Ponseti method for congenital talipes equinovarus (clubfoot), which component of the deformity is typically corrected last?

Explanation

The Ponseti sequence of correction is represented by the acronym CAVE: Cavus, Adductus, Varus, and Equinus. Equinus is corrected last and often requires a percutaneous Achilles tenotomy.

Question 81

A 45-year-old highly active male is undergoing a total hip arthroplasty. To minimize wear rates and the risk of osteolysis, which of the following bearing surface combinations is most appropriate?

Explanation

Ceramic-on-ceramic bearing surfaces offer the lowest volumetric wear rates among total hip arthroplasty options. They are highly suitable for young, active patients, despite a small risk of fracture or squeaking.

Question 82

A 30-year-old motorcyclist sustains an anteroposterior compression (APC) type III pelvic ring injury. What is the most common primary source of life-threatening hemorrhage in this specific injury pattern?

Explanation

Although arterial injuries can occur, the vast majority of retroperitoneal bleeding in severe pelvic fractures originates from the disrupted presacral venous plexus and exposed cancellous bone surfaces.

Question 83

A patient complains of numbness in the thumb, index, and middle fingers. Symptoms are exacerbated by tapping over the volar wrist. Which nerve is compressed, and in which anatomical space?

Explanation

Carpal tunnel syndrome results from compression of the median nerve within the carpal tunnel. It presents with sensory changes in the radial three and a half digits and a positive Tinel's sign at the wrist.

Question 84

A 24-year-old football player sustains a hyperplantarflexion injury to his midfoot. Radiographs show widening of the space between the medial cuneiform and the base of the second metatarsal. What is the primary stabilizing structure injured?

Explanation

The Lisfranc ligament uniquely connects the medial cuneiform to the base of the second metatarsal. It is the primary stabilizer of the tarsometatarsal articulation, and its disruption leads to midfoot instability.

Question 85

A 14-year-old gymnast presents with chronic low back pain. Radiographs reveal a pars interarticularis defect with a 25% forward slip of L5 on S1. According to the Meyerding classification, what is the grade of this spondylolisthesis?

Explanation

The Meyerding classification grades the degree of forward translation of the superior vertebra over the inferior one. Grade I represents 0 to 25% slip, Grade II is 26 to 50%, Grade III is 51 to 75%, and Grade IV is 76 to 100%.

Question 86

One year following a posterior-stabilized total knee arthroplasty, a patient presents with a painful popping sensation when extending the knee from a flexed position. What is the most likely etiology?

Explanation

Patellar clunk syndrome is a known complication of posterior-stabilized TKA designs. It occurs when a fibrous nodule forms on the undersurface of the quadriceps tendon and catches in the femoral component's box during extension.

Question 87

A 20-year-old male suffers a traumatic anterior shoulder dislocation. Post-reduction radiographs show a posterolateral humeral head impaction fracture. What is the eponym for this specific lesion?

Explanation

A Hill-Sachs lesion is an impaction fracture of the posterolateral humeral head. It occurs when the humeral head dislocates anteriorly and forcefully impacts against the harder anterior glenoid rim.

Question 88

A 4-year-old boy presents with an acute limp, fever of 38.8°C, refusal to bear weight, and a WBC count of 14,000/mm³. According to the Kocher criteria, what is the approximate probability that this child has septic arthritis of the hip?

Explanation

The Kocher criteria evaluate four predictors: non-weight-bearing, ESR >40 mm/hr, fever >38.5°C, and WBC >12,000/mm³. Having three of these four predictors yields a 93% probability of septic arthritis.

Question 89

A 55-year-old female presents with medial ankle pain and a progressive flatfoot deformity. Examination reveals an inability to perform a single-leg heel rise, but the hindfoot remains flexible and correctable. Which of the following surgical interventions is most appropriate for this stage of disease?

Explanation

This patient has Stage II posterior tibial tendon dysfunction (PTTD), characterized by a flexible hindfoot and inability to perform a single-leg heel rise. Treatment involves a joint-sparing procedure such as an FDL transfer combined with a medial displacement calcaneal osteotomy.

Question 90

During open reduction and internal fixation of a Weber C ankle fracture, the syndesmosis is reduced and clamped. Which of the following radiographic parameters best confirms accurate reduction of the syndesmosis on a standard mortise view?

Explanation

On the anteroposterior and mortise views, the tibiofibular clear space should be less than 5 mm when measured 1 cm proximal to the joint line. This is the most reliable and consistent two-dimensional radiographic indicator of syndesmotic reduction.

Question 91

A 22-year-old professional basketball player sustains an acute fracture of the proximal fifth metatarsal at the metaphyseal-diaphyseal junction (Zone 2). What is the most appropriate management to minimize the risk of nonunion and expedite return to play?

Explanation

Acute Jones fractures in elite athletes are best treated with intramedullary screw fixation. This operative approach significantly decreases the time to clinical union and allows a faster, safer return to competitive sports compared to conservative management.

Question 92

A 60-year-old patient with poorly controlled diabetes presents with a deep, non-healing plantar ulcer probing to bone. MRI confirms osteomyelitis of the first metatarsal head. Which of the following is the most definitive method to identify the causative organism and direct targeted antibiotic therapy?

Explanation

Bone biopsy is the gold standard for diagnosing osteomyelitis and accurately directing pathogen-specific antibiotic therapy. Superficial swabs often isolate colonizing flora rather than the true bone pathogen, leading to inadequate treatment.

Question 93

A 45-year-old weekend warrior feels a 'pop' in his posterior ankle while playing tennis. Clinical examination reveals a positive Thompson test. If non-operative management is chosen, which of the following functional rehabilitation protocols yields outcomes most comparable to surgical repair regarding re-rupture rates?

Explanation

Early functional rehabilitation with protected weight-bearing in a brace has been shown to reduce re-rupture rates in non-operatively managed Achilles tendon ruptures. This dynamic protocol makes clinical outcomes highly comparable to surgical repair while avoiding wound complications.

Question 94

A 52-year-old patient with long-standing peripheral neuropathy presents with an acutely swollen, warm, and erythematous left foot. Radiographs show no fractures or dislocations, and laboratory markers (ESR, CRP) are within normal limits. What is the most appropriate initial management?

Explanation

The clinical presentation is classic for acute Eichenholtz stage 0 Charcot arthropathy (warm, swollen foot with normal radiographs and normal inflammatory markers). The standard of care to prevent progressive architectural collapse and fragmentation is immediate strict offloading via total contact casting.

Question 95

A 30-year-old male sustains a severely displaced talar neck fracture following a high-speed motor vehicle collision. Disruption of which of the following blood vessels places the talar body at the highest risk for developing avascular necrosis (AVN)?

Explanation

The artery of the tarsal canal, a major branch of the posterior tibial artery, provides the dominant blood supply to the talar body. Displaced talar neck fractures routinely disrupt this critical vascular supply, leading to a high incidence of avascular necrosis.

Question 96

A 40-year-old female presents with painful bunions. Weight-bearing radiographs demonstrate a hallux valgus angle of 35 degrees and an intermetatarsal angle of 15 degrees. Clinical exam reveals gross hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most indicated?

Explanation

The Lapidus procedure (arthrodesis of the first tarsometatarsal joint) is specifically indicated for moderate to severe hallux valgus associated with first ray hypermobility. It definitively stabilizes the medial column and reliably corrects the intermetatarsal angle.

Question 97

A 48-year-old woman complains of burning pain in the plantar forefoot radiating to the third and fourth toes, worsening with tight shoes. A palpable Mulder's click is present. If standard operative treatment is performed following failed conservative measures, what is the most common post-surgical complication?

Explanation

The standard surgical treatment for refractory Morton's neuroma is dorsal or plantar excision of the affected interdigital nerve. The most common complication of this neurectomy is the formation of a symptomatic stump neuroma, causing recurrent or worsened pain.

Question 98

A 35-year-old roofer falls from a height and sustains a severely comminuted intra-articular calcaneal fracture. Which of the following radiographic findings on a lateral foot radiograph best indicates the loss of calcaneal height and collapse of the posterior facet?

Explanation

Bohler's angle (normally 20 to 40 degrees) is formed by lines drawn tangentially to the anterior and posterior aspects of the superior calcaneus. A flattened or negative Bohler's angle is the primary radiographic hallmark indicating collapse of the posterior facet and severe loss of calcaneal height.

Orthopedic Prometric Exam Preparation MCQs - Part 1

Orthopedic Prometric Exam Preparation MCQs - Part 4

Orthopedic Prometric Exam Preparation MCQs - Part 4

Chapter Index