ORTHOPEDICS HYPERGUIDE 2022 MCQ-1101   1150

1101. (393) Q3-526:

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

1) Triple arthrodesis

3) Posterior tibial tendon transfer through the interosseous membrane

2) Subtalar arthrodesis

5) Posterior tibial tendon transfer to the peroneus longus

4) Split anterior tibial tendon transfer

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

■Correct Answer: Split anterior tibial tendon transfer

1102. (395) Q3-528:

Figure 1

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

1) Primary talonavicular arthrodesis

3) C losed reduction cast immobilization

2) Open reduction internal fixation

5) C losed reduction percutaneous pin fixation

4) C losed reduction external fixation

The prognosis following fracture dislocation of the navicular is not good regardless of treatment. Although one may be tempted to perform an open reduction and immediate primary talonavicular arthrodesis, this is not necessary. Following open reduction and internal fixation, arthritis of the talonavicular joint may occur.

■Correct Answer: Open reduction internal fixation

1103. (397) Q3-530:

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

1) Rare

3) 40%

2) 20%

5) 100%

4) 70%

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

■Correct Answer: Rare

1104. (399) Q3-532:

Figure 1

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

1) Wound culture, oral antibiotic therapy, and debridement

3) Debridement and split thickness skin grafting

2) Wound culture, intravenous antibiotic therapy, and debridement

5) Debridement and application of a total contact cast

4) Debridement, bone biopsy, and appropriate organism specific antibiotic therapy

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

■Correct Answer: Debridement and application of a total contact cast

1105. (400) Q3-533:

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

1) Hindfoot valgus

3) Plantarflexed 1st metatarsal

2) Forefoot pronation

5) Interphalangeal (IP) joint flexion

4) Metatarsophalangeal (MTP) joint hyperextension

Hindfoot varus develops to counter forefoot pronation due to weakness of evertors with preservation of inverter muscle strength.

The first metatarsal plantarflexes relative to the other metatarsals, leading to pronation of the forefoot.

Plantarflexion of the first metatarsal occurs as part of the windlass mechanism as the intrinsics and plantar fascia contract. As the intrinsics weaken, the toe extensors pull the metatarsophalangeal (MTP) joint into hyperextension as part of the claw toe deformity.

When the MTP joint hyperextends, the strength of the long toe flexors pulls the interphalangeal joint into flexion contributing to the claw toe deformity.

 

■Correct Answer: Hindfoot valgus

1106. (402) Q3-535:

Figure 1

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

1) Injury to the flexor hallucis longus

3) Adhesions laterally to the peroneus brevis

2) Turf toe injury

5) Excessive scarring and malfunction of the posterior tibial tendon

4) Use of the peroneus longus in the ankle reconstruction

The primary function of the peroneus longus is to depress or plantarflex the first metatarsal and oppose the effect of the anterior tibialis on the base of the first metatarsal. The peroneus longus is no longer functioning, and first metatarsus elevatus is present.

■Correct Answer: Use of the peroneus longus in the ankle reconstruction

1107. (404) Q3-537:

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

1) Silastic joint replacement of the hallux and osteotomy of the lesser metatarsals

3) Arthrodesis of the hallux MP joint and resection of the lesser metatarsal heads

2) Resection arthroplasty of the hallux and silastic arthroplasty of the lesser toe MP joints

5) Resection arthroplasties of all the MP joints

4) Bunionectomy, proximal metatarsal osteotomy, and resection arthroplasty of the lesser MP joints

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

■Correct Answer: Arthrodesis of the hallux MP joint and resection of the lesser metatarsal heads

1108. (406) Q3-539:

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

1) Ultrasound, whirlpool, and joint mobilization

3) Rest, compression, toe taping, and gradual rehabilitation

2) Short leg cast or boot for 4 weeks

5) Active toe exercises and resumption of activities to prevent joint stiffness

4) Joint injection of corticosteroid and lidocaine

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

■Correct Answer: Rest, compression, toe taping, and gradual rehabilitation

1109. (1391) Q3-1762:

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

1) To increase the range of motion of the MP joint

3) To decrease the impingement on the terminal branch of the deep peroneal nerve

2) To remove the osteophytes from the medial and lateral surface of the metatarsal head

5) To decrease the likelihood of a subsequent arthrodesis of the MP joint

4) To decrease pain

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

■Correct Answer: To decrease pain

1110. (1392) Q3-1763:

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

1) A recurrent fibroma

3) Wound dehiscence

2) Infection

5) Injury to the lateral plantar nerve

4) Injury to the medial plantar nerve

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

■Correct Answer: A recurrent fibroma

1111. (1393) Q3-1764:

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

1) Flexor tenotomy and extensor tenotomy

3) Proximal interphalangeal (PIP) joint resection arthroplasty

2) Dorsal capsulectomy, extensor lengthening, and flexor tenotomy

5) Subtotal proximal phalangectomy with tendon transfer

4) PIP joint arthrodesis

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

■Correct Answer: Subtotal proximal phalangectomy with tendon transfer

1112. (1394) Q3-1765:

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

1) Abnormal ankle biomechanics

3) A varus heel

2) C hronic unrecognized ankle instability

5) C hronic avascularity of the fifth metatarsal base

4) Bone sclerosis of the fifth metatarsal base

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

■Correct Answer: A varus heel

1113. (1395) Q3-1766:

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

1) The peroneus longus tendon attaches to the first metatarsal.

3) The peroneus brevis tendon has muscle attached to the tendon at a level lower than the peroneus longus tendon.

2) The peroneus brevis tendon is a plantarflexor of the ankle.

5) There are two separate retinacular sheaths for the peroneal tendons distal to the tip of the fibula.

4) The peroneus longus tendon lies anterior to the peroneus brevis tendon at the level of the distal fibula.

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

■Correct Answer: The peroneus longus tendon lies anterior to the peroneus brevis tendon at the level of the distal fibula.

1114. (1396) Q3-1767:

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

1) Peroneal tendon dislocation

3) C alcaneofibular impingement pain

2) Achilles tendonitis

5) Tarsal tunnel syndrome

4) Subtalar arthritis

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

■Correct Answer: C alcaneofibular impingement pain

1115. (1397) Q3-1768:

A patient presents for treatment of a painful ankle 2 years after a hindfoot injury. He was treated nonsurgically for a calcaneus fracture that occurred when he fell. His symptoms include anterior ankle pain, weakness during pushing off, and pain along the lateral aspect of the hindfoot. On examination, he has pain to palpation at the tip of the fibula, absent inversion and eversion,

20° of plantarflexion, and no dorsiflexion. Plantarflexion strength appears adequate, and there is no compromise of the forefoot flexor function. The recommended surgical procedure is:

1) Anterior ankle cheilectomy and lateral calcaneus ostectomy

3) In situ subtalar arthrodesis and lateral calcaneus ostectomy

2) Anterior ankle cheilectomy and subtalar arthrodesis

5) Triple arthrodesis and Achilles tendon lengthening

4) Subtalar bone block distraction arthrodesis and lateral calcaneus ostectomy

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

■Correct Answer: Subtalar bone block distraction arthrodesis and lateral calcaneus ostectomy

1116. (1398) Q3-1769:

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

1) Entrapment of the medial plantar nerve

3) Tethering of the flexor hallucis longus under the sustentaculum tali

2) Flexor digitorum longus stenosis associated with entrapment in the deep muscle layer of the foot

5) Unrecognized compartment syndrome of the foot

4) Unrecognized injury to the forefoot at the time of the original calcaneus fracture

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

■Correct Answer: Unrecognized compartment syndrome of the foot

1117. (1399) Q3-1770:

Slide 1

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

1) Total ankle replacement

3) Ankle arthroscopy and joint debridement

2) Ankle arthrodesis

5) Anterior ankle cheilectomy, Achilles lengthening, and joint debridement

4) Osteotomy of the fibula

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

■Correct Answer: Osteotomy of the fibula

1118. (1400) Q3-1771:

Slide 1

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

1) Total ankle replacement

3) Arthroscopy ankle and joint debridement

2) Ankle arthrodesis

5) Anterior ankle cheilectomy, Achilles lengthening, and joint debridement

4) Osteotomy of the tibia and fibula

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

■Correct Answer: Osteotomy of the tibia and fibula

1119. (1401) Q3-1772:

Slide 1

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

1) A tear of the posterior tibial tendon

3) A tear of the short plantar ligament

2) A tear of the spring ligament

5) A tear of the metatarsocuneiform ligament

4) A tear of the deltoid ligament

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

■Correct Answer: A tear of the metatarsocuneiform ligament

1120. (1402) Q3-1773:

Slide 1                             Slide 2

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

1) Open reduction and internal fixation (ORIF)

3) Open reduction and primary arthrodesis

2) No weight bearing and immobilization in a removable boot

5) Debridement of the foot, deep tissue cultures, and organism-specific intravenous antibiotics

4) Hospitalization, bedrest, and intravenous antibiotics

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

■Correct Answer: Open reduction and primary arthrodesis

1121. (1403) Q3-1774:

Slide 1

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

1) Short leg cast immobilization

3) Debridement of the insertion of the Achilles tendon

2) High heel shoe with no heel counter

5) Achilles stretching exercises and physical therapy modalities including corticosteroid application

4) Osteotomy of the calcaneus

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

■Correct Answer: Osteotomy of the calcaneus

1122. (1404) Q3-1775:

Slide 1

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

1) C hronic degenerative tendinosis

3) Acute inflammatory tendinopathy

2) Acute paratendinitis

5) C hronic myxoid degeneration

4) Acute tendon rupture

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

■Correct Answer: Acute tendon rupture

1123. (1405) Q3-1776:

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

1) Paratendinitis of the Achilles tendon is commonly associated with racket sports.

3) Paratendinitis of the Achilles tendon is effectively treated with Achilles stretching and orthoses.

2) Paratendinitis of the Achilles tendon is common in patients who have a cavus foot.

5) Paratendinitis of the Achilles tendon leads to chronic rupture of the tendon.

4) Paratendinitis of the Achilles tendon is associated with tendon degeneration.

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

■Correct Answer: Paratendinitis of the Achilles tendon is effectively treated with Achilles stretching and orthoses.

1124. (1406) Q3-1777:

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

1) To increase the ground reaction forces medially

3) To improve the weight bearing tripod effect of the foot

2) To make the Achilles tendon vector lateral to the axis of the subtalar joint

5) To decrease the valgus force of the gastrocnemius on the hindfoot

4) To augment the flexor transfer medially

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

■Correct Answer: To make the Achilles tendon vector lateral to the axis of the subtalar joint

1125. (1407) Q3-1778:

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

1) Flexor hallucis longus

3) Peroneus longus

2) Flexor digitorum longus

5) Extensor digitorum longus

4) Peroneus brevis

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

■Correct Answer: Flexor hallucis longus

1126. (1408) Q3-1779:

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

1) Intermediate dorsal cutaneous branch superficial peroneal

3) Medial cutaneous branch superficial peroneal

2) Medial cutaneous branch deep peroneal

5) Intermediate cutaneous branch deep peroneal

4) Dorsal cutaneous branch medial plantar

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

■Correct Answer: Medial cutaneous branch superficial peroneal

1127. (1409) Q3-1780:

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

1) Recurrent hallux valgus

3) Stiffness of the hallux metatarsophalangeal joint

2) Hallux varus

5) Stress fracture of the second metatarsal

4) C ock-up deformity of the hallux

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

■Correct Answer: C ock-up deformity of the hallux

1128. (1410) Q3-1781:

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

1) Short plantar

3) Anterior talofibular

2) Long plantar

5) Bifurcate

4) C alcaneofibular

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

■Correct Answer: Bifurcate

1129. (1411) Q3-1783:

Slide 1

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

1) A short femur

3) A talocalcaneal fusion

2) A short fibula

5) Missing lateral rays of the foot

4) C avovarus

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

■Correct Answer: C avovarus

1130. (1412) Q3-1784:

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

1) A metastatic tumor to the forefoot

3) A primary tumor in the forefoot and midfoot

2) Severe infection in the foot

5) Trauma to the hindfoot

4) Peripheral vascular disease

Although the Syme amputation was once popular because it allowed patients to ambulate for short distances (e.g., around their house) without using a prosthesis, surgeons now perform more below the knee amputations because of newer prosthetic designs. The Syme procedure still remains in our surgical armamentarium.

The only factor listed in the answer choices that may preclude amputation at this level is peripheral vascular disease. A more important factor that would contraindicate performing a Syme amputation is perfusion to the heel pad.

■Correct Answer: Peripheral vascular disease

1131. (1413) Q3-1786:

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

1) A fracture of the junction of the proximal metaphyseal and diaphyseal portion of the fifth metatarsal is the least likely of all fifth metatarsal fractures to heal.

3) The mechanism of injury is forced abduction.

2) Fractures treated nonoperatively heal from medial to lateral on serial radiographs.

5) Up to one-third of patients treated with casting may refracture in long-term follow-up.

4) Radiographic evidence of union lags behind clinical healing examination.

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

■Correct Answer: The mechanism of injury is forced abduction.