ORTHOPEDICS HYPERGUIDE 2022 MCQ-1251-1300

 

 

1251. (4058) Q3-4025:

The incidence of compartment syndrome following calcaneus fracture is:

1) 5%

3) 15%

2) 10%

5) 30%

4) 20%

In a review article by Myerson, compartment syndrome was described to occur in 10% of calcaneal fractures. Of these, half will develop clawing, stiffness, or neurologic dysfunction. Diagnosis is confirmed by multistick invasive catheterization, especially the calcaneal compartment.

■Correct Answer: 10%

1252. (3205) Q3-4026:

Posterior antiglide plating of AO type B lateral malleolar fractures may be associated with:

1) Early loss of fixation

3) Syndesmotic irritation

2) Greater wound healing complications

5) Greater risk for nonunion

4) Peroneal tendonitis or peroneal tendon lesions

Posterior antiglide plating is associated with an increased need for hardware removal (43%) and an increased incidence of peroneal tendon lesions. The highest risk for peroneal tendon lesions was with distal placement of the plate and a protruding screw head in the most distal hole.

■Correct Answer: Peroneal tendonitis or peroneal tendon lesions

1253. (3206) Q3-4027:

Displaced talar neck fractures should be treated:

1) Emergently within 6 hours to minimize the risk of avascular necrosis

3) There is no correlation between emergent or urgent fixation of talar neck fractures and risk of talar avascular necrosis.

2) Urgently within 1 day to minimize the risk of avascular necrosis

5) Emergently within 3 hours of injury

4) Emergently within 1 hour of injury

A retrospective review of 102 talar neck fractures that underwent open reduction internal fixation showed no decrease in the development of osteonecrosis in fractures that were treated earlier. The mean time to fixation was 3.4 days for patients who had development of osteonecrosis, compared with 5 days for patients who did not have development of osteonecrosis.

■Correct Answer: There is no correlation between emergent or urgent fixation of talar neck fractures and risk of talar avascular necrosis.

1254. (3207) Q3-4028:

How many weeks following open reduction and internal fixation of a right ankle fracture can patients resume driving with normal braking times:

1) 6 weeks

3) 12 weeks

2) 9 weeks

5) 18 weeks

4) 16 weeks

Total braking time following open reduction and internal fixation of right ankle fractures was tested at 6, 9, and 12 weeks postoperatively. These patients were managed with a functional brace, non-weight bearing, and early range of motion in the postoperative period. Braking time was significantly slower than normal at 6 weeks, but had returned to near normal by 9 weeks postoperatively.

■Correct Answer: 9 weeks

1255. (3208) Q3-4029:

Time to radiographic fusion following arthroscopic ankle arthrodesis is:

1) Longer than following an open technique arthrodesis

3) The same as open technique

2) Shorter than following an open technique arthrodesis

5) Is affected by whether two-screw or three-screw fixation is utilized

4) Is affected by whether external bone stimulation is utilized

Time to radiographic fusion following arthroscopic ankle arthrodesis is shorter than following open ankle arthrodesis. Theoretically, the decreased dissection and soft-tissue stripping contributes to greater vascular inflow to heal the fusion site.

■Correct Answer: Shorter than following an open technique arthrodesis

1256. (3209) Q3-4030:

Superficial peroneal nerve injury following ankle fracture:

1) Does not occur with nonoperative treatment

3) Did not ultimately affect the final AOFAS ankle-hindfoot score

2) C an best be avoided during open reduction internal fixation with a posterolateral approach to the fibula

5) C an best be avoided during open reduction internal fixation with an anterolateral approach to the fibula

4) Occurs in fewer than 5% of operatively fixed fibula fractures

One hundred twenty patients with ankle fractures were evaluated. Symptomatic superficial peroneal nerve injury was identified in

21% of patients who underwent open reduction internal fixation and 9% of nonoperatively treated patients. AOFAS scores were decreased in patients with symptomatic superficial peroneal nerve injury. No injuries to the superficial peroneal nerve occurred in patients who underwent surgery involving a posterolateral approach to the fibula.

■Correct Answer: C an best be avoided during open reduction internal fixation with a posterolateral approach to the fibula

1257. (3210) Q3-4031:

Which of the following is the most reliable way to determine that a deltoid ligament injury is associated with a Weber B level lateral malleolus fracture:

1) The presence of medial tenderness on clinical examination

3) The presence of significant medial swelling on clinical examination

2) The presence of medial ecchymosis on clinical examination

5) The presence of lateral malleolus tenderness

4) Evidence of medial clear space widening on stress radiographs

Weber B supination, external rotation ankle fractures were evaluated to determine the reliability of medial tenderness, ecchymosis, and swelling in predicting deltoid incompetence. These clinical signs were poorly predictive, and stress radiographs were recommended for an accurate diagnosis of instability.

■Correct Answer: Evidence of medial clear space widening on stress radiographs

1258. (3211) Q3-4032:

The optimal position for ankle arthrodesis is:

1) 5° plantarflexion, 5° valgus, 5° external rotation

3) Neutral flexion, 0° varus/valgus, 5° external rotation

2) Neutral flexion, 5° valgus, 5° external rotation

5) 5° dorsiflexion, 5° valgus, 5° external rotation

4) Neutral flexion, 5° valgus, 5° internal rotation

The optimal position for ankle arthrodesis is neutral flexion, 5° valgus, and 5° external rotation. Historically, surgeons thought that women should be fused in some amount of equinus to better allow them to wear heeled shoes. However, this can increase the development of neighboring joint arthritis and also create a knee recurvatum deformity when ambulating barefoot. C urrently it is recommended that all patients are fused in neutral dorsi-/plantarflexion.

■Correct Answer: Neutral flexion, 5° valgus, 5° external rotation

1259. (3212) Q3-4033:

Varus malunion following talar neck fracture is best corrected by:

1) Subtalar arthrodesis

3) Deltoid ligament release and lateral ligament reconstruction

2) Rotational calcaneal osteotomy with a bone block

5) Lateral column lengthening

4) Talar neck osteotomy with lengthening or by triple arthrodesis

The best way to address varus malunion in talar neck fractures and maintain motion is by talar neck osteotomy. However, there is a further possible risk of talar avascular necrosis with this procedure. The other acceptable treatment is a triple arthrodesis, although this eliminates all hindfoot motion.

■Correct Answer: Talar neck osteotomy with lengthening or by triple arthrodesis

1260. (3213) Q3-4034:

Neighboring joint arthritis following ankle arthrodesis has not been found in the:

1) Knee joint

3) First metatarsophalangeal joint

2) Naviculocuneiform joint

5) Hindfoot joint

4) Subtalar joint

Long-term follow-up of ankle fusions show that nearly all patients develop arthritis in the hindfoot, midfoot, and 1st metatarsophalangeal joint. There is no evidence to show that the hip or knee is at greater risk for developing arthritis following ankle fusion.

■Correct Answer: Knee joint

1261. (3214) Q3-4035:

Following calcaneus fracture, risk factors for later need for subtalar arthrodesis due to painful posttraumatic arthritis include all of the following except:

1) Bohlerâs angle <0°

3) Workersâ compensation

2) Sanders type IV fractures

5) Female gender

4) Initial nonoperative care

Buckley conducted a series of large prospective studies following calcaneus fracture outcomes in C anada. All of the above factors were associated with the need for later subtalar fusion except female gender. In his other studies, it was demonstrated that male gender was a risk factor for not having a significantly better clinical outcome with surgery versus nonsurgical treatment.

■Correct Answer: Female gender

1262. (3215) Q3-4036:

Range of motion following total ankle replacement is closely correlated with:

1) Amount of osteophytes resected during surgery

3) Level of tibial and talar saw cuts

2) Meticulous ligament balancing

5) Size of implant

4) Preoperative range of motion

A radiographic study comparing preoperative to postoperative tibio-talar range of motion as measured by radiographs showed that the amount of motion that patients had following ankle replacement was most dependent upon the motion they had before surgery.

■Correct Answer: Preoperative range of motion

1263. (3216) Q3-4037:

Patients sustaining a crushing injury to the foot with midfoot tenderness but without any radiographic signs of fracture or dislocation:

1) Should be managed with a postoperative shoe and early physical therapy until the tenderness resolves

3) Should be protected in a cast boot with early weight bearing to tolerance

2) Should be splinted and kept non-weight bearing until nontender

5) C an be discharged with no further follow-up

4) Requires open reduction internal fixation to prevent long-term arthritis

Patients who sustain a foot injury and have clinical midfoot tenderness should be assumed to have a serious midfoot sprain until proven otherwise. These patients should be protected non-weight bearing until the tenderness is gone before weight-bearing and physical therapy begins.

■Correct Answer: Should be splinted and kept non-weight bearing until nontender

1264. (3217) Q3-4038:

The distinguishing factor in a Hawkins type 4 talar neck fracture is:

1) The presence of an incongruent ankle joint

3) The presence of an incongruent subtalar joint

2) Incongruity of the ankle and/or subtalar joint with the presence of a talonavicular dislocation.

5) The presence of a posterior process of the talus fracture

4) The presence of an associated talar body fracture

Hawkins type 1 fractures are nondisplaced. Hawkins type 2 fractures have an incongruent subtalar joint. Hawkins type 3 fractures have an incongruent ankle and subtalar joint. Hawkins type 4 fractures have the above injuries and incongruent talo-navicular joint.

■Correct Answer: Incongruity of the ankle and/or subtalar joint with the presence of a talonavicular dislocation.

1265. (3218) Q3-4039:

The calcaneal compartment of the foot contains all of the following structures except:

1) Quadratus plantae muscle

3) Lateral plantar nerve, artery, and vein

2) Posterior tibial nerve, artery, and vein

5) 1st dorsal metatarsal artery

4) Interossei muscles

The four interossei muscles are contained in their respective interosseous compartments. The calcaneal compartment may also variably contain the medial plantar nerve. The remaining compartments of the foot are the adductor, medial, lateral, and superficial.

■Correct Answer: Interossei muscles

1266. (3219) Q3-4040:

Gustilo-Anderson type I and type IIA open calcaneal fractures with a medial wound can be treated:

1) With initial washout and subsequent open reduction internal fixation with a lateral plate once the soft tissues and swelling have stabilized

3) With initial washout and late reconstruction once the soft tissue has healed to address the malunion

2) With initial washout and external fixation only due to the risk of osteomyelitis

5) With immediate fasciotomy

4) Washout is unnecessary for type I and IIA open calcaneal fractures

Forty-three open calcaneal fractures were studied, showing that open reduction internal fixation with plate and screws of type I and type IIA fractures with medial wounds had outcomes similar to closed injuries. Type IIIB open calcaneal fractures should undergo early flap coverage. Early internal fixation should be avoided in these injuries due to the high rates of osteomyelitis and amputation.

■Correct Answer: With initial washout and subsequent open reduction internal fixation with a lateral plate once the soft tissues and swelling have stabilized

1267. (3220) Q3-4041:

Take-down of ankle arthrodesis and conversion to total ankle replacement:

1) Is impossible if the fibula has been resected

3) Has a poor clinical success rate if there is no clear underlying cause of pain from the ankle fusion

2) Is a dependable procedure with a rate of complications similar to primary ankle replacement

5) Requires custom made prosthetic implants

4) Results in minimal gains in ankle range of motion

This article studied the success rates of revising previous ankle fusions to ankle replacement. The authors found that if the etiology of a patientâs pain was unclear, the patients did poorly. Patients with prior fibula resection could still be revised to ankle replacement with allograft bone to support the lateral side of the implant. Range of motion following revision to arthroplasty was comparable to primary replacement.

■Correct Answer: Has a poor clinical success rate if there is no clear underlying cause of pain from the ankle fusion

1268. (3221) Q3-4042:

The distinction between a Lauge-Hansen supination-external rotation III injury and a Lauge-Hansen supination-external rotation

IV injury is:

1) A spiral oblique fracture of the lateral malleolus

3) Posteroinferior tibiofibular ligament (PITFL) disruption or posterior malleolus fracture

2) Anteroinferior tibiofibular ligament (AITFL) disruption

5) Anterior talo-fibular ligament disruption

4) Deltoid ligament disruption or medial malleolus fracture

The sequence of injury according to the Lauge-Hansen classification system in supination-external rotation injuries is AITFL disruption, spiral oblique fracture of the lateral malleolus, PITFL disruption or posterior malleolus fracture, and finally stage IV, which is a deltoid ligament disruption or medial malleolus fracture.

■Correct Answer: Deltoid ligament disruption or medial malleolus fracture

1269. (3222) Q3-4043:

Development of hindfoot arthritis following total ankle replacement is seen in:

1) 0% of patients

3) 50% of patients

2) <25% of patients

5) >75% of patients

4) 75% of patients

Although it is felt that the retention of some degree of ankle motion with ankle replacement can help prevent the development of hindfoot arthritis, in a 9-year follow-up study nearly 25% of patients still had radiographic signs of arthritis.

■Correct Answer: <25% of patients

1270. (3223) Q3-4044:

When using external fixation in the treatment of tibial pilon fractures, distal transfixation wires:

1) Should always traverse the distal tibia-fibula joint to get optimal fixation

3) Are not at risk for causing joint infection

2) Should remain >12.2 mm above the subchondral plate of the distal tibia

5) C annot be olive wires because of a higher risk for pin-tract infection

4) Are least at risk for penetrating the joint capsule over the anterolateral aspect of the ankle

In cadaver specimens, the anterolateral capsular reflection of the ankle joint extended proximally the highest with an average of

9.3 mm and a maximum of 12.2 mm. There was a 100% communication between the distal tibia-fibula joint and the ankle joint.

■Correct Answer: Should remain >12.2 mm above the subchondral plate of the distal tibia

1271. (3224) Q3-4045:

C linical improvement following ankle distraction arthroplasty:

1) Typically reaches its maximal improvement by the end of 1 year

3) C an take up to 5 years to reach maximal improvement

2) Is accompanied by major gains in ankle range of motion

5) Is usually realized within the first month following removal of the frame

4) Is not accompanied by improvement in radiographic joint space

Distraction arthroplasty with an Ilizarov external fixator is usually associated with half of the clinical improvement occurring within the first year, and the other half happening over the next 5 years.

■Correct Answer: C an take up to 5 years to reach maximal improvement

1272. (3225) Q3-4046:

Failure following supramalleolar osteotomy for ankle arthritis is associated with:

1) Inadequate correction and poor cartilage on initial arthroscopy

3) Early weight bearing postoperatively

2) Opening wedge supramalleolar osteotomy with bone graft

5) Use of internal fixation

4) Addition of a fibular osteotomy to the procedure

In their clinical series, Takakura and colleagues showed that inadequate correction and initial chondromalacia were predictors of poor outcome following supramalleolar osteotomy.

■Correct Answer: Inadequate correction and poor cartilage on initial arthroscopy

1273. (3226) Q3-4047: Isolated talonavicular fusion:

1) Decreases subtalar motion by 25%

3) Locks subtalar motion

2) Decreases subtalar motion by 50%

5) Decreases subtalar motion by 10%

4) Has no effect on subtalar motion

This cadaver study examined the motion that remained in the hindfoot joints following sequential immobilization of the talo- navicular, subtalar, and calcaneo-cuboid joints. Fixing the talo-navicular joint virtually locked all subtalar motion.

■Correct Answer: Locks subtalar motion

1274. (3227) Q3-4048:

Following triple arthrodesis, ankle range of motion is:

1) Unaffected

3) Decreased

2) Increased

5) Increases initially, but then returns to preoperative levels

4) Improves over time

This clinical study following triple arthrodesis patients for 10 years showed a 27% loss of ankle plantarflexion but no loss of dorsiflexion.

■Correct Answer: Decreased

1275. (3228) Q3-4049:

Triple arthrodesis is associated with:

1) Long-term clinical stability with respect to pain relief

3) Worse patient satisfaction when ankle arthritis is present

2) High rates of nonunion

5) No increased risk for ankle arthritis

4) Development of ankle arthritis over time

Saltzman and colleagues followed 67 patients who underwent triple arthrodesis at 44-year follow-up. Nearly all patients had ankle arthritis at final follow-up. C linical relief of pain deteriorated over time between intermediate 25-year follow-up and 44-year

follow-up in the same group of patients.

■Correct Answer: Development of ankle arthritis over time

1276. (3229) Q3-4050: Isolated subtalar arthrodesis:

1) Increases transverse tarsal joint over time

3) Decreased talonavicular joint motion but increases calcaneocuboid joint motion

2) Decreases talonavicular motion less than calcaneocuboid motion

5) Increases subtalar motion

4) Decreases talonavicular motion more than calcaneocuboid motion

Subtalar fusion decreased talonavicular motion more so than calcaneocuboid motion in this cadaver study. Isolated talonavicular fusion is the most influential of the hindfoot joints, locking hindfoot motion.

■Correct Answer: Decreases talonavicular motion more than calcaneocuboid motion

1277. (3230) Q3-4051: Isolated subtalar fusion:

1) Is not associated with development of ankle or transverse tarsal joint arthritis

3) Is associated only with development of ankle arthritis, but the transverse tarsal joints are spared

2) Is associated only with development of transverse joint arthritis, but the ankle joint is spared

5) Is associated with knee joint degenerative arthritis

4) Is associated with the development of both ankle and transverse tarsal joint arthritis

In 48 subtalar fusions followed for 5 years, 36% of patients developed ankle arthritis and 41% of patients developed transverse tarsal joint arthritis.

■Correct Answer: Is associated with the development of both ankle and transverse tarsal joint arthritis

1278. (3231) Q3-4052:

Following anatomic open reduction and internal fixation of a Lisfranc fracture-dislocation:

1) Development of tarsometatarsal arthritis will not occur.

3) If tarsometatarsal arthritis develops, then subsequent arthrodesis is required.

2) Tarsometatarsal arthritis may still arise in approximately 25% of patients.

5) The screws should be routinely removed at 6 weeks.

4) The screws should be routinely removed at 12 weeks.

In a series of patients who underwent open reduction internal fixation of Lisfranc fracture dislocations, 25% of patients developed midfoot arthritis at final follow-up, but only half of these patients required eventual midfoot arthrodesis.

■Correct Answer: Tarsometatarsal arthritis may still arise in approximately 25% of patients.

1279. (3232) Q3-4053:

Which injury is likely to have a worse clinical outcome:

1) A purely ligamentous Lisfranc injury

2) A Lisfranc fracture-dislocation

Purely ligamentous Lisfranc injuries have a worse clinical outcome than injuries associated with bony fractures.

■Correct Answer: A

purely ligamentous Lisfranc injury

1280. (3233) Q3-4054:

Hallux rigidus is associated with:

1) Metatarsus primus elevatus

3) Long first metatarsal

2) First ray hypermobility

5) Bipartate sesamoid

4) Flat- or chevron-shaped metatarsal head

In a large series of patients with hallux rigidus, risk factors were evaluated. The only factor that had a positive correlation with having hallux rigidus was the radiographic shape of the 1st metatarsal head. Metatarsus primus elevatus, first ray hypermobility, or long first metatarsal head were not significantly associated with hallux rigidus.

■Correct Answer: Flat- or chevron-shaped metatarsal head

1281. (3234) Q3-4055:

C urrently recommended indications for surgical management of hallux rigidus with an arthrodesis include:

1) Positive axial grind test on preoperative clinical examination

3) Osteophytes over the dorsolateral head of the first metatarsal

2) >50% of the cartilage on the metatarsal head remaining

5) Normal first metatarsophalangeal joint motion

4) Osteophytes over the dorsal aspect of the proximal phalanx

C oughlin and colleagues recommend that when pain with axial grind testing of the metatarsophalangeal joint is present or >50% loss of articular cartilage occurs intraoperatively, then first metatarsophalangeal arthrodesis should be performed.

■Correct Answer: Positive axial grind test on preoperative clinical examination

1282. (3235) Q3-4056:

A Moberg procedure for hallux rigidus is:

1) An oblique first metatarsal shortening osteotomy

3) A medial closing wedge osteotomy of the proximal phalanx

2) An ostectomy of the medial eminence of the metatarsal

5) A lateral closing wedge osteotomy of the proximal phalanx

4) A dorsal closing wedge osteotomy of the proximal phalanx

The Moberg procedure involves a dorsal closing wedge osteotomy of the proximal phalanx. This sets the hallux higher off the floor, allowing for easier toe-off with less dorsal impingement during gait.

■Correct Answer: A dorsal closing wedge osteotomy of the proximal phalanx

1283. (3236) Q3-4057:

The optimal position for hallux interphalangeal joint arthrodesis is:

1) 5° to 10° of plantarflexion

3) Neutral flexion

2) 5° to 10° of dorsiflexion

5) 10° of valgus

4) Slight supination of the toe

The optimal position for hallux interphalangeal joint arthrodesis is 5° to 10° of plantarflexion, neutral varus-valgus, and neutral rotation. The plantarflexion helps the toe pad to contact the ground during gait.

■Correct Answer: 5° to 10° of plantarflexion

1284. (3237) Q3-4058:

First metatarsophalangeal prosthetic joint replacements:

1) Significantly increase joint range of motion

3) Provide less pain relief than first metatarsophalangeal arthrodesis

2) Have less complications than first metatarsophalangeal arthrodesis

5) Provide greater pain relief than first metatarsophalangeal arthrodesis

4) Have not been found to undergo osteolysis or loosening

First metatarsophalangeal joint replacement in this prospective comparative study performed poorly compared to arthrodesis. Patients with arthroplasties had greater pain and little improvement in range of motion.

■Correct Answer: Provide less pain relief than first metatarsophalangeal arthrodesis

1285. (3327) Q3-4183:

Deep infection following open reduction internal fixation (ORIF) for tibial pilon fractures is most commonly associated with:

1) Open fractures

3) Anterior incision

2) Postoperative wound dehiscence

5) Low energy injury

4) Medial and lateral plating

Deep infection following ORIF of pilon fractures is correlated with postoperative wound dehiscence or skin slough but not with the presence of an open fracture in a series of 60 pilon fractures treated by ORIF.

■Correct Answer: Postoperative wound dehiscence

1286. (3328) Q3-4185:

Talar body fractures are best classified by a fracture line:

1) That extends superiorly into the trochlea

3) That extends inferiorly, posterior to the lateral process

2) That extends anywhere posterior to the talar neck

5) That extends into the talar head

4) That extends inferiorly, anterior to the lateral process

Talar neck and body fractures can be difficult to distinguish, especially when they extend superiorly into the anteromedial aspect of the trochlea. These two fractures have a different prognosis. The authors recommend classification of these fractures based on the inferior fracture line; if anterior to lateral process of the talus, then it is a neck fracture; if posterior to lateral process of the talus, then it is a body fracture.

■Correct Answer: That extends inferiorly, posterior to the lateral process

1287. (4061) Q3-4186:

The most effective fixation technique that will ensure adequate visualization (imaging) of avascular necrosis changes following talar neck fracture is:

1) Fixation with 0.062-inch K-wires

3) Fixation with stainless steel mini-fragment screws

2) C losed reduction

5) Fixation with a stainless steel locking plate

4) Fixation with titanium screws

High-quality magnetic resonance images of the talus can consistently be obtained in the presence of titanium screws in contrast to images obtained with stainless steel implants. Magnetic resonance imaging is better than plain radiographs at assessing the volume of talar avascular necrosis.

■Correct Answer: Fixation with titanium screws

1288. (3329) Q3-4189:

The plantar ecchymosis sign is:

1) An indication of possible compartment syndrome

3) An indication of possible Lisfranc fracture or sprain

2) Related to a specific bacterial infection

5) Requires immediate fasciotomy

4) Described as a sign of plantar fascia rupture

The plantar ecchymosis sign is described as an ecchymotic area on the plantar midfoot that is indicative of possible injury to the plantar tarsometatarsal ligaments.

■Correct Answer: An indication of possible Lisfranc fracture or sprain

1289. (3330) Q3-4190:

The joint contact area of the second tarsometatarsal joint after Lisfranc dislocation diminishes the greatest with:

1) Dorsolateral subluxation

3) Lateral subluxation

2) Dorsal subluxation

5) Plantar subluxation

4) Medial subluxation

Minor degrees of displacement not apparent on plain radiographs lead to significant decrease in the contact area of the second tarsometatarsal joint. Dorsolateral subluxation of the second tarsometatarsal joint suffers a loss of contact area more severely than pure dorsal or lateral subluxation. Just 3 mm of dorsolateral subluxation causes a 38% loss of contact area.

■Correct Answer: Dorsolateral subluxation

1290. (3331) Q3-4191:

The âfleck signâ in midfoot injuries is a result of avulsion of the:

1) Lisfranc ligament that extends from the first metatarsal base to the second metatarsal base

3) Lisfranc ligament that extends from the medial cuneiform to the first metatarsal base

2) Lisfranc ligament that extends from the middle cuneiform to the first metatarsal base

5) Lisfranc ligament that extends from the lateral cuneiform to the third metatarsal base

4) Lisfranc ligament that extends from the medial cuneiform to the second metatarsal base

The âfleck signâ was described as an avulsion of the ligament that runs from the medial cuneiform to the base of the second metatarsal, the so-called Lisfranc ligament. It is considered pathognomonic for a tarsometatarsal injury.

■Correct Answer: Lisfranc ligament that extends from the medial cuneiform to the second metatarsal base

1291. (3332) Q3-4192:

Delayed unions and nonunions of base of fifth metatarsal fractures have been demonstrated to heal by:

1) Prolonged cast immobilization and non-weight bearing

3) C ontinued use of a fracture boot with protected weight-bearing

2) Pulsed electromagnetic fields

5) Rigid carbon fiber shoe inserts

4) Injection of demineralized bone matrix

Nine delayed unions and nonunions of the proximal fifth metatarsal were treated with pulsed electromagnetic fields. All fractures healed in a mean of 4 months (follow-up 39 months, no refractures).

■Correct Answer: Pulsed electromagnetic fields

1292. (3333) Q3-4194:

The strongest hardware configuration for fixation of talar neck fractures is:

1) Two crossed screws from distal to proximal

3) One large screw from posterior to anterior

2) Two parallel screws inserted from distal to proximal

5) One oblique screw from distal to proximal

4) Two parallel screws from posterior to anterior

Biomechanical cadaveric testing of several screw configurations showed two parallel screws from proximal to distal as the strongest fixation. The screws can be inserted either open or percutaneously. All screw configurations were stronger than K-wire configurations.

■Correct Answer: Two parallel screws from posterior to anterior

1293. (3334) Q3-4195:

According to Sandersâ computed tomography (C T) classification for calcaneus fractures, a Sanders III fracture has:

1) One fracture line in the posterior facet

3) Three fracture lines in the posterior facet

2) Two fracture lines in the posterior facet

5) Five fracture lines in the posterior facet

4) Three fracture lines in the posterior facet

The Sanders C T classification is determined on coronal C T scans of the calcaneus at the level where the posterior facet is widest. A Sanders I is a nondisplaced fracture; Sanders II consists of a single fracture line splitting the posterior facet into two main fragments; Sanders III has two fracture lines with three main posterior facet fragments; and a Sanders IV has four or more articular fragments present.

■Correct Answer: Two fracture lines in the posterior facet

1294. (3335) Q3-4196:

The incidence of compartment syndrome following calcaneus fracture is:

1) 5%

3) 15%

2) 10%

5) 30%

4) 20%

In a review article by Myerson, compartment syndrome was described to occur in 10% of calcaneal fractures. Of these, half will develop clawing, stiffness, or neurologic dysfunction. Diagnosis is confirmed by multistick invasive catheterization, especially the calcaneal compartment.

■Correct Answer: 10%

1295. (3336) Q3-4197:

Posterior antiglide plating of AO type B lateral malleolar fractures may be associated with:

1) Early loss of fixation

3) Syndesmotic irritation

2) Greater wound healing complications

5) Greater risk for nonunion

4) Peroneal tendonitis or peroneal tendon lesions

Posterior antiglide plating is associated with an increased need for hardware removal (43%) and an increased incidence of peroneal tendon lesions. The highest risk for peroneal tendon lesions was with distal placement of the plate and a protruding screw head in the most distal hole.

■Correct Answer: Peroneal tendonitis or peroneal tendon lesions

1296. (3337) Q3-4198:

Displaced talar neck fractures should be treated:

1) Emergently within 6 hours to minimize the risk of avascular necrosis

3) There is no correlation between emergent or urgent fixation of talar neck fractures and risk of talar avascular necrosis.

2) Urgently within 1 day to minimize the risk of avascular necrosis

5) Emergently within 3 hours of injury

4) Emergently within 1 hour of injury

A retrospective review of 102 talar neck fractures that underwent open reduction internal fixation showed no decrease in the development of osteonecrosis in fractures that were treated earlier. The mean time to fixation was 3.4 days for patients who had development of osteonecrosis, compared with 5 days for patients who did not have development of osteonecrosis.

■Correct Answer: There is no correlation between emergent or urgent fixation of talar neck fractures and risk of talar avascular necrosis.

1297. (3338) Q3-4200:

Superficial peroneal nerve injury following ankle fracture:

1) Does not occur with nonoperative treatment

3) Did not ultimately affect the final AOFAS ankle-hindfoot score

2) C an best be avoided during open reduction internal fixation with a posterolateral approach to the fibula

5) C an best be avoided during open reduction internal fixation with an anterolateral approach to the fibula

4) Occurs in fewer than 5% of operatively fixed fibula fractures

One hundred twenty patients with ankle fractures were evaluated. Symptomatic superficial peroneal nerve injury was identified in

21% of patients who underwent open reduction internal fixation and 9% of nonoperatively treated patients. AOFAS scores were decreased in patients with symptomatic superficial peroneal nerve injury. No injuries to the superficial peroneal nerve occurred in patients who underwent surgery involving a posterolateral approach to the fibula.

■Correct Answer: C an best be avoided during open reduction internal fixation with a posterolateral approach to the fibula

1298. (3339) Q3-4201:

Which of the following is the most reliable way to determine that a deltoid ligament injury is associated with a Weber B level lateral malleolus fracture:

1) The presence of medial tenderness on clinical examination

3) The presence of significant medial swelling on clinical examination

2) The presence of medial ecchymosis on clinical examination

5) The presence of lateral malleolus tenderness

4) Evidence of medial clear space widening on stress radiographs

Weber B supination, external rotation ankle fractures were evaluated to determine the reliability of medial tenderness, ecchymosis, and swelling in predicting deltoid incompetence. These clinical signs were poorly predictive, and stress radiographs were recommended for an accurate diagnosis of instability.

■Correct Answer: Evidence of medial clear space widening on stress radiographs

1299. (3340) Q3-4202:

Varus malunion following talar neck fracture is best corrected by:

1) Subtalar arthrodesis

3) Deltoid ligament release and lateral ligament reconstruction

2) Rotational calcaneal osteotomy with a bone block

5) Lateral column lengthening

4) Talar neck osteotomy with lengthening or by triple arthrodesis

The best way to address varus malunion in talar neck fractures and maintain motion is by talar neck osteotomy. However, there is a further possible risk of talar avascular necrosis with this procedure. The other acceptable treatment is a triple arthrodesis, although this eliminates all hindfoot motion.

■Correct Answer: Talar neck osteotomy with lengthening or by triple arthrodesis

1300. (3341) Q3-4203:

Following calcaneus fracture, risk factors for later need for subtalar arthrodesis due to painful posttraumatic arthritis include all of the following except:

1) Bohlerâs angle <0°

3) Workersâ compensation

2) Sanders type IV fractures

5) Female gender

4) Initial nonoperative care

Buckley conducted a series of large prospective studies following calcaneus fracture outcomes in C anada. All of the above factors were associated with the need for later subtalar fusion except female gender. In his other studies, it was demonstrated that male gender was a risk factor for not having a significantly better clinical outcome with surgery versus nonsurgical treatment.

■Correct Answer: Female gender