Foot and Ankle FREE ORTHOPEDICS MCQS Question 11 

Question 11

A 43-year-old woman with long-standing rheumatoid arthritis has a large prominence with soft-tissue swelling under the fifth metatarsal head and over the lateral eminence of the fifth metatarsophalangeal (MTP) joint. She has minimal hammer toes with no significant metatarsalgia. Radiographs show a 4-5 intermetatarsal angle of 7° and a congruent fifth MTP joint. What is the recommended surgical treatment to address this problem?

A.      Simple exostectomy 

B.      Metatarsal head excision 

C.      Diaphyseal metatarsal osteotomy 

D.      Simple exostectomy with soft-tissue mass excision

R: D

Exostectomy with soft-tissue mass excision is the treatment of choice. The patient has a type 1 bunionette but most of her symptoms are coming from a rheumatoid nodule that is under the metatarsal head. This is mainly a soft-tissue problem and does not require any type of osteotomy because the 4-5 intramedullary angle is minimally elevated. A metatarsal head resection is commonly performed in patients with rheumatoid arthritis, but is not indicated in this patient because there is a normal fifth MTP joint and no metatarsalgia.

Question 12

Figure 1 is the radiograph of a patient with a history of pain at the insertion of the Achilles tendon who sustained a sudden onset of severe pain when jumping off a horse. On examination, the patient had a loss of plantar flexion with Thompson test and pain with palpation over the distal Achilles. What is the most appropriate treatment?

A.    Early rehabilitation in a functional brace with heel lift

B.     Direct end-to-end suture repair 

C.     Casting in equinus 

D.    Surgical reconstruction with possible flexor hallucis longus (FHL) transfer

R: D

Achilles tendon sleeve avulsions are noted for the small fragments of bone visible on radiographs. These injuries do not have sufficient distal tendon for a direct repair nor is there sufficient bone for internal fixation. The recommended treatment is direct repair of the Achilles tendon to the calcaneus, either with suture anchors or sutures through bone tunnels. It has been proposed that these injuries are associated with insertional disease and that treatment should address any preexisting conditions. Often times, with insertional ruptures, after debridement of the diseased tissue, an FHL transfer may be necessary.

Question 13

A 45-year-old man has had 6 weeks of pain, worse with exercise, in the distal Achilles tendon proximal to the insertion. What kind of physical therapy is most effective in treating this issue?

A.      Concentric strengthening 

B.      Eccentric strengthening 

C.      Hydrotherapy 

D.      Electric stimulation

R: B

Eccentric strengthening has been shown in multiple studies to be more effective than other nonsurgical management options for midsubstance Achilles tendinopathy. Eccentric therapy involves loading the ankle into dorsiflexion, thought to stimulate increased type 1 collagen synthesis, which helps repair the damaged tendon.

Question 14

A 28-year-old man has a 3-year history of right ankle pain. He reports having an injury 3 years ago and undergoing subsequent arthroscopy and microfracture at that time. He has continued to have pain, locking, and swelling with activity. What factors shown on the MRI scans in Figures 1 through 4 are predictive of a worse clinical outcome?

A.    Large size and uncontained lesion 

B.     Subchondral cysts and uncontained lesion 

C.     Subchondral cysts and lateral location 

D.    Location of the legion in the lateral talus

R: A

The most common first-line surgical treatment of osteochondral lesions of the talus is marrow stimulation with either drilling or microfracture. A retrospective study was undertaken to determine which factors are predictive of a poor clinical outcome for patients undergoing surgical treatment of osteochondral defects of the talus with drilling or microfracture. It was found that size >1.5cm2, younger age (<33 years), and uncontained lesions were the factors predictive of a poor clinical outcome. The size of the lesion was found to be the most significant factor in predicting poor clinical outcome and may be a reason to consider a more extensive initial surgical treatment.

Question 15

Figures 1 and 2 are the AP and lateral radiographs of a 6-year-old boy who has had 2 weeks of intermittent right foot pain that does not interfere with most activities. On examination, the patient has pain and tenderness to palpation over the dorsomedial aspect of the foot. No significant deformities of the foot are noted. What is the best next step?

A.    Vascularized bone grafting of navicular 

B.     Open reduction and internal fixation of the navicular 

C.     Non-weight-bearing cast for 6 weeks  

D.    Activity modification with soft arch supports

R: D

Kohler's disease is a rare, self-limiting, osteonecrosis of the navicular bone. It affects boys more than girls and typical age of onset is between 4 and 5 years. The etiology is thought to be related to the mechanical compression of the navicular from the ossified talus and cuneiforms because the navicular is the last tarsal bone to ossify. This mechanical effect compresses the navicular bone's perichondral ring of blood vessels, resulting in ischemia of the central spongy bone and osteonecrosis. The prognosis remains excellent because of this radial arrangement of blood supply. Radiologic findings show patchy areas of navicular with sclerosis, with loss of normal trabecular pattern. Occasionally, the navicular may appear collapsed or may simply have increased density with minimal fragmentation. Management includes pain control and use of soft arch supports or a medial heel wedge. Patients with disabling symptoms may benefit from a short-leg walking cast for 4 to 6 weeks. Symptoms in untreated patients persist longer than symptoms in treated patients. Because this is a self-limited process, treatment does not affect the course of the disease. Patients with persistent pain should be examined for other conditions such as talar coalition.

Question 16

A 60-year-old active man has lateral ankle pain and subjective instability. Physical examination demonstrates tenderness over the peroneal tendons and lateral ankle ligaments. There is pain with resisted eversion and associated weakness, but no tendon subluxation. Anterior drawer and talar tilt examination demonstrate lateral ligamentous laxity. Standing alignment demonstrates a varus hindfoot and pes cavus. A Coleman block test demonstrates fixed hindfoot varus. Initial nonsurgical management with bracing and physical therapy is unsuccessful. Regarding the surgical management of this patient’s condition, in addition to addressing the patient’s peroneus longus tear and lateral ankle instability, what other procedure is critical for successful treatment?

A.      Flexor hallucis longus tendon transfer 

B.      Ankle arthroscopy 

C.      Lateralizing calcaneal osteotomy 

D.      Dorsiflexion osteotomy of first metatarsal

R: C

Peroneal tendon tears and chronic lateral ankle instability are common in the setting of symptomatic cavovarus foot deformity. Chronic varus stress on the ankle causes failure of the lateral supporting structures, resulting in lateral instability and overload of the peroneal tendons, causing tendinopathy and/or rupture. Many peroneal tears are asymptomatic; however, if the tear progresses, it can result in eversion weakness and further stress on the adjacent peroneal tendon and lateral ankle ligaments. In this case, the patient has a chronic tear of the peroneus longus tendon. Failure to address the underlying hindfoot varus deformity through a lateralizing calcaneal osteotomy in this patient may result in failure of the peroneal tendon repair and lateral ligamentous reconstruction. Flexor hallucis longus transfer is indicated as an augmentation if both peroneus longus and brevis are irreparable. Dorsiflexion osteotomy of the first metatarsal alone would not be indicated because the deformity is not flexible based on Coleman block testing. Lastly, in the absence of intra-articular pathology of the ankle, arthroscopy is not indicated.

Question 17

What is the most common pathogen for soft-tissue infection of the foot caused by a puncture wound?

A.      Staphylococcus aureus 

B.      Pseudomonas aeruginosa 

C.      Eikenella corrodens 

D.      Pasteurella multocida

R: A

Staphylococcus and Streptococcus species are the most common causes of soft-tissue infections in the foot due to punctures. Pseudomonas is the most common cause of osteomyelitis of the foot due to puncture wounds. Pasteurella and Eikenella are seen in animal and human bites, respectively.

Question 18

Figure 1 is the radiograph of a 20-year-old man with chronic medial-sided left midfoot pain stemming from mixed martial arts injury approximately 2 years ago. What is the most appropriate treatment?

A.    Open reduction internal fixation 

B.     Arthrodesis 

C.     Osteotomy 

D.    Walking boot

R: B

Arthrodesis is the preferred method of surgical intervention in the setting of chronic Lisfranc injuries and variants with posttraumatic arthrosis. ORIF is appropriate for acute trauma management, osteotomy is indicated for associated foot deformity, and walking boot may provide temporary pain amelioration.

Question 19

Video 1 is the presurgical lateral ankle examination of a 45-year-old woman who has had pain and discomfort for 2 years along the posterolateral ankle following a sudden dorsiflexion injury. She notes occasional clicking and popping, and she has not experienced resolution of her symptoms despite immobilization and physical therapy. Examination reveals a stable ankle-to-anterior drawer and inversion stress testing. No strength deficit is noted, but she has apprehension with resisted eversion. MR images do not reveal evidence of tendonosis or tear. The most appropriate surgical intervention is

A.    imbrication of the lateral collateral ligaments with reinforcement with the extensor retinaculum (modified Brostrom procedure). 

B.     peroneal tendon synovectomy and tubularization of the peroneus brevis. 

C.     groove deepening of the fibula with imbrication of the peroneal retinaculum. 

D.    excision of the peroneus brevis with tenodesis of the proximal stump to the peroneus longus.

R: C

This patient has a clear history of dorsiflexion injury complicated by chronic peroneal tendon dislocation. The symptoms and findings are consistent with dislocation in this particular case. Groove deepening of the posterior fibula with associated imbrication of the peroneal retinaculum is the most effective surgical procedure. Associated synovitis or tendonosis should be addressed. However, failure to deepen the groove and imbricate the retinaculum will result in continued discomfort. Consequently, both responses that involve isolated tendon surgery are not appropriate. Associated subjective instability can be noted in these patients. The examination is critical to determine the stability of the lateral collateral complex, which is intact in this case (so imbrication is not indicated). A sense of apprehension is a common examination finding because patients sense that the peroneals will subluxate with resisted eversion. Placement of the examiner's hands on the peroneals to stabilize the tendons should relieve this apprehension. A patient may not be able to voluntarily dislocate the tendon. Dynamic ultrasound is the most sensitive radiographic examination for detection of dislocation. Intrasheath peroneal subluxation may also occur and is treated similarly.

Question 20

Figures 1 and 2 are the radiographs of a 52-year-old laborer who has a 2-year history of pain in his great toe while working. He is specifically interested in discussing whether orthotics could be of benefit. Which orthotic is most appropriate for treating this condition?

A.    Full-length orthotic with medial posting 

B.     Full-length orthotic with lateral posting 

C.     Three-quarter length orthotic with a metatarsal pad 

D.    Carbon fiber insert with a Morton's extension

R: D

The radiographs show a patient with significant hallux rigidus. Nonsurgical treatment consists of nonsteroidal anti-inflammatory drugs, activity modification, shoewear modification, corticosteroid injections, and orthotics. The classic orthotic used in the treatment of hallux rigidus is a Morton's extension to limit dorsiflexion of the hallux metatarsophalangeal joint.