Full Question & Answer Text (for Search Engines)
Question 1:
Patients sustaining a crushing injury to the foot with midfoot tenderness but without any radiographic signs of fracture or dislocation:
Options:
- Should be managed with a postoperative shoe and early physical therapy until the tenderness resolves
- Should be splinted and kept non-weight bearing until nontender
- Should be protected in a cast boot with early weight bearing to tolerance
- Requires open reduction internal fixation to prevent long-term arthritis
- C an be discharged with no further follow-up
Correct Answer: Should be splinted and kept non-weight bearing until nontender
Explanation:
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.
Question 2:
The calcaneal compartment of the foot contains all of the following structures except:
Options:
- Quadratus plantae muscle
- Posterior tibial nerve, artery, and vein
- Lateral plantar nerve, artery, and vein
- Interossei muscles
- 1st dorsal metatarsal artery
Correct Answer: Interossei muscles
Explanation:
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.
Question 3:
Time to radiographic fusion following arthroscopic ankle arthrodesis is:
Options:
- Longer than following an open technique arthrodesis
- Shorter than following an open technique arthrodesis
- The same as open technique
- Is affected by whether external bone stimulation is utilized
- Is affected by whether two-screw or three-screw fixation is utilized
Correct Answer: Shorter than following an open technique arthrodesis
Explanation:
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.
Question 4:
Neighboring joint arthritis following ankle arthrodesis has not been found in the:
Options:
- Knee joint
- Naviculocuneiform joint
- First metatarsophalangeal joint
- Subtalar joint
- Hindfoot joint
Correct Answer: Knee joint
Explanation:
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.
Question 5:
Range of motion following total ankle replacement is closely correlated with:
Options:
- Amount of osteophytes resected during surgery
- Meticulous ligament balancing
- Level of tibial and talar saw cuts
- Preoperative range of motion
- Size of implant
Correct Answer: Preoperative range of motion
Explanation:
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.
Question 6:
Take-down of ankle arthrodesis and conversion to total ankle replacement:
Options:
- Is impossible if the fibula has been resected
- Is a dependable procedure with a rate of complications similar to primary ankle replacement
- Has a poor clinical success rate if there is no clear underlying cause of pain from the ankle fusion
- Results in minimal gains in ankle range of motion
- Requires custom made prosthetic implants
Correct Answer: Has a poor clinical success rate if there is no clear underlying cause of pain from the ankle fusion
Explanation:
This article studied the success rates of revising previous ankle fusions to ankle replacement. The authors found that if the etiology of a patientâ s 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.
Question 7:
Development of hindfoot arthritis following total ankle replacement is seen in:
Options:
- 0% of patients
- <25% of patients
- 50% of patients
- 75% of patients
- >75% of patients
Correct Answer: <25% of patients
Explanation:
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.
Question 8:
Clinical improvement following ankle distraction arthroplasty:
Options:
- Typically reaches its maximal improvement by the end of 1 year
- Is accompanied by major gains in ankle range of motion
- C an take up to 5 years to reach maximal improvement
- Is not accompanied by improvement in radiographic joint space
- Is usually realized within the first month following removal of the frame
Correct Answer: C an take up to 5 years to reach maximal improvement
Explanation:
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.
Question 9:
Isolated subtalar arthrodesis:
Options:
- Increases transverse tarsal joint over time
- Decreases talonavicular motion less than calcaneocuboid motion
- Decreased talonavicular joint motion but increases calcaneocuboid joint motion
- Decreases talonavicular motion more than calcaneocuboid motion
- Increases subtalar motion
Correct Answer: Decreases talonavicular motion less than calcaneocuboid motion
Explanation:
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.
Question 10:
Which injury is likely to have a worse clinical outcome:
Options:
- A purely ligamentous Lisfranc injury
- 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
Question 11:
C urrently recommended indications for surgical management of hallux rigidus with an arthrodesis include:
Options:
- Positive axial grind test on preoperative clinical examination
- >50% of the cartilage on the metatarsal head remaining
- Osteophytes over the dorsolateral head of the first metatarsal
- Osteophytes over the dorsal aspect of the proximal phalanx
- Normal first metatarsophalangeal joint motion
Correct Answer: Positive axial grind test on preoperative clinical examination
Explanation:
Coughlin 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.
Question 12:
The main blood supply to the talar body is from the:
Options:
- Peroneal artery
- Dorsalis pedis artery
- Artery of the tarsal canal
- Artery of the sinus tarsi
- 1st dorsal metatarsal artery
Correct Answer: Artery of the tarsal canal
Explanation:
The main blood supply to the body of the talus is the artery of the tarsal canal, which is a branch off the posterior tibial artery. The dorsalis pedis and the artery of the sinus tarsi supply the talar head.
Question 13:
How many weeks following open reduction and internal fixation of a right ankle fracture can patients resume driving with normal braking times:
Options:
- 6 weeks
- 9 weeks
- 12 weeks
- 16 weeks
- 18 weeks
Correct Answer: 9 weeks
Explanation:
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.
Question 14:
When using external fixation in the treatment of tibial pilon fractures, distal transfixation wires:
Options:
- Should always traverse the distal tibia-fibula joint to get optimal fixation
- Should remain >12.2 mm above the subchondral plate of the distal tibia
- Are not at risk for causing joint infection
- Are least at risk for penetrating the joint capsule over the anterolateral aspect of the ankle
- C annot be olive wires because of a higher risk for pin-tract infection
Correct Answer: Should remain >12.2 mm above the subchondral plate of the distal tibia
Explanation:
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.
Question 15:
Treatment of significant loss of height and posttraumatic arthritis following nonoperative treatment of calcaneus fractures should include:
Options:
- Subtalar distraction bone block arthrodesis
- C orrective osteotomy
- Tibiotalocalcaneal arthrodesis
- C ustom Arizona ankle brace with heel lift
- C ustom orthotics with lateral heel posting
Correct Answer: Subtalar distraction bone block arthrodesis
Explanation:
Management of late loss of height following calcaneus fracture is best addressed by a distraction arthrodesis of the subtalar joint using a wedge- shaped structural bone graft.
Question 16:
Incisions made through blood-filled fracture blisters have:
Options:
- A lower risk of wound healing problems than clear fluid-filled fracture blisters
- No increased risk of wound healing problems than through normal skin
- The same ability to heal as clear fluid-filled fracture blisters
- A higher risk of wound healing problems than clear fluid-filled fracture blisters
- Should be left open to heal by secondary intention
Correct Answer: A higher risk of wound healing problems than clear fluid-filled fracture blisters
Explanation:
Biopsies of the edge of fracture blisters following ankle fracture show that blood-filled blisters represent a deeper injury than clear fluid-filled blisters. The dermis of clear blisters still showed some epithelial cells remaining, while the dermis of blood blisters showed no epithelial cells. Therefore, blood-filled blisters are more difficult to heal.
Question 17:
Following triple arthrodesis, ankle range of motion is:
Options:
- Unaffected
- Increased
- Decreased
- Improves over time
- Increases initially, but then returns to preoperative levels
Correct Answer: Decreased
Explanation:
This clinical study following triple arthrodesis patients for 10 years showed a 27% loss of ankle plantarflexion but no loss of dorsiflexion.
Question 18:
A Moberg procedure for hallux rigidus is:
Options:
- An oblique first metatarsal shortening osteotomy
- An ostectomy of the medial eminence of the metatarsal
- A medial closing wedge osteotomy of the proximal phalanx
- A dorsal closing wedge osteotomy of the proximal phalanx
- A lateral closing wedge osteotomy of the proximal phalanx
Correct Answer: A dorsal closing wedge osteotomy of the proximal phalanx
Explanation:
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.
Question 19:
The distinguishing factor in a Hawkins type 4 talar neck fracture is:
Options:
- The presence of an incongruent ankle joint
- The presence of a talonavicular dislocation
- The presence of an incongruent subtalar joint
- The presence of an associated talar body fracture
- The presence of an associated talar body fracture
Correct Answer: The presence of an incongruent ankle joint
Explanation:
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.
Question 20:
First metatarsophalangeal prosthetic joint replacements:
Options:
- Significantly increase joint range of motion
- Have less complications than first metatarsophalangeal arthrodesis
- Provide less pain relief than first metatarsophalangeal arthrodesis
- Have not been found to undergo osteolysis or loosening
- Provide greater pain relief than first metatarsophalangeal arthrodesis
Correct Answer: Provide less pain relief than first metatarsophalangeal arthrodesis
Explanation:
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.
Question 21:
The optimal position for ankle arthrodesis is:
Options:
- 5° plantarflexion, 5° valgus, 5° external rotation
- Neutral flexion, 5° valgus, 5° external rotation
- Neutral flexion, 0° varus/valgus, 5° external rotation
- Neutral flexion, 5° valgus, 5° internal rotation
- 5° dorsiflexion, 5° valgus, 5° external rotation
Correct Answer: Neutral flexion, 5° valgus, 5° external rotation
Explanation:
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. Currently it is recommended that all patients are fused in neutral dorsi- /plantarflexion.
Question 22:
Isolated talonavicular fusion:
Options:
- Decreases subtalar motion by 25%
- Decreases subtalar motion by 50%
- Locks subtalar motion
- Has no effect on subtalar motion
- Decreases subtalar motion by 10%
Correct Answer: Locks subtalar motion
Explanation:
This cadaver study examined the motion that remained in the hindfoot joints following sequential immobilization of the talonavicular, subtalar, and calcaneo-cuboid joints. Fixing the talo-navicular joint virtually locked all subtalar motion.
Question 23:
The distinction between a Lauge-Hansen supination-external rotation III injury and a Lauge-Hansen supination-external rotation IV injury is:
Options:
- A spiral oblique fracture of the lateral malleolus
- Anteroinferior tibiofibular ligament (AITFL) disruption
- Posteroinferior tibiofibular ligament (PITFL) disruption or posterior malleolus fracture
- Deltoid ligament disruption or medial malleolus fracture
- Anterior talo-fibular ligament disruption
Correct Answer: Deltoid ligament disruption or medial malleolus fracture
Explanation:
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.
Question 24:
Isolated subtalar fusion:
Options:
- Is not associated with development of ankle or transverse tarsal joint arthritis
- Is associated only with development of transverse joint arthritis, but the ankle joint is spared
- Is associated only with development of ankle arthritis, but the transverse tarsal joints are spared
- Is associated with the development of both ankle and transverse tarsal joint arthritis
- Is associated with knee joint degenerative arthritis
Correct Answer: Is not associated with development of ankle or transverse tarsal joint arthritis
Explanation:
In 48 subtalar fusions followed for 5 years, 36% of patients developed ankle arthritis and 41% of patients developed transverse tarsal joint arthritis.C orrect Answer: Is associated with the development of both ankle and transverse tarsal joint arthritis
Question 25:
The optimal position for hallux interphalangeal joint arthrodesis is:
Options:
- 5° to 10° of plantarflexion
- 5° to 10° of dorsiflexion
- Neutral flexion
- Slight supination of the toe
- 10° of valgus
Correct Answer: 5° to 10° of plantarflexion
Explanation:
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.
Question 26:
Following anatomic open reduction and internal fixation of a Lisfranc fracture-dislocation:
Options:
- Development of tarsometatarsal arthritis will not occur.
- Tarsometatarsal arthritis may still arise in approximately 25% of patients.
- If tarsometatarsal arthritis develops, then subsequent arthrodesis is required.
- The screws should be routinely removed at 12 weeks.
- The screws should be routinely removed at 6 weeks.
Correct Answer: Tarsometatarsal arthritis may still arise in approximately 25% of patients.
Explanation:
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.
Question 27:
The maximal joint reactive force in the ankle is approximately:
Options:
- Two times body weight
- Three times body weight
- Five times body weight
- Seven times body weight
- Eight times body weight
Correct Answer: Five times body weight
Explanation:
Stauffer and colleagues quantified ankle joint reactive force to be approximately 5 times body weight. This is a significant concern for prosthetic ankle arthroplasty because the implant surface area is relatively small over which these forces must be spread out.
Question 28:
Hallux rigidus is associated with:
Options:
- Metatarsus primus elevatus
- First ray hypermobility
- Long first metatarsal
- Flat- or chevron-shaped metatarsal head
- Bipartate sesamoid
Correct Answer: Flat- or chevron-shaped metatarsal head
Explanation:
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.
Question 29:
Which nerve is NOT one of the terminal branches of Baxterâ s nerve, also known as the first branch of the lateral plantar nerve:
Options:
- Nerve to the medial calcaneal periosteum (sensory)
- Lateral dorsal cutaneous nerve (sensory)
- Nerve to the flexor digitorum brevis muscle (motor)
- Nerve to the abductor digiti minimi muscle (motor)
- None of the above
Correct Answer: Lateral dorsal cutaneous nerve (sensory)
Explanation:
The three terminal branches of Baxterâ s nerve are the nerve to the medial calcaneal periosteum, the nerve to the flexor digitorum brevis, and the nerve to the abductor digiti minimi. The lateral dorsal cutaneous nerve is a branch of the sural nerve.
Question 30:
A regimen of ankle bracing and supervised physical therapy:
Options:
- Has no beneficial effect on stage II posterior tibial tendon dysfunction
- Is helpful in relieving the pain symptoms associated with stage II posterior tibial tendon dysfunction but does not increase strength
- C an significantly relieve pain and increase strength in stage II posterior tibial tendon dysfunction
- Is only useful for postoperative rehabilitation after flexor digitorum longus tendon transfer and medial slide calcaneal osteotomy
- Prevents patients from requiring surgery in only 11% of cases
Correct Answer: C an significantly relieve pain and increase strength in stage II posterior tibial tendon dysfunction
Explanation:
In a study performed by Alvarez and colleagues, 47 patients with stage I or II posterior tibial tendon dysfunction were treated nonoperatively with either a hinged ankle-foot orthosis or foot orthosis and a supervised physical therapy program. After 10 therapy visits, 83% of patients had successful subjective and functional outcomes. Eighty-nine percent of patients were satisfied with the outcome of nonoperative treatment. This included significant improvement in visual analog scale scores and increased strength, concentrically and eccentrically. In this study, 11% of patients failed conservative treatment and required surgery.
Question 31:
The use of hyperbaric oxygen (HBO) in the treatment of problematic diabetic foot wounds has been shown to do all of the following except:
Options:
- To increase the healing rate
- To decrease the amputation rate
- To be potentially cost-effective when the costs of long-term care of a nonhealing wound and limb amputation are considered
- To be ineffective in changing the outcome of diabetic foot wounds
- To increase the juxta-wound pO2
Correct Answer: To be ineffective in changing the outcome of diabetic foot wounds
Explanation:
A meta-analysis of 12 studies showed that healing rates increased from 48% to 76%, and amputation rates decreased from 45% to 19% with the use of hyperbaric oxygen (HBO) and local wound care. In randomized controlled trials, wound area decreased significantly and days to healing decreased significantly in patients treated with HBO. The juxta-wound pO2 was also significantly increased in the HBO-treatment group.
Question 32:
The greatest insult to the vascular supply of the first metatarsal head during chevron bunionectomy with lateral release according to intraoperative laser Doppler blood flow measurements was:
Options:
- During the lateral release
- During the adductor tenotomy
- During the metatarsal osteotomy
- During the medial capsular release
- During skin incision
Correct Answer: During the metatarsal osteotomy
Explanation:
Twenty patients were prospectively monitored with laser Doppler measurements of metatarsal head blood flow during chevron bunionectomy with lateral release. The greatest loss of blood flow occurred with the medial capsulotomy (45% decrease). The lateral release combined with the adductor tenotomy decreased the blood flow to the metatarsal head by 13%, and the metatarsal osteotomy decreased blood flow by an additional 13%. Total decrease in blood flow to the head was 71%. No patients developed avascular necrosis.
Question 33:
In a randomized controlled trial comparing first metatarsophalangeal arthrodesis versus total joint replacement arthroplasty for end-stage hallux rigidus, all of the following statements are true except:
Options:
- There was a significant improvement in functional outcome in the arthrodesis group compared to the arthroplasty group.
- Following arthroplasty, there was a significant increase in dorsiflexion compared to preoperative status.
- Following arthroplasty, patients tend to bear weight on the lateral border of the foot.
- The cost ratio was 2:1 in favor of arthrodesis.
- Fusion had a lower complication rate than arthroplasty.
Correct Answer: There was a significant improvement in functional outcome in the arthrodesis group compared to the arthroplasty group.
Explanation:
In the study by Gibson and Thomson, 38 fusions and 39 arthroplasties were prospectively compared at 2-year follow-up. There was an 82% improvement in the arthrodesis group and only a 45% improvement in the arthroplasty group. Fusion also had lower complication rates and lower cost. There was not a significant increase in first metatarsophalangeal joint dorsiflexion between preoperative and postoperative levels following total joint replacement.
Question 34:
The nonunion rate for the Lapidus procedure (first tarsometatarsal arthrodesis) for the treatment of moderate to severe hallux valgus is:
Options:
Correct Answer: 7%
Explanation:
In a prospective cohort study following 105 Lapidus bunionectomies for 3.7 years, the nonunion rate was found to be 6.7%. The American Orthopaedic Foot & Ankle Society scores improved significantly, and loss of correction over 3.7 years was less than 1° for intermetatarsal and hallux valgus angles.
Question 35:
When using external fixation in the treatment of tibial pilon fractures, distal transfixation wires:
Options:
- Should always traverse the distal tibia-fibula joint for optimal fixation
- Should remain more than 12.2 mm above the subchondral plate of the distal tibia
- Are not at risk for causing joint infection
- Are least at risk for penetrating the joint capsule over the anterolateral aspect of the ankle
- Should remain at least 5 mm above the subchondral plate of the distal tibia
Correct Answer: Should remain more than 12.2 mm above the subchondral plate of the distal tibia
Explanation:
In a cadaveric and in vivo study of the reflections of the ankle joint capsule, the distal tibia-fibula joint was found to communicate with the ankle joint capsule, thus representing a risk for ankle sepsis if it is penetrated by a transfixion wire. The anterolateral capsule displayed the most proximal reflection in all specimens.
Question 36:
The clinical variable found to be associated with a higher risk of complications following open reduction and internal fixation of unstable ankle fractures in diabetic patients was:
Options:
- Presence of a severe fracture pattern
- Presence of an open fracture
- Insulin-dependent diabetes mellitus
- Peripheral neuropathy or vasculopathy
- Presence of nephropathy
Correct Answer: Peripheral neuropathy or vasculopathy
Explanation:
A retrospective Level IV study followed 84 patients with diabetes who underwent open reduction internal fixation of unstable ankle fractures. After analyzing multiple patient factors including sex, fracture pattern, open or closed injury, nephropathy, hypertension, vasculopathy, peripheral neuropathy, and diabetic control (insulin-dependent compared with non- insulindependent), the only factors that predicted a higher rate of complications were vasculopathy and peripheral neuropathy. There was a 12% rate of postoperative infection and an overall 14% rate of complications.
Question 37:
Which modality for the treatment of chronic insertional Achilles tendinopathy was shown to have the best clinical outcome:
Options:
- C oncentric Achilles tendon stretching
- Eccentric Achilles tendon stretching
- Short-term immobilization of the ankle in equinus
- Low-energy shockwave therapy
- Topical anesthetic
Correct Answer: Low-energy shockwave therapy
Explanation:
A randomized controlled trial compared recalcitrant insertional Achilles tendinopathy treated with eccentric heel cord stretching versus low-energy shockwave therapy. At 4 months, 28% of the stretching group and 64% of the shockwave therapy group reported complete relief of symptoms or greatly improved symptoms. All outcome measures showed favorable results with shockwave therapy.
Question 38:
Urgent closed reduction of ankle fracture-dislocations using intraarticular lidocaine injection:
Options:
- Provides a similar degree of analgesia compared to conscious sedation
- Requires more time to perform the reduction and splint the leg than with conscious sedation
- Results in inferior reduction of ankle deformity compared to conscious sedation
- Requires frequent repeat reduction procedures due to persistent fracture malalignment
- Is painful due to distension of the joint capsule
Correct Answer: Provides a similar degree of analgesia compared to conscious sedation
Explanation:
A prospective randomized study compared intraarticular lidocaine injection to conscious sedation for analgesia during reduction of ankle fracture- dislocations. There was no difference in the amount of analgesia provided by the two methods. Time for reduction and splinting was less in the local anesthetic group. Quality of reduction was similar in both groups.
Question 39:
A tailorâ s bunion is an abnormal prominence of the lateral aspect of the 5th metatarsal head. Similar to hallux valgus deformities, tailorâ s bunions can be due to a widened intermetatarsal angle between the 4th and 5th metatarsal shafts. The normal 4-5 intermetatarsal angle is:
Options:
- Less than 8°-9°
- Less than 12°
- Less than 15°
- Less than 20°
- Less than 25°
Correct Answer: Less than 8°-9°
Explanation:
4-5 intermetarsal angle in normal feet averages 6.2 degrees. Different authors believe an abnormally wide 4-5 intermetatarsal angle to be anything greater than 8°-9°.
Question 40:
A 54-year-old woman with a 10-year history of type II diabetes mellitus develops a Wagner grade 2 ulceration under the first metatarsal head, which has not healed for 3 months. There is no gross cellulitis or drainage. A tagged white blood cell scan shows no signs of osteomyelitis, and noninvasive vascular studies reveal normal hemodynamics. She has failed wet-to-dry normal saline dressings and bacitracin ointment local wound care. The next step in treating this patientâ s chronic ulcer is:
Options:
- Application of hydro-colloid gel dressings
- Use of a custom-made pressure off-loading plastizote insole
- Application of a total contact cast by a qualified physician or cast technician
- Regular debridment of the ulcer
- Amoxicillin/clavulanate potassium 875 mg twice daily
Correct Answer: Application of hydro-colloid gel dressings
Explanation:
The description of the ulcer indicates that it is not grossly infected and that there is no underlying bony involvement. According to evidence based medicine, the only treatments that are likely to be effective in the healing of diabetic foot ulcerations are topical growth factors, total contact casting, and for severely infected ulcers hyperbaric oxygen.
Question 41:
Which is the best match in surface topography when performing an osteochondral autograft transplantation procedure from the distal femur to the talar dome for an osteochondral lesion of the talus:
Options:
- From the superior-medial femoral condyle to the antero-medial talar dome
- From the inferior-medial femoral condyle to the postero-medial talar dome
- From the superior-lateral femoral condyle to any position on the medial talar dome
- From the inferior-medial femoral condyle to the centro-medial talar dome
- From the inferior-lateral femoral condyle to the antero-medial talar dome
Correct Answer: From the superior-medial femoral condyle to the antero-medial talar dome
Explanation:
In a magnetic resonance imaging topography study looking for the best corresponding shape of the articular surface between the non-weightbearing femoral condyle and the medial talar dome, plugs from the supero-lateral femoral condyle had the best fit with osteochondral lesions of the medial talus in the anterior, central, and posterior zones.
Question 42:
The most frequent location for osteochondral lesions of the talar dome is:
Options:
- Anterolateral talar dome (Raikin zone 3)
- Posteromedial talar dome (Raikin zone 7)
- Lateral talar dome, mid-body (Raikin zone 6)
- Medial talar dome, mid-body (Raikin zone 4)
- Anteromedial talar dome (Raikin zone 1)
Correct Answer: Medial talar dome, mid-body (Raikin zone 4)
Explanation:
A survey of 428 osteochondral lesions of the talus was undertaken using a nine zone anatomical grid system to determine the most frequent location in which these lesions occur. Results showed that 62% of lesions occurred in the medial talar dome and 34% over the lateral talar dome. The most frequent location along the medial dome was the mid-body of the talus. Medial lesions were larger in surface area as well as deeper than lateral lesions.
Question 43:
Which gait parameters are significantly improved following first metatarsophalangeal arthrodesis for symptomatic hallux rigidus:
Options:
- Maximal ankle push off power
- Stride length
- Walking velocity
- C adence
- Foot progression angle
Correct Answer: Maximal ankle push off power
Explanation:
A prospective gait study was performed measuring various gait parameters 1 week prior to and 1 year following first metatarsophalangeal joint arthrodesis. The three significant changes in gait were increased maximal ankle push off power, increased single limb support time on the affected limb, and decreased step width. Stride length, walking velocity, and cadence were not significantly different after fusion.
Question 44:
Which clinical or radiographic finding is not commonly associated with moderate or severe hallux valgus deformity in adults:
Options:
- Positive family history
- Presence of bilateral bunion deformity
- Oval or curved metatarsophalangeal joint on radiographs
- Longer 1st metatarsal than 2nd metatarsal
- Achilles tendon contracture
Correct Answer: Achilles tendon contracture
Explanation:
A clinical series of 122 bunions was evaluated for demographic, etiologic, and radiographic findings associated with moderate to severe hallux valgus deformity. The following findings were reported: 83% of patients had a positive family history of bunions 84% of patients had bilateral bunion deformities 71% of patients had curved or oval-shaped metatarsophalangeal joints 71% of patients had a longer 1st metatarsal compared to the 2nd metatarsal by an average of 2.4 mm 11% of bunions were associated with an Achilles tendon contracture
Question 45:
A 58-year-old runner has symptoms of chronic noninsertional Achilles tendinopathy for 8 months. Rest, ice, anti-inflammatory medications, and heel wedges have not helped. Which of the following treatments may help alleviate this patientâ s symptoms:
Options:
- C oncentric Achilles tendon stretching
- Topical lidocaine patches
- Intratendinous cortisone injection
- Topical glyceryl trinitrate
- Oral fluorquinolone therapy
Correct Answer: Topical glyceryl trinitrate
Explanation:
Noninsertional Achilles tendinosis is a noninflammatory degenerative condition that is common in middle-aged athletes. In a 3- year follow-up study examining the use of topical glyceryl trinitrate for Achilles tendinosis, patients were noted to have significantly less tendon tenderness and improved clinical scores compared to the placebo group. At 3 years, 88% of treated patients were asymptomatic. Novel nonoperative measures include sclerosing injections into the Achilles tendon with polidocanol and shock- wave therapy to the Achilles tendon.
Question 46:
When comparing complication rates following operative and nonoperative management of ankle fractures in the elderly (age 65- 99):
Options:
- Operatively managed patients have a higher mortality rate and a higher rehospitalization rate than conservatively managed patients.
- Operatively managed patients have a higher mortality rate but a lower rehospitalization rate than conservatively managed patients.
- Operatively managed patients have a lower mortality rate and a lower rehospitalization rate than conservatively managed patients.
- Operatively managed patients have a lower mortality rate but a higher rehospitalization rate than conservatively managed patients.
- Operatively managed patients have a high rate of revision of internal fixation, conversion to arthroplasty or arthrodesis, or amputation.
Correct Answer: Operatively managed patients have a higher mortality rate and a higher rehospitalization rate than conservatively managed patients.
Explanation:
A study using the National Medicare C laims History System was performed looking at outcomes following ankle fracture in 33,704 elderly patients, specifically looking at mortality, rehospitalization, and the need for additional surgery. Researchers found that conservatively managed patients had a higher mortality rate up to 2 years following injury compared to patients who underwent open reduction internal fixation. Operatively treated patients had a higher rate of rehospitalization following their injury. Less than 1% of patients required revision of internal fixation, arthroplasty, arthrodesis, or amputation.
Question 47:
Exposure of tendons to ciprofloxacin in vitro causes all of the following except:
Options:
- A decrease in fibroblast proliferation
- An increase in proteoglycan synthesis
- A decrease in proteoglycan synthesis
- An increase in matrix degrading proteolytic activity
- A decrease in collagen synthesis
Correct Answer: An increase in proteoglycan synthesis
Explanation:
Ciprofloxacin was shown to cause a decrease in fibroblast proliferation, proteoglycan synthesis, and collagen synthesis. Matrix degrading proteolytic activity was increased.
Question 48:
The Brostrom lateral ligament reconstruction is a reliable technique for primary stabilization of ankle instability. The Gould modification of this technique uses which structure to reinforce the repair:
Options:
- One half of the peroneus brevis
- One half of the peroneus longus
- The calcaneofibular ligament
- The inferior extensor retinaculum
- The posterior inferior tibiofibular ligament
Correct Answer: The inferior extensor retinaculum
Explanation:
The initial description of the Gould modification of the Brostrom procedure recommended â suturing what one finds (there is always some ligament present) and reinforcing the anterior talofibular ligament repair with overlap of the nearby lateral talocalcaneal ligament plus the marginal ankle retinaculumâ .
Question 49:
Following ankle injury, which radiographic parameter is indicative of syndesmotic instability:
Options:
- Medial clear space greater than 2 mm
- Syndesmotic clear space greater than 5 mm measured 2 cm above the ankle joint on the anteroposterior (AP) view
- Syndesmotic overlap of less than 1 mm measured 1 cm above the ankle joint on the mortise view
- Syndesmotic clear space greater than 5 mm measured 1 cm above the ankle joint on the mortise view
- Syndesmotic overlap of less than 1 mm measured 1 cm above the ankle joint on the AP view
Correct Answer: Syndesmotic clear space greater than 5 mm measured 2 cm above the ankle joint on the anteroposterior (AP) view
Explanation:
The normal radiographic findings of the syndesmosis on plain radiographs of the ankle are: Medial clear space less than or equal to 4 mm Syndesmotic clear space less than 5 mm measured 1 cm above the ankle joint on the AP view of the ankle Syndesmotic overlap greater than 1 mm measured 1 cm above the ankle joint on the mortise view of the ankle
Question 50:
In children between ages 7 and 11 with bilateral flexible flatfeet and without any pathologic findings, the use of custom-made orthotics or off-the-shelf orthotics demonstrate:
Options:
- Significant improvement in motor proficiency compared to controls treated without orthotics
- Significant improvement in visual analog pain scores compared to controls treated without orthotics
- Significant improvement in exercise efficiency compared to controls treated without orthotics
- Significant negative effects on the childâ s self-perception compared to controls treated without orthotics
- No significant difference compared to controls with regards to motor proficiency, pain, exercise efficiency, or self-perception
Correct Answer: Significant improvement in motor proficiency compared to controls treated without orthotics
Explanation:
In a randomized controlled trial comparing children with flatfeet treated with custom orthotics, off-the-shelf orthotics, and no treatment, there were no differences in the above parameters found. The study concluded that no significant difference was found with regard to motor proficiency, pain, exercise efficiency, or self-perception.
