OITE & ABOS Orthopedic Board Prep: Foot & Trauma MCQs

Question 1

When using a two-incision approach for open reduction and internal fixation of a Hawkins III talar fracture-dislocation involving the talar neck and body, what anatomic structure must be preserved to optimize outcome?

Explanation

DISCUSSION: A Hawkins III fracture-dislocation generally presents with posteromedial displacement with the deltoid ligament intact. Therefore, the only remaining blood supply is the deltoid branch of the artery of the tarsal canal originating from the posterior tibial artery. Often, the medial malleolus is fractured, assisting in reduction and visualization of fracture reduction. If the medial malleolus is intact, a medial malleolus osteotomy allows visualization of the reduction without compromising the last remaining blood supply to the talus.
REFERENCES: Mulfinger GL, Trueta J: The blood supply of the talus. J Bone Joint Surg Br 1970;52:160-167.
Vallier HA, Nork SE, Barei DP, et al: Talar neck fractures: Results and outcomes. J Bone Joint Surg Am 2004;86:1616-1624.

Question 2

A 10-year-old boy who is active in soccer has had activity-related heel pain for the past 3 months. Examination reveals tenderness over the posterior heel and a tight Achilles tendon. Radiographs demonstrate a 2-cm cyst in the anterior body of the calcaneus. His physes have not closed. Based on these findings, what is the most appropriate management?

Explanation

DISCUSSION: The most likely diagnosis is Sever’s disease, which is considered either an apophysitis or a para-apophyseal stress fracture. It is common in athletic children and is associated with a tight Achilles tendon. Cast immobilization may be necessary if activity reduction fails. Calcaneal cysts are quite common and do not require any further diagnostic testing or treatment unless they occupy the full width of the calcaneus or one third of the length of the calcaneus.
REFERENCES: Ogden JA, Ganey TM, Hill JD, et al: Sever’s injury: A stress fracture of the immature calcaneal metaphysis. J Ped Orthop 2004;24:488-492.
Pogoda P, Priemel M, Linhart W, et al: Clinical relevance of calcaneal bone cysts: A study of 50 cysts in 47 patients. Clin Orthop Relat Res 2004;424:202-210.

Question 3

A 35-year-old woman states that she stepped on a piece of glass 6 months ago and reports numbness and shooting pain along the plantar lateral forefoot. She had previously received steroid injections in the 3 to 4 webspace. Examination reveals mild tenderness along the plantar fascia; no Tinel’s sign is noted plantar medially and no Mulder’s click is noted distally. An MRI scan is shown in Figure 7. What is the most likely cause of the numbness?

Explanation

DISCUSSION: The MRI scan reveals a laceration through the abductor hallucis musculature and lateral plantar nerve, producing numbness along its distribution. There is no evidence of a foreign body on the MRI scan. Baxter’s nerve, or nerve to the abductor digiti quinti muscle, is the first branch off the lateral plantar nerve and impingement of this nerve typically produces a Tinel’s sign along the nerve branch deep to the abductor hallucis muscle. Interdigital neuroma would be suggested by the presence of a Mulder’s click. A digital nerve laceration would exhibit isolated numbness more distally.
REFERENCES: Baxter DE, Pfeffer GB: Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop Relat Res 1992;279:229-236.
Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional. Philadelphia, PA, JB Lippincott, 1983.

Question 4

A 69-year-old man reports pain over his bunion while wearing shoes and pain in the joint with push-off when barefoot. Nonsurgical management has failed to provide relief. Radiographs are shown in Figures 8a and 8b. What is the surgical procedure of choice?

Explanation

DISCUSSION: Arthrodesis is indicated for severe bunion and hallux valgus deformities, but particularly with extensive degenerative disease of the first metatarsophalangeal joint. The other bunionectomy procedures have different indications, none of which include symptomatic first metatarsophalangeal degenerative disease.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 3-15.
Tourne Y, Saragaglia D, Zattara A, et al: Hallux valgus in the elderly: Metatarsophalangeal arthrodesis of the first ray. Foot Ankle Int 1997;18:195-198.

Question 5

A 65-year-old man has chronic Achilles insertional tendinitis that is refractory to nonsurgical management. A radiograph is shown in Figure 9. Preoperative counseling should include a discussion of the realistic duration of postoperative recovery. You should inform the patient that his expected recovery will last

Explanation

DISCUSSION: An older patient with calcaneal enthesopathy may take a year or more to recover after tendon debridement and calcaneal ostectomy. Young patients, and those with purely tendon pathology, may recover more quickly.
REFERENCES: McGarvey WC, Palumbo RC, Baxter DE, et al: Insertional Achilles tendinitis: Surgical treatment through a central tendon splitting approach. Foot Ankle Int 2002;23:19-25.
Watson AD, Anderson RB, Davis WH: Comparison of results of retrocalcaneal decompression for retrocalcaneal bursitis and insertional Achilles tendinosis with calcific spur. Foot Ankle Int 2000;21:638-642.

Question 6

Figures 10a and 10b show the clinical photograph and MRI scan of a plantar foot lesion. If excisional biopsy is performed, what is the most likely complication?

Explanation

DISCUSSION: The MRI scan shows plantar fibromatosis. The treatment is usually nonsurgical.

If surgery is indicated, wide local excision with excision of the entire plantar fascia is usually indicated. The main problem with simple excision of the lesion is the high chance of recurrence. The other listed complications are those that are a result of the wide local excision.
REFERENCES: Aluisio FV, Mair SD, Hall RL: Plantar fibromatosis: Treatment of primary and recurrent lesions and factors associated with recurrence. Foot Ankle Int 1996;17:672-678.
Bos GD, Esther RJ, Woll TS: Foot tumors: Diagnosis and treatment. J Am Acad Orthop Surg 2002;10:259-270.

Question 7

A patient with rheumatoid arthritis with both ankle and subtalar involvement was treated as shown in Figures 11a and 11b. What complication is unique to this type of fixation?

Explanation

DISCUSSION: The interlocking screws at the proximal end of the rod can act as a stress riser and lead to fracture. Postoperative pain at this level should prompt inclusion of this diagnosis in the differential. Removing the screws following bone union can decrease the chances of this occurring. A short rod that avoids the diaphyseal area may also be beneficial. Rotatory deformity is controlled by the perpendicularly oriented distal transfixion screws. Talar osteonecrosis would be unusual since the dissection can be minimized with an intramedullary rod. Any type of hardware can fail if the construct does not lead to a solid arthrodesis.
REFERENCES: Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 236-237.
Thordarson DB, Chang D: Stress fractures and tibial cortical hypertrophy after tibiotalocalcaneal arthrodesis with an intramedullary nail. Foot Ankle Int 1999;20:497-500.
Hammett R, Hepple S, Forster B, et al: Tibiotalocalcaneal (hindfoot) arthrodesis by retrograde intramedullary nailing using a curved locking nail: The results of 52 procedures. Foot Ankle Int 2005;26:810-815.

Question 8

A 68-year-old man fell off a 20-foot mountain cliff and was seen in the emergency department the following morning. A radiograph is shown in Figure 12. He is a nonsmoker with medical comorbidities of hypertension and hypercholesterolemia that is well controlled with medicine and diet. Capillary refill and sensation are intact distally and the patient is able to move his toes with mild discomfort. Serosanguinous fracture blisters are present laterally, and the foot is swollen and red. What is the most appropriate management?

Explanation

DISCUSSION: Whereas a patient age of older than 50 years used to be a contraindication for open reduction and internal fixation of displaced intra-articular calcaneal fractures, new data suggest that the presence of associated medical comorbidities that affect wound healing such as smoking, diabetes mellitus, and peripheral vascular disease are more relevant to postoperative functional outcome. Surgical treatment of Sanders II and III displaced intra-articular calcaneal fractures with initial Bohler angles of > 15 degrees results in better outcomes as compared to nonsurgical management. Indications for primary fusion might include Sanders IV fractures in which articular congruity or Bohler angles cannot be restored. Given the condition of the soft tissues at presentation, delayed fixation is recommended.
REFERENCES: Herscovici D Jr, Widmaier J, Scaduto JM, et al: Operative treatment of calcaneal fractures in elderly patients. J Bone Joint Surg Am 2005;87:1260-1264.
Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744.
Csizy M, Buckley R, Tough S, et al: Displaced intra-articular calcaneal fractures: Variables predicting late subtalar fusion. J Orthop Trauma 2003;17:106-112.

Question 9

A 45-year-old woman has had intense pain in her foot for the last 3 days. She also reports a mild fever and difficulty with shoe wear. Examination reveals a swollen, slightly erythematous warm foot with tenderness at the great toe metatarsophalangeal joint and pain with passive motion of the joint. An AP radiograph is shown in Figure 13. Which of the following will best aid in determining a definitive diagnosis?

Explanation

DISCUSSION: The patient has gouty arthropathy of the first metatarsophalangeal joint. This definitive diagnosis is achieved with aspiration of the joint and polarized light microscopy that shows needle-shaped negatively birefringent monosodium urate crystals. Differential diagnoses of infectious arthritis and pseudogout are also definitively made through joint aspiration. Although rheumatoid arthritis is a possibility, a serum rheumatoid factor is not always diagnostic and a patient with rheumatoid arthritis may have concomitant gouty arthritis. The radiographic findings are not typical of diabetes mellitus or of a patient with Charcot arthropathy.
REFERENCES: Wise CM, Agudelo CA: Diagnosis and management of complicated gout. Bull Rheum Dis 1998;47:2-5.
Harris MD, Siegel LB, Alloway JA: Gout and hyperuricemia. Am Fam Physician 1999;59:925-934.

Question 10

Figures 14a and 14b show the clinical photographs of a patient who was stranded in a subzero region for several days. The photographs were taken the morning after arrival in the hospital. The patient is otherwise healthy and fit, and takes no medication. He has no clinical signs of sepsis. He reports burning pain and tingling in both feet. What is the best treatment?

Explanation

DISCUSSION: The patient has no clinical or observed signs of sepsis. The skin just proximal to the gangrenous tissue appears somewhat hyperemic and is clearly viable. These wounds should be managed much like burn wounds. Moist dressings should be used until the tissue clearly demarcates. Much of the insult may simply be superficial and only require late debridement.
REFERENCES: McAdams TR, Swenson DR, Miller RA: Frostbite: An orthopedic perspective.

Am J Orthop 1999;28:21-26.
Taylor MS: Cold weather injuries during peacetime military training. Milit Med 1992;157:602-604.

Question 11

The peroneus tertius is a commonly used landmark for arthroscopic portal placement. What is the function of this tendon?

Explanation

DISCUSSION: The peroneus tertius, although absent in 10% of the population, originates on the distal third of the extensor surface of the fibula and inserts onto the base of the fifth metatarsal, possibly extending to the fascia over the fourth interosseous space. The muscle is located in the anterior compartment of the leg and is innervated by the deep peroneal nerve. The tendon produces dorsiflexion and eversion when walking and can be used as an insertion point during tendon transfers to assist dorsiflexion. This tendon is peculiar to humans and is a proximally migrated deep extensor of the fifth toe.
REFERENCES: Joshi SD, Joshi SS, Athavale SA: Morphology of the peroneus tertius muscle.

Clin Anat 2006;19:611-614.
Williams PL, Bannister LH, Berry MM, et al (eds): Gray’s Anatomy, ed 38. London, Churchill Livingston, 1995, p 883.
Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, p 21.

Question 12

A 45-year-old man is seen in the emergency department after returning from a 2-hour airplane flight. He is reporting severe pain in his right leg but has no trouble moving his ankle, leg, or knee. Venous doppler testing reveals no evidence of deep venous thrombosis. He is placed on IV cephazolin but continues to worsen. On the third day in the hospital he has increased pain, some respiratory distress, and trouble maintaining his blood pressure. His leg takes on the appearance seen in Figure 15. An urgent MRI scan shows thickening of the subcutaneous tissues and superficial swelling in the leg but no evidence of an abscess. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has necrotizing fasciitis, a rare and sometimes fatal disease that has many different etiologies. Signs that this is not a normal infection are the worsening clinical symptoms despite IV antibiotics and the systemic symptoms. He needs urgent surgical care before he becomes completely septic and unstable. He needs very aggressive debridement of his tissues. Hyperbaric oxygen and immunoglobulins are only anecdotally helpful, and would only be used

after surgery.
REFERENCES: Fontes RA, Ogilvie CM, Miclau T: Necrotizing soft-tissue infections. J Am Acad Orthop Surg 2000;8:151-158.
Ozalay M, Ozkoc G, Akpinar S, et al: Necrotizing soft-tissue infection of a limb: Clinical presentation and factors related to mortality. Foot Ankle Int 2006;27:598-605.

Question 13

A 17-year-old girl with Charcot-Marie-Tooth disease reports the development of progressive instability when walking on uneven surfaces. Her involved heel is positioned in varus when viewed from behind. Examination reveals that she walks on the outer border of the involved foot. She has full passive motion of the ankle and hindfoot joints. She is able to dorsiflex the ankle against resistance. The heel varus fully corrects with the Coleman block test. Standing radiographs reveal a cavus deformity with valgus of the forefoot. She would like to avoid using an ankle-foot orthosis. What is the best surgical option?

Explanation

DISCUSSION: This deformity is early in the disease process. The foot is still flexible, as evidenced by correction with the Coleman block test. A simple dorsiflexion osteotomy of the first metatarsal should provide a plantigrade foot. More complex osteotomies are required later in the disease process when the foot is not flexible and the deformity does not correct with the Coleman block test. The patient may also require a tibialis anterior transfer later in the disease process but not at the present time.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Upate: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 135-144.
Dehne R: Congenital and acquired neurologic disorders, in Coughlan MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 525-557.

Question 14

A 58-year-old man with type 1 diabetes mellitus is seen in the emergency department and he reports a 3-day history of a red swollen foot but no history of trauma. Examination reveals that the skin is intact, and the patient has discomfort with passive range of motion at the ankle, hindfoot, and midfoot joints. He denies any fever. Laboratory studies show a WBC count of 7,800/mm 3 , an erythrocyte sedimentation rate of 40 mm/h, a C-reactive protein level of 23, and a serum glucose of 100. A radiograph and MRI scans are shown in Figures 16a through 16c. What is the next most appropriate step in management?

Explanation

DISCUSSION: Whereas it is difficult to distinguish between cellulitis, septic joint, osteomyelitis, and early Eichenholtz stage 1 Charcot, the presence of a fracture in the absence of ulcerations with a normal WBC count and serum glucose strongly indicates that the described symptoms are due to an early Charcot process alone. A technetium Tc 99m scan alone would not be helpful; however, the addition of a sulfur colloid marrow scan or indium In 111 scan may be more specific to rule out infection, though it is not warranted here. Total contact casting with non-weight-bearing or limited weight bearing during Eichenholtz stage 1 when the foot is warm, erythematous, and swollen is advised to help prevent deformity. Alternatively, stabilization with pneumatic bracing may also be considered. While some authors have proposed early fixation or arthrodesis for Eichenholtz stage 1, the gold standard is still total contact casting with no to limited weight bearing until the swelling resolves and evidence of consolidation is seen on radiographs.
REFERENCES: Trepman E, Nihal A, Pinzur MS: Current topics review: Charcot neuropathy of the foot and ankle. Foot Ankle Int 2005;26:46-63.
Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 123-134.
Simon SR, Tejwani SG, Wilson DL, et al: Arthrodesis as an early alternative to nonoperative management of Charcot arthropathy of the diabetic foot. J Bone Joint Surg Am 2000;82:939-950.

Question 15

Which of the following conditions is not associated with an increased risk of developing Achilles tendinopathy?

Explanation

DISCUSSION: Diabetes mellitus, obesity, and exposure to steroids have all been associated with the development of Achilles tendinopathy. In addition, Achilles tendinopathy has been associated with a history of hormone replacement therapy and the use of oral contraceptives. Quinolone antibiotics have also been linked to Achilles tendinopathy.
REFERENCES: Holmes GB, Lin J: Etiologic factors associated with symptomatic Achilles tendinopathy. Foot Ankle Int 2006;27:952-959.
Holmes GB, Mann RA, Well L: Epidemiological factors associated with rupture of the Achilles tendon. Contemp Orthop 1991;23:327-331.

Question 16

Figures 17a through 17c show the radiographs of a 38-year-old man following a motorcycle accident. The posterior portion of the talus extruded through a posterolateral wound. The extruded talar body is visible in the wound along with some road debris. Management should now consist of surgical irrigation, debridement, and

Explanation

DISCUSSION: The extruded talus should be placed in sterile bacitracin solution, irrigated thoroughly, gently debrided, and immediately replanted in the OR. Open reduction and internal fixation of the talar fracture may be attempted immediately depending on the soft-tissue envelope, or delayed after soft-tissue stabilization with an external fixator. A retrospective study of 19 patients with an extruded talus reported that 12 patients had no subsequent surgery after definitive fixation,

7 had subsequent procedures, and 2 patients developed infections that were treated successfully at an average of 42-month follow-up. Successful outcome in this series was attributed to multiple debridements, soft-tissue stabilization, and primary wound closure.
REFERENCES: Smith CS, Nork SE, Sangeorzan BJ: The extruded talus: Results of reimplantation. J Bone Joint Surg Am 2006;88:2418-2424.
Brewster NT, Maffulli N: Reimplantation of the totally extruded talus. J Orthop Trauma 1997;11:42-45.
Marsh JL, Saltzman CL, Iverson M, et al: Major open injuries of the talus. J Orthop Trauma 1995;9:371-376.

Question 17

Figures 18a and 18b show the radiographs of a patient who has pain with walking. On careful questioning, it is determined that the discomfort occurs at push-off, or when the patient attempts to climb stairs. What nonsurgical option is most likely to ameliorate the symptoms?

Explanation

DISCUSSION: The patient has a malunion of an attempted open reduction of a Lisfranc dislocation. The pain occurs during the terminal stance phase of gait as load is being transferred from the hindfoot to the forefoot. The bending moment can be best neutralized with shoe modification with a cushioned heel and rocker sole, which best unloads the tarsal-metatarsal junction.
REFERENCES: Bono CM, Berberian WS: Orthotic devices: Degenerative disorders of the foot and ankle. Foot Ankle Clin 2001;6:329-340.
Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 58-63.

Question 18

An 18-year-old football player reports acute pain and swelling after a direct injury to his plantar flexed foot. Examination reveals midfoot swelling and tenderness. Nonstanding radiographs are normal. What is the next most appropriate step in management?

Explanation

DISCUSSION: Differentiating between a midfoot sprain and Lisfranc diastasis is critical in the management of the athlete with an acute injury to the midfoot. Greater than 2 mm of displacement between the first and second metatarsals on a weight-bearing radiograph is an indication for anatomic reduction with internal fixation of the tarsometatarsal joints. If no subluxation is noted, treatment should consist of a non-weight-bearing cast for 6 weeks, followed by a gradual return

to activity.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.
Chiodo CP, Myerson MS: Developments and advances in the diagnosis and treatment of injuries with the transmetatarsal joint. Orthop Clin North Am 2001;32:11-20.

Question 19

A 36-year-old woman is wearing an ankle-foot orthosis for a foot drop secondary to spastic hemiplegia following a postpartum stroke 2 years ago. Knee and hip motion and strength are within normal ranges. She has undergone multiple rounds of physical therapy but has seen no improvement over the past several months. No improvement has been recorded by electromyography (EMG) studies over the past year. Examination reveals a 5-degree plantar flexion contracture with clonus, heel varus, and compensatory knee hyperextension when standing. She has 4/5 power in the tibialis anterior and gastrocnemius soleus complex with resistance testing. Everters are 2/5 to resistance testing. EMG gait studies show that the tibialis anterior demonstrates activity during both swing and stance phase that is increased during swing phase. Premature firing of the triceps surae is noted when positioning the foot in equinus prior to floor contact. What is the most appropriate management?

Explanation

DISCUSSION: The patient has a dynamic varus deformity secondary to spasticity of the tibialis anterior during stance phase with inverter/everter imbalance. The patient still has active motion of the tibialis anterior; therefore, an out-of-phase posterior tibial tendon transfer should not be performed. The same is true of the Bridle procedure. Transfer of the posterior tibialis in this patient may also result in subsequent planovalgus deformity. Lengthening of the Achilles tendon through a percutaneous tenotomy will restore dorsiflexion and decrease clonus from the stretch response. If adequate dorsiflexion is not obtained intraoperatively, then posterior tibialis tendon lengthening may be considered. A split tibialis anterior tendon transfer to the lateral cuneiform, or, transfer of the entire tendon to the cuneiform should correct the varus component and compensate for the weakened peroneals.
REFERENCES: Yamamoto H, Okumura S, Morita S, et al: Surgical correction of foot deformities after stroke. Clin Orthop Relat Res 1992;282:213-218.
Piazza SJ, Adamson RL, Moran MF, et al: Effects on tensioning errors in split transfers of tibialis anterior and posterior tendons. J Bone Joint Surg Am 2003;85:858-865.
Morita S, Muneta T, Yamamoto H, et al: Tendon transfers for equinovarus deformed foot caused by cerebrovascular disease. Clin Orthop Relat Res 1998;350:166-173.

Question 20

A 52-year-old woman slipped on ice in her driveway. Radiographs are shown in Figures 19a and 19b. The patient was treated in a short leg cast with weight bearing as tolerated for 6 weeks. Due to persistent tenderness at the fracture site, a CAM walker was used for an additional 8 weeks. Nine months after the injury, the patient still walks with a limp and reports pain with deep palpation at the fracture site. What is the next most appropriate step in management?

Explanation

DISCUSSION: Persistent pain at the fracture site in the absence of infection is most likely due to a nonunion, best detected by CT. Walsh and DiGiovanni reported on a series of closed rotational fibular fractures in which nonunions were detected by CT in the absence of standard ankle radiographic findings. Repeat immobilization would not be appropriate at this late date. Pain management/sympathetic blocks would be considered if the patient displayed pain with light touch and disproportionate pain consistent with a complex mediated pain syndrome. Acupuncture would be expected to be of limited benefit.
REFERENCES: Walsh EF, DiGiovanni C: Fibular nonunion after closed rotational ankle fracture. Foot Ankle Int 2004;25:488-495.
Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 182-183.

Question 21

What is the most frequent complication of percutaneous repair of an acute Achilles tendon rupture?

Explanation

DISCUSSION: Sural nerve entrapment is the major risk of percutaneous repair. A small mini-open technique with a suture guide can obviate that issue. Re-rupture rates after surgical repair are approximately 3%. Infection and wound problems are rarely encountered with percutaneous repair; they are issues with open repair.
REFERENCES: Aracil J, Pina A, Lozano JA, et al: Percutaneous suture of Achilles tendon ruptures. Foot Ankle 1992;13:350-351.
Sutherland A, Maffulli N: A modified technique of percutaneous repair of the ruptured Achilles tendon. Oper Orthop Traumatol 1998;10:50-58.
Assal M, Jung M, Stern R, et al: Limited open repair of Achilles tendon ruptures: A technique with a new instrument and findings of a prospective multicenter study. J Bone Joint Surg Am

2002;84:161-170.

Question 22

A 2-year-old child is brought in by his parents for evaluation of intoeing. The child has a normal neuromuscular examination, but the heel bisector line is in the fourth web space, indicating a severe flexible metatarsus adductus deformity. The remainder of the lower extremity examination is unremarkable. What is the most appropriate treatment?

Explanation

DISCUSSION: Weinstein reported on 31 patients (45 feet) with congenital metatarsus adductus followed for an average of 33 years. Twenty-nine feet had moderate to severe deformities treated with manipulation and casting with a 90% success rate. In a young child, surgery is not indicated until nonsurgical management has failed. In patients 2 to 4 years of age, tarsometatarsal capsulotomies are indicated, whereas multiple metatarsal osteotomies are reserved for recalcitrant deformities in children older than 4 years of age. Mild or moderate metatarsus adductus that is passively correctable will resolve without treatment.
REFERENCES: Beaty J: Congenital anomalies of the lower extremity, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 10. Philadelphia PA, Mosby, 2003, pp 983-988.
Katz K, David R, Soudry M: Below-knee plaster cast for the treatment of metatarsus adductus.

J Pediatr Orthop 1999;19:49-50.
Weinstein SL: Bristol-Myers Squibb/Zimmer award for distinguished achievement in orthopaedic research. Long-term follow-up of pediatric orthopaedic conditions: Natural history and outcomes

of treatment. J Bone Joint Surg Am 2000;82:980-990.

Question 23

A 34-year-old man has had a 13-month history of an equinovarus deformity of the foot and ankle after a motorcycle accident. His foot and ankle are flexible, but bracing has become uncomfortable. Active dorsiflexion and eversion are absent. What is the most appropriate treatment?

Explanation

DISCUSSION: Arthrodesis of any of the ankle or hindfoot joints should be reserved for fixed deformities or end-stage degenerative arthritis. Achilles tendon lengthening is necessary to correct the equinus and to improve dorsiflexion-plantar flexion balance. Similarly, transfer of the posterior tibialis tendon reduces both plantar flexion and inversion torque.
REFERENCES: Hansen ST: Function Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 442-447.
Atesalp AS, Yildiz C, Komurcu M, et al: Posterior tibial tendon transfer and tendo-Achilles lengthening for equinovarus foot deformity due to severe crush injury. Foot Ankle Int 2002;23:1103-1106.

Question 24

Figures 20a and 20b show the radiographs of a 14-year-old boy who sustained a twisting injury to his ankle. If attempted closed reduction is unsuccessful, what is the primary reason to proceed with surgical treatment?

Explanation

DISCUSSION: Triplane fractures generally occur in children who are near skeletal maturity. The injury is generally caused by a supination external rotation mechanism. The number of fracture fragments present (two or three) depends on what part of the physes is closed at the time of injury. Articular congruity is the major concern in the management of these injuries since the patient has almost reached skeletal maturity. The goal is to restore articular congruity to minimize the development of posttraumatic arthritis.
REFERENCES: Vaccaro A (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 757-765.
Kling TF Jr, Bright RW, Hensinger RN: Distal tibial physeal fractures in children that may require open reduction. J Bone Joint Surg Am 1984;66:647-657.
Spiegel PG, Mast JW, Cooperman DR, et al: Triplane fractures of the distal tibial epiphysis.

Clin Orthop Relat Res 1984;188:74-89.

Question 25

A 75-year-old woman reports foot pain and states that her foot has become progressively “flatter” in the past 3 years. Custom inserts and physical therapy have failed to provide relief. Examination reveals a flexible hindfoot and mild heel cord contracture. The patient is able to perform a single limb heel rise. Weight-bearing radiographs are shown in Figures 21a through 21d. What is the most appropriate surgical management?

Explanation

DISCUSSION: The patient has end-stage midfoot arthritis, with a secondary flatfoot deformity through the midfoot. The ability to perform a single limb heel rise indicates that the posterior tibial tendon is functioning, and the weight-bearing radiographs show normal calcaneal pitch and talar head coverage, thus confirming that the flatfoot deformity is isolated to the midfoot. Therefore, the most appropriate treatment is medial column arthrodesis and heel cord lengthening. The other listed procedures are not indicated because they are used in the management of adult flatfoot from posterior tibial tendon insufficiency.
REFERENCES: Toolan BC: Midfoot arthrodesis: Challenges and treatment alternatives. Foot Ankle Clin 2002;7:75-93.
Horton GA, Olney BW: Deformity correction and arthrodesis of the midfoot with a medial plate. Foot Ankle 1993;14:493-499.

Question 26

A 52-year-old woman who underwent cheilectomy 1 year ago for hallux rigidus now reports continued pain in the first metatarsophalangeal joint. She did not have any incision healing problems, and has not had any fevers, erythema, or drainage. Which of the following procedures will provide the best combination of pain relief and function?

Explanation

DISCUSSION: All but the Moberg osteotomy are capable of providing pain relief; however, arthrodesis offers the best long-term results and restores weight bearing and propulsion function to the first ray.
REFERENCES: Machacek F Jr, Easley ME, Gruber F, et al: Salvage of a failed Keller resection arthroplasty. J Bone Joint Surg Am 2004;86:1131-1138.
Myerson MS, Schon LC, McGuigan FX, et al: Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int

2000;21:297-306.

Question 27

During a posterior approach to the right Achilles tendon, the surgeon encounters a nerve running with the small saphenous vein as shown in Figure 22. This nerve innervates what part of the foot?

Explanation

DISCUSSION: The sural nerve runs with the small saphenous vein on the posterior leg just lateral to the Achilles tendon. It is formed by contributions from both the tibial and common peroneal nerves and provides sensation on the dorso-lateral aspect of the foot.
REFERENCES: Aktan Ikiz ZA, Ucerler H, Bilge O: The anatomic features of the sural nerve with an emphasis on its clinical importance. Foot Ankle Int 2005;26:560-567.
Lawrence SJ, Botte MJ: The sural nerve in the foot and ankle: An anatomic study with clinical and surgical implications. Foot Ankle Int 1994;15:490-494.

Question 28

A 23-year-old woman has had a 14-month history of ankle pain after surgical treatment of multiple injuries resulting from a motor vehicle accident. Weight bearing began 4 months after surgery. The pain occurs with weight bearing and motion, but there is very little pain at rest. She has no pertinent medical history and does not smoke. Figures 23a and 23b show current radiographs. What is the most appropriate surgical option?

Explanation

DISCUSSION: The radiographs reveal nonunion of a talar neck fracture. There is no radiographic evidence of osteonecrosis or significant degenerative arthritis. The results of talectomy are suboptimal. Arthrodesis would be indicated for degenerative arthritis. Revision ORIF is feasible and preserves motion. A vascularized graft should be considered whenever osteonecrosis is present, but the talar body appears viable in this case.
REFERENCES: Calvert E, Younger A, Penner M: Post talus neck fracture reconstruction.

Foot Ankle Clin 2007;12:137-151.
Migues A, Solari G, Carrasco NM, et al: Repair of talar neck nonunion with indirect corticocancellous graft technique: A case report and review of the literature. Foot Ankle Int 1996;17:690-694.

Question 29

What type of physical therapy is most effective for chronic noninsertional Achilles tendinopathy?

Explanation

DISCUSSION: Eccentric gastrocsoleus strengthening (especially with heavy loads) consistently has been shown to be superior in the management of Achilles tendinopathy. Decreases in pain and increases in strength have been demonstrated despite the frequently refractory nature of this condition.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 91-102.
Vora AM, Myerson MS, Oliva F, et al: Tendinopathy of the main body of the Achilles tendon.

Foot Ankle Clin 2005;10:293-308.

Question 30

A 27-year-old man was struck by a taxi cab and sustained comminuted right distal third tibia and fibula fractures; treatment consisted of placement of an intramedullary nail in the tibia the following morning. At his 6-month follow-up, he has clawing of all five toes. Examination reveals flexion deformities of the distal and proximal interphalangeal joints that are flexible with plantar flexion and rigid with dorsiflexion. Calluses are present on the dorsum and tip of the toes. Single heel rise is normal. He has a mild equinus contracture (relative to the left leg) that is not relieved with knee flexion. What is the most appropriate treatment option?

Explanation

DISCUSSION: This is an example of tethering of the flexor hallucis longus/flexor digitorum longus (FHL/FDL) to the fracture site. Additional time and/or physical therapy and bracing would not be expected to be of benefit. Release of the FHL and FDL from the fracture site or retromalleolar lengthening will address the posttraumatic claw toe deformity and Achilles tendon lengthening will address the mild equinus. Posterior tibial tendon transfer is not appropriate as the patient demonstrates a normal heel rise. Midfoot releases and hallux fusion are also not indicated.
REFERENCES: Feeny MS, Williams RL, Stephens MM: Selective lengthening of the proximal flexor tendon in the management of acquired claw toes. J Bone Joint Surg Br 2001;83:335-338.
Clawson DK: Claw toes following tibial fracture. Clin Orthop Relat Res 1974;103:47-48.

Question 31

A 24-year-old man reports the development of a foot drop following a knee dislocation 1 year ago. The common peroneal nerve was found to be in continuity at the time of surgical reconstruction of the posterolateral corner of the knee joint. He would like to eliminate the need for an ankle-foot orthosis. What is the best option to achieve elimination of the orthosis?

Explanation

DISCUSSION: The ankle dorsiflexor muscles have been denervated for too long a period to expect reinnervation to be successful. Even if the extensor hallucis longus tendon was functional, it is unlikely to have sufficient strength to achieve dynamic ankle dorsiflexion. The tibialis posterior tendon transfer has been shown to predictably achieve these goals in a high percentage of patients. Successful ankle fusion is likely to fail with time due to the development of forefoot equinus.
REFERENCES: Pinzur MS, Kett N, Trilla M: Combined anteroposterior tibial tendon transfer in post-traumatic peroneal palsy. Foot Ankle 1988;8:27l-275.
Lipscomb P, Sanchez J: Anterior transplantation of the posterior tibial tendon for persistant palsy of the common peroneal nerve. J Bone Joint Surg Am 1961;43:60-66.

Question 32

A 21-year-old male construction worker fell from a roof and sustained an injury to his left foot. Radiographs and CT scans are shown in Figures 24a through 24e. Compared to nonsurgical management, surgical treatment offers which of the following advantages?

Explanation

DISCUSSION: The radiographs and CT scans show a displaced intra-articular calcaneal fracture, with loss of calcaneal height and length. Recent multicenter, randomized, prospective studies suggest that surgical treatment of displaced intra-articular calcaneal fractures is associated with an almost six-fold decrease in the risk of posttraumatic subtalar arthritis (necessitating subtalar arthrodesis) compared to nonsurgical treatment. Despite ongoing controversy, surgical treatment has not been shown to be advantageous with respect to activity, time to return to work, or subtalar joint range of motion. A nonunion of a calcaneal fracture is exceedingly rare regardless of the treatment method.
REFERENCES: Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744.
Csizy M, Buckley R, Tough S, et al: Displaced intra-articular calcaneal fractures: Variables predicting late subtalar fusion. J Orthop Trauma 2003;17:106-112.

Question 33

A 51-year-old plumber has a failed peroneus brevis tendon repair. He reports continued pain and swelling in the distal retrofibular area. MRI shows longitudinal tears of the peroneus longus and peroneus brevis. What is the surgical treatment of choice at this time?

Explanation

DISCUSSION: A flexor digitorum longus transfer, while not as strong as the peroneals, improves the tendon balance and maintains hindfoot mobility. Subtalar fusion is a salvage procedure. Posterior tibial tendon transfer compromises inversion strength and arch height. Functional absence of the peroneals results in an imbalance that could lead to forefoot varus.
REFERENCES: Redfern D, Myerson M: The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int 2004;25:695-707.
Borton DC, Lucas P, Jomha NM, et al: Operative reconstruction after transverse rupture of the tendons of both peroneus longus and brevis: Surgical reconstruction by transfer of the flexor digitorum longus tendon. J Bone Joint Surg Br 1998;80:781-784.

Question 34

Which of the following imaging modalities is most accurate in locating a toothpick in the plantar arch of the foot?

Explanation

DISCUSSION: Ultrasound is best at imaging abrupt changes in the density of adjacent tissue and therefore is best at imaging wood in the soft tissues of the foot.
REFERENCES: Mizel MS, Steinmetz ND, Trepman E: Detection of wooden foreign bodies in muscle tissue: Experimental comparison of computed tomography, magnetic resonance imaging, and ultrasonography. Foot Ankle Int 1994;15:437-443.
Jacobson JA, Powell A, Craig JG, et al: Wooden foreign bodies in soft tissue: Detection at US. Radiology 1998;206:45-48.

Question 35

A 35-year-old man is seen in the emergency department with a bullet wound to the foot that occurred 2 hours ago. Examination reveals a 0.5-cm entrance wound on the dorsum of the foot and a 1.5-cm exit wound on the plantar aspect. Exploration of the plantar wound in the emergency department reveals bone and metal fragments. Radiographs reveal a comminuted, unstable fracture of the base of the first metatarsal and cuneiform. Management should consist of tetanus toxoid, and

Explanation

DISCUSSION: The patient sustained a type I unstable fracture that requires debridement of superficial fragments from the sole and surgical stabilization. Low-velocity wounds less than 8 hours old are considered type I open fractures. In contrast, gunshot wounds with associated fractures more than 8 hours old are considered type II open fractures using the Gustilo and Anderson classification. Gustilo type I stable fractures due to gunshot wounds and seen within 8 hours can be treated with tetanus toxoid (if no history of immunization or booster within 5 years), surface irrigation, and casting or a hard sole shoe. Antibiotics are not required unless gross contamination is present. However, if the extent of contamination is unclear, or if a joint is penetrated, then routine antibiotic prophylaxis is recommended. Indications for surgery include: articular involvement, unstable fractures, presentation 8 or more hours after injury, tendon involvement, and superficial fragments in the palm or sole. Type I unstable fractures may be stabilized with internal or external fixation. Type II unstable fractures should be treated with external fixation and repeat debridements until clean.
REFERENCES: Holmes GB Jr: Gunshot wounds of the foot. Clin Orthop Relat Res

2003;408:86-91.
Bartlett CS, Helfet DL, Hausman MR, et al: Ballistics and gunshot wounds: Effects on musculoskeletal tissues. J Am Acad Orthop Surg 2000;8:21-36.

Question 36

What is the most frequent location of entrapment of the deep peroneal nerve?

Explanation

DISCUSSION: The most frequently described entrapment of the deep peroneal nerve is the anterior tarsal tunnel syndrome. This syndrome refers to entrapment of the deep peroneal nerve under the inferior extensor retinaculum. Entrapment can also occur as the nerve passes under the tendon of the extensor hallucis brevis. Compression by underlying dorsal osteophytes of the talonavicular joint and an os intermetatarseum (between the bases of the first and second metatarsals) have previously been described in runners.
REFERENCES: Kopell HP, Thompson WA: Peripheral entrapment neuropathies of the lower extremity. N Engl J Med 1960;262:56-60.
Schon LC, Mann RA: Diseases of the nerves, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 1, pp 675-677.

Question 37

What is the most common malignant tumor of the foot?

Explanation

DISCUSSION: Whereas chondrosarcoma is the most frequently occurring malignant bone tumor of the foot and synovial sarcoma is the most common soft-tissue foot malignancy, the most common malignant tumor overall is melanoma. It constitutes approximately 25% of lesions found on the lower extremity. Furthermore, 31% of all melanomas arise in the foot.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 11-26.
Bos GD, Ester RJ, Woll TS: Foot tumors: Diagnosis and treatment. J Am Acad Orthop Surg 2002;10:259-270.

Question 38

A 40-year-old man underwent an ankle arthroscopy 6 months ago for a talus osteochondral defect. He continues to have pain and burning on the lateral portal but states that the pain is now more superficial than his original pain. Examination reveals that he has shooting pain to his medial foot and ankle when his lateral portal is tapped. A previous injection around the lateral portal gave him relief for about 2 weeks. What treatment will best eliminate his pain?

Explanation

DISCUSSION: The patient clearly has entrapment of the superficial peroneal nerve in the lateral portal. It is most likely only the medial branch by examination. If the nerve is in good condition, it can simply be released. If the nerve is cut or severely thinned, it is better excised and buried. The sural nerve most likely would be caught in a posterior-lateral portal.
REFERENCES: Jobe MT, Wright PE: Peripheral nerve injuries, in Canale ST (ed): Campbell’s Operative Orthopaedics. St Louis, MO, Mosby, 1998, pp 3839-3844.
Saito A, Kikuchi S: Anatomic relations between ankle arthroscopic portal sites and the superficial peroneal and saphenous nerves. Foot Ankle Int 1998;19:748-752.

Question 39

When performing a Weil osteotomy of a lesser metatarsal, the desired angle of the saw cut should be approximately

Explanation

DISCUSSION: Appropriate orientation of the saw cut when performing a Weil osteotomy is approximately parallel with the plantar surface of the foot. This is done in an effort to minimize plantar displacement of the capital fragment. The removal of additional bone from the osteotomy site either by removing a separate wafer of bone or using a thicker saw blade has also been described to minimize plantar displacement of the distal fragment.
REFERENCES: Trnka H, Nyska M, Parks BG, et al: Dorsiflexion contracture after the Weil osteotomy: Results of cadaver study and three-dimensional analysis. Foot Ankle Int 2001;22:47-50.
Grimes J, Coughlin M: Geometric analysis of the Weil osteotomy. Foot Ankle Int 2006;27:985-992.

Question 40

A patient with diabetic peripheral neuropathy undergoes a partial first ray amputation for a chronic ulcer beneath the first metatarsal head. The insertion of the anterior tibialis is preserved. The patient has 10 degrees of passive dorsiflexion at the ankle and no other foot deformities or ulcers. Which of the following is considered appropriate shoe wear for this patient?

Explanation

DISCUSSION: The steel shank is a flat 1-inch steel strip placed between layers of the shoe to extend the foot lever and prevent deformity at the toe break seen following a partial first ray amputation. A rocker sole may be added as well to facilitate transition from foot flat to the toe-off phase of gait. Proper shoe fit is important, but “snug” fitting shoes in a patient with peripheral neuropathy and likely fluctuations in volume from intermittent swelling are to be avoided. A custom shoe is an unnecessary expense. The patient has at least 10 degrees of dorsiflexion at the ankle with an intact anterior tibialis muscle; therefore, catching the sole on carpeting should not be a problem.
REFERENCES: Philbin TM, Leyes M, Sferra JJ, et al: Orthotic and prosthetic devices in partial foot amputations. Foot Ankle Clin 2001;6:215-228.
Pinzur MS, Dart HC: Pedorthic management of the diabetic foot. Foot Ankle Clin 2001;6:205-214.

Question 41

A 32-year-old laborer reports left ankle pain and deformity. History reveals that he sustained a left ankle fracture 2 years ago and was treated with closed reduction and casting. Radiographs are shown in Figures 25a through 25c. What is the most appropriate management?

Explanation

DISCUSSION: Corrective osteotomy of fibular malunions, with appropriate lengthening, even in the presence of early arthritis, has been shown to decrease ankle pain and increase stability. Reduction and bone grafting of the medial malleolar nonunion is also needed. There is no evidence supporting the use of intra-articular steroids or hyaluronic acid in the ankle joint. Lateral talar displacement of even 1 mm has been reproducibly shown to decrease tibiotalar contact by 40% to 42%, causing a predisposition to arthritis.
REFERENCES: Weber D, Friederich NF, Muller W: Lengthening osteotomy of the fibula for post-traumatic malunion: Indication, technique and results. Int Orthop 1998;22:149-152.
Lloyd J, Elsayed S, Hariharan K, et al: Revisiting the concept of talar shift in ankle fractures. Foot Ankle Int 2006;27:793-796.
Offierski CM, Graham JD, Hall JH, et al: Later revision of fibular malunion in ankle fractures. Clin Orthop Relat Res 1982;171:145-149.
Yablon IG, Leach RE: Reconstruction of malunited fractures of the lateral malleolus. J Bone Joint Surg Am 1989;71:521-527.

Question 42

Preservation or reconstruction of which of the following structures is essential to minimize the risk of hallux valgus developing after removal of part or all of the medial sesamoid?

Explanation

DISCUSSION: Complications of medial sesamoidectomy include stiffness, claw toe, and hallux valgus. Each sesamoid sits within its respective head of the flexor hallucis brevis tendon. Excision of one sesamoid can result in slack in its flexor hallucis brevis tendon; therefore, it is imperative to preserve or repair the flexor hallucis brevis tendon when removing the medial sesamoid.
REFERENCES: Dedmond BT, Cory JW, McBryde A Jr: The hallucal sesamoid complex. J Am Acad Orthop Surg 2006;14:745-753.
Lee S, James WC, Cohen BE, et al: Evaluation of hallux alignment and functional outcome after isolated tibial sesamoidectomy. Foot Ankle Int 2005;26:803-809.

Question 43

In the nonsurgical management of posterior tibial tendon dysfunction with flexible deformity, a common strategy is to prescribe an ankle-foot orthosis or a University of California Biomechanics Laboratory (UCBL) orthosis with medial posting. A high patient satisfaction rating and favorable outcome with this nonsurgical management is most likely in which of the following situations?

Explanation

DISCUSSION: Most authors recommend an initial trial of nonsurgical management in the treatment of adult-acquired flatfoot deformity such as posterior tibial tendon dysfunction. Chao and associates found that there is high patient satisfaction with ankle-foot orthoses and UCBL-type inserts in elderly patients with a relatively sedentary lifestyle. Alternatively, there was a higher dissatisfaction rate in young active patients, those with balance and ambulation difficulties (Parkinson’s, severe arthritis of the hip or knee), and patients with inflammatory systemic disorders.
REFERENCES: Chao W, Wapner KL, Lee TH, et al: Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int 1996;17:736-741.
Noll KH: The use of orthotic devices in adult acquired flatfoot deformity. Foot Ankle Clin 2001;6:25-36.

Question 44

Figure 26 shows the clinical photograph of a patient who has developed a residual limb ulcer following a traumatic transtibial amputation 2 years ago. What is the preferred treatment to resolve the ulcer?

Explanation

DISCUSSION: The first step in the treatment of an amputation residual limb (stump) ulcer is local wound care and adjustment of the residual limb-prosthetic interface, as well as adjusting prosthetic alignment. Surgical revision should be undertaken only when prosthetic modification is unsuccessful.
REFERENCES: Murnaghan JJ, Bowker JH: Musculoskeletal complications, in Smith DG, Michael JW, Bowker JH (eds): Atlas of Amputations and Limb Deficiencies, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 683-700.
Smith DG, Ferguson JR: Transtibial amputations. Clin Orthop Relat Res 1999;361:108-115.

Question 45

The spring ligament of the foot connects what two bones?

Explanation

DISCUSSION: The spring ligament is also known as the calcaneonavicular ligament and connects the calcaneus to the navicular. This ligament supports the talar head and is an important anatomic supporting structure of the medial longitudinal arch of the foot.
REFERENCES: Choi K, Lee S, Otis JC, et al: Anatomical reconstruction of the spring ligament using peroneus longus tendon graft. Foot Ankle Int 2003;24:430-436.
Davis WH, Sobel M, DiCarlo EF, et al: Gross, histological and microvascular anatomy and biomechanical testing of the spring ligament complex. Foot Ankle Int 1996;17:95-102.

Question 46

An obese 62-year-old man reports a 10-year history of progressive flatfoot deformity and a 3-month history of a painful callus along the plantar medial midfoot that has not improved with custom shoe wear, pedorthics, and callus care. There is no hindfoot motion, but functional ankle motion remains. He does not have diabetes mellitus. Radiographs are shown in Figures 27a and 27b. What is the best surgical option at this point?

Explanation

DISCUSSION: The deformity is long-standing, the hindfoot is immobile, and the radiographs reveal severe degenerative arthritis involving the entire hindfoot, severe deformity, and talonavicular dislocation. The “exostosis” responsible for the callus is the talar head; resection would severely destabilize the foot. Degenerative arthritis and fixed deformity preclude lateral column lengthening, medial slide calcaneal osteotomy, and talonavicular arthrodesis. Triple arthrodesis is the only viable option.
REFERENCES: Johnson JE, Yu JR: Arthrodesis techniques in the management of Stage II and III acquired adult flatfoot deformity. Instr Course Lect 2006;55:531-542.
Pinney SJ, Lin SS: Current concept review: Acquired adult flatfoot deformity. Foot Ankle Int 2006;27:66-75.

Question 47

A 20-year-old collegiate football player sustains an injury to his left foot 3 weeks before the start of the fall season. Examination reveals localized tenderness over the lateral midfoot and normal foot alignment. Radiographs are shown in Figures 28a through 28c. What is the treatment of choice?

Explanation

DISCUSSION: Due to the relatively high incidence of delayed union and nonunion associated with this mildly displaced Jones-type fracture, and the temporal proximity to his playing season, intramedullary screw fixation is the treatment of choice in this collegiate athlete to best ensure healing and expedite his return to football. If nonsurgical management were elected, application of a non-weight-bearing short leg cast would be appropriate since a higher likelihood of healing is expected with it versus a short leg walking cast. The risk of recurrent fracture of fractures that heal with nonsurgical management has reportedly been high (approximately 30%).
REFERENCES: Quill GE: Fractures of the proximal fifth metatarsal. Orthop Clin North Am 1995;26:353-361.
Torg JS, Balduini FC, Zelko RR, et al: Fractures of the base of the fifth metatarsal distal to the tuberosity: Classification and guidelines for nonsurgical and surgical management. J Bone Joint Surg Am 1984;66:209-214.
Dameron TB Jr: Fractures of the proximal fifth metatarsal: Selecting the best treatment option.

J Am Acad Orthop Surg 1995;3:110-114.

Question 48

When the great toe deviates into a valgus position, the action of the abductor hallucis muscle becomes one of

Explanation

DISCUSSION: The abductor hallucis muscle inserts together with the medial tendon of the flexor hallucis brevis into the medial base of the proximal phalanx of the great toe. When the hallux assumes a valgus position, the action of the abductor becomes one of flexion and pronation of the first metatarsal.
REFERENCES: Resch S: Functional anatomy and topography of the foot and ankle, in Myerson M (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, vol 1, pp 25-49.
Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.

Question 49

When performing a bunionectomy with a release of the lateral soft-tissue structures, the surgeon is cautioned against releasing the conjoined tendon that inserts along the lateral base of the proximal phalanx of the great toe. This conjoined tendon is made up of what two muscles?

Explanation

DISCUSSION: Owens and Thordardson cautioned surgeons not to release the conjoined tendon from the base of the proximal phalanx of the great toe because of an increased risk of iatrogenic hallux varus. Release of the transverse and oblique heads of the adductor hallucis is largely accomplished by releasing the soft tissue adjacent to the lateral sesamoid, without releasing tissue from the base of the proximal phalanx. The conjoined tendon is made up of the flexor hallucis brevis and the adductor hallucis.
REFERENCES: Owens S, Thordardson DB: The adductor hallucis revisited. Foot Ankle Int 2001;22:186-191.
Sarrafian SK: Anatomy of the Foot and Ankle. Philadelphia, PA, JB Lippincott, 1983, chapter 5.

Question 50

Figures 29a and 29b show a clinical photograph and radiographs of a patient who sustained an open calcaneus fracture in a motor vehicle accident. The patient received immediate IV antibiotics and an emergent irrigation and debridement. The swelling has subsided by 3 weeks and the medial wound is clean. What do you tell the patient about the likelihood of infection if a formal open reduction and internal fixation via a lateral approach is performed?

Explanation

DISCUSSION: Multiple authors have shown similar infection rates for grade 1 and 2 open medial fractures and closed fractures that have been treated with an extensile lateral approach and open reduction and internal fixation. Patients only need IV antibiotics for 2 to 3 days after surgery. Formal open reduction and internal fixation is not recommended for grade 3 medial wounds and most lateral wounds.
REFERENCES: Heier KA, Infante AF, Walling AK, et al: Open fractures of the calcaneus: Soft-tissue injury determines outcome. J Bone Joint Surg Am 2003;85:2276-2282.
Buckley RE, Tough S: Displaced intra-articular calcaneal fractures. J Am Acad Orthop Surg 2004;12:172-178.

Question 51

A 21-year-old collegiate basketball player sustains an acute Zone 2 fracture of the proximal fifth metatarsal. He wishes to return to play as soon as safely possible. What is the most appropriate management?

Explanation

Elite athletes with acute Jones (Zone 2) fractures are best treated with intramedullary screw fixation to minimize nonunion risk and expedite return to play. Non-operative management carries a high rate of delayed union or nonunion in this population.

Question 52

In the surgical management of a displaced Hawkins III talar neck fracture, the surgeon must be mindful of the blood supply to the talar body. Which of the following arteries provides the dominant blood supply to the body of the talus?

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, provides the dominant blood supply to the talar body. It forms an anastomotic sling with the artery of the tarsal sinus.

Question 53

A 24-year-old collegiate offensive lineman sustains a purely ligamentous Lisfranc injury with 3 mm of displacement between the medial cuneiform and the base of the second metatarsal. What is the most appropriate definitive management?

Explanation

Primary arthrodesis of the medial columns (1st, 2nd, and 3rd TMT joints) is recommended over ORIF for purely ligamentous Lisfranc injuries due to better functional outcomes and lower reoperation rates. The 4th and 5th TMT joints should be left mobile to accommodate foot adaptation during gait.

Question 54

A 45-year-old roofer falls 15 feet, sustaining a displaced intra-articular calcaneus fracture. During the standard lateral extensile approach for open reduction and internal fixation, the surgeon must reduce the displaced fragments to the 'constant' fragment. Which anatomical structure is this fragment primarily attached to?

Explanation

The sustentacular (anteromedial) fragment is considered the 'constant' fragment because it remains strongly tethered to the talus by the interosseous talocalcaneal and deltoid ligaments. It serves as the anatomical foundation for reconstruction of the calcaneus.

Question 55

A 38-year-old male undergoes percutaneous repair of an acute Achilles tendon rupture. Compared to traditional postoperative immobilization in a cast, early functional rehabilitation with immediate weight-bearing in a functional brace is associated with which of the following?

Explanation

Early functional rehabilitation with weight-bearing in a functional brace provides equivalent re-rupture rates compared to prolonged immobilization. However, it significantly improves early functional outcomes and accelerates return to work.

Question 56

A 55-year-old woman presents with progressive flatfoot deformity. Examination shows she is unable to perform a single-leg heel rise, has forefoot abduction with a 'too many toes' sign, and flexible hindfoot valgus. Which of the following surgical procedures is most appropriate?

Explanation

Stage IIb adult acquired flatfoot deformity involves a flexible hindfoot with significant forefoot abduction (greater than 30-40% uncoverage of the talar head). This requires an FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening to correct the forefoot abduction.

Question 57

A 20-year-old elite basketball player presents with lateral foot pain after an inversion injury. Radiographs reveal a fracture pattern identical to the one shown.

The fracture is transverse at the metaphyseal-diaphyseal junction extending into the fourth-fifth intermetatarsal articulation. What is the most appropriate management to ensure rapid return to play?

Explanation

This is a Zone 2 (Jones) fracture, which has a high risk of delayed union or nonunion due to a watershed blood supply. In elite athletes, early intramedullary screw fixation is the standard of care to minimize nonunion risk and expedite return to play.

Question 58

A 24-year-old male athlete presents with severe midfoot pain and plantar ecchymosis following an axial load injury to a plantarflexed foot. Weight-bearing radiographs demonstrate a 2 mm diastasis between the first and second metatarsal bases. What is the primary stabilizing ligament of this articulation, and what is its anatomic origin and insertion?

Explanation

The Lisfranc ligament is the primary soft-tissue stabilizer of the second tarsometatarsal joint. It originates on the lateral aspect of the medial cuneiform and inserts on the medial base of the second metatarsal on the plantar surface.

Question 59

A 35-year-old recreational basketball player sustains an acute Achilles tendon rupture. After discussing treatment options, he elects to pursue nonoperative management utilizing a functional rehabilitation protocol. Compared to traditional open surgical repair, what is the most likely outcome of functional nonoperative management?

Explanation

Current literature demonstrates that functional rehabilitation protocols for acute Achilles ruptures yield re-rupture rates similar to operative repair. Nonoperative management inherently avoids surgical complications such as wound infections and sural nerve injuries.

Question 60

A 28-year-old female involved in a motor vehicle collision sustains a Hawkins Type III talar neck fracture.

Which blood supply is most commonly disrupted, leading to the high risk of avascular necrosis (AVN) in the talar body?

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, provides the dominant blood supply to the talar body. Disruption of this artery in displaced talar neck fractures (Hawkins II-IV) is the primary cause of avascular necrosis.

Question 61

A 42-year-old roofer falls 15 feet, sustaining a closed, displaced intra-articular calcaneus fracture (Sanders type III). You plan an open reduction and internal fixation utilizing an extensile lateral approach. Which of the following arteries is the primary blood supply to the full-thickness subperiosteal flap raised in this approach?

Explanation

The lateral calcaneal artery, a terminal branch of the peroneal artery, supplies the lateral skin flap used in the extensile lateral approach. A full-thickness subperiosteal flap must be developed to protect this vessel and minimize the risk of wound edge necrosis.

Question 62

A 21-year-old collegiate wide receiver sustains a fracture of the fifth metatarsal at the metaphyseal-diaphyseal junction. To ensure proper trajectory of an intramedullary screw and avoid lateral cortex penetration, what is the ideal starting point on the fifth metatarsal?

Explanation

The ideal starting point for intramedullary screw fixation of a Jones fracture is dorsal and medial on the fifth metatarsal base. This trajectory accommodates the natural lateral and plantar bow of the bone, preventing lateral cortical breach.

Question 63

A 19-year-old female track athlete presents with insidious onset, ill-defined midfoot pain. A CT scan confirms a partial stress fracture of the tarsal navicular in the sagittal plane.

In which anatomical zone of the navicular do these stress fractures most commonly occur, and what is the primary reason?

Explanation

Tarsal navicular stress fractures predominantly occur in the central third of the bone in the sagittal plane. This region is a watershed area of relative avascularity, predisposing it to stress failure and delayed healing.

Question 64

A 26-year-old professional soccer player sustains an external rotation ankle injury. Radiographs show medial clear space widening but no fracture. MRI demonstrates disruption of the anterior inferior tibiofibular ligament (AITFL) and interosseous membrane. During operative stabilization, what is the most appropriate ankle position while placing the syndesmotic fixation?

Explanation

Current biomechanical evidence supports fixing the syndesmosis with the ankle in a neutral (0 degrees) position to provide optimal anatomic reduction. Historically, full dorsiflexion was taught, but it is no longer deemed necessary to prevent over-constriction.

Question 65

A 22-year-old football running back suffers a hyperextension injury to his first metatarsophalangeal (MTP) joint.

Examination reveals marked swelling, ecchymosis, and inability to bear weight. MRI shows a complete tear of the plantar plate with proximal retraction of the sesamoids. Which of the following is an absolute indication for operative repair?

Explanation

Indications for operative intervention in turf toe include large intra-articular loose bodies, sesamoid fracture with diastasis, traumatic bunion deformity, and proximal migration of the sesamoids. Proximal migration signifies a complete, unstable Grade III plantar plate disruption.

Question 66

A 45-year-old man sustains a closed ankle fracture. Radiographs demonstrate a transverse medial malleolus fracture, a high proximal fibular fracture (Maisonneuve), and widening of the tibiofibular syndesmosis. According to the Lauge-Hansen classification, what is the mechanism of injury?

Explanation

A transverse medial malleolar fracture (or deltoid rupture) followed by a high fibula fracture characterizes a Pronation-External Rotation (PER) injury. The initial pronation applies tension to medial structures, while external rotation tears the syndesmosis and fractures the proximal fibula.

Question 67

A 30-year-old skier presents with lateral ankle pain and a snapping sensation posterior to the lateral malleolus after a twisting fall. Examination reveals visible subluxation of the peroneal tendons over the lateral malleolus with resisted active eversion.

This pathology is most directly associated with incompetence of which anatomical structure?

Explanation

Peroneal tendon subluxation or dislocation is caused by tearing or avulsion of the superior peroneal retinaculum (SPR) from the distal fibula. This typically occurs via sudden, forceful dorsiflexion and eversion of the ankle.

OITE & ABOS Orthopedic Exam MCQs: Trauma, Foot & Knee Board Review Part 132

OITE & ABOS Orthopedic Board Prep: Foot, Ankle, Trauma & Sports Medicine MCQs | Part 62

Key Takeaway

OITE & ABOS Orthopedic Board Prep: Foot, Ankle, Trauma & Sports Medicine MCQs | Part 62

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