OITE & AAOS Board Review MCQs: Knee, Foot & Ankle

Question 1

A 22-year-old female presents with recurrent patellar instability. You plan a medial patellofemoral ligament (MPFL) reconstruction. Intraoperatively, fluoroscopy is used to determine the exact femoral tunnel position. According to Schöttle's criteria, which of the following radiographic landmarks best describes the correct anatomical femoral attachment of the MPFL on a true lateral radiograph?

Explanation

Schöttle's point is a reliable fluoroscopic landmark for anatomical MPFL femoral tunnel placement. It is located 1 mm anterior to the posterior cortical line extension, 2.5 mm distal to the posterior articular border of the medial femoral condyle, and proximal to the intersection of Blumensaat's line and the posterior cortical line.

Question 2

A 65-year-old female undergoes primary total knee arthroplasty (TKA) for severe fixed valgus osteoarthritis. During trial reduction, the knee is found to be excessively tight in both flexion and extension on the lateral side. According to the sequential lateral release technique, which specific lateral structure is primarily responsible for balancing the knee in BOTH flexion and extension?

Explanation

The lateral collateral ligament (LCL) provides primary restraint to varus stress in both flexion and extension. Therefore, in a fixed valgus knee that is tight in both the flexion and extension gaps, the LCL is the most critical structure to release. The popliteus primarily affects the flexion gap, while the iliotibial band (ITB) and posterolateral capsule primarily affect the extension gap.

Question 3

A 55-year-old woman presents with a progressive flatfoot deformity. Examination reveals a flexible pes planovalgus, an inability to perform a single-leg heel rise, and > 40% uncovering of the talonavicular joint on weight-bearing AP radiographs. What is the most appropriate surgical management for this Stage IIb adult-acquired flatfoot?

Explanation

Stage IIb adult-acquired flatfoot (posterior tibial tendon dysfunction) is characterized by a flexible deformity with significant forefoot abduction (typically >40% talonavicular uncoverage). An FDL transfer and MDCO are standard for Stage IIa, but the significant forefoot abduction in Stage IIb requires the addition of a lateral column lengthening procedure (such as an Evans calcaneal osteotomy) to adequately restore the medial column arch and foot alignment.

Question 4

A 14-year-old boy sustains an ankle injury while playing soccer. Radiographs reveal a Salter-Harris III fracture of the anterolateral distal tibia. Which ligament's avulsion force is fundamentally responsible for this specific fracture pattern?

Explanation

The patient has a Tillaux fracture, which is an avulsion fracture of the anterolateral aspect of the distal tibial epiphysis. It occurs during adolescence due to an external rotation force pulling on the anterior inferior tibiofibular ligament (AITFL). This happens because the distal tibial physis closes in a specific pattern: central, then medial, and finally lateral. The lateral physis is the last to close, making it vulnerable to avulsion by the AITFL.

Question 5

A 25-year-old male presents with a posterolateral corner (PLC) knee injury. During anatomical reconstruction, the surgeon must aim to recreate the primary static stabilizers to restore normal kinematics. What are the three primary static stabilizers of the PLC?

Explanation

The posterolateral corner (PLC) of the knee is a complex arrangement of structures providing restraint against varus opening, external tibial rotation, and posterior translation. The three primary static stabilizers that are most crucial for surgical reconstruction are the lateral collateral ligament (LCL), the popliteus tendon (PLT), and the popliteofibular ligament (PFL).

Question 6

When evaluating and treating a suspected Lisfranc injury, an understanding of the local anatomy is critical. Which of the following statements regarding the Lisfranc ligament complex is true?

Explanation

The Lisfranc ligament complex connects the medial cuneiform to the base of the second metatarsal, not the third. It consists of three components: dorsal, interosseous, and plantar. The interosseous component is the strongest, followed by the plantar component. The dorsal component is the weakest. A key anatomical feature contributing to the vulnerability of this joint is the lack of a direct intermetatarsal ligament connecting the bases of the first and second metatarsals.

Question 7

A 45-year-old avid runner presents with severe posterior heel pain. MRI demonstrates a thickened Achilles tendon with marked intrasubstance degeneration 4 cm proximal to its insertion. There is no Haglund deformity. Six months of eccentric stretching and physical therapy have failed. Which of the following is the most appropriate surgical treatment?

Explanation

The patient has non-insertional Achilles tendinopathy, which typically occurs 2 to 6 cm proximal to the calcaneal insertion due to a zone of relative hypovascularity. After failure of prolonged nonoperative management, the surgical treatment of choice is longitudinal tenotomy, debridement of the degenerative tendinotic tissue, and tubularization of the remaining healthy tendon. Calcaneal exostectomy and detachment/reattachment are reserved for insertional tendinopathy with a Haglund deformity.

Question 8

A 58-year-old patient with long-standing poorly controlled diabetes presents with a swollen, erythematous, and warm foot. Radiographs demonstrate periarticular fragmentation, subluxation of the tarsometatarsal joints, and bony debris, but no signs of consolidation, fusion, or sclerosis. According to the Eichenholtz classification, what stage of Charcot arthropathy is this, and what is the current standard of care?

Explanation

This presentation describes acute Stage I (Developmental/Fragmentation phase) Charcot arthropathy, characterized by clinical signs of inflammation (erythema, warmth, swelling) and radiographic evidence of fragmentation, joint subluxation/dislocation, and debris without consolidation. The standard of care during this acute, hyperemic phase is strict immobilization and offloading, almost universally utilizing a total contact cast (TCC), to prevent further mechanical destruction until the foot reaches Stage II (Coalescence).

Question 9

An opening wedge high tibial osteotomy (HTO) is planned for a 45-year-old male laborer with isolated medial compartment osteoarthritis and varus malalignment. What is a common unintended consequence on the sagittal plane biomechanics of the knee if the osteotomy gap is opened equally anteriorly and posteriorly?

Explanation

During a medial opening wedge HTO, opening the osteotomy gap equally anteriorly and posteriorly typically leads to an unintended increase in the posterior tibial slope. This occurs because the proximal tibia is triangular, being narrower anteriorly than posteriorly. To maintain the native sagittal slope, the anterior opening gap must be approximately half the size of the posterior gap. An increased posterior slope can inadvertently increase anterior tibial translation and stress the ACL.

Question 10

A 50-year-old female presents with an acute onset of medial knee pain after a deep squat. MRI reveals a complete radial tear adjacent to the medial meniscus posterior root attachment. What are the biomechanical consequences of this specific injury if left untreated?

Explanation

A complete medial meniscus posterior root tear unanchors the meniscus from the tibial plateau. This disrupts the meniscus's ability to convert axial compressive loads into circumferential hoop stresses. Biomechanically, this results in significant meniscal extrusion under load and is equivalent to a total medial meniscectomy, leading to vastly increased peak contact pressures and rapid onset of unicompartmental osteoarthritis.

Question 11

A 28-year-old male presents with a progressive cavovarus foot deformity secondary to Charcot-Marie-Tooth disease. A Coleman block test is performed during the clinical examination, and the hindfoot completely corrects to a neutral/valgus position. What does this specific finding imply regarding the nature of the deformity?

Explanation

The Coleman block test is utilized to evaluate the flexibility of the hindfoot in a cavovarus foot. By placing the lateral border of the foot (heel and lateral metatarsals) on a block and allowing the first metatarsal to drop off the edge, the biomechanical influence of a rigidly plantarflexed first ray is eliminated. If the hindfoot corrects from varus to a neutral or valgus alignment on the block, it indicates that the hindfoot deformity is flexible and is being primarily driven by the forefoot pathology. Treatment should therefore prioritize addressing the forefoot (e.g., dorsiflexion osteotomy of the 1st metatarsal).

Question 12

A 26-year-old athlete reports persistent anterolateral ankle pain after sustaining a severe sprain 6 months ago. MRI identifies a 12 mm x 10 mm osteochondral lesion of the anterolateral talar dome. The overlying cartilage is visually intact with no detachment. After a failed 3-month course of conservative management, which of the following is the most appropriate initial surgical intervention?

Explanation

For primary osteochondral lesions of the talus (OLT) that are smaller than 1.5 cm² (150 mm²) and have failed conservative treatment, arthroscopic bone marrow stimulation (microfracture, drilling) is considered the gold standard initial surgical treatment. It promotes the filling of the defect with fibrocartilage (Type I collagen). Larger lesions (>1.5 cm²), or those that have failed primary marrow stimulation, may require OATS or ACI.

Question 13

During an anterior cruciate ligament (ACL) reconstruction, the surgeon inadvertently places the femoral tunnel too anteriorly (i.e., too 'shallow' or high in the notch on a lateral radiograph) on the lateral femoral condyle. Which of the following kinematic complications will reliably occur as a result of this error?

Explanation

The anatomical femoral attachment of the ACL is posterior in the notch. Placing the femoral tunnel too anteriorly (too shallow) places it eccentric to the knee's center of rotation. As the knee flexes, the distance between this anteriorly misplaced femoral origin and the tibial insertion increases. Consequently, the graft becomes pathologically tight in flexion (limiting knee flexion or stressing the graft) and loose in extension, failing to control anterior translation near full extension.

Question 14

A 22-year-old competitive skier presents with lateral ankle pain and an audible 'snapping' sensation behind the lateral malleolus during forced dorsiflexion and eversion. Clinical examination is notable for visible subluxation of the peroneal tendons over the fibula. Which primary anatomical restraint is most likely incompetent in this condition?

Explanation

Peroneal tendon subluxation or dislocation is primarily caused by injury, attenuation, or congenital incompetence of the superior peroneal retinaculum (SPR). The SPR is the primary static restraint that holds the peroneus longus and brevis tendons within the retromalleolar groove of the distal fibula. Surgical management typically involves repair or reconstruction of the SPR, often combined with fibular groove deepening.

Question 15

A 34-year-old male sustains a severe knee dislocation (Schenck KD III-M, involving ACL, PCL, and MCL) following a high-speed motorcycle crash. His limb is well-perfused, ABIs are 1.1, and compartment pressures are normal. Assuming no absolute contraindications, what is the most appropriate timing and approach for definitive surgical reconstruction?

Explanation

For multiligament knee injuries without vascular compromise or impending compartment syndrome, delayed single-stage reconstruction (at 2 to 3 weeks) is currently favored. This brief delay allows the acute inflammatory phase and soft tissue swelling to subside, the joint capsule to seal (preventing massive fluid extravasation during arthroscopy), and early range of motion to commence, which dramatically lowers the risk of severe arthrofibrosis compared to immediate surgery. Waiting beyond 3-4 weeks is not ideal due to tissue retraction and excessive scar tissue formation.

Question 16

A professional American football player presents with acute, severe pain at the first metatarsophalangeal (MTP) joint after a forced hyperextension injury of the hallux while being tackled. MRI reveals a complete tear of the plantar plate and capsuloligamentous complex with proximal retraction of the sesamoids. What is the grade of this injury, and what is the recommended management for this high-level athlete?

Explanation

A 'turf toe' injury involves sprain or tear of the capsuloligamentous complex of the first MTP joint via forced hyperextension. A Grade 3 injury involves a complete tear of the plantar plate, typically demonstrating gross instability and proximal migration of the sesamoids on imaging. In a high-level competitive athlete, a Grade 3 injury with significant retraction and instability is generally an absolute indication for operative surgical repair to restore push-off strength and prevent chronic deformity.

Question 17

Tarsal navicular stress fractures are notoriously difficult to heal and carry a high risk of delayed union or nonunion. This complication is primarily attributed to a watershed zone of relative avascularity located in which specific anatomic portion of the navicular bone?

Explanation

The blood supply to the tarsal navicular relies on branches from the dorsalis pedis and medial plantar arteries, entering primarily from the medial (tuberosity) and lateral (dorsal) aspects. The intraosseous microvascular network converges toward the center of the bone, creating a central third watershed zone that is relatively avascular. This renders the central third highly susceptible to stress fractures and explains the high rates of delayed union and nonunion if not managed aggressively.

Question 18

A 24-year-old track athlete complains of severe calf cramping, numbness, and paresthesias that reliably occur after 15 minutes of running and resolve rapidly after 10 minutes of rest. Resting and post-exertional compartment pressure testing is within normal limits. Her resting ankle-brachial index (ABI) is normal, but it drops significantly when she performs active, forceful plantarflexion. What is the most likely pathophysiological mechanism of her condition?

Explanation

The clinical presentation is classic for popliteal artery entrapment syndrome (PAES). The key diagnostic finding that differentiates PAES from chronic exertional compartment syndrome (CECS) is the drop in the ankle-brachial index (ABI) or obliteration of distal pulses specifically during active plantarflexion (which tightens the gastrocnemius muscle). The most common anatomic variation causing this is an anomalous origin or course of the medial head of the gastrocnemius, which compresses the popliteal artery against the medial femoral condyle during contraction.

Question 19

In the surgical management of chronic, neglected Achilles tendon ruptures with a massive gap defect (> 6 cm), a flexor hallucis longus (FHL) tendon transfer is frequently the procedure of choice. What is the primary anatomical advantage of utilizing the FHL tendon over the flexor digitorum longus (FDL) or peroneus brevis for this specific reconstruction?

Explanation

The FHL is the preferred tendon transfer for chronic, large-gap Achilles tendon ruptures primarily because its muscle belly extends very distally (often to the level of the tibiotalar joint). When transferred, this brings a robust, highly vascularized muscle belly directly into the hypovascular, scarred defect of the Achilles tendon, significantly enhancing the biologic healing potential. Furthermore, the FHL is biomechanically strong (the second strongest plantarflexor of the foot after the triceps surae) and shares an identical axis of pull.

Question 20

Following open reduction and internal fixation of a Weber C fibula fracture, the surgeon intraoperatively evaluates the integrity of the distal tibiofibular syndesmosis. Which of the following radiographic parameters on a standard non-rotated AP and mortise radiograph is considered the most reliable indicator of a well-reduced syndesmosis?

Explanation

The tibiofibular clear space, measured 1 cm proximal to the tibial plafond, should normally be < 6 mm on both AP and mortise radiographs. It is widely considered the most reliable plain radiographic parameter for evaluating syndesmotic integrity because, unlike the tibiofibular overlap (which is highly sensitive to the degree of leg rotation), the clear space remains relatively constant regardless of minor variations in rotation.

Question 21

A 26-year-old athlete undergoes posterior cruciate ligament (PCL) reconstruction. The surgeon aims to reconstruct the anterolateral (AL) bundle of the PCL. At what knee position is this specific bundle typically the tightest and evaluated for optimal tension during graft fixation?

Explanation

The PCL consists of two main bundles: the anterolateral (AL) and posteromedial (PM). The AL bundle is larger and is tightest in flexion (around 90 degrees), whereas the PM bundle is tightest in extension.

Question 22

A 34-year-old female presents with a progressive cavovarus foot deformity. On examination, a Coleman block test is performed by placing her heel and lateral border of the foot on a block while allowing the first metatarsal to hang free. The hindfoot varus completely corrects. Which of the following is the most appropriate surgical intervention for her deformity?

Explanation

A flexible hindfoot varus that corrects with a Coleman block test indicates the deformity is forefoot-driven, primarily due to a plantarflexed 1st ray. The appropriate treatment is a dorsiflexion osteotomy of the 1st metatarsal to correct the primary pathology.

Question 23

During a primary total knee arthroplasty for a severe varus deformity, trial components are placed. The knee is found to be well-balanced in extension but excessively tight medially in flexion. Which of the following medial structures should be released to specifically address the tight medial flexion gap?

Explanation

In the varus knee, the anterior portion of the superficial MCL is the primary restraint to flexion medially. Releasing it selectively opens the medial flexion gap without significantly affecting the extension gap.

Question 24

A 22-year-old collegiate basketball player sustains a fracture at the diaphyseal junction of the proximal fifth metatarsal. Radiographs show a transverse fracture line without sclerosis (Zone 3). To minimize the risk of nonunion and allow early return to play, what is the treatment of choice?

Explanation

Zone 3 fractures (diaphyseal stress fractures) occur in a vascular watershed area and have a high rate of nonunion, especially in high-level athletes. Intramedullary screw fixation is the gold standard to ensure healing and expedite return to sports.

Question 25

A 28-year-old male sustains a multiligamentous knee injury. On examination, a dial test is performed. There is 15 degrees of increased external rotation at 30 degrees of knee flexion compared to the contralateral side. At 90 degrees of knee flexion, the external rotation is symmetric bilaterally. What injury pattern does this indicate?

Explanation

An increase in external rotation of >10 degrees at 30 degrees of flexion, but not at 90 degrees, is classic for an isolated posterolateral corner (PLC) injury. If external rotation is increased at both 30 and 90 degrees, it indicates a combined PCL and PLC injury.

Question 26

A 55-year-old diabetic patient presents with a warm, swollen, and erythematous left foot and ankle. Radiographs reveal fragmentation, periarticular debris, and joint subluxation at the midfoot. According to the Eichenholtz classification, what stage of Charcot arthropathy is this, and what is the initial management?

Explanation

This clinical and radiographic picture (fragmentation, debris, subluxation) describes Eichenholtz Stage I (Developmental/Fragmentation stage) Charcot arthropathy. The gold standard initial management is immobilization with a total contact cast to prevent further deformity.

Question 27

Regarding the anatomy of the anterior cruciate ligament (ACL), which of the following statements correctly describes the biomechanical role of its two distinct bundles?

Explanation

The ACL has two main bundles: the anteromedial (AM) and posterolateral (PL) bundles. The AM bundle tightens in flexion to resist anterior tibial translation, while the PL bundle tightens in extension to resist rotatory loads.

Question 28

A 40-year-old patient underwent open reduction and internal fixation (ORIF) with syndesmotic screw fixation for an unstable ankle fracture. Postoperatively, malreduction of the syndesmosis is suspected. Which imaging modality and specific anatomical relationship provide the most accurate assessment of syndesmotic reduction?

Explanation

Axial CT scanning is the gold standard for assessing syndesmotic reduction, as plain radiographs have low sensitivity and specificity for malreduction. The assessment focuses on the anatomical relationship of the fibula centered within the tibial incisura.

Question 29

A surgeon is performing a medial opening wedge high tibial osteotomy (HTO) to treat medial compartment osteoarthritis in a varus knee. To avoid unintentionally increasing the posterior tibial slope (creating a "flexion osteotomy"), what must the ratio of the anterior osteotomy gap to the posterior osteotomy gap approximately be?

Explanation

Because the proximal tibia is triangular, opening the osteotomy equally anteriorly and posteriorly will inadvertently increase the posterior tibial slope. To maintain the native sagittal slope, the anterior gap should be approximately one-half the size of the posterior gap (1:2 ratio).

Question 30

A 45-year-old male presents with dorsal midfoot pain. Examination reveals pain with terminal hallux dorsiflexion but no pain in the mid-range of motion. Radiographs show a dorsal osteophyte on the 1st metatarsal head with relative preservation of the joint space. What is the most appropriate surgical treatment if non-operative management fails?

Explanation

The patient has early-stage hallux rigidus (Coughlin and Shurnas Grade 1 or 2) with pain only at terminal dorsiflexion and preserved joint space. Cheilectomy (removal of the dorsal osteophyte and a portion of the dorsal metatarsal head) is the treatment of choice.

Question 31

A 45-year-old female experiences a sudden "pop" in the back of her knee while ascending stairs, followed by mild effusion and posteromedial pain. MRI reveals a posterior root tear of the medial meniscus with 3 mm of meniscal extrusion. What is the most significant biomechanical consequence of leaving this tear untreated?

Explanation

A posterior root tear of the medial meniscus disrupts the circumferential hoop stresses, rendering the meniscus functionally incompetent. Biomechanically, this results in increased peak compartment contact pressures equivalent to those seen after a total meniscectomy, rapidly leading to osteoarthritis.

Question 32

When comparing operative vs. non-operative management (using a functional rehabilitation protocol) for acute Achilles tendon ruptures, high-level evidence demonstrates which of the following regarding complication rates?

Explanation

Recent meta-analyses indicate that operative management of Achilles ruptures slightly decreases the re-rupture rate compared to traditional non-operative management, but carries a significantly higher risk of complications such as infection and sural nerve injury. With modern functional rehab, functional outcomes and re-rupture rates are very similar.

Question 33

Which of the following component malpositions in a primary total knee arthroplasty (TKA) is most likely to result in lateral patellar subluxation or tracking issues?

Explanation

Internal rotation of either the femoral or tibial components increases the Q angle by relatively lateralizing the tibial tubercle or medializing the trochlear groove, both of which strongly predispose the patient to lateral patellar maltracking.

Question 34

A 30-year-old male falls from a height and sustains a Hawkins Type III talar neck fracture.

What best describes the displacement pattern and the approximate risk of avascular necrosis (AVN) of the talar body?

Explanation

A Hawkins Type III fracture is a talar neck fracture with subluxation or dislocation of both the subtalar and tibiotalar joints. Because all three major blood supplies to the talar body are disrupted, the risk of AVN is nearly 100%.

Question 35

A 25-year-old football player sustains a purely ligamentous Lisfranc injury.

Recent prospective randomized trials comparing open reduction internal fixation (ORIF) with primary arthrodesis for this specific injury pattern show which of the following advantages for primary arthrodesis?

Explanation

For purely ligamentous Lisfranc injuries, level I evidence (e.g., Ly and Coetzee) has demonstrated that primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) results in superior functional outcomes, less need for hardware removal, and fewer reoperations compared to ORIF.

Question 36

A 12-year-old boy presents with vague knee pain and catching. Radiographs reveal an osteochondritis dissecans (OCD) lesion. What is the most common anatomical location for this lesion in the knee?

Explanation

The classic and most common location for an osteochondritis dissecans (OCD) lesion in the knee is the lateral aspect of the medial femoral condyle, accounting for roughly 70-80% of cases.

Question 37

In the pathogenesis of adult-acquired flatfoot deformity (posterior tibial tendon dysfunction), failure of static stabilizers occurs sequentially. Which ligamentous structure is considered the primary static stabilizer of the talonavicular joint and is typically the first to fail?

Explanation

The spring ligament (plantar calcaneonavicular ligament) complex, specifically the superomedial band, is the primary static stabilizer of the talonavicular joint. Its attenuation or rupture is a critical step in the progression of adult-acquired flatfoot deformity.

Question 38

A 24-year-old male presents to the emergency department after a high-energy trauma with a grossly dislocated knee (Schenck KD-III). The knee is reduced in the ED. Pulses are palpable, but the Ankle-Brachial Index (ABI) is 0.85. What is the next most appropriate step in management?

Explanation

In knee dislocations, an Ankle-Brachial Index (ABI) less than 0.9, even with palpable pulses or normal clinical vascular exam, is highly suspicious for a vascular intimal tear. Immediate advanced imaging with CT angiography (CTA) is mandated to evaluate the popliteal artery.

Question 39

The deltoid ligament complex is crucial for medial ankle stability. Which component of the deltoid ligament is the primary restraint to lateral displacement (talar shift) and external rotation of the talus within the ankle mortise?

Explanation

The deep deltoid ligament, particularly the thick deep posterior tibiotalar ligament, is the strongest component of the deltoid complex and is the primary restraint to lateral talar shift and external rotation within the mortise.

Question 40

During arthroscopy for an acute anterior cruciate ligament (ACL) rupture, the surgeon evaluates the posterior horn of the medial meniscus. A longitudinal tear at the meniscocapsular junction is identified, which was not visible from the standard anterior portals until the arthroscope was advanced through the intercondylar notch. What is the specific term for this type of lesion?

Explanation

A longitudinal tear of the peripheral meniscocapsular attachment of the posterior horn of the medial meniscus is known as a "ramp lesion." It is highly associated with ACL tears and is often missed if the posteromedial compartment is not evaluated via an intercondylar notch view or posteromedial portal.

Question 41

A 68-year-old male presents with a feeling of instability 6 months after a primary total knee arthroplasty. Examination reveals the knee is stable in full extension but has 15 degrees of varus/valgus laxity at 90 degrees of flexion. Which of the following technical errors most likely caused this specific instability pattern?

Explanation

An undersized femoral component in the anteroposterior (AP) dimension excessively increases the flexion gap without affecting the extension gap. This results in isolated flexion instability.

Question 42

A 52-year-old female presents with acute medial knee pain after a deep squat. MRI reveals a complete posterior horn medial meniscus root tear with 4 mm of meniscal extrusion. Biomechanically, this injury is most equivalent to which of the following?

Explanation

A complete posterior horn medial meniscus root tear disrupts the hoop stresses of the meniscus. Biomechanically, this alters contact pressures to a degree equivalent to a total meniscectomy, leading to rapid chondrolysis.

Question 43

A 34-year-old male sustains a Hawkins Type III talar neck fracture following a motor vehicle collision. At 8 weeks post-ORIF, an AP radiograph of the ankle demonstrates a subchondral radiolucent band in the talar dome. What does this radiographic finding indicate?

Explanation

The Hawkins sign is a subchondral radiolucent band seen at 6-8 weeks post-injury, indicating subchondral bone resorption. This requires an intact blood supply, thereby confirming preserved vascularity to the talar body and excluding avascular necrosis.

Question 44

During surgical fixation of a severe acute Lisfranc injury, the surgeon must restore the primary structural stabilizer of the tarsometatarsal articulation. Between which two bones does the true Lisfranc ligament travel?

Explanation

The Lisfranc ligament is a stout interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is the largest and strongest ligament of the tarsometatarsal complex.

Question 45

A 24-year-old football player sustains a contact knee injury. On examination, the dial test demonstrates 20 degrees of increased external rotation at 30 degrees of knee flexion compared to the contralateral side, but symmetric external rotation at 90 degrees of flexion. Which structure is most likely injured?

Explanation

The dial test evaluates for posterolateral corner (PLC) and PCL injuries. Increased external rotation (>10 degrees) at 30 degrees of flexion only indicates an isolated PLC injury, whereas increased rotation at both 30 and 90 degrees indicates a combined PLC and PCL injury.

Question 46

A 28-year-old male undergoes open reduction and internal fixation for a Weber C ankle fracture with syndesmotic disruption. Which of the following intraoperative fluoroscopic parameters is the most reliable indicator of accurate syndesmotic reduction?

Explanation

Absolute radiographic measurements for syndesmotic reduction are highly variable due to rotational positioning. Comparison with the contralateral, uninjured ankle is the most reliable radiographic method to assess accurate syndesmotic reduction.

Question 47

A 70-year-old female complains of an audible and painful "pop" in her knee when rising from a chair, 14 months after a posterior-stabilized total knee arthroplasty (TKA). Examination reveals a palpable catch at roughly 40 degrees of flexion as the knee extends. What is the most likely etiology?

Explanation

Patellar clunk syndrome occurs primarily in posterior-stabilized TKA designs when a fibrous nodule forms at the superior pole of the patella. As the knee extends from a flexed position, this nodule catches in the intercondylar notch of the femoral component, usually around 30 to 45 degrees of flexion.

Question 48

A 48-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and evidence of hypermobility at the first tarsometatarsal (TMT) joint.

Which surgical intervention is most appropriate?

Explanation

A first TMT joint arthrodesis (Lapidus procedure) is indicated for moderate to severe hallux valgus (IMA > 15 degrees) associated with first ray hypermobility. It permanently corrects the IMA and stabilizes the medial column.

Question 49

A 68-year-old male presents with instability when descending stairs one year after a primary posterior-stabilized total knee arthroplasty (TKA). Clinical examination and stress radiographs demonstrate a well-balanced knee in full extension, but significant laxity is noted at 90 degrees of flexion. Which of the following intraoperative component adjustments would have best prevented this specific complication?

Explanation

Upsizing the AP dimension of the femoral component tightens the flexion gap without affecting the extension gap. Increasing polyethylene thickness or adding distal augments would alter the extension gap, which is already balanced in this patient.

Question 50

During open reduction and internal fixation of a severe supination-external rotation ankle fracture, you note widening of the syndesmosis on the Cotton test. You decide to place a syndesmotic position screw. Which of the following ligaments provides the greatest resistance to diastasis of the distal tibiofibular syndesmosis?

Explanation

The posterior inferior tibiofibular ligament (PITFL) provides the majority (approximately 42%) of the strength of the syndesmotic complex. The AITFL contributes approximately 35%, while the interosseous ligament provides about 22%.

Question 51

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 42 degrees and an Intermetatarsal Angle (IMA) of 18 degrees. There is no evidence of first tarsometatarsal hypermobility or midfoot arthritis. What is the most appropriate surgical intervention?

Explanation

An IMA greater than 13 to 15 degrees is considered severe and typically requires a proximal metatarsal osteotomy (e.g., Ludloff, Scarf) or Lapidus procedure. A distal osteotomy alone is insufficient for this degree of intermetatarsal widening.

Question 52

A 24-year-old soccer player undergoes anterior cruciate ligament (ACL) reconstruction. Postoperatively, the patient complains of the knee 'giving way' when pivoting. Examination reveals a firm endpoint on the Lachman test but a positive pivot shift test. What is the most likely technical error made during the surgery?

Explanation

A vertically placed femoral tunnel in ACL reconstruction controls anterior-posterior translation (negative Lachman) but fails to adequately control rotational forces, resulting in a persistent pivot shift.

Question 53

A 30-year-old male sustains a purely ligamentous Lisfranc injury after falling from a horse. The first, second, and third tarsometatarsal (TMT) joints are diastased. Which of the following surgical treatments yields the best long-term functional outcome for this specific injury pattern?

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the first, second, and third TMT joints has been shown to have superior functional outcomes and a lower reoperation rate compared to open reduction and internal fixation (ORIF).

Question 54

A 52-year-old female experiences a sudden pop in the back of her knee while squatting. MRI demonstrates an extrusion of the medial meniscus by 4 mm and a radial tear at the posterior root attachment. What is the recommended surgical management to halt the progression of rapidly advancing osteoarthritis?

Explanation

Medial meniscus posterior root tears lead to a loss of hoop stresses and rapid articular degeneration. Transtibial pull-out repair or suture anchor repair anatomically restores the root, re-establishes hoop stresses, and prevents further meniscal extrusion.

Question 55

A 58-year-old male with poorly controlled type 2 diabetes mellitus presents with a swollen, erythematous, and warm right foot without any open ulcers. Plain radiographs are normal. MRI shows diffuse marrow edema in the midfoot. What is the most appropriate initial management?

Explanation

This patient presents with Eichenholtz stage 0 (pre-fragmentation) Charcot arthropathy, characterized by clinical signs of inflammation and MRI edema but normal X-rays. The standard of care is immediate offloading with a total contact cast to prevent deformity.

Question 56

A 21-year-old collegiate basketball player sustains an acute transverse fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal (Zone 2) during a game. To minimize the risk of nonunion and expedite his return to play, what is the treatment of choice?

Explanation

Zone 2 (Jones) fractures occur in a vascular watershed area with a high rate of nonunion. In competitive athletes, intramedullary screw fixation is recommended to ensure healing and allow for a faster return to play.

Question 57

A 65-year-old female presents with a painful catching sensation in her anterior knee when moving from flexion to extension, exactly 14 months after undergoing a posterior-stabilized total knee arthroplasty (PS-TKA). What is the most likely etiology of her symptoms?

Explanation

This describes 'patellar clunk syndrome,' a known complication of PS-TKA where a fibrous nodule forms at the superior pole of the patella. As the knee extends from flexion, the nodule catches in the femoral intercondylar box, causing a painful 'clunk.'

Question 58

When performing a minimally invasive surgical repair of an acute Achilles tendon rupture, care must be taken to avoid injury to the sural nerve. At approximately what distance proximal to the calcaneal insertion does the sural nerve typically cross the lateral border of the Achilles tendon?

Explanation

The sural nerve courses distally in the posterior calf and crosses the lateral border of the Achilles tendon roughly 9 to 12 cm proximal to its calcaneal insertion, making it highly vulnerable during percutaneous or minimally invasive repairs in this zone.

Question 59

During a knee examination of a trauma patient, the dial test demonstrates 15 degrees of increased external rotation at 30 degrees of knee flexion compared to the contralateral side. However, at 90 degrees of knee flexion, the external rotation is symmetric bilaterally. Which structure is injured?

Explanation

An asymmetric increase in external rotation at 30 degrees of flexion that corrects at 90 degrees indicates an isolated posterolateral corner (PLC) injury. If the asymmetry persists or increases at 90 degrees, a combined PLC and PCL injury is present.

Question 60

A 14-year-old male presents with poorly localized knee pain and intermittent mechanical symptoms. Radiographs reveal an osteochondritis dissecans (OCD) lesion. What is the most common anatomical location for this lesion in the knee?

Explanation

The most common location for osteochondritis dissecans in the knee is the lateral aspect of the medial femoral condyle (often remembered by the mnemonic LAME: Lateral Aspect Medial Epicondyle/condyle).

Question 61

A 32-year-old male falls from a height and sustains a Hawkins Type III fracture of the talar neck. What is the approximate rate of avascular necrosis (AVN) of the talar body associated with this specific injury pattern?

Explanation

A Hawkins Type III fracture is a displaced talar neck fracture with dislocation of both the subtalar and tibiotalar joints. It severely disrupts the blood supply, leading to an AVN rate of 75% to 100%.

Question 62

You are performing a medial opening wedge high tibial osteotomy (HTO) on a 40-year-old active male with medial compartment osteoarthritis and varus malalignment. To optimize load distribution and long-term survivorship of the osteotomy, where should the postoperative mechanical axis pass on the tibial plateau (measured from medial to lateral)?

Explanation

The target for correction in an HTO is the Fujisawa point, which is located at approximately 62% of the tibial plateau width from medial to lateral. This transfers the mechanical axis slightly into the healthy lateral compartment, relieving medial stress.

Question 63

A 45-year-old runner complains of burning heel pain that radiates into the medial arch of the foot. Examination reveals a positive Tinel's sign posterior to the medial malleolus, and dorsiflexion-eversion exacerbates the symptoms. Which nerve is entrapped in this condition?

Explanation

This patient has tarsal tunnel syndrome, caused by the entrapment or compression of the posterior tibial nerve (or its branches) as it passes beneath the flexor retinaculum posterior to the medial malleolus.

Question 64

A 35-year-old roofer sustains a severe axial load injury to his heel. Lateral radiographs demonstrate a depressed intra-articular calcaneus fracture. In a normal, uninjured foot, what is the expected range for Böhler's angle?

Explanation

Böhler's angle is formed by the intersection of a line drawn from the highest point of the anterior process to the highest point of the posterior facet, and a line from the posterior facet to the superior tuberosity. Its normal range is 20 to 40 degrees.

Question 65

During a total knee arthroplasty (TKA), the surgeon inadvertently places both the femoral and tibial components in internal rotation. What is the most likely resulting complication?

Explanation

Internal rotation of either the femoral or tibial component in TKA increases the Q-angle dynamically, leading to lateral patellar maltracking, anterior knee pain, and potentially lateral patellar subluxation or dislocation.

Question 66

A professional football player suffers a severe hyperdorsiflexion injury to his great toe. MRI shows a complete tear of the plantar plate with proximal retraction of the sesamoids. What grade of 'Turf Toe' is this, and what is the primary indication for surgical intervention in this specific case?

Explanation

A complete tear of the plantar plate with sesamoid retraction represents a Grade 3 Turf Toe injury. Due to the significant loss of the push-off mechanism and frank instability, surgical repair of the plantar plate is generally indicated in high-level athletes.

Question 67

A 25-year-old male sustains an anterior knee dislocation after a motorcycle accident. The knee is reduced in the emergency department. The patient has palpable, symmetric 2+ dorsalis pedis and posterior tibial pulses. However, the ankle-brachial index (ABI) is measured at 0.85. What is the most appropriate next step in management?

Explanation

In the setting of a knee dislocation, palpable pulses do not definitively rule out an intimal flap tear of the popliteal artery. An ABI less than 0.9 is highly sensitive for vascular injury and mandates advanced imaging, such as a CT angiogram.

Question 68

A 28-year-old skier presents with acute pain behind the lateral malleolus after catching his edge. He reports a snapping sensation on the lateral side of his ankle when dorsiflexing and everting his foot against resistance. Disruption of which anatomical structure is primarily responsible for his symptoms?

Explanation

The patient is describing peroneal tendon subluxation, which is typically caused by forced dorsiflexion and eversion leading to a tear or avulsion of the superior peroneal retinaculum (SPR) from the posterior lateral malleolus.

Question 69

During a posterior stabilized total knee arthroplasty, the surgeon performs a posterior capsular release. The popliteal artery is at highest risk of injury in this region. At the level of the tibial cut, what is the anatomical relationship of the popliteal artery to the posterior capsule and popliteal vein?

Explanation

At the level of the knee joint, the popliteal artery is the most anterior (deepest) structure in the popliteal fossa, lying directly anterior to the popliteal vein and immediately posterior to the joint capsule.

Question 70

A 24-year-old athlete sustains a hyperplantarflexion injury to the midfoot. Non-weight-bearing radiographs are normal, but weight-bearing views show a 3 mm diastasis between the base of the first and second metatarsals with no fractures. What is the most appropriate management?

Explanation

This patient has a purely ligamentous Lisfranc injury, which implies instability. Operative management (ORIF or primary arthrodesis) is indicated for any diastasis greater than 2 mm to prevent chronic pain and post-traumatic arthritis.

Question 71

When performing an anterior cruciate ligament (ACL) reconstruction, placing the femoral tunnel using a traditional transtibial technique rather than an independent anteromedial portal technique most commonly results in a tunnel that is:

Explanation

The traditional transtibial technique constrains the femoral tunnel trajectory based on the tibial tunnel, frequently resulting in a femoral tunnel that is placed too vertical and too anterior in the intercondylar notch, failing to control rotational instability.

Question 72

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle of 42 degrees, an intermetatarsal angle of 18 degrees, and clinical hypermobility of the first tarsometatarsal joint. Which of the following procedures is most appropriate?

Explanation

A Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA > 15 degrees) combined with first ray hypermobility, as it addresses both the large deformity and the instability at the apex.

Question 73

During a primary cruciate-retaining total knee arthroplasty, the trial reduction reveals that the knee is symmetric and balanced in extension but excessively tight in flexion. Which of the following is the most appropriate intraoperative adjustment?

Explanation

Increasing the posterior tibial slope effectively opens the flexion gap without significantly affecting the extension gap. Recutting the distal femur or releasing the posterior capsule would primarily affect the extension gap.

Question 74

A 35-year-old recreational athlete sustains an acute Achilles tendon rupture. He elects for non-operative management utilizing an early functional rehabilitation protocol. Compared to operative management, this non-operative approach is most closely associated with:

Explanation

Recent meta-analyses show that non-operative management with early functional rehabilitation yields a re-rupture rate similar to surgical repair, while avoiding the risks of surgical wound complications and nerve injury.

Question 75

The posterior cruciate ligament (PCL) consists of two main bundles. Which of the following best describes the biomechanical behavior of the anterolateral (AL) bundle?

Explanation

The PCL has a larger anterolateral (AL) bundle that is tight in flexion and loose in extension, and a smaller posteromedial (PM) bundle that is tight in extension and loose in flexion.

Question 76

A 58-year-old male with poorly controlled diabetes presents with a swollen, warm, and erythematous right foot. Radiographs demonstrate early fragmentation of the midfoot with subluxation and bony debris. According to the Eichenholtz classification, what is the current stage and most appropriate management?

Explanation

Eichenholtz Stage 1 (development/fragmentation) is characterized by acute inflammation, bony fragmentation, and joint subluxation. The gold standard treatment is offloading with a total contact cast until the acute inflammatory phase resolves.

Question 77

A 12-year-old male presents with vague knee pain. Radiographs show an osteochondritis dissecans (OCD) lesion on the lateral aspect of the medial femoral condyle. MRI confirms a 1.5 cm lesion with no fluid behind it. The physes are widely open. What is the most appropriate initial management?

Explanation

In skeletally immature patients with a stable OCD lesion (intact cartilage, no fluid behind the lesion on MRI), non-operative management with activity restriction is highly successful and is the appropriate first-line treatment.

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

Orthopedic Board Review MCQs: Knee, Foot & Ankle | Part 86

Key Takeaway

Orthopedic Board Review MCQs: Knee, Foot & Ankle | Part 86

Chapter Index