ORTHOPEDIC MCQS ONLINE QUESTION BANK H1D

ORTHOPEDIC MCQS ONLINE QUESTION BANK H1D

1132. (1414) Q3-1787:

A foot is maximally dorsiflexed during this point of the gait cycle:

 

1) Midswing

3) Toe off

2) Midstance

5) First one-third of stance

4) Heelstrike

 

During gait, a foot is dorsiflexed during midswing and foot flat. During midswing, the anterior tibial muscle maintains the foot in a dorsiflexed position to facilitate a smooth heelstrike. This is an active dorsiflexion of the foot and ankle. The maximum dorsiflexion of the foot, however, is passive and occurs as the leg moves forward over the foot during foot flat at midstance.Correct Answer: Midstance

 

 

1133. (1415) Q3-1788:

Which of the following structures is disrupted in patients with an acute medial subtalar dislocation:

 

1) Lisfranc ligament

3) Talocalcaneal ligament

2) Long plantar ligament

5) Anterior talofibular ligament

4) Calcaneonavicular ligament

 

As the foot and the subtalar joint move medially, the subtalar ligaments and the ligaments on the lateral aspect of the ankle are disrupted. The talocalcaneal, or interosseous, ligament is the only ligament that is vulnerable in an acute medial subtalar dislocation.Correct Answer: Talocalcaneal ligament

 

 

1134. (1416) Q3-1791:

An 8-year-old soccer player has had bilateral heel pain for 3 months. He has no constitutional complaints. Isolated tenderness to the posterior aspect of his calcaneal tuberosity is present. Recommended treatment is:

 

1) Bone scan to rule out infectious and/or malignant conditions

3) A short leg cast

2) Magnetic resonance image to assess for signs of calcaneal avascular necrosis

5) Achilles tendon stretching

4) Computerized tomography scan to rule out osseous abnormality and/or coalition

 

Posterior heel pain in a child is common. This scenario describes an apophysitis of the insertion of the Achilles tendon, referred to as Severâs disease. The condition is self-limited and responds well to stretching of the Achilles tendon, temporary limitation of activities, and ice applied to the heel after exercise.Correct Answer: Achilles tendon stretching

 

 

1135. (1417) Q3-1792:

A 26-year-old recreational volleyball player presents with complaints of recurrent right ankle instability. She has undergone 3 months of peroneal strengthening and proprioceptive training without success. She has tried and failed ankle bracing. She has a positive anterior drawer finding on examination, and her hindfoot is in neutral alignment. The recommended surgical plan is:

 

1) Transfer half of the peroneus brevis tendon obliquely through the fibula to recreate the vector of the anterior talofibular and calcaneofibular ligaments

3) Calcaneal osteotomy with reconstruction of the anterior talofibular and calcaneofibular ligaments

2) Reconstruction of the anterior talofibular and calcaneofibular ligaments with imbrication and advancement of the extensor retinaculum

5) Ankle ligament reconstruction with additional attention to the osteochondral talar dome injury

4) Allograft ligament reconstruction

 

In an athlete, unless there are unusual anatomic and physical findings, the appropriate ankle reconstruction is an anatomic repair of the ligaments as originally described by Brostrum. Procedures that use the peroneal tendon or tendon grafts should be used in circumstances when a high demand is put on the ankle (e.g., if the patient is heavy or if generalized ligamentous laxity is present).Correct Answer: Reconstruction of the anterior talofibular and calcaneofibular ligaments with imbrication and advancement of the extensor retinaculum

1136. (1418) Q3-1793:

A 65-year-old woman presents with pain along the posteromedial aspect of her right ankle. She has a clinical deformity of her foot with loss of normal arch height. Her hindfoot is in valgus but is passively correctable to neutral. She has weakness with inversion and cannot perform a single stance heel raise. She has not had any form of treatment. Recommended treatment includes:

 

1) Debridement of posterior tibial tendon

3) A molded ankle orthosis

2) Transfer of the flexor digitorum longus tendon and medial displacement calcaneal osteotomy

5) Lateral column lengthening with flexor digitorum longus tendon transfer

4) Corticosteroid injection of posterior tibial tendon sheath

 

Although there is the likelihood that this patient may ultimately require surgery, the nonoperative management of posterior tibial tendon rupture is important. The success rate of bracing is variable, but bracing must be used as the first line of treatment for a patient as described above.Correct Answer: A molded ankle orthosis

 

 

1137. (1419) Q3-1794:

After counseling a 22-year-old patient who is scheduled to undergo a triple arthrodesis, he wants to know the risk that he will develop ankle arthritis. You tell him:

 

1) The risk of developing ankle arthritis after a triple arthrodesis is unknown.

3) 100% at 5 years

2) Ankle arthritis does not occur following triple arthrodesis.

5) 50% at 5 years

4) 25% at 5 years

 

Ankle arthritis commonly occurs following a triple arthrodesis. In a recent study by Pell and colleagues, the incidence of ankle arthritis in 134 patients who underwent a triple arthrodesis with a 5.6-year mean follow-up was 53%. Although not all of these patients are symptomatic, this is a problem.Correct Answer: 50% at 5 years

 

 

1138. (1420) Q3-1795:

A 57-year-old woman presents for treatment of a painful flatfoot deformity. She says that her foot has been painful for 4 years, but she does not recall any injury to the foot. The opposite foot is not bothersome. Upon examination, she has pain in the midfoot and hindfoot. Resisted inversion is strong and painful. She is able to perform a single and repetitive heel rise test. The most likely diagnosis is:

 

1) An unrecognized Lisfranc injury

3) Rupture of the spring ligament

2) Posterior tibial tendon rupture

5) Calcaneonavicular tarsal coalition

4) Idiopathic tarsometatarsal arthritis

 

Osteoarthritis of the tarsometatarsal joints in the adult is common. Patients are usually 50 to 60 years old, and the condition typically presents with pain in the midfoot and becomes progressively worse over time. The posterior tibial tendon is not torn, but as the foot becomes flatter and the forefoot more abducted there may be secondary stretching or tearing of the posterior tibial tendon.Correct Answer: Idiopathic tarsometatarsal arthritis

 

 

1139. (1421) Q3-1796:

Which clinical examination is likely to confirm a suspected rupture of the posterior tibial tendon:

 

1) Active plantarflexion of the foot against resistance

3) Resisted active inversion of the foot when the foot is positioned in abduction

2) Combined active plantarflexion and inversion of the foot against resistance

5) The presence of forefoot abduction upon standing and inability to adduct the foot

4) Ability to perform a single heel rise test

 

The anterior tibial tendon can compensate for a weak posterior tibial tendon. The primary function of the anterior tibial tendon is dorsiflexion, although the tendon may also invert the foot, particularly against resistance in the presence of a ruptured posterior tibial tendon. To prevent the anterior tibial tendon from inverting the foot, position the foot in plantarflexion and abduction to begin with when testing resistance to inversion.Correct Answer: Resisted active inversion of the foot when the foot is positioned in abduction

 

1140. (1422) Q3-1797:

The most reliable indication of an interdigital neuroma in the second web space is:

 

1) Pain upon compression of the web space

3) Absent sensation between the second and third toes

2) A painful click in the web space when compressing the forefoot

5) A neuroma of the second web space visible on magnetic resonance image

4) Burning, tingling, and numbness of the third toe

 

A click when compressing the forefoot (referred to as a positive Mulder sign) is not diagnostic of a neuroma and is present due to an enlarged intermetatarsal bursa. The sensation of pain and burning is varied, and some patients report only a vague numbness. Magnetic resonance imaging can have a false positive and false negative result; therefore, it must not be relied upon for diagnosis. The most reliable finding on physical examination is pain on compression of the affected web space.Correct Answer: Pain upon compression of the web space

 

 

1141. (1423) Q3-1798:

A 68-year-old patient presents for evaluation of ankle pain. He is unable to walk more than 10 minutes without pain and stiffness. He has been treated with anti-inflammatory medication, intra-articular injection of steroid, and an ankle foot orthosis. He has 35° of clinical motion associated with crepitus and pain and there is no motion in the subtalar joint. Radiographs demonstrate large osteophytes in the anterior ankle, no joint space, and mild osteophytes of the talonavicular joint. The recommended surgical treatment is:

 

1) Anterior ankle cheilectomy

3) Ankle arthrodesis

2) Ankle arthroscopy

5) Total ankle replacement

4) Tibiotalocalcaneal arthrodesis

 

A patient with good range of motion of the ankle associated with poor subtalar motion and ankle arthritis is a candidate for a total ankle replacement. Although ankle arthrodesis may be considered, in the presence of a stiff subtalar joint, osteophytes of the talonavicular joint, and good ankle motion, this procedure is likely to lead to a high incidence of peritalar arthritis and pain.Correct Answer: Total ankle replacement

 

 

1142. (1424) Q3-1799:

A 21-year-old recreational athlete presents for treatment of ankle weakness. She notes that she trips frequently, that the ankle feels unstable, particularly on uneven ground surfaces, and that she has experienced frequent sprains. On examination, the ankle appears to be unstable and radiographs demonstrate no instability on stress testing. The most likely diagnosis is:

 

1) Generalized ligamentous laxity

3) Tear of the calcaneofibular ligament

2) Tear of the anterior talofibular ligament

5) Tear of the anterior talofibular and calcaneofibular

4) Tear of the talocalcaneal interosseous ligament

 

This patient has subtalar instability. When there is no instability demonstrated on radiographic stress testing despite a history of recurrent ankle sprains, the subtalar joint must be assessed.Correct Answer: Tear of the talocalcaneal interosseous ligament

 

 

1143. (1425) Q3-1800:

The symptoms of a tarsal tunnel syndrome may become aggravated by:

 

1) Pronation of the foot

3) Dorsiflexion of the ankle

2) Plantarflexion of the foot

5) Rotation of the ankle

4) Inversion of the foot

 

Pronation of the foot places increased stretch on the tibial nerve. This motion has important implications for treatment because the pronated flatfoot should be supported with an orthotic arch support in patients with symptoms of a tarsal tunnel syndrome.Correct Answer: Pronation of the foot

1144. (1426) Q3-1801:

A 56-year-old woman presents for evaluation and treatment of a painful hallux. She notes the pain over the dorsal surface of the hallux metatarsophalangeal (MP) joint and on the plantar aspect of the hallux interphalangeal (IP) joint. Clinically, there is no range of motion in dorsiflexion of the hallux MP joint, pain upon attempted movement of the MP joint, and 20° of extension of the hallux IP joint. Radiographs demonstrate arthritis of the hallux MP joint and normal alignment of the first metatarsal. The surgical procedure that is likely to cause further mechanical problems for this patient is:

 

1) Resection arthroplasty of the hallux MP joint

3) Interposition arthroplasty of the hallux MP joint

2) Cheilectomy of the hallux MP joint

5) Plantarflexion osteotomy of the first metatarsal

4) Arthrodesis of the hallux MP joint

 

This patient has end stage arthritis and rigidus of the hallux MP joint. Hyperextension of the IP joint is already present. If arthrodesis of the MP joint were performed, then further load and instability of the IP joint would occur.Correct Answer: Arthrodesis of the hallux MP joint

 

 

1145. (1427) Q3-1802:

 

 

 

Slide 1 Slide 2

A 38-year-old woman presents for evaluation of painful hallux rigidus. Her clinical and radiographic images are shown (Slide 1 and Slide 2). Based upon her presentation, what is the likelihood that first metatarsus elevatus is responsible for her clinical condition:

 

1. Rare

   3) 50%

2. 25%

   5) 100%

   4) 75%

    

   Surgeons cannot assume that an elevated first metatarsal is responsible for causing hallux rigidus. On a lateral radiograph, there may be notable elevation of the first metatarsal (as present in this patient), but the elevation may be a secondary result of the limited motion of the hallux metatarsophalangeal joint. Studies have demonstrated that there is no difference in the elevation of the first metatatarsal in patients with hallux rigidus.Correct Answer: Rare

    

   1146. (1428) Q3-1803:

    

    

    

   Slide 1 Slide 2

   The patient shown in Slide 1 and Slide 2 underwent surgical correction of painful hallux rigidus. The purpose of the procedure on the hallux was:

    

   1. To increase the range of motion of the hallux metatarsophalangeal (MP) joint

3. To depress the hallux and improve push off strength

1. To elevate the hallux off the ground

5) To change the kinematics of the hallux MP joint, thereby decreasing the likelihood of recurrent deformity

4) To decrease the jamming of the hallux MP joint on push off

 

The osteotomy of the proximal phalanx of the hallux (the Moberg osteotomy) is designed to elevate the hallux off the ground. The procedure does not improve the range of motion of the MP joint, but it increases the available motion of the hallux in toe off.Correct Answer: To elevate the hallux off the ground

 

 

1147. (1429) Q3-1804:

Of the proximal first metatarsal osteotomies listed below, which has the least stability for dorsiflexion load:

 

1) Ludloff osteotomy

3) Scarf osteotomy

2) Crescentic osteotomy

5) Closing wedge osteotomy

4) Chevron osteotomy

 

The crescentic osteotomy is inferior on mechanical testing to the other proximal first metatarsal osteotomies. This must be considered when planning correction of deformity associated with hallux valgus, particularly in a patient with osteopenia.Correct Answer: Crescentic osteotomy

 

 

1148. (1430) Q3-1805:

A 54-year-old patient presents for correction of painful hallux valgus. She has a prominent medial eminence, pain on pressure over the metatarsophalangeal (MP) joint, increased elevation of the first metatarsal, and painful callosity under the second metatarsal. The recommended procedure is:

 

1) Arthrodesis of the hallux MP joint

3) Distal metatarsal osteotomy and distal soft tissue release

2) Proximal first metatarsal osteotomy and distal soft tissue release

5) Proximal first metatarsal osteotomy, distal soft tissue release, and condylectomy of the second metatarsal head

4) Arthrodesis of the metatarsocuneiform joint

 

This patient has typical findings of hypermobility of the first metatarsal. The increased pressure under the second metatarsal head may be the result of elevation of the first metatarsal or dysfunction of the windlass mechanism that depresses the first metatarsal upon toe off. Hypermobility of the first ray associated with hallux valgus is successfully treated with arthrodesis of the metatarsocuneiform joint or the modified Lapidus procedure.Correct Answer: Arthrodesis of the metatarsocuneiform joint

1149. (1431) Q3-1807:

 

 

 

Slide 1 Slide 2

This patient was treated for metatarsalgia with an oblique osteotomy of the metatarsal head and neck (Weil osteotomy). Although the symptoms of metatarsalgia dissipated, she has continued complaints about the position of the toe (Slide 1 and Slide 2). This complication is a result of which of the following anatomic deformities:

 

1) Subluxation of the metatarsophalangeal (MP) joint

3) Dorsal shift of the interosseous tendon

2) Tearing of the volar plate

5) Persistent contracture of the lumbrical tendons

4) Scarring in the skin and subcutaneous tissue

 

Following an oblique osteotomy of the metatarsal head and neck (Weil osteotomy), the interosseous tendons shift dorsal to the axis of the metatarsal head. Instead of functioning as strong plantarflexors of the MP joint, they may now function as dorsiflexors, leading to the elevation of the toe off the ground and dorsal contracture.Correct Answer: Dorsal shift of the interosseous tendon

 

 

1150. (1432) Q3-1808:

The strongest plantarflexor of the metatarsophalangeal (MP) joint of the lesser toes is the:

 

1) Long flexor tendon

3) Lumbrical tendon

2) Volar plate

5) Interosseous tendon

4) Short flexor tendon

 

Although the short flexor tendon plantarflexes the MP joint of the lesser toes, the interosseous tendons are stronger. When intrinsic atrophy or dysfunction of the forefoot is present, an intrinsic minus deformity occurs. The long flexor tendon does not flex the MP joint.Correct Answer: Interosseous tendon

 

 

1151. (1433) Q3-1810:

Which of the following procedures is not indicated as part of the reconstruction of the cavovarus hindfoot:

 

1) Anterior tibial tendon transfer to the middle cuneiform

3) Posterior tibial tendon transfer to the lateral cuneiform

2) Peroneus longus tendon to peroneus brevis tendon transfer

5) Posterior tibial tendon transfer to the peroneus brevis tendon

4) Extensor hallucis tendon transfer to the first metatarsal

 

All of the above tendon transfers may be used as part of a reconstruction of the cavus foot except the anterior tibial tendon. The imbalance between the anterior tibial tendon and the peroneus longus tendons are responsible for the cavovarus deformity.Correct Answer: Anterior tibial tendon transfer to the middle cuneiform

 

1152. (1434) Q3-1811:

Transfer of the extensor hallucis longus tendon to the first metatarsal and arthrodesis of the hallux interphalangeal joint is indicated for which of the following deformities:

 

1) A 36-year-old patient with a cavus foot following a compartment syndrome

3) Correction of hallux varus deformity

2) A 20-year-old patient with a flexible cavovarus deformity

5) A 42-year-old patient with Charcot-Marie-Tooth disease and pes planovalgus deformity

4) Correction of a laceration of the extensor hallucis longus

 

Correction of the claw hallux and first metatarsal equinus deformity may be accomplished by transfer of the extensor hallucis longus tendon and arthrodesis of the hallux interphalangeal joint. Once the deformity of the forefoot is fixed (e.g., following a compartment syndrome), the extensor hallucis longus tendon can no longer dorsiflex the first metatarsal. Although Charcot-Marie-Tooth disease is often associated with a cavus foot, the transfer is not indicated when a planovalgus foot is present.Correct Answer: A 20-year-old patient with a flexible cavovarus deformity

 

 

1153. (1435) Q3-1812:

A 43-year-old diabetic patient has had an ulcer on the plantar aspect of her foot for 9 months. She has no systemic symptoms. There is minimal drainage from the ulcer, and she has no pain in the foot. Initial management of this patient must include:

 

1) Culture and sensitivity of the ulcer with initiation of culture-specific antibiotic therapy

3) An indium scan to determine the presence of osteomyelitis

2) A technetium bone scan to determine the presence of osteomyelitis

5) Irrigation and debridement of the ulcer, deep tissue cultures, and appropriate antibiotic therapy

4) A total contact cast

 

This neuropathic ulcer is stable. There is minimal drainage and no clinical findings to suggest an active infection. Culture of the ulcer yields multiple nonpathogenic organisms and antibiotic therapy is not indicated. Treatment is initiated with either a total contact cast or a total contact walker boot.Correct Answer: A total contact cast

 

 

1154. (1436) Q3-1813:

 

 

 

Slide 1

The primary cause for the deformity shown (Slide) is:

 

1) Malunion of the metatarsal osteotomy

3) Laceration of the flexor hallucis brevis tendon

2) Overplication of the medial capsule of the hallucis metatarsophalangeal joint

5) Fibular sesamoidectomy

4) Laceration of the flexor hallucis longus tendon

 

Overplication of the medial capsule, overcorrection of the metatarsal osteotomy, and excessive lateral soft tissue release can lead to a hallux varus deformity. The most likely cause, however, is interference with the varus-valgus balance of the hallux as a result of a fibular sesamoidectomy.Correct Answer: Fibular sesamoidectomy

1155. (1437) Q3-1814:

 

 

 

Slide 1

A patient had a fixed deformity of the hallux interphalangeal (IP) joint (Slide) for 3 years following forefoot surgery. She complains of pain over the distal aspect of the hallux where rubbing occurs on the shoe. On examination, the hallux is flexible at the metatarsophalangeal (MP) and IP joints, there is no crepitus of the MP joint, and radiographs demonstrate normal alignment of the first metatarsal. The recommended procedure for correcting this deformity is:

 

1) Arthrodesis of the hallux MP joint

3) Transfer of the extensor hallucis brevis tendon

2) Resection arthroplasty of the hallux MP joint

5) Lengthening of the abductor hallucis and repair of the lateral capsule and the flexor hallucis brevis tendon with a bone suture anchor

4) Arthrodesis of the hallux IP joint with transfer of the flexor hallucis longus tendon

 

Arthrodesis and resection arthroplasty of the hallux MP joint are indicated in the presence of arthritis of the hallux MP joint. A tendon transfer is preferred, and the extensor hallucis brevis tendon is an effective transfer. Use of the extensor hallucis longus tendon with arthrodesis of the hallux IP joint is indicated when there is a fixed deformity of the hallux IP joint.Correct Answer: Transfer of the extensor hallucis brevis tendon

 

 

1156. (1438) Q3-1815:

 

 

 

Slide 1

A 33-year-old recreational athlete presents for treatment of chronic ankle pain. He recalls multiple ankle sprains that occurred 10 years ago. He has not undergone any surgical treatment. On examination, his ankle is stable, there is no crepitus on range of motion, and pain is present to palpation of the posterior ankle. A computerized axial tomography is presented (Slide). The surgical procedure most consistent with a rapid recovery and predictable outcome is:

 

1) Ankle arthrodesis

3) Osteoarticular autograft procedure

2) Arthroscopy of the ankle with drilling of the osteochondral defect

5) Osteoarticular allograft procedure

4) Cartilage cell harvest with staged debridement of the talus and cartilage cell implantation

 

Ankle arthrodesis must be used as a salvage procedure for failed management of the osteochondral lesion of the talus. Although osteoarticular autograft is a popular procedure, the results are variable and unpredictable, particularly in posteromedial lesions. Ankle arthroscopy with transarticular drilling is the most predictable procedure with expected satisfactory results in approximately 80% of patients.Correct Answer: Arthroscopy of the ankle with drilling of the osteochondral defect

 

1157. (1439) Q3-1816:

 

 

 

Slide 1

A 52-year-old man presents for treatment of acute pain in the forefoot. He notes that the onset of pain started 24 hours ago, and he is unable to walk. Examination of the hallux (Slide) is uncomfortable. The recommended treatment for this condition is:

 

1) Bed rest and intravenous antibiotic therapy

3) Immobilization of the foot in a short leg walking cast

2) Drainage of the hallux metatarsophalangeal joint, cultures, and initiation of a broad spectrum antibiotic

5) Intra-articular steroid injection

4) A wide comfortable shoe or sandal until the joint inflammation settles down

 

This patient presents with a classic acute gout attack. Although the hallux is in severe valgus, it is unlikely that this is the cause of the joint pain. Note the swelling of the hallux and the shiny skin from the acute inflammation. These clinical findings are typical of gout. Intra-articular injection of steroids is effective treatment and can be combined with oral anti-inflammatory agents.Correct Answer: Intra-articular steroid injection

 

 

1158. (1440) Q3-1817:

 

 

 

Slide 1 Slide 2

A 43-year-old patient presents for treatment of a chronically painful ankle. He notes pain with ambulation, is unable to exercise, and has had marked swelling of the ankle for the last 6 months. When walking, he notes continued instability of the ankle.

Examination of the ankle is unremarkable with the exception of swelling. A plain radiograph and intraoperative photograph are shown (Slide 1 and Slide 2). The most likely cause for this condition is:

 

1) Recurrent ankle sprain with proliferative synovitis

3) Early onset rheumatoid arthritis

2) Hemorrhagic synovitis

5) Synovitis associated with pseudogout

4) Pigmented villonodular synovitis

 

The appearance of the synovium is typical of pigmented villonodular synovitis. Staining of the synovium is characteristic. It is unlikely that a 43-year-old man will present with rheumatoid arthritis, although synovitis may appear similar. Recurrent ankle sprains cause a nonspecific synovitis that is not pigmented.Correct Answer: Pigmented villonodular synovitis

1159. (1441) Q3-1818:

A patient sustains a crush injury when heavy farm equipment rolls over his foot. He presents to the emergency department 4 hours later with pain and swelling in the foot. Radiographic examination is normal. You examine him for a compartment syndrome. The intracompartmental pressure in the interosseous compartment is 20 mm Hg. The next phase of management may include all of the following except:

 

1) Examination under anesthesia followed by fasciotomy

3) Observation and repeat compartment pressure monitoring

2) Application of an intermittent foot pump device

5) Admission to hospital for elevation and management of pain with narcotics

4) Application of a bulky soft tissue dressing with a posterior plaster splint

 

Fasciotomy of the foot is not indicated when pressures are less than 20 mm Hg. All of the alternatives are reasonable forms of treatment including application of an intermittent foot pump device that has been demonstrated to decrease compartment pressures of the foot. If pressures were more than 30 mm Hg, then a fasciotomy may be indicated.Correct Answer: Examination under anesthesia followed by fasciotomy

 

 

1160. (1442) Q3-1819:

 

 

 

Slide 1 Slide 2 Slide 3 Slide 4

A 61-year-old woman presents for treatment of a painful ankle. She reports that 4 years ago, she sustained a fracture of her ankle that was treated with cast immobilization. She has experienced progressively worsening pain over the past 2 years. On examination, she has good range of motion of the ankle with crepitus and pain. Radiographs are presented (Slide 1 and Slide 2). All of the following are acceptable forms of surgical correction except:

 

1) Supramalleolar osteotomy of the tibia

3) Ankle arthrodesis

2) Ankle arthroscopy

5) Distraction lengthening osteotomy of the fibula

4) Total ankle replacement

 

Each of the alternatives presented is reasonable except for ankle arthroscopy because it has a limited role in the management of posttraumatic arthritis of the ankle. In this patient, there is a possibility to salvage the ankle before arthrodesis or joint replacement with an osteotomy of the tibia and or the fibula. Both have a definite role in management of ankle deformity and arthritis. A closing wedge osteotomy of the tibia was performed in this patient, and she remains asymptomatic 4 years later (Slide 3 and Slide 4).Correct Answer: Ankle arthroscopy

 

 

1161. (1443) Q3-1820:

This patient developed a peripheral neuropathy of uncertain etiology. She has a partial peroneal nerve palsy with lack of extensor function of the hallux. She repeatedly stubs and catches the hallux when walking. Upon examination, she has good strength of the extensor digitorum longus tendon, as well as the anterior tibial tendon. Flexor strength of the foot is intact. All of the following are acceptable surgical alternatives except:

 

1) Arthrodesis of the hallux metatarsophalangeal (MP) joint

3) Tenodesis of the extensor hallucis longus tendon to the anterior tibial tendon

2) Tenodesis of the extensor hallucis longus tendon to the extensor digitorum longus tendon

5) Transfer of a portion of the extensor digitorum longus tendon to the extensor hallucis longus tendon

4) Transfer of the peroneus tertius tendon to the extensor hallucis longus tendon

 

When arthrodesis of the hallux MP joint is performed, it stabilizes the MP joint and continued flexion of the hallux with recurrent deformity occurs because the hallux interphalangel joint is not controlled with MP arthrodesis. All of the other procedures are satisfactory alternatives.Correct Answer: Arthrodesis of the hallux metatarsophalangeal (MP) joint

 

1162. (2788) Q3-3286:

A 28-year-old professional athlete presents for treatment of foot pain following an inversion injury to her ankle. She has been immobilized in a short leg walker boot for 1 month with minimal relief of symptoms. On examination, pain is present in the sinus tarsi. The patientâs ankle is not painful or unstable. Radiographs demonstrate a calcaneonavicular coalition. Recommended treatment includes:

 

1) Corticosteroid and lidocaine injection into the sinus tarsi

3) Physical therapy treatments aimed at mobilizing the subtalar joint

2) Continued immobilization in a boot for an additional month

5) Excision of the tarsal coalition

4) Subtalar arthrodesis

 

When a tarsal coalition becomes symptomatic in an adult, surgery becomes necessary. Initial immobilization may be attempted, although prolonged immobilization in an athlete is not ideal. Manipulation of the foot will exacerbate the pain, and therapy is not indicated. If arthrodesis of the hindfoot is performed for treatment of a calcaneonavicular coalition, then a triple arthrodesis is performed. Excision of the adult calcaneonavicular coalition is the preferred treatment.Correct Answer: Excision of the tarsal coalition

 

 

1163. (2789) Q3-3287:

A 43-year-old woman presents for treatment of pain in her forefoot that has been present for 1 year. The pain is localized to the second toe and radiates out to the tip of the toe with activities. When the patient wears high heel shoes, the pain is associated with numbness and burning of the toe. Your initial treatment consists of:

 

1) Excision of a third web space neuroma

3) Transfer of the flexor tendon to stabilize the metatarsophalangeal joint

2) Excision of a second web space neuroma

5) None of the above

4) Oblique metatarsal head osteotomy

 

This patient has typical symptoms of an interdigital neuroma, most likely involving the second web space. The likelihood of resolution of pain with nonsurgical treatment is good despite the duration of symptoms. Treatment can be initiated with a wide shoe, an orthotic arch support, or an injection of corticosteroid into the affected web space.Correct Answer: None of the above

 

 

1164. (2790) Q3-3288:

A 62-year-old man presents for treatment of ankle pain. He suffered a fibular fracture 7 months ago while hiking in the mountains. He was treated with a short leg walking cast. On examination, he has pain on range of motion of the ankle, pain over the distal fibula, and no instability or crepitus to range of motion of the ankle. Pain is present on external rotation of the foot under the leg. Radiographs of the ankle demonstrate a healed fibular fracture with 7 mm of shortening and slight external rotation. There is a 7° valgus tilt of the tibiotalar joint and a widening of the medial clear space. The joint space laterally appears slightly narrowed. Recommended treatment includes:

 

1) Total ankle replacement

3) Lengthening osteotomy of the fibula

2) Ankle arthrodesis

5) Ankle arthroscopy

4) Deltoid ligament reconstruction

 

This patient has a malunion of the fibula that does not appear to be associated with ankle arthritis, despite the radiographic changes. The valgus tilt of the ankle joint is common with shortening of the fibula and does not imply arthritis. Therefore, arthrodesis and ankle replacement are not indicated. Lengthening osteotomy of the fibular combined with excision of the medial joint scar is ideal to realign the tibiotalar joint. Although ankle arthroscopy may be performed in conjunction with the fibular osteotomy, it is not sufficient treatment.Correct Answer: Lengthening osteotomy of the fibula

1165. (2791) Q3-3289:

The most common complication following operative treatment of an acute rupture of the Achilles tendon is:

 

1) Wound infection

3) Re-rupture

2) Sural neuritis

5) Thickening of the tendon

4) Excessive dorsiflexion of the foot

 

Although all of the above complications may occur following repair of an acute Achilles rupture, improper tensioning of the repair and stretching of the repair occur most commonly.

This is due to a number of factors including the position of the foot during the repair, incorrect tensioning of the repair, and premature unprotected dorsiflexion of the foot following surgery. When suturing the tendon ends, the sutures must be inserted correctly and not into the frayed tendon ends, which will lead to incorrect tension on the repair. It is preferable to position the foot in slight equinus during the repair.

 

 

 

 

Correct Answer: Excessive dorsiflexion of the foot 1166. (2792) Q3-3290:

 

Slide 1

A 67-year-old obese patient presents for treatment of ankle pain. Twenty-five years ago, he underwent a total ankle replacement. He was asymptomatic for 15 years, and his symptoms have become intolerable. He has limited ankle motion, associated with pain in the ankle. His radiograph is presented (Slide). Which of the following is the preferred surgical procedure:

 

1) Revision total ankle replacement with graft and a larger prosthesis

3) Tibiotalocalcaneal arthrodesis

2) Ankle arthrodesis

5) Removal of the implant

1. Pantalar arthrodesis

    

   Removal of the implant is necessary but will not be sufficient to alleviate pain from arthritis. In this obese patient, an arthrodesis is necessary. An extended hindfoot arthrodesis is only necessary when pain and arthritis are present in joints adjacent to the ankle. An ankle arthrodesis with interposition graft is sufficient.Correct Answer: Ankle arthrodesis

    

    

   1167. (2793) Q3-3291:

   A 53-year-old woman presents for treatment of recurrent symptoms following excision of a third web space interdigital neuroma. She was asymptomatic for 6 months following surgery. On examination, pain is present in the third web space and reproduced with compression of the forefoot. The likelihood of a good result following revision surgery is:

    

   1) 50%

   3) 70%

   2) 60%

2. 90%

4) 80%

 

The reported results following revision surgery following recurrence of symptoms after excision of an interdigital neuroma are poor. In a large series, Stamatis and Myerson reported less than a 50% good outcome following revision surgery.Correct Answer: 50%

 

1168. (2794) Q3-3292:

A patient presents for treatment of a dislocated second metatarsophalangeal joint. Radiographs demonstrate the dislocation. In addition to soft tissue balancing, you perform an oblique shortening osteotomy of the second metatarsal head (Weil). The most common complication following this osteotomy is:

 

1. Recurrent dislocation

3) Arthritis of the second metatarsophalangeal joint

2) Avascular necrosis of the metatarsal head

5) Claw toe deformity

4) Elevation of the second toe

 

The Weil osteotomy is a good procedure to correct deformity about the lesser metatarsophalangeal joint but is associated with potential complications, the most common of which is elevation of the second toe. As a result of shortening and plantar shifting of the metatarsal, the intrinsic muscles shift dorsally and can function as a dorsiflexor of the metatarsophalangeal joint.Correct Answer: Elevation of the second toe

 

 

1169. (2795) Q3-3293:

A 26-year-old professional football player presents for evaluation of ankle pain. He was playing in a match 2 days ago and felt a pop in his ankle. On examination, the peroneal tendon is felt to subluxate anterior to the fibula. Magnetic resonance imaging confirms a tear of the superior peroneal retinaculum. Recommended treatment includes:

 

1) Immobilization in a short leg walking cast

3) Repair of the superior peroneal retinaculum

2) Immobilization in a hinged range of motion walker boot

5) Periosteal-tendon flap repair of the subluxated tendon

4) Deepening of the fibular groove

 

An acute dislocation of the peroneal tendon must be repaired. The results of immobilization are not predictable and, in a professional athlete, the added potential for failure with nonoperative treatment must be considered. With a rupture of the superior peroneal retinaculum likely to be the cause of the dislocation, the peroneal tendon should be repaired. When repair of an acute dislocation is performed, it should not be necessary to deepen the fibular groove.Correct Answer: Repair of the superior peroneal retinaculum

 

 

1170. (2796) Q3-3294:

A patient presents for treatment of a painful hallux. The pain is over the dorsal surface of the hallux metatarsophalangeal joint and is worsened with plantar flexion of the toe. The passive range of motion is 30° of dorsiflexion and 10° of plantarflexion. The radiographs confirm the presence of mild arthritis of the metatarsophalangeal joint, with dorsal osteophytes on the metatarsal head. Which of the following procedures is most likely to be associated with a long-term satisfactory outcome:

 

1) Arthrodesis of the hallux metatarsophalangeal joint

3) Implant hemiarthroplasty

2) Soft tissue interposition arthroplasty

5) Cheilectomy of the metatarsophalangeal joint

4) Total joint arthroplasty

 

The pain present in plantarflexion is common and associated with friction of the capsule against the dorsal osteophytes. This patient has noted only mild arthritis of the metatarsophalangeal joint. An arthrodesis is not a necessary treatment, although it is a reasonable alternative. Implant and interposition arthroplasty are alternatives for the treatment of arthritis of the metatarsophalangeal joint but preferably only when the condition is advanced.Correct Answer: Cheilectomy of the metatarsophalangeal joint

 

1171. (2797) Q3-3295:

 

 

 

Slide 1

This patient is a 17-year-old athlete who presents for treatment of a feeling of giving way of the ankle. The inversion clinical stress is demonstrated below (Slide). Which statement concerning the image presented below is correct:

 

1) Ankle instability is present.

3) Ankle and subtalar instability are present.

2) Subtalar instability is present.

5) No determination of instability can be made from this picture.

4) Generalized ligamentous laxity is present.

 

Although some laxity may be present in this patient, it is impossible to determine whether this is present in the ankle or the subtalar joint based upon this clinical test. Simple inversion stress without simultaneously palpating the lateral shoulder of the talus cannot indicate the presence or the type of instability. An anterior drawer that is positive and, in particular, is associated with a vacuum phenomenon in the anterolateral ankle is more diagnostic of ankle instability.Correct Answer: No determination of instability can be made from this picture.

 

 

1172. (2798) Q3-3296:

 

 

 

Slide 1

What structure is held in between the forceps in this photograph (Slide):

 

1) Anterior talofibular ligament

3) Calcaneofibular ligament

2) Peroneus tertius tendon

5) Interosseous ligament

4) Extensor retinaculum

 

The extensor retinaculum is an important structure in maintaining and possibly augmenting the stability of the lateral ankle and subtalar joint. The inferior root of the extensor retinaculum inserts in the floor of the sinus tarsi, improving stability of the subtalar joint. This structure can be used to augment a repair of ankle instability.Correct Answer: Extensor retinaculum

 

1173. (2799) Q3-3297:

 

 

 

Slide 1

A 37-year-old woman injured her ankle 17 weeks ago when stepping off a sidewalk. She has experienced pain in the ankle since that time, and no treatment has yet been initiated. Presented is a view of the ankle performed with external rotation stress (Slide). The recommended treatment at this time is:

 

1) Repair of the deltoid ligament

3) Screw fixation of the syndesmosis

2) Repair of the deltoid ligament and open reduction of the syndesmosis

5) Open reduction internal fixation of a high fibular fracture and repair of the deltoid ligament

4) Open reduction internal fixation of a high fibular fracture

 

This unstable ankle is associated with a complete disruption of the syndesmosis. With the information available, it is not likely that a high fibular fracture is present. One has to assume that the injury is limited to the syndesmosis. Although the deltoid ligament may be torn, one cannot determine this until the time of surgery. At surgery, if the mortise reduces well following insertion of screw(s), then the deltoid is left alone. If the talus does not reduce, then there may be deltoid tissue that needs to be removed before the reduction can be accomplished.Correct Answer: Screw fixation of the syndesmosis

 

 

1174. (2800) Q3-3298:

 

 

 

Slide 1 Slide 2

A 42-year-old male patient presents with a history of repeated giving way of his ankle. He notes that this has been present for 1 year. He does not experience any pain, even with the episodic bouts of the ankle buckling. On examination, the ankle range of motion is normal, no pain is elicited, and there is no crepitus. A stress radiograph (Slide 1) and a lateral weight-bearing radiograph (Slide 2) are presented. The patient does not want to undergo surgery, but he needs to know the possibility of problems with his ankle in the future. The patient should be advised that:

 

1) A high incidence of subsequent ankle arthritis is likely.

3) He is likely to develop an osteochondral injury of the talus.

2) The episodes of ankle instability will decrease over time.

5) He is not likely to experience any problem other than intermittent giving way of the ankle in the future.

4) His ankle may dislocate with a future inversion injury.

 

Ankle arthritis is rarely idiopathic. In the United States, the most common source of ankle arthritis is following trauma, usually of a major nature. Repetitive ankle injury, particularly when associated with recurrent instability and a varus or cavus foot, will likely lead to the development of ankle arthritis. Patients should be counseled that recurrent instability of the ankle, particularly when osteophytes are already present, frequently leads to arthritis.Correct Answer: A high incidence of subsequent ankle arthritis is likely.

 

1175. (2801) Q3-3299:

 

 

 

Slide 1

A 73-year-old woman states that she has been tripping over her right foot for the past year (Slide). She walks with a limp, and she states that her foot âslapsâ the ground. On examination, weakness in which muscle is likely present:

 

1) Gastrocnemius

3) Posterior tibial

2) Anterior tibial

5) Peroneus longus and brevis

4) Flexor hallucis longus

 

This patient presents with a typical rupture of the anterior tibial tendon. She reports a drop foot, commonly perceived by the patient as a slapping sensation of the foot when attempting to lift the foot up as the heel contacts the ground. Note the slight extension of the hallux, indicating chronic overuse in an attempt to provide accessory dorsiflexion of the ankle.Correct Answer: Anterior tibial

 

 

1176. (2802) Q3-3300:

 

 

 

Slide 1

A 76-year-old man has experienced aching in the anterior aspect of his ankle for 6 months. He felt a sudden onset of soreness 6 months ago. Since then, he has noted weakness of the foot. He walks with a limp, and the foot hits the ground during the heel contact phase of gait. On examination there is a mobile subcutaneous mass in the anterior ankle. The patientâs magnetic resonance image (MRI) is presented (Slide). Which of the following is the most accurate diagnosis:

 

1) A ganglion of the anterior ankle

3) Pigmented villonodular synovitis

2) Synovial sarcoma

5) An accessory extensor hallucis longus

4) A rupture of the anterior tibial tendon

 

This MRI presents the typical appearance of an anterior tibial tendon rupture. There is no continuity of the tendon distally, and the retracted tendon end has formed a scar palpable as a subcutaneous mass. The clinical history of the weakness associated with a drop foot gait is characteristic of the tendon rupture.Correct Answer: A rupture of the anterior tibial tendon

1177. (2803) Q3-3301:

 

 

 

Slide 1

A 23-year-old carpenter fell off a roof 4 weeks ago. He has pain in the ankle and a deformity. The lateral radiograph is presented (Slide). Which of the following treatments is most likely to return this patient to work with a functioning foot and ankle:

 

1) Open reduction internal fixation of the calcaneus fracture

3) Immediate vigorous physical therapy emphasizing range of motion

2) Short leg cast, no weight bearing for 8 weeks, followed by physical therapy

5) Physical therapy, followed by subtalar arthrodesis at 6 months

4) Open reduction internal fixation of the calcaneus fracture with primary subtalar arthrodesis

 

The calcaneus fracture is associated with subluxation of the subtalar joint, giving the appearance of injury to the talus and calcaneus. The true extent of the injury cannot be determined without a computed tomography scan; however, the question is not as to the outcome of treatment, but the ability to return this patient to his occupation. At 4 weeks following injury, while open reduction internal fixation of the fracture is possible, anatomic reduction may be difficult. The most likely means of returning this patient to work is with early arthrodesis, which should be combined with an open reduction internal fixation of the calcaneus.Correct Answer: Open reduction internal fixation of the calcaneus fracture with primary subtalar arthrodesis

 

 

1178. (2804) Q3-3302:

 

 

 

Slide 1 Slide 2

A patient underwent an arthrodesis of the hallux metatarsophalangeal joint for correction of painful arthritis (Slide 1 and Slide 2). She remains symptomatic and cannot walk without pain. The most likely cause for her pain is:

 

1) Fusion of the hallux in too much plantarflexion

3) Fusion of the hallux in too much varus

2) Fusion of the hallux in too much dorsiflexion

5) Removal of too much bone in the metatarsophalangeal joint during fusion, leading to lesser toe metatarsalgia

4) Removal of too much bone in the metatarsophalangeal joint during fusion, leading to claw hallux

 

The ideal position for arthrodesis of the hallux metatarsophalangeal joint is in 5° of valgus, 10° of dorsiflexion relative to the ground, and neutral rotation. Although the hallux is short and may be associated with painful metatarsalgia, the most likely cause of pain is abutment of the hallux against the shoe because it was fused in varus.Correct Answer: Fusion of the hallux in too much varus

1179. (2805) Q3-3303:

 

 

 

Slide 1

A 53-year-old woman presents for treatment of painful toe and metatarsal deformities (Slide). She underwent surgery to the hallux 2 years ago for correction of arthritis of the hallux metatarsophalangeal joint. Pain in the joint persists. She has no systemic disease, and the opposite foot is normal. What is the ideal surgical correction for her forefoot:

 

1) Capsulotomy of the lesser toe metatarsophalangeal joints and extensor tendon lengthening with temporary K-wire fixation

3) Arthrodesis of the hallux metatarsophalangeal joint with interposition bone block graft

2) Resection of the lesser metatarsal heads

5) Revision resection arthroplasty of the hallux and resection of the lesser metatarsal heads

4) Shortening osteotomies of the lesser toe metatarsals and arthrodesis of the hallux metatarsophalangeal joint

 

Resection of the lesser metatarsal heads is an operation that is commonly performed for patients with rheumatoid arthritis; however, this may also be performed for patients with debilitating metatarsalgia in the absence of systemic disease. Capsulotomy and tendon lengthening will not correct the alignment of the lesser toes or address the metatarsalgia. Revision of the resection arthroplasty will not address the metatarsalgia, and recurrent deformity of the hallux is likely. Shortening osteotomies of the metatarsal will decompress the joint, realign the toes, and decrease the metatarsalgia, particularly if performed in conjunction with metatarsophalangeal arthrodesis. A lengthening bone block fusion is not necessary.Correct Answer: Shortening osteotomies of the lesser toe metatarsals and arthrodesis of the hallux metatarsophalangeal joint

 

 

 

1180. (2806) Q3-3304:

A 17-year-old patient presents with pain in the second toe. Pain becomes worse with exercise and has been present for 6 months. On examination, swelling is present around the metatarsophalangeal joint, and pain is present over the joint and upon squeezing the forefoot. Radiographic evaluation demonstrates a lucency in the second metatarsal head. The most likely cause of this condition is:

 

1) Second web space neuroma

3) Stress fracture of the second metatarsal

2) Idiopathic synovitis of the second metatarsophalangeal joint

5) Osteochondrosis of the second metatarsal head

4) Pigmented villonodular synovitis of the second metatarsophalangeal joint

 

This patient has the typical features of Freibergâs osteochondrosis of the second metatarsal head. There is swelling present, which is not noted in association with a neuroma, even though the clinical findings may be similar. Synovitis is common but not associated with radiographic changes.Correct Answer: Osteochondrosis of the second metatarsal head

 

1181. (2900) Q3-3401:

 

 

 

Slide 1 Slide 2 Slide 3

An 11-year-old girl presents with chronic foot pain. Her mother notes that her daughter has had flatfeet since birth, but the condition is worsening. The patient has aching in her foot, the arch of her foot, and her leg with walking and activities. She has been treated for 3 years with various orthotic arch supports. The foot is mobile and flexible on examination. Radiographs (Slide 1 and Slide 2) and a photograph (Slide 3) of her foot are presented. Which of the following surgical treatment alternatives is unacceptable in this patient:

 

1) Excision of an accessory navicular

3) Excision of a middle facet tarsal coalition

2) Subtalar arthroerisis

5) Lateral column lengthening osteotomy of the calcaneus

4) Medial calcaneus osteotomy

 

This patient has a flexible flatfoot deformity associated with a painful accessory navicular. No clinical or radiographic findings of a tarsal coalition are present. In addition to excision of the accessory navicular and advancement of the posterior tibial tendon, either a subtalar arthroerisis or an osteotomy of the calcaneus may be necessary.Correct Answer: Excision of a middle facet tarsal coalition

 

 

1182. (2901) Q3-3402:

 

 

 

Slide 1 Slide 2

A 12-year-old girl was successfully treated for a flexible flatfoot deformity on the left foot. A clinical photograph (Slide 1) of her foot and a lateral radiograph (Slide 2) are presented. What is the purpose of the implant noted under the talus in the radiograph:

 

1) To plantarflex the first metatarsal

3) To restrict eversion of the subtalar joint

2) To tighten the Achilles tendon

5) To improve the alignment of the foot

4) To control sinus tarsi irritation by joint distraction

 

The subtalar arthroerisis, as demonstrated in the radiograph, is used to control eversion of the subtalar joint during the foot flat phase of gait. A subtalar arthroerisis limits excessive eversion but does not restrict subtalar motion further. This procedure is indicated for a patient who has a flexible flatfoot deformity and can be used either as the sole or an adjunctive procedure for correction.Correct Answer: To restrict eversion of the subtalar joint

1183. (2902) Q3-3403:

 

 

 

Slide 1 Slide 2

The patient presented (Slide 1 and Slide 2) has a hereditary sensory motor neuropathy. Based upon the photographs, a surgeon should be able to determine the pattern of muscle weakness. Weakness in which muscle is most likely the cause of this deformity:

 

1) Anterior tibial

3) Gastrocnemius

2) Posterior tibial

5) Peroneus brevis

4) Peroneus longus

 

Although the anterior tibial muscle is weak, the cavus is the predominant deformity of this condition, caused by weakness of the peroneus brevis. The peroneus longus is functioning and is responsible for the plantarflexion of the first metatarsal.Correct Answer: Peroneus brevis

 

 

1184. (2903) Q3-3404:

 

 

 

Slide 1 Slide 2

You are planning a tendon transfer to help correct deformity in a patient with hereditary sensory motor neuropathy. Which of the following muscles will be used for the transfer based upon the clinical appearance of the foot (Slide 1 and Slide 2):

 

1) Posterior tibial

3) Extensor hallucis longus

2) Anterior tibial

5) Flexor hallucis longus

4) Peroneus brevis

 

The posterior tibial tendon transfer is a commonly performed surgery for correction of cavus foot deformity associated with weakness of the anterior tibial muscle and varying degrees of drop foot deformity. The removal of the force of the posterior tibial tendon adds to the correction of the deformity of the foot by balancing the absent peroneus brevis. Although the extensor hallucis longus can be used as a tendon transfer, it will not be the primary muscle used or sufficient to correct deformity.Correct Answer: Posterior tibial

1185. (2904) Q3-3405:

Which combination of muscle weakness is typically associated with hereditary sensory motor neuropathy:

 

1) Anterior tibial, extensor hallucis longus

3) Gastrocnemius, peroneus brevis

2) Peroneus longus, extensor hallucis brevis

5) Anterior tibial, peroneus brevis

4) Posterior tibial, extensor digitorum brevis

 

The peroneus brevis is usually the first muscle to atrophy. Varying patterns of loss of the other muscles of the lower extremity include the anterior tibial and, in particular, the intrinsic foot muscles. Weakness in these muscles accounts for the cavus and the claw foot deformities noted in patients with hereditary sensory motor neuropathy.Correct Answer: Anterior tibial, peroneus brevis

 

 

1186. (2905) Q3-3406:

 

 

 

Slide 1

A 42-year-old man with diabetes presents for treatment of a swollen foot (Slide). He does not recall the onset of swelling, and he states that his foot is not painful. On examination, the foot is hot to touch and swollen. Upon radiographic examination, no deformities are evident. Which of the following treatment options should be used next:

 

1) Short leg cast

3) Biopsy of the midfoot

2) Magnetic resonance image scan

5) Initiation of organism-specific intravenous antibiotic therapy

4) Technetium and indium scan

 

This patient presents with an acute neuroarthropathy. The acute painless swelling, associated with warmth and absence of radiographic findings, is typical of the acute phase of a Charcot process. A short leg cast or a boot to immobilize the foot is ideal, and no weight bearing should be permitted until the acute phase of this neuroarthropathy has subsided.Correct Answer: Short leg cast

 

1187. (2906) Q3-3407:

 

 

 

Slide 1

A 29-year-old woman presents for treatment of a swollen foot. Although her foot is not painful, it has been swollen for 2 weeks. The patient walks into the office without any assistive device. On examination, the foot is swollen and warm. The patient does not have protective sensation in the foot, and she denies a history of diabetes and does not have a clinically relevant medical history. A radiograph of her foot is presented (Slide). Which of the following tests will be most helpful in determining the etiology of her condition:

 

1) Hemoglobin A1

3) White cell count

2) C-reactive protein

5) Spinal fluid analysis from lumbar puncture

4) Sedimentation rate

 

This patient most likely has diabetes. Patients may present for the first time with an acute neuroarthropathy of the foot as a result of diabetes, even without a clinical history of the disease. Although the sedimentation rate will likely be elevated, it will not help in the diagnosis. Infection is not a likely consideration in this patient.Correct Answer: Hemoglobin A1

 

 

1188. (2907) Q3-3408:

 

 

 

Slide 1 Slide 2 Slide 3

A patient with diabetes and severe peripheral neuropathy has been treated for a Charcot ankle deformity for 9 months (Slide 1, Slide 2, and Slide 3). An ankle foot orthosis has been used for 4 months. No skin breakdown occurred in the brace. Swelling is present but has decreased over the past month. Ankle range of motion is limited, and crepitus is present upon examination of the ankle. Which surgical procedure is most consistent with the future treatment of this patient:

 

1) Surgery with tibiotalocalcaneal arthrodesis

3) Surgery with pantalar arthrodesis

2) Surgery with ankle arthrodesis

5) Continued use of an orthosis

4) Talectomy and tibiocalcaneal arthrodesis

 

The indication for surgery is intractable deformity, which is refractory to all forms of bracing. By refractory, one implies that skin breakdown or imminent infection is present. If surgery were performed, then it would consist of a tibiotalocalcaneal arthrodesis. There are no indications for this surgery in this patient. Once the neuropathic process has reached a stable point, a deformity is not likely to progress.Correct Answer: Continued use of an orthosis

 

1189. (2908) Q3-3409:

 

 

 

Slide 1

An 83-year-old woman presents for treatment of a painful second toe deformity. The hallux, the bunion, and the third toe are not painful. A fixed crossover toe deformity is present (Slide), with a dislocation of the second metatarsophalangeal joint noted radiographically. Which procedure is likely to give the patient rapid pain relief:

 

1) Arthrodesis of the hallux metatarsophalangeal joint and resection arthroplasty of the second proximal interphalangeal joint

3) Shortening osteotomies of the second and third metatarsals and interphalangeal arthroplasty

2) Osteotomy of the second toe and metatarsal

5) Resection arthroplasty of the hallux metatarsophalangeal joint

4) Amputation of the second toe at the metatarsophalangeal joint

 

In this age group, amputation of the second toe is a reasonable treatment. It is not possible to correct the second toe deformity without correction of the hallux, either by arthrodesis or arthroplasty at the metatarsophalangeal joint. The hallux is asymptomatic, which is common in this age group, and the simplest treatment is to amputate the toe.Correct Answer: Amputation of the second toe at the metatarsophalangeal joint

 

 

1190. (2909) Q3-3410:

 

 

 

Slide 1

A 60-year-old man experiences pain under the lesser metatarsal heads. Prominence of the metatarsal heads under the second, third, and fourth metatarsal is noted, as well as associated fixed claw toe deformities (Slide). The etiology of the foot pain is:

 

1) Contracture of the long flexor tendons

3) Atrophy of the intrinsic muscles of the foot

2) Fat pad atrophy

5) Idiopathic (the cause is either unknown or not understood)

4) Contracture of the long extensor tendon

 

The cause of claw toe deformity is not idiopathic. Claw toe deformity is a common deformity in adults, particularly in women as a result of lack of use of the intrinsic muscles of the foot, leading to an imbalance between the extrinsic and intrinsic muscles in the foot. As the intrinsic muscle atrophies, the long extensor and flexor tendons cause the deformity (as presented in this patient), with resulting metatarsalgia.Correct Answer: Atrophy of the intrinsic muscles of the foot

 

1191. (2910) Q3-3411:

 

 

 

Slide 1

A patient presents with a claw toe deformity (Slide). What is the strongest flexor of the metatarsophalangeal joint, which in this patient is not functioning adequately:

 

1) Flexor digitorum longus

3) Lumbrical

2) Flexor digitorum brevis

5) Interosseous

4) Volar plate

 

Although the long and short flexor tendons have some effect albeit indirect on the flexion of the metatarsophalangeal joint, the flexor that acts directly on the joint is the interosseous muscle. Intrinsic atrophy will lead to claw toe deformity.Correct Answer: Interosseous

 

 

1192. (2911) Q3-3412:

 

 

 

Slide 1

A 54-year-old woman presents for treatment of an ulcer (Slide). She has diabetes, no protective sensation, and slight deformity of the foot. There is no inflammation of the foot and no purulent drainage. Slight serous oozing is present daily. Initial evaluation and treatment should consist of:

 

1) Ambulation in a total contact cast

3) Bed rest, no weight bearing, and daily dressing changes

2) Biopsy, culture, and organism-specific oral antibiotic therapy

5) Correction of the Charcot foot deformity and antibiotic therapy

4) Ambulation in a stiff-soled surgical shoe with a protective dressing

 

Ambulatory treatment for a patient with diabetes is always the preferable treatment. In this patient, there is no evidence of infection. Unless drainage is purulent and the ulcer is in contact with bone, there should be minimal concern for infection.

Reconstruction of a Charcot deformity of the midfoot is only indicated following repeated failure of nonoperative treatments.Correct Answer: Ambulation in a total contact cast

 

1193. (2912) Q3-3413:

 

 

 

Slide 1

A 63-year-old patient underwent a triple arthrodesis for correction of flatfoot deformity. He presents with continued ankle pain, as well as a hindfoot valgus deformity. The ankle deformity is flexible, and the joint can be reduced. All of the following are reasonable surgical alternatives as a single or staged procedure with the exception of:

 

1) Ankle arthrodesis

3) Total ankle replacement

2) Revision of the triple arthrodesis and translational osteotomy of the calcaneus

5) Peroneal tendon transfer

4) Deltoid ligament repair

 

Repair of a chronically torn deltoid ligament is not sufficient to correct this type of deformity. The ligament has degenerated, and the quality of the ligament is insufficient. Each of the other alternatives is reasonable either performed as the sole or adjunctive procedure.Correct Answer: Deltoid ligament repair

 

 

1194. (2913) Q3-3414:

A 34-year-old patient presents for treatment of painful ankle arthritis. Deformity of the ankle is present with posttraumatic arthritis and 20° of varus deformity as a result of erosion of the distal tibial plafond. There is minimal motion of the subtalar joint, and the forefoot is plantigrade. You plan an ankle arthrodesis. In addition to the position of the ankle arthrodesis, what additional procedure should you consider:

 

1) Subtalar arthrodesis

3) Medial translational calcaneus osteotomy

2) Ankle ligament reconstruction

5) Triple arthrodesis

4) First metatarsal dorsal wedge osteotomy

 

This patient has a fixed deformity of the ankle, as well as the hindfoot. The subtalar joint has adapted to the varus position of the ankle but is stiff. Following the ankle arthrodesis, which has to be performed by bringing the ankle into a few degrees of varus, the forefoot will not be able to compensate for the fixed changes that have taken place in the hindfoot. To keep the forefoot plantigrade, a dorsal wedge osteotomy of the first metatarsal should be performed to keep the foot plantigrade.Correct Answer: First metatarsal dorsal wedge osteotomy

 

 

1195. (2914) Q3-3415:

A 26-year-old woman presents for treatment of ankle arthritis following trauma. She is an active individual despite her arthritis. On examination, her foot is fixed in equinus, no ankle motion is present, and the motion in the subtalar joint is normal. Ankle arthritis is noted radiographically. In a preoperative discussion, she states the desire to have as mobile a foot as possible, wear high heel shoes, and participate in realistic exercise activities. You perform an ankle arthrodesis. What is the ideal position for the arthrodesis:

 

1) 10° of dorsiflexion, 5° of valgus, and neutral rotation

3) 10° of plantarflexion, 10° of valgus, and neutral rotation

2) Neutral dorsiflexion, 15° of valgus, and neutral rotation

5) Neutral dorsiflexion, 5° of valgus, and neutral rotation

4) 10° of plantarflexion, neutral valgus, and 10° of external rotation

 

Regardless of patient activities, desire for shoe wear, and age, the ankle must be fused in a standard position of neutral dorsiflexion and slight valgus. This is important because any deviation of this position, particularly in equinus, will increase the likelihood of arthritis in the talonavicular and subtalar joint.Correct Answer: Neutral dorsiflexion, 5° of valgus, and neutral rotation

 

1196. (2915) Q3-3416:

 

 

 

Slide 1 Slide 2

A 22-year-old man has experienced pain in his foot and ankle for 10 years. His radiographs are presented (Slide 1 and Slide 2). The foot is flexible, and pain is present in the sinus tarsi and along the medial border of the foot. With the subtalar joint held in a reduced neutral position, the forefoot is in 15° of supination. You attempt orthotic arch supports and when these do not alleviate his pain, a brace is suggested. He refuses to wear a brace. You plan an osteotomy of the calcaneus with lengthening bone graft at the neck of the calcaneus (lateral column lengthening). The most common complication following this procedure is:

 

1) Calcaneocuboid joint arthritis

3) Persistent sinus tarsi pain

2) Subtalar arthritis

5) Elevation of the first metatarsal

4) Equinus deformity

 

This patient demonstrates the common finding of fixed forefoot varus associated with a flexible flatfoot deformity. It is likely that a gastrocnemius contracture is also present, but this is not always the case. Arthritis of the calcaneocuboid joint rarely occurs following a lengthening calcaneal osteotomy in an adult. Correction of the forefoot varus is best accomplished with an opening wedge osteotomy of the medial cuneiform. Arthrodesis of the first tarsometatarsal joint may be performed in selected patients with noted instability at this joint.Correct Answer: Elevation of the first metatarsal

 

 

1197. (2916) Q3-3417:

 

 

 

Slide 1 Slide 2 Slide 3

A 44-year-old obese man presents for treatment of acute ankle pain. He does not have a history of trauma or a systemic history of note. His opposite foot has had multiple episodes of acute pain in the past, lasting from 3 to 5 days. On examination, the ankle is warm, swollen, and exquisitely tender to palpation and any range of motion (Slide1, Slide 2, and Slide 3). Concerned about the source of pain, you aspirate the joint and send the sample for analysis. You expect to find:

 

1) Gram-positive cocci

3) Normal joint fluid

2) Gram-negative rods

5) A high red cell count

4) Sodium monourate crystals

 

This patient most likely has an acute attack of gout. The prior episodes of foot pain and the sudden onset lasting 5 days for each bout is characteristic. The ankle is not a common location for gout (the most frequent site is the hallux metatarsophalangeal joint). The treatment should consist of injection of a corticosteroid into the joint and administration of appropriate oral anti-inflammatory medication.Correct Answer: Sodium monourate crystals

 

1198. (2917) Q3-3418:

 

 

 

Slide 1

This patient presents for treatment of a painful hallux varus deformity following correction of hallux valgus deformity (Slide). All of the following procedures may be acceptable surgical alternatives for correction of deformity with the exception of:

 

1) Split extensor hallucis longus tendon transfer

3) Extensor hallucis brevis tendon transfer

2) Abductor hallucis transfer

5) Hallux metatarsophalangeal joint arthrodesis

4) First metatarsal osteotomy

 

The extensor hallucis longus or the extensor hallucis brevis (rarely the abductor hallucis) may be used as a tendon transfer for correction. Arthrodesis of the hallux interphalangeal joint may be performed for correction of a fixed claw deformity of the interphalangeal joint, usually in conjunction with a tendon transfer. Arthrodesis of the metatarsophalangeal joint is a reasonable alternative provided there is no fixed deformity of the interphalangeal joint present and when arthritis or fixed deformity of the metatarsophalangeal joint is present.Correct Answer: First metatarsal osteotomy

 

 

1199. (3084) Q3-3592:

Which of the following is true concerning Achilles tendon ruptures:

 

1) More common in women than men

3) More common in patients using cephalosporins

2) More common on the right side compared to the left

5) Occurs most commonly in normal tendons

1. A common mechanism of injury is sudden forced foot plantarflexion

    

   Important points to remember about Achilles tendon ruptures:

   1. Most common in middle-aged men

   2. Often intermittent sports activity

   3. Left more than right

   4. Often the tendon is abnormal (degenerative)

   5. Mechanism

      1. Sudden forced plantarflexion

      2. Unexpected dorsiflexion

      3. Violent dorsiflexion of the plantar flexed foot Factors which may make the patient more prone to rupture:

1. Steroids

2. Fluoroquinolones

Correct Answer: A common mechanism of injury is sudden forced foot plantarflexion

 

1200. (3085) Q3-3593:

Which of the following is true concerning the repair of acute Achilles tendon ruptures:

 

1) Open treatment has a higher rerupture and infection rate than nonoperative treatment.

3) Open treatment has a lower rerupture rate but higher infection rate compared to nonoperative treatment.

2) Open treatment has a higher rerupture rate but lower infection rate compared to nonoperative treatment.

5) Open treatment has the same rerupture rate compared to nonoperative treatment.

4) Open treatment has a lower rerupture rate and lower infection rate compared to nonoperative treatment.

 

This meta-analysis showed:

Operative versus nonoperative (pooled rates):

Rerupture

Operative 3.5% (6/173) (relative risk 0.27)

Nonoperative 12.6% (23/183)

 

Complications (adhesions, infection, disturbed sensibility) Operative 34.1% (59/173) (relative risk 10.60)

Nonoperative 2.7% (5/183)

 

Infection

Operative 4.0% (7/173) (relative risk 4.89)

Nonoperative 0%

Correct Answer: Open treatment has a lower rerupture rate but higher infection rate compared to nonoperative treatment.

 

 

1201. (3086) Q3-3594:

When counseling a patient concerning the treatment of an acute Achilles tendon rupture, which of the following is true:

 

1) The relative risk of rerupture is 10 times greater in patients treated nonoperatively.

3) The relative risk of complications in the operative group is twice as high as those treated nonoperatively.

2) The relative risk of infection is five times greater in patients treated operatively.

5) The relative risk of rerupture is two times higher with nonoperative treatment.

4) The relative risk of rerupture is equal between the operative and nonoperative treatment.

 

This meta-analysis showed:

Operative versus nonoperative (pooled rates):

Rerupture

Operative 3.5% (6/173) (relative risk 0.27)

Nonoperative 12.6% (23/183)

 

Complications (adhesions, infection, disturbed sensibility) Operative 34.1% (59/173) (relative risk 10.60)

Nonoperative 2.7% (5/183)

 

Infection

Operative 4.0% (7/173) (relative risk 4.89)

Nonoperative 0%

Correct Answer: The relative risk of infection is five times greater in patients treated operatively.

 

1202. (3087) Q3-3595:

Following open repair of an Achilles tendon rupture, which of the following is true:

 

1) Casting alone has a lower risk or rerupture compared to casting followed by functional bracing.

3) There is a higher complication rate in the group treated by casting followed by functional bracing compared to casting alone.

2) Casting alone has a higher rate of rerupture compared to casting followed by functional bracing.

5) Casting followed by functional bracing has an unacceptable rerupture rate.

4) Casting alone has a lower rerupture rate and complication rate compared to casting followed by functional bracing.

 

This meta-analysis showed:

Postoperative splinting: cast alone compared with cast followed by functional bracing Rerupture

Cast alone 5.0% (7/140) (relative risk 2.04) Cast followed by functional bracing 2.3% (3/133)

 

Complications (adhesions, infection, disturbed sensibility):

Cast alone 35.7% (50/140) (relative risk 1.88) Cast followed by functional bracing 19.5% (26/133)

Correct Answer: Casting alone has a higher rate of rerupture compared to casting followed by functional bracing.

 

 

1203. (3095) Q3-3605:

Which of the following is the most useful symptom or sign of a foot compartment syndrome:

 

1) Numbness in the lateral plantar nerve distribution

3) Decreased capillary refill

2) Weakness of toe extension (interossei muscles)

5) Weakness of ankle plantarfexion

4) Severe pain

 

Pain out of proportion to injury is the most reliable indicator of a foot compartment syndrome. Foot compartment syndromes can be difficult to diagnose compared to compartment syndromes of the leg. In the leg, one can rely on motor and nerve testing while motor testing in the foot is difficult secondary to the pain from the injury. The severe pain is usually out of proportion to injury.

Pain suggestive of compartment syndrome includes:

 

Unremitting pain

 

Pain not responsive to increasing doses of narcotics

 

 

Pain that is so severe the patient cannot lie still or cooperate with the examiner Correct Answer: Severe pain

 

1204. (3096) Q3-3606:

Which of the following is the most useful sign in diagnosing a foot compartment syndrome:

 

1) Numbness in the lateral plantar nerve distribution

3) Weakness with toe dorsiflexion

2) Numbness in the medial plantar nerve distribution

5) Severe pain with passive toe flexion

4) Weakness when testing ankle plantarflexion

 

Pain with passive stretch is a reliable sign in compartment syndrome of the leg, foot, and ankle. In Myersonâs study, he found that pain with passive stretch was present in 86% of patients when those intrinsic muscles of the foot were stretched.Correct Answer: Severe pain with passive toe flexion

 

1205. (3097) Q3-3607:

Which of the following compartments are most commonly involved (increased tissue pressure) in compartment syndrome of the foot:

 

1) Superficial

3) Calcaneal

2) Medial

5) First interosseus

4) Adductor

 

The calcaneal compartment is most commonly involved in foot compartment syndromes. Approximately 5% to 10% of calcaneus fractures are complicated by a compartment syndrome. The cancellous bone of the calcaneus may have significant bleeding.

Swelling of the hindfoot can be severe.Correct Answer: Calcaneal

 

 

1206. (3098) Q3-3608:

Which of the following is the most commonly accepted number of foot compartments:

 

1) Three

3) Eight

2) Five

5) Twelve

4) Nine

 

The foot can be divided into nine distinct compartments.

 

1. Calcaneal compartment

   1. Quadratus plantae

   2. Posterior tibial nerve, artery, and vein

   3. Lateral plantar nerve, artery, and vein

   4. Medial plantar nerve (variable)

*Remember that the calcaneal compartment may communicate with the posterior tibial compartment.

1. Interosseiâ(four separate compartments)

2. Adductor muscle

3. Medial

   1. Flexor hallucis brevis

   2. Abductor hallucis

4. Lateral

   1. Abductor digiti minimi

   2. Flexor digiti minimi

5. Superficial

   1. Flexor digitorum brevis

   2. Lumbricals (four)

   3. Flexor digitorum longus

       

   4. Medial plantar nerve (variable) Correct Answer: Nine

1207. (3099) Q3-3609:

Which of the following structures is in the calcaneal compartment of the foot:

 

1) Flexor hallucis

3) Flexor digitorum longus

2) Abductor digiti minimi

5) Flexor digiti minimi

4) Quadratus plantae

 

The foot can be divided into nine distinct compartments.

 

1. Calcaneal compartment

   1. Quadratus plantae

   2. Posterior tibial nerve, artery, and vein

   3. Lateral plantar nerve, artery, and vein

   4. Medial plantar nerve (variable)

      *Remember that the calcaneal compartment may communicate with the posterior tibial compartment.

2. Interosseiâ(four separate compartments)

3. Adductor muscle

4. Medial

   1. Flexor hallucis

   2. Abductor hallucis

5. Lateral

   1. Abductor digiti minimi

   2. Flexor digiti minimi

6. Superficial

   1. Flexor digitorum brevis

   2. Lumbricals (four)

   3. Flexor digitorum longus

       

   4. Medial plantar nerve (variable) Correct Answer: Quadratus plantae

1208. (3100) Q3-3610:

Which of the following structures is in the medial compartment of the foot:

 

1) Abductor digiti minimi

3) Abductor hallucis

2) Flexor digiti minimi

5) Flexor digitorum longus

4) Flexor digitorum brevis

 

The foot can be divided into nine distinct compartments.

 

1. Calcaneal compartment

   1. Quadratus plantae

   2. Posterior tibial nerve, artery, and vein

   3. Lateral plantar nerve, artery, and vein

   4. Medial plantar nerve (variable)

      *Remember that the calcaneal compartment may communicate with the posterior tibial compartment.

2. Interosseiâ(four separate compartments)

3. Adductor muscle

4. Medial

   1. Flexor hallucis

   2. Abductor hallucis

5. Lateral

   1. Abductor digiti minimi

   2. Flexor digiti minimi

6. Superficial

   1. Flexor digitorum brevis

   2. Lumbricals (four)

   3. Flexor digitorum longus

       

   4. Medial plantar nerve (variable) Correct Answer: Abductor hallucis

1209. (3101) Q3-3611:

Which of the following foot compartments communicates with the deep posterior tibial compartment:

 

1) Medial

3) Adductor

2) Lateral

5) Superficial

4) Calcaneal

 

The foot can be divided into nine distinct compartments.

 

1. Calcaneal compartment

   1. Quadratus plantae

   2. Posterior tibial nerve, artery, and vein

   3. Lateral plantar nerve, artery, and vein

   4. Medial plantar nerve (variable)

      *Remember that the calcaneal compartment may communicate with the posterior tibial compartment.

2. Interosseiâ(four separate compartments)

3. Adductor muscle

4. Medial

   1. Flexor hallucis

   2. Abductor hallucis

5. Lateral

   1. Abductor digiti minimi

   2. Flexor digiti minimi

6. Superficial

   1. Flexor digitorum brevis

   2. Lumbricals (four)

   3. Flexor digitorum longus

       

   4. Medial plantar nerve (variable) Correct Answer: Calcaneal

 

1210. (3102) Q3-3612:

A 45-year-old man has severe, unremitting pain after sustaining a displaced calcaneus fracture. He is immobilized in a bulky compression dressing with plaster splints. After removing his dressing, he is noted to have marked swelling with no resolution of his pain. The next step in management is:

 

1) Ice and elevation

3) Application of a foot pump

2) Ice, elevation, and an increase in pain medication

5) Measurement of the calcaneal compartment tissue pressure

4) Epidural block for pain control

 

The patient has the most reliable finding in foot compartment syndromesâunremitting pain that is out of proportion to injury. When patients have unremitting pain following removal of a compression dressing, the compartment pressures should be measured to determine if a compartment syndrome is present.

 

If the tissue pressure is within 30 mm Hg of the diastolic pressure, the pressures are above 30 mm Hg, and a neurological deficit is present, a compartment syndrome has occurred and the patient should undergo an emergency fasciotomy.Correct Answer: Measurement of the calcaneal compartment tissue pressure

 

1211. (3103) Q3-3613:

A 45-year-old man has severe, unremitting pain after sustaining a displaced calcaneus fracture. His hindfoot is swollen. The calcaneal compartment tissue pressure is 47 mm Hg. His diastolic pressure is 70 mm Hg. The next step in management is:

 

1) Ice and elevation

3) Application of a foot pump

2) Ice, elevation, and an increase in pain medication

5) Emergent release of the foot compartments

4) Epidural block for pain control

 

The patient has the most reliable finding in foot compartment syndromesâunremitting pain that is out of proportion to injury. When patients have unremitting pain following removal of a compression dressing, the compartment pressures should be measured to determine if a compartment syndrome is present.

 

If the tissue pressure is within 30 mm Hg of the diastolic pressure, the pressures are above 30 mm Hg, and a neurological deficit is present, a compartment syndrome has occurred and the patient should undergo an emergency fasciotomy.Correct Answer: Emergent release of the foot compartments

 

 

1212. (3104) Q3-3614:

Which of the following groups of muscles are located in the first layer of the foot muscles:

 

1) Abductor hallucis, flexor digitorum brevis, quadratus plantae

3) Abductor, hallucis, flexor digitorum brevis, abductor digiti minimi

2) Flexor hallucis brevis, adductor hallucis, flexor digiti, minimi

5) Abductor hallucis, quadratus plantae, lumbricals

4) Quadratus plantae, lumbricals

 

The muscles of the foot and their innervations are as follows:

First Layer

Abductor hallucis Flexor digitorum brevis Abductor digit minimi	MPN (S2,S3) MPN (S2,S3) LPN (S2,S3)	abducts and flexes flexes lateral four digits abducts and flexes fifth digit
Second Layer
Quadratus plantae	LPN (S2,S3)	flexes lateral. four digits
Lumbricals	Medial one: MPN	flex MTPJ, ext PIP, DIP
Â	Lateral three: LPN	Â
Third Layer
Flexor hallucis brevis	MPN (S2, S3)	flex MTPJ
Adductor hallucis	LPN (S2, S3)	abducts first digit
Flexor digiti minimi	LPN (S2, S3)	flex MTPJ
Fourth Layer
Plantar interossei	LPN (S2,S3)	adducts digits flex MTPJ
Dorsal interossei	LPN (S2,S3)	adducts digits flex MTPJ

 

Abbreviations: MPN=medial plantar nerve, LPN=lateral plantar nerve, MTPJ=metatarsophalangeal joint, PIP=proximal interphalangeal joint, and DIP=distal interphalangeal joint.

Correct Answer: Abductor, hallucis, flexor digitorum brevis, abductor digiti minimi

 

1213. (3105) Q3-3615:

Which of the following muscles are in the second layer of the foot:

 

1) Abductor hallucis, flexor digitorum brevis, abductor digiti minimi

3) Flexor hallucis brevis, abductor hallucis, flexor digiti minimi

2) Abductor hallucis, quadratus plantae

5) Plantar interossei, dorsal interossei

4) Quadratus plantae, lumbricals

 

The muscles of the foot and their innervations are as follows:

First Layer

Abductor hallucis Flexor digitorum brevis Abductor digit minimi	MPN (S2,S3) MPN (S2,S3) LPN (S2,S3)	abducts and flexes flexes lateral four digits abducts and flexes fifth digit
Second Layer
Quadratus plantae	LPN (S2,S3)	flexes lateral. four digits
Lumbricals	Medial one: MPN	flex MTPJ, ext PIP, DIP
Â	Lateral three: LPN	Â
Third Layer
Flexor hallucis brevis	MPN (S2, S3)	flex MTPJ
Adductor hallucis	LPN (S2, S3)	abducts first digit
Flexor digiti minimi	LPN (S2, S3)	flex MTPJ
Fourth Layer
Plantar interossei	LPN (S2,S3)	adducts digits flex MTPJ
Dorsal interossei	LPN (S2,S3)	adducts digits flex MTPJ

 

Abbreviations: MPN=medial plantar nerve, LPN=lateral plantar nerve, MTPJ=metatarsophalangeal joint, PIP=proximal interphalangeal joint, and DIP=distal interphalangeal joint.

Correct Answer: Quadratus plantae, lumbricals

 

1214. (3106) Q3-3616:

Which of the following groups of muscles are in the third layer of the foot:

 

1) Abductor hallucis, flexor digitorum brevis, abductor digiti minimi

3) Flexor hallucis brevis, adductor hallucis, flexor digiti minimi

2) Quadratus plantae, lumbricals

5) Dorsal interossei, plantar interossei

4) Flexor hallucis brevis, quadratus plantae, abductor digiti minimi

 

The muscles of the foot and their innervations are as follows:

First Layer

Abductor hallucis Flexor digitorum brevis Abductor digit minimi	MPN (S2,S3) MPN (S2,S3) LPN (S2,S3)	abducts and flexes flexes lateral four digits abducts and flexes fifth digit
Second Layer
Quadratus plantae	LPN (S2,S3)	flexes lateral. four digits
Lumbricals	Medial one: MPN	flex MTPJ, ext PIP, DIP
Â	Lateral three: LPN	Â
Third Layer
Flexor hallucis brevis	MPN (S2, S3)	flex MTPJ
Adductor hallucis	LPN (S2, S3)	abducts first digit
Flexor digiti minimi	LPN (S2, S3)	flex MTPJ
Fourth Layer
Plantar interossei	LPN (S2,S3)	adducts digits flex MTPJ
Dorsal interossei	LPN (S2,S3)	adducts digits flex MTPJ

 

Abbreviations: MPN=medial plantar nerve, LPN=lateral plantar nerve, MTPJ=metatarsophalangeal joint, PIP=proximal interphalangeal joint, and DIP=distal interphalangeal joint.

Correct Answer: Flexor hallucis brevis, adductor hallucis, flexor digiti minimi

 

1215. (3107) Q3-3617:

Which of the following muscles are innervated by the medial plantar nerve:

 

1) Abductor digiti minimi

3) Abductor hallucis, flexor digitorum brevis, flexor hallucis brevis, medial lumbrical

2) Adductor hallucis, flexor digitorum brevis

5) Plantar interossei, dorsal interossei

4) Adductor hallucis, flexor digiti minimi, plantar interossei

 

The muscles of the foot and their innervations are as follows:

First Layer

Abductor hallucis Flexor digitorum brevis Abductor digit minimi	MPN (S2,S3) MPN (S2,S3) LPN (S2,S3)	abducts and flexes flexes lateral four digits abducts and flexes fifth digit
Second Layer
Quadratus plantae	LPN (S2,S3)	flexes lateral. four digits
Lumbricals	Medial one: MPN	flex MTPJ, ext PIP, DIP
	Lateral three: LPN
Third Layer
Flexor hallucis brevis	MPN (S2, S3)	flex MTPJ
Adductor hallucis	LPN (S2, S3)	abducts first digit
Flexor digiti minimi	LPN (S2, S3)	flex MTPJ
Fourth Layer
Plantar interossei	LPN (S2,S3)	adducts digits flex MTPJ
Dorsal interossei	LPN (S2,S3)	adducts digits flex MTPJ

 

Abbreviations: MPN=medial plantar nerve, LPN=lateral plantar nerve, MTPJ=metatarsophalangeal joint, PIP=proximal interphalangeal joint, and DIP=distal interphalangeal joint.

Correct Answer: Abductor hallucis, flexor digitorum brevis, flexor hallucis brevis, medial lumbrical

 

 

1216. (3108) Q3-3618:

Which of the following is true of interdigital neuromas:

 

1) Interdigital neuromas are a benign neoplasm of the Schwann cell

3) Numbness is a common finding in interdigital neuromas

2) Interdigital neuromas most commonly occur in the second web space

5) There is an equal incidence of interdigital neuromas in men and women

4) Interdigital neuromas most commonly occur in the third web space

 

Discussion

Important core knowledge of interdigital neuroma (Morton's syndrome) includes:

1. Etiology-neither a neuroma nor a tumor; most likely degenerative from repetitive trauma from the transverse intermetatarsal ligament.

   1. Pathology-most commonly perineural fibrosis

2. Most common in the third web space (about 80%)

   1. Medial branch of the lateral plantar nerve joins the lateral branch of medial plantar curve

3. More common in women than men

4. Presentation

   1. Paresthesias, dysesthesias, burning sensation

   2. Diffuse symptoms in forefoot

   3. Pain is relieved by massaging the foot

   4. Numbness occurs as a late finding

5. Physical examination

   1. Tenderness to direct pressure in the web space

   2. Tenderness with forefoot compression

Correct Answer: Interdigital neuromas most commonly occur in the third web space

 

 

1217. (3109) Q3-3619:

Which of the following structures can cause chronic impingement-type posterior ankle pain athletes:

 

1) Flexor digitorum longus

3) Gastrocnemius soleus complex

2) Posterior tibialis

5) Peroneus quartus

4) Peroneus longus

 

Discussion

Posterior impingent can be caused by anomalous muscles. The most common is the peroneus quartus. Here are some important points.

Posterior ankle impingement-compression of the talus and surrounding soft tissues between the tibia and calcaneus

1. Cause-forced or repetitive plantar flexion of the foot

2. Occurs in dancers and athletes

3. Presentation-pain in the medial or lateral aspect of the ankle posteriorly with activities, especially plantar flexion

4. Physical examination-tenderness medial or lateral to the Achilles tendon

5. Diagnosis is difficult to make and often missed because of the following:

   1. Symptoms are reproduced by plantar flexion of the ankle

   2. Injections can be performed to see if the injection relieves the symptoms Anomalous muscles about the ankle

1. Most common is the peroneus quartus (prevalence of the muscle between 7% and 22%)

   1. Arises from peroneus brevis and inserts into retrotrochlear eminence of the calcaneus

2. Peroneocalcaneus internus (1%)

   1. Arises from the fibula and inserts into under surface of sustentaculum tali

3. Long accessory to the long flexors or quadratus plantae (1%-8%)

4. Tibiocalcaneus internus

5. Accessory soleus

Correct Answer: Peroneus quartus

 

1218. (3110) Q3-3620:

Which of the following may cause impingement-type posterior ankle pain in dancers?

 

1) Gastrocnemius-soleus complex

3) Peroneus longus

2) Posterior tibialis

5) Flexor hallucis longus

4) Peroneus brevis

 

Discussion

Posterior ankle impingement caused by compression of the talus and surrounding soft tissues between the tibia and calcaneus. In dancers, symptoms may be caused by a low lying or enlarged flexor hallucis longus muscle.

1. Cause â forced or repetitive plantar flexion of the foot

2. Occurs in dancers and athletes

3. Presentation â pain in the medial or lateral aspect of the ankle posteriorly with activities, especially plantar flexion

4. Physical examination â tenderness medial or lateral to the Achilles tendon

5. Diagnosis is difficult to make and often missed

   1. Symptoms are reproduced by plantar flexion of the ankle

   2. Injections can be performed to see if the injection relieves the symptoms Causes of posterior impingement:

1. Os trigonum

2. Enlarged lateral process of the talus

 

 

Enlarged posterior process of the calcaneus Posterior intermalleolar ligament

 

 

Soft tissue impingement Loose bodies

 

Ganglia

 

 

Low lying flexor hallucis longus muscle body Anomalous muscle bodies

Correct Answer: Flexor hallucis longus

 

1219. (3112) Q3-3622:

Which of the following statements about the gait cycle is true:

 

1) The swing phase is longer than the stance phase and lasts for 62% of the cycle.

3) At heel strike, the anterior tibialis muscle is quiescent.

2) From heel rise to toe-off, the tibia goes into external rotation.

5) From heel strike to toe-off, the transverse tarsal joint unlocks.

4) At toe-off, the gastroc-soleus complex is eccentric contracting.

 

Discussion

 

Because gait cycle questions are common on examinations, remember the following points: Stance phase: 62% of cycle

 

Swing phase: 38% of cycle Muscle firing

Electromyography findings during gait cycle:

Muscle Activity

Heel strike Anterior tibialis

Gastroc-soleus

Foot flat Anterior tibialis Gastroc-soleus

Eccentric contraction Quiet

Quiet

Eccentric contraction

Heel-off Gastroc-soleus Concentric contraction Toe-off Gastroc-soleus Concentric contraction

Subtalar joint

 

 

 

 

Heel strike to foot flat: Three important points Eversion of the subtalar joint Unlocking of the transverse tarsal joint Internal rotation of the tibia

 

 

Heel rise to toe-off

 

 

 

Inversion of the subtalar joint Locking of the transverse tarsal joint External rotation of the tibia

 

Correct Answer: From heel rise to toe-off, the tibia goes into external rotation.

 

1220. (3119) Q3-3630:

Which of the following statements describes the subtalar joint during walking:

 

1) Heel strike to toe-off: Internal rotation of the tibia

3) Heel strike to toe-off: Eversion of the subtalar joint

2) Heel strike to toe-off: Unlocking if transverse tarsal joint

5) Heel rise to toe-off: Locking of the transverse tarsal joint

4) Heel rise to toe-off: Eversion of the subtalar joint

 

Discussion

 

Because gait cycle questions are common on examinations, remember these points: Stance phase: 62% of cycle

 

Swing phase: 38% of cycle Muscle firing

Electromyography findings during gait cycle:

Muscle Activity

Heel strike Anterior tibialis

Gastroc-soleus

Foot flat Anterior tibialis Gastroc-soleus

Eccentric contraction Quiet

Quiet

Eccentric contraction

Heel-off Gastroc-soleus Concentric contraction Toe-off Gastroc-soleus Concentric contraction

Subtalar joint

 

 

 

 

Heel strike to foot flat: Three important points Eversion of the subtalar joint Unlocking of the transverse tarsal joint Internal rotation of the tibia

 

 

Heel rise to toe-off

 

 

 

Inversion of the subtalar joint Locking of the transverse tarsal joint External rotation of the tibia

 

Correct Answer: Heel rise to toe-off: Locking of the transverse tarsal joint

 

 

1221. (3120) Q3-3631:

Which of the following tendons is the main inverter of the hind foot:

 

1) Peroneus longus tendon

3) Flexor hallucis longus tendon

2) Peroneus brevis tendon

5) Posterior tibial tendon

4) Flexor digitorum longus tendon p class="subHeader"> Discussion

The posterior tibial tendon is the main inverter of the hindfoot. To conduct a sensitive test for posterior tibial tendon function, ask

a patient to perform a single leg rise and observe if the hindfoot inverts. Patients with no posterior tibial tendon function are unable to invert the hindfoot on single leg rise.

Correct Answer: Posterior tibial tendon

 

1222. (3121) Q3-3634:

 

 

 

Slide 1 Slide 2 Slide 3 Slide 4

A 35-year-old woman has a swollen and painful small toe. The radiographs of her foot are shown in Slides 1 and 2, and biopsy specimens in Slides 3 and 4. The most likely diagnosis is:

 

1) Enchondroma

3) Chondromyxoid fibroma

2) Plasmacytoma

5) Epidermoid inclusion cyst

4) Chondroblastoma

 

The radiographs show an expansile, lytic destructive lesion, which has replaced the distal and middle phalanxes of the little toe. The biopsy specimen shows the squamous epithelium of the skin with keratin production extending into the medullary cavity of the bone. The patient has an epidermoid inclusion cyst. These cysts are usually secondary to trauma. The treatment should be curettage and grafting.Correct Answer: Epidermoid inclusion cyst

 

 

1223. (3122) Q3-3635:

 

 

 

Slide 1 Slide 2 Slide 3 Slide 4

A 35-year-old woman has a swollen and painful small toe. The radiographs of her foot are shown in Slides 1 and 2, and biopsy specimens are shown in Slides 3 and 4. The most appropriate treatment would be:

 

1) Curettage with or without grafting

3) External beam irradiation

2) Toe amputation

5) Toe amputation and chemotherapy

4) Curettage and external beam irradiation

 

The radiographs show an expansile, lytic destructive lesion, which has replaced the distal and middle phalanxes of the little toe. The biopsy specimen shows the squamous epithelium of the skin with keratin production extending into the medullary cavity of the bone. The patient has an epidermoid inclusion cyst. These cysts are usually secondary to trauma. The treatment should be curettage and grafting.Correct Answer: Curettage with or without grafting

 

1224. (3123) Q3-3636:

Which of the following statements about plantar fasciitis is true:

 

1) Occurs in men more often than in women

3) Normal thickness of the plantar fascia is 15 mm

2) Bilateral involvement is rare

5) Plantar fascia inserts at the base of the metatarsals

4) Plantar fascia supports the medial longitudinal arch

 

Discussion

Plantar fasciitis: General features

 

 

 

Most common cause of heel pain Frequently occurs in athletes Men and women affected equally

 

 

Symptoms are bilateral in 10% of patients Clinical findings

 

Pain on the bottom of the heel

 

 

 

 

Pain is worse with first steps in the morning Pain is worse with weight bearing after sitting Pain is worse with activities of daily living Tenderness over the plantar fascia

 

Pain is worsened by dorsiflexion of the toes

Plantar fascia

 

Broad, thick structure that originates from the medial calcaneal tuberosity and inserts on the plantar plates of the metatarsalphalangeal joints and proximal phalanges

 

Supports the medial longitudinal arch

 

Although the etiology of plantar fasciitis is not known, one theory is excessive stress on the plantar fascia causes micro tears

 

 

Biopsies show fibroblastic proliferation and chronic granulomatous tissue The fascia can be as thick as 15 mm (3 mm is normal)

Correct Answer: Plantar fascia supports the medial longitudinal arch

 

1225. (3124) Q3-3637:

Which of the following statements describes the results of extracorporeal shock wave therapy for chronic plantar fasciitis:

 

1) No improvement in pain scores occurred at 4 or 12 weeks.

3) Pain scores significantly improved at 4 and 12 weeks.

2) No improvement in pain scores occurred at 4 weeks, but significant improvement occurred at 12 weeks.

5) Although pain scores improved, less than 50% of the patients were satisfied.

4) Pain scores improved, but function did not improve.

 

Discussion

In a recent study in Orthopaedics, Furia showed that a significant improvement in pain and function scores occurred in patients who had plantar fasciitis treated with extracorporeal shock wave therapy. Approximately 80% of the patients were satisfied with the treatment and would have the shock wave treatment again.

 

Results

Pain Visual Analog Scale (VAS)

 

 

Pre-treatment VAS 9.2 standard deviation (SD) 0.7 Post-treatment VAS (4 weeks) 3.4 SD 1.9 (P<.05)

 

Post-treatment VAS (12 weeks) 2.4 SD dev 1.8 (P<.05)

RAND Score Physical functioning

 

Pre-treatment 40.4 SD 1.3

 

Post-treatment (4 weeks) 91.5 SD 11.5 (P<.05)

 

Post-treatment (12 weeks) 91.5 SD 10.6 (P<.05) RAND Score Pain

 

Pre-treatment 3.3 SD dev 1.1

 

Post-treatment (4 weeks) 88.6 SD 16 (P<.05)

 

Post-treatment (12 weeks) 90.0 SD 11.6 (P<.05)

 

Patient satisfaction

 

At 4 and 12 weeks post treatment, 49 (82%) patients were satisfied, and all patients would undergo the procedure again.

Correct Answer: Pain scores significantly improved at 4 and 12 weeks.

 

1226. (3125) Q3-3638:

 

 

 

Slide 1 Slide 2 Slide 3

A 40-year-old man has pain in his foot after minor trauma. A radiograph is shown in Slide 1 and biopsy specimens are shown in Slides 2 and 3. The most likely diagnosis is:

 

1) Low-grade chondrosarcoma

3) Enchondroma

2) High-grade chondrosarcoma

5) Chondromyxoid fibroma

4) Chondroblastoma

 

The radiograph shows a lucent lesion in the proximal phalanx of the second toe and expansion of the proximal phalanx. The bone is expanded with a thin periosteal rim. Faint calcifications are also seen within the medullary cavity. This radiographic appearance is characteristic of an enchondroma.

 

The low-power hematoxylin and eosin stain shows abundant blue hyaline matrix and a paucity of cells. The high-power hematoxylin and eosin stain shows the small dark and uniform nuclei present in enchondromas. No pleomorphism or nuclear atypia are present.

 

 

 

 

 

 

 

 

Correct Answer: Enchondroma 1227. (3126) Q3-3639:

 

Slide 1 Slide 2 Slide 3

A 40-year-old man has pain in his foot after minor trauma. A radiograph is shown in Slide 1 and biopsy specimens are shown in Slides 2 and 3. Which of the following would be the most appropriate treatment:

 

1) Curettage and bone grafting

3) Toe amputation

2) Wide resection and allograft reconstruction

5) Curettage, cement augmentation, and external beam irradiation

4) External beam irradiation

 

The radiograph shows a lucent lesion in the proximal phalanx of the second toe and expansion of the proximal phalanx. The bone is expanded with a thin periosteal rim. Faint calcifications are also seen within the medullary cavity. This radiographic appearance is fairly characteristic of an enchondroma.

 

The low-power hematoxylin and eosin stain shows abundant blue hyaline matrix and a paucity of cells. The high-power hematoxylin and eosin stain shows the small dark and uniform nuclei present in enchondromas. No pleomorphism or nuclear atypia are present.

 

Correct Answer: Curettage and bone grafting

 

1228. (3127) Q3-3640:

 

 

 

Slide 1 Slide 2 Slide 3

A 40-year-old man has pain in his foot after minor trauma. A radiograph is shown in Slide 1 and biopsy specimens are shown in Slides 2 and 3. Which of the following best describes this condition:

 

1) Benign bone tumor

3) High-grade malignant bone tumor

2) Low-grade malignant bone tumor

5) Metabolic condition

4) Benign reactive lesion (non-neoplastic)

 

The radiograph shows a lucent lesion in the proximal phalanx of the second toe and expansion of the proximal phalanx. The bone is expanded with a thin periosteal rim. Faint calcifications are also seen within the medullary cavity. This radiographic appearance is fairly characteristic of an enchondroma.

 

The low-power hematoxylin and eosin stain shows abundant blue hyaline matrix and a paucity of cells. The high-power hematoxylin and eosin stain shows the small dark and uniform nuclei present in enchondromas. No pleomorphism or nuclear atypia are present.

 

 

 

 

 

 

 

 

Correct Answer: Benign bone tumor 1229. (3128) Q3-3641:

 

Slide 1 Slide 2 Slide 3

A 35-year-old man has experienced foot pain for 6 months. The anteroposterior and oblique radiographs are shown in Slides 1 and 2, and a biopsy specimen is shown in Slide 3. The most likely diagnosis is:

 

1) Metastatic adenocarcinoma

3) Eosinophilic granuloma (Langerhans cell histiocytosis)

2) Multiple myeloma

5) Hemangioendothelioma

4) Aneursymal bone cyst

 

The radiographs show lytic destructive lesions in the first and second metatarsals. Malignant vascular tumors, such as hemangioendothelioma, characteristically manifest as multiple lytic lesions in the same extremity in young patients.

The biopsy shows vasoformative cells, which are trying to form blood vessels. The correct diagnosis is hemangioendothelioma of bone, which is a low-grade malignancy with a low risk of pulmonary metastases. Patients are typically treated with external beam irradiation. This patient opted for below-knee amputation. He could have also been treated with irradiation.

 

Correct Answer: Hemangioendothelioma

 

1230. (3129) Q3-3642:

 

 

 

Slide 1 Slide 2 Slide 3

A 35-year-old man has foot pain for 6 months. The anteroposterior and oblique radiographs are shown in Slides 1 and 2, and a biopsy specimen is shown in Slide 3. Which of the following treatments is the most appropriate:

 

1) Preoperative chemotherapy and wide resection

3) Chemotherapy and external beam irradiation

2) Wide resection and external beam irradiation

5) External beam irradiation alone

4) Wide resection alone

 

The radiographs show lytic destructive lesions in the first and second metatarsals. Malignant vascular tumors, such as hemangioendothelioma, characteristically manifest as multiple lytic lesions in the same extremity in young patients.

The biopsy shows vasoformative cells, which are trying to form blood vessels. The correct diagnosis is hemangioendothelioma of bone, which is a low-grade malignancy with a low risk of pulmonary metastases. Patients are typically treated with external beam irradiation. This patient opted for below-knee amputation. He could have also been treated with irradiation.

 

 

 

 

 

 

 

 

Correct Answer: External beam irradiation alone 1231. (3130) Q3-3643:

 

Slide 1 Slide 2 Slide 3

A 35-year-old man has foot pain for 6 months. The anteroposterior and oblique radiographs are shown in Slides 1 and 2, and a biopsy specimen is shown in Slide 3. The etiology of this condition is most likely:

 

1) Benign neoplasm

3) High-grade malignant neoplasm

2) Low-grade malignant neoplasm

5) Infectious

4) Post-traumatic

 

The radiographs show lytic destructive lesions in the first and second metatarsals. Malignant vascular tumors, such as hemangioendothelioma, characteristically manifest as multiple lytic lesions in the same extremity in young patients.

The biopsy shows vasoformative cells, which are trying to form blood vessels. The correct diagnosis is hemangioendothelioma of bone, which is a low-grade malignancy with a low risk of pulmonary metastases. Patients are typically treated with external beam irradiation. This patient opted for below-knee amputation. He could have also been treated with irradiation.

 

Correct Answer: Low-grade malignant neoplasm

 

1232. (3131) Q3-3847:

Which of the following medications is an effective alternative to intravenous vancomycin for the treatment of severe soft tissue infections caused by methicillin-resistant Staphylococcus aureus (MRSA):

 

1) Ciprofloxacin

3) Linezolid

2) Dicloxacillin

5) Clindamycin

4) Gentamicin

 

Oral linezolid (600 mg twice a day) is an effective oral alternative to intravenous vancomycin. Below is a summary of a recent prospective, randomized study showing the efficacy of linezolid.

Staphylococcus aureus complicates soft tissue and skin infections. Approximately 30% of S aureus infections are methicillin-resistant. Although vancomycin has been the treatment of choice for MRSA, linezolid inhibits bacterial protein synthesis by blocking formation of the 70S initiation complex and can be administered orally, which is an advantage over vancomycin.

 

This is a single-center study of adult patients. Investigators randomized 60 patients with S aureus (culture proven) to intravenous vancomycin or oral linezolid. The median length of therapy was 10 days. Seven patients in the vancomycin group required amputation, whereas no amputations were performed in the linezolid group. The median length of hospital stay was shorter in the linezolid group, and outpatient therapy was $100 per day less expensive (approximately $6,500 was saved on the hospital stay). A higher clinical cure rate (94%) was reported with the linezolid group compared to 84% with vancomycin.

 

Linezolid is given orally, 600 mg every 12 hours, and it is well tolerated. No adverse effects were reported in this study. Other studies have had similar results. This is an important study for orthopedic surgeons because the number of patients presenting with MRSA infections is increasing. Athletes may be at an increased risk for the infection because of the potential for spread in locker rooms. This can be a limb-threatening infection and must be taken seriously.

 

Correct Answer: Linezolid

 

 

1233. (3132) Q3-3848:

The mechanism of action of linezolid is:

 

1) Inhibition of cell wall synthesis

3) Inhibition of deoxyribonucleic acid synthesis

2) Inhibition of ribonucleic acid synthesis

5) Inhibition of protein prehylation

4) Inhibition of the 70S initiation complex

 

Oral linezolid (600 mg twice a day) is an effective oral alternative to intravenous vancomycin. Below is a summary of a recent prospective, randomized study showing the efficacy of linezolid.

Staphylococcus aureus complicates soft tissue and skin infections. Approximately 30% of S aureus infections are methicillin-resistant. Although vancomycin has been the treatment of choice for methicillin-resistant S aureus (MRSA), linezolid inhibits bacterial protein synthesis by blocking formation of the 70S initiation complex and can be administered orally, which is an advantage over vancomycin.

 

This is a single-center study of adult patients. Investigators randomized 60 patients with S aureus (culture proven) to intravenous vancomycin or oral linezolid. The median length of therapy was 10 days. Seven patients in the vancomycin group required amputation, whereas no amputations were performed in the linezolid group. The median length of hospital stay was shorter in the linezolid group, and outpatient therapy was $100 per day less expensive (approximately $6,500 was saved on the hospital stay). A higher clinical cure rate (94%) was reported with the linezolid group compared to 84% with vancomycin.

 

Linezolid is given orally, 600 mg every 12 hours, and it is well tolerated. No adverse effects were reported in this study. Other studies have had similar results. This is an important study for orthopedic surgeons because the number of patients presenting with MRSA infections is increasing. Athletes may be at an increased risk for the infection because of the potential for spread in locker rooms. This can be a limb-threatening infection and must be taken seriously.

 

Correct Answer: Inhibition of the 70S initiation complex

 

1234. (3133) Q3-3850:

A 25-year-old minor league baseball player has a severe soft tissue infection on the sole of his foot. The infection has not responded to oral cephalexin. There is 4 cm of surrounding erythema and induration, and a small amount of exudate can be expressed. The most likely organism is:

 

1) Streptococcus

3) Methicillin-resistant S aureus (MRSA)

2) Staphyloccus aureus

5) Enteroccocus

4) Corynebacterium

 

Staphylococcus aureus complicates soft tissue and skin infections. Approximately 30% of S aureus infections are methicillin-resistant. Although vancomycin has been the treatment of choice for MRSA, linezolid inhibits bacterial protein synthesis by blocking formation of the 70S initiation complex and can be administered orally, which is an advantage over vancomycin.

 

This is a single-center study of adult patients. Investigators randomized 60 patients with S aureus (culture proven) to intravenous vancomycin or oral linezolid. The median length of therapy was 10 days. Seven patients in the vancomycin group required amputation, whereas no amputations were performed in the linezolid group. The median length of hospital stay was shorter in the linezolid group, and outpatient therapy was $100 per day less expensive (approximately $6,500 was saved on the hospital stay). A higher clinical cure rate (94%) was reported with the linezolid group compared to 84% with vancomycin.

 

Linezolid is given orally, 600 mg every 12 hours, and it is well tolerated. No adverse effects were reported in this study. Other studies have had similar results. This is an important study for orthopedic surgeons because the number of patients presenting with MRSA infections is increasing. Athletes may be at an increased risk for the infection because of the potential for spread in locker rooms. This can be a limb-threatening infection and must be taken seriously.

 

 

 

 

 

 

 

 

 

 

Correct Answer: Methicillin-resistant S aureus (MRSA) 1235. (3134) Q3-3851:

 

Slide 1 Slide 2 Slide 3 Slide 4

A 15-year-old boy has a large mass underneath the toenail of his great toe. His nail is raised and ulceration is present. The plain radiograph is shown in Slide 1, and biopsy specimens are shown in Slides 2, 3, and 4. The most likely diagnosis is:

 

1) Low-grade osteosarcoma

3) Fibrosarcoma

2) High-grade osteosarcoma

5) Subungual exostosis

4) Parosteal osteosarcoma

 

The plain radiograph shows a large bone lesion arising from the dorsal surface of the distal phalanx. This radiographic appearance is characteristic of a subungual exostosis. Osteochondromas do not occur in the distal phalanx, and there is no communication between the lesion and the medullary cavity.

 

The biopsy specimens show the new bone formation and a fibroblastic stroma, which can be confused with osteosarcoma. The diagnosis is subungual exostosis and the treatment is simple excision.

Correct Answer: Subungual exostosis

 

1236. (3135) Q3-3852:

 

 

 

Slide 1 Slide 2 Slide 3 Slide 4

A 15-year-old boy has a large mass underneath the toenail of his great toe. His nail is raised and ulceration is present. The plain radiograph is shown in Slide 1, and biopsy specimens are shown in Slides 2, 3, and 4. Which of the following is the best form of treatment:

 

1) Toe amputation

3) External beam irradiation

2) Preoperative chemotherapy followed by toe amputation

5) Simple excision

4) External beam irradiation and chemotherapy

 

The plain radiograph shows a large bone lesion arising from the dorsal surface of the distal phalanx. This radiographic appearance is characteristic of a subungual exostosis. Osteochondromas do not occur in the distal phalanx, and there is no communication between the lesion and the medullary cavity.

 

The biopsy specimens show the new bone formation and a fibroblastic stroma, which can be confused with osteosarcoma. The diagnosis is subungual exostosis and the treatment is simple excision.

 

 

 

 

 

 

 

 

 

Correct Answer: Simple excision 1237. (3136) Q3-3853:

 

Slide 1 Slide 2 Slide 3 Slide 4

A 15-year-old boy has a large mass underneath the toenail of his great toe. His nail is raised and ulceration is present. The plain radiograph is shown in Slide 1, and biopsy specimens are shown in Slides 2, 3, and 4. Which of the following best describes this condition:

 

1) Low-grade malignancy

3) Inactive benign neoplasm

2) High-grade malignancy

5) Benign reactive condition (non-neoplastic)

4) Aggressive benign neoplasm

 

The plain radiograph shows a large bone lesion arising from the dorsal surface of the distal phalanx. This radiographic appearance is characteristic of a subungual exostosis. Osteochondromas do not occur in the distal phalanx, and there is no communication between the lesion and the medullary cavity.

 

The biopsy specimens show the new bone formation and a fibroblastic stroma, which can be confused with osteosarcoma. The diagnosis is subungual exostosis and the treatment is simple excision.

Correct Answer: Benign reactive condition (non-neoplastic)

 

1238. (3192) Q3-4011:

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

 

1) Open fractures

3) Anterior incision

2) Postoperative wound dehiscence

5) Low energy injury

4) Medial and lateral plating

 

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

 

 

1239. (3193) Q3-4012:

Polyglycolide screws used for fixation of ankle fractures:

 

1) Are associated with a higher rate of sterile effusion than polylactide screws

3) Are not associated with sterile effusion

2) Are associated with a lower rate of sterile effusion than polylactide screws

5) Do not resorb over time

4) Provide more rigid fixation than polylactide screws

 

Polyglycolide screws have a high incidence of sterile effusions as a result of rapid hydrolysis; polylactide screws showed no soft tissue reactions.Correct Answer: Are associated with a higher rate of sterile effusion than polylactide screws

 

 

1240. (3194) Q3-4014:

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

 

1) Fixation with 0.062-inch K-wires

3) Fixation with stainless steel mini-fragment screws

2) Closed reduction

5) Fixation with a stainless steel locking plate

4) Fixation with titanium screws

 

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

 

 

1241. (3195) Q3-4015:

Treatment of significant loss of height and posttraumatic arthritis following nonoperative treatment of calcaneus fractures should include:

 

1) Subtalar distraction bone block arthrodesis

3) Tibiotalocalcaneal arthrodesis

2) Corrective osteotomy

5) Custom orthotics with lateral heel posting

4) Custom Arizona ankle brace with heel lift

 

Management of late loss of height following calcaneus fracture is best addressed by a distraction arthrodesis of the subtalar joint using a wedge-shaped structural bone graft.Correct Answer: Subtalar distraction bone block arthrodesis

 

1242. (3196) Q3-4016:

Incisions made through blood-filled fracture blisters have:

 

1) A lower risk of wound healing problems than clear fluid-filled fracture blisters

3) The same ability to heal as clear fluid-filled fracture blisters

2) No increased risk of wound healing problems than through normal skin

5) Should be left open to heal by secondary intention

4) A higher risk of wound healing problems than clear fluid-filled fracture blisters

 

Biopsies of the edge of fracture blisters following ankle fracture show that blood-filled blisters represent a deeper injury than clear fluid-filled blisters. The dermis of clear blisters still showed some epithelial cells remaining, while the dermis of blood blisters showed no epithelial cells. Therefore, blood-filled blisters are more difficult to heal.Correct Answer: A higher risk of wound healing problems than clear fluid-filled fracture blisters

 

 

1243. (3197) Q3-4017:

The plantar ecchymosis sign is:

 

1) An indication of possible compartment syndrome

3) An indication of possible Lisfranc fracture or sprain

2) An indication of possible compartment syndrome

5) Requires immediate fasciotomy

4) Described as a sign of plantar fascia rupture

 

The plantar ecchymosis sign is described as an ecchymotic area on the plantar midfoot that is indicative of possible injury to the plantar tarsometatarsal ligaments.Correct Answer: An indication of possible Lisfranc fracture or sprain

 

 

1244. (3198) Q3-4018:

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

 

1) Dorsolateral subluxation of the second metatarsal

3) Lateral subluxation of the second metatarsal

2) Dorsal subluxation of the second metatarsal

5) Plantar subluxation of the second metatarsal

4) Medial subluxation of the second metatarsal

 

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

 

 

1245. (3199) Q3-4019:

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

 

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

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

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

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

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

 

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

 

1246. (3200) Q3-4020:

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

 

1) Prolonged cast immobilization and non-weight bearing

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

2) Pulsed electromagnetic fields

5) Rigid carbon fiber shoe inserts

4) Injection of demineralized bone matrix

 

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

 

 

1247. (3201) Q3-4021:

The main blood supply to the talar body is from the:

 

1) Peroneal artery

3) Artery of the tarsal canal

2) Dorsalis pedis artery

5) 1st dorsal metatarsal artery

4) Artery of the sinus tarsi

 

The main blood supply to the body of the talus is the artery of the tarsal canal, which is a branch off the posterior tibial artery. The dorsalis pedis and the artery of the sinus tarsi supply the talar head.Correct Answer: Artery of the tarsal canal

 

 

1248. (3202) Q3-4022:

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

 

1) Two crossed screws from distal to proximal

3) One large screw from posterior to anterior

2) Two parallel screws inserted from distal to proximal

5) One oblique screw from distal to proximal

4) Two parallel screws from posterior to anterior

 

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

 

 

1249. (3203) Q3-4023:

The maximal joint reactive force in the ankle is approximately:

 

1) Two times body weight

3) Five times body weight

2) Three times body weight

5) Eight times body weight

4) Seven times body weight

 

Stauffer and colleagues quantified ankle joint reactive force to be approximately 5 times body weight. This is a significant concern for prosthetic ankle arthroplasty because the implant surface area is relatively small over which these forces must be spread out.Correct Answer: Five times body weight

 

1250. (3204) Q3-4024:

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

 

1) One fracture line in the posterior facet

3) Three fracture lines in the posterior facet

2) Two fracture lines in the posterior facet

5) Five fracture lines in the posterior facet

1. Four fracture lines in the posterior facet

    

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

    

    

   1251. (4058) Q3-4025:

   The incidence of compartment syndrome following calcaneus fracture is:

    

   1) 5%

   3) 15%

   2) 10%

2. 30%

4) 20%

 

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

 

 

1252. (3205) Q3-4026:

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

 

1. Early loss of fixation

3) Syndesmotic irritation

2) Greater wound healing complications

5) Greater risk for nonunion

4) Peroneal tendonitis or peroneal tendon lesions

 

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

 

 

1253. (3206) Q3-4027:

Displaced talar neck fractures should be treated:

 

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

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

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

5) Emergently within 3 hours of injury

4) Emergently within 1 hour of injury

 

A retrospective review of 102 talar neck fractures that underwent open reduction internal fixation showed no decrease in the development of osteonecrosis in fractures that were treated earlier. The mean time to fixation was 3.4 days for patients who had development of osteonecrosis, compared with 5 days for patients who did not have development of osteonecrosis.Correct Answer: There is no correlation between emergent or urgent fixation of talar neck fractures and risk of talar avascular necrosis.

 

1254. (3207) Q3-4028:

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

 

1) 6 weeks

3) 12 weeks

2) 9 weeks

5) 18 weeks

4) 16 weeks

 

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

 

 

1255. (3208) Q3-4029:

Time to radiographic fusion following arthroscopic ankle arthrodesis is:

 

1) Longer than following an open technique arthrodesis

3) The same as open technique

2) Shorter than following an open technique arthrodesis

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

4) Is affected by whether external bone stimulation is utilized

 

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

 

 

1256. (3209) Q3-4030:

Superficial peroneal nerve injury following ankle fracture:

 

1) Does not occur with nonoperative treatment

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

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

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

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

 

One hundred twenty patients with ankle fractures were evaluated. Symptomatic superficial peroneal nerve injury was identified in 21% of patients who underwent open reduction internal fixation and 9% of nonoperatively treated patients. AOFAS scores were decreased in patients with symptomatic superficial peroneal nerve injury. No injuries to the superficial peroneal nerve occurred in patients who underwent surgery involving a posterolateral approach to the fibula.Correct Answer: Can best be avoided during open reduction internal fixation with a posterolateral approach to the fibula

 

 

1257. (3210) Q3-4031:

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

 

1) The presence of medial tenderness on clinical examination

3) The presence of significant medial swelling on clinical examination

2) The presence of medial ecchymosis on clinical examination

5) The presence of lateral malleolus tenderness

4) Evidence of medial clear space widening on stress radiographs

 

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

 

1258. (3211) Q3-4032:

The optimal position for ankle arthrodesis is:

 

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

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

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

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

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

 

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

 

 

1259. (3212) Q3-4033:

Varus malunion following talar neck fracture is best corrected by:

 

1) Subtalar arthrodesis

3) Deltoid ligament release and lateral ligament reconstruction

2) Rotational calcaneal osteotomy with a bone block

5) Lateral column lengthening

4) Talar neck osteotomy with lengthening or by triple arthrodesis

 

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

 

 

1260. (3213) Q3-4034:

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

 

1) Knee joint

3) First metatarsophalangeal joint

2) Naviculocuneiform joint

5) Hindfoot joint

4) Subtalar joint

 

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

 

 

1261. (3214) Q3-4035:

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

 

1) Bohlerâs angle <0°

3) Workersâ compensation

2) Sanders type IV fractures

5) Female gender

4) Initial nonoperative care

 

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

 

1262. (3215) Q3-4036:

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

 

1) Amount of osteophytes resected during surgery

3) Level of tibial and talar saw cuts

2) Meticulous ligament balancing

5) Size of implant

4) Preoperative range of motion

 

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

 

 

1263. (3216) Q3-4037:

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

 

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

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

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

5) Can be discharged with no further follow-up

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

 

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

 

 

1264. (3217) Q3-4038:

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

 

1) The presence of an incongruent ankle joint

3) The presence of an incongruent subtalar joint

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

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

4) The presence of an associated talar body fracture

 

Hawkins type 1 fractures are nondisplaced. Hawkins type 2 fractures have an incongruent subtalar joint. Hawkins type 3 fractures have an incongruent ankle and subtalar joint. Hawkins type 4 fractures have the above injuries and incongruent talo-navicular joint.Correct Answer: Incongruity of the ankle and/or subtalar joint with the presence of a talonavicular dislocation.

 

 

1265. (3218) Q3-4039:

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

 

1) Quadratus plantae muscle

3) Lateral plantar nerve, artery, and vein

2) Posterior tibial nerve, artery, and vein

5) 1st dorsal metatarsal artery

4) Interossei muscles

 

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

 

1266. (3219) Q3-4040:

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

 

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

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

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

5) With immediate fasciotomy

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

 

Forty-three open calcaneal fractures were studied, showing that open reduction internal fixation with plate and screws of type I and type IIA fractures with medial wounds had outcomes similar to closed injuries. Type IIIB open calcaneal fractures should undergo early flap coverage. Early internal fixation should be avoided in these injuries due to the high rates of osteomyelitis and amputation.Correct Answer: With initial washout and subsequent open reduction internal fixation with a lateral plate once the soft tissues and swelling have stabilized

 

 

1267. (3220) Q3-4041:

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

 

1) Is impossible if the fibula has been resected

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

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

5) Requires custom made prosthetic implants

4) Results in minimal gains in ankle range of motion

 

This article studied the success rates of revising previous ankle fusions to ankle replacement. The authors found that if the etiology of a patientâs pain was unclear, the patients did poorly. Patients with prior fibula resection could still be revised to ankle replacement with allograft bone to support the lateral side of the implant. Range of motion following revision to arthroplasty was comparable to primary replacement.Correct Answer: Has a poor clinical success rate if there is no clear underlying cause of pain from the ankle fusion

 

 

1268. (3221) Q3-4042:

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

 

1) A spiral oblique fracture of the lateral malleolus

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

2) Anteroinferior tibiofibular ligament (AITFL) disruption

5) Anterior talo-fibular ligament disruption

4) Deltoid ligament disruption or medial malleolus fracture

 

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

 

 

1269. (3222) Q3-4043:

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

 

1) 0% of patients

3) 50% of patients

2) <25% of patients

5) >75% of patients

4) 75% of patients

 

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

 

1270. (3223) Q3-4044:

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

 

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

3) Are not at risk for causing joint infection

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

5) Cannot be olive wires because of a higher risk for pin-tract infection

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

 

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

9.3 mm and a maximum of 12.2 mm. There was a 100% communication between the distal tibia-fibula joint and the ankle joint.Correct Answer: Should remain >12.2 mm above the subchondral plate of the distal tibia

 

 

1271. (3224) Q3-4045:

Clinical improvement following ankle distraction arthroplasty:

 

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

3) Can take up to 5 years to reach maximal improvement

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

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

4) Is not accompanied by improvement in radiographic joint space

 

Distraction arthroplasty with an Ilizarov external fixator is usually associated with half of the clinical improvement occurring within the first year, and the other half happening over the next 5 years.Correct Answer: Can take up to 5 years to reach maximal improvement

 

 

1272. (3225) Q3-4046:

Failure following supramalleolar osteotomy for ankle arthritis is associated with:

 

1) Inadequate correction and poor cartilage on initial arthroscopy

3) Early weight bearing postoperatively

2) Opening wedge supramalleolar osteotomy with bone graft

5) Use of internal fixation

4) Addition of a fibular osteotomy to the procedure

 

In their clinical series, Takakura and colleagues showed that inadequate correction and initial chondromalacia were predictors of poor outcome following supramalleolar osteotomy.Correct Answer: Inadequate correction and poor cartilage on initial arthroscopy

 

 

1273. (3226) Q3-4047:

Isolated talonavicular fusion:

 

1) Decreases subtalar motion by 25%

3) Locks subtalar motion

2) Decreases subtalar motion by 50%

5) Decreases subtalar motion by 10%

4) Has no effect on subtalar motion

 

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

 

1274. (3227) Q3-4048:

Following triple arthrodesis, ankle range of motion is:

 

1) Unaffected

3) Decreased

2) Increased

5) Increases initially, but then returns to preoperative levels

4) Improves over time

 

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

 

 

1275. (3228) Q3-4049:

Triple arthrodesis is associated with:

 

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

3) Worse patient satisfaction when ankle arthritis is present

2) High rates of nonunion

5) No increased risk for ankle arthritis

4) Development of ankle arthritis over time

 

Saltzman and colleagues followed 67 patients who underwent triple arthrodesis at 44-year follow-up. Nearly all patients had ankle arthritis at final follow-up. Clinical relief of pain deteriorated over time between intermediate 25-year follow-up and 44-year follow-up in the same group of patients.Correct Answer: Development of ankle arthritis over time

 

 

1276. (3229) Q3-4050:

Isolated subtalar arthrodesis:

 

1) Increases transverse tarsal joint over time

3) Decreased talonavicular joint motion but increases calcaneocuboid joint motion

2) Decreases talonavicular motion less than calcaneocuboid motion

5) Increases subtalar motion

4) Decreases talonavicular motion more than calcaneocuboid motion

 

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

 

 

1277. (3230) Q3-4051:

Isolated subtalar fusion:

 

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

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

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

5) Is associated with knee joint degenerative arthritis

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

 

In 48 subtalar fusions followed for 5 years, 36% of patients developed ankle arthritis and 41% of patients developed transverse tarsal joint arthritis.Correct Answer: Is associated with the development of both ankle and transverse tarsal joint arthritis

1278. (3231) Q3-4052:

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

 

1) Development of tarsometatarsal arthritis will not occur.

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

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

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

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

 

In a series of patients who underwent open reduction internal fixation of Lisfranc fracture dislocations, 25% of patients developed midfoot arthritis at final follow-up, but only half of these patients required eventual midfoot arthrodesis.Correct Answer: Tarsometatarsal arthritis may still arise in approximately 25% of patients.

 

 

1279. (3232) Q3-4053:

Which injury is likely to have a worse clinical outcome:

 

1. A purely ligamentous Lisfranc injury

2. A Lisfranc fracture-dislocation

    

   Purely ligamentous Lisfranc injuries have a worse clinical outcome than injuries associated with bony fractures.Correct Answer: A purely ligamentous Lisfranc injury

    

    

   1280. (3233) Q3-4054:

   Hallux rigidus is associated with:

    

   1. Metatarsus primus elevatus

3. Long first metatarsal

   1. First ray hypermobility

   5) Bipartate sesamoid

   4) Flat- or chevron-shaped metatarsal head

    

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

    

    

   1281. (3234) Q3-4055:

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

    

   1) Positive axial grind test on preoperative clinical examination

   3) Osteophytes over the dorsolateral head of the first metatarsal

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

   5) Normal first metatarsophalangeal joint motion

   4) Osteophytes over the dorsal aspect of the proximal phalanx

    

   Coughlin and colleagues recommend that when pain with axial grind testing of the metatarsophalangeal joint is present or >50% loss of articular cartilage occurs intraoperatively, then first metatarsophalangeal arthrodesis should be performed.Correct Answer: Positive axial grind test on preoperative clinical examination

    

   1282. (3235) Q3-4056:

   A Moberg procedure for hallux rigidus is:

    

   1) An oblique first metatarsal shortening osteotomy

   3) A medial closing wedge osteotomy of the proximal phalanx

   2) An ostectomy of the medial eminence of the metatarsal

   5) A lateral closing wedge osteotomy of the proximal phalanx

   4) A dorsal closing wedge osteotomy of the proximal phalanx

    

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

    

    

   1283. (3236) Q3-4057:

   The optimal position for hallux interphalangeal joint arthrodesis is:

    

   1) 5° to 10° of plantarflexion

   3) Neutral flexion

   2) 5° to 10° of dorsiflexion

   5) 10° of valgus

   4) Slight supination of the toe

    

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

    

    

   1284. (3237) Q3-4058:

   First metatarsophalangeal prosthetic joint replacements:

    

   1) Significantly increase joint range of motion

   3) Provide less pain relief than first metatarsophalangeal arthrodesis

   2) Have less complications than first metatarsophalangeal arthrodesis

   5) Provide greater pain relief than first metatarsophalangeal arthrodesis

   4) Have not been found to undergo osteolysis or loosening

    

   First metatarsophalangeal joint replacement in this prospective comparative study performed poorly compared to arthrodesis. Patients with arthroplasties had greater pain and little improvement in range of motion.Correct Answer: Provide less pain relief than first metatarsophalangeal arthrodesis

    

    

   1285. (3327) Q3-4183:

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

    

   1) Open fractures

   3) Anterior incision

   2) Postoperative wound dehiscence

   5) Low energy injury

   4) Medial and lateral plating

    

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

   1286. (3328) Q3-4185:

   Talar body fractures are best classified by a fracture line:

    

   1) That extends superiorly into the trochlea

   3) That extends inferiorly, posterior to the lateral process

   2) That extends anywhere posterior to the talar neck

   5) That extends into the talar head

   4) That extends inferiorly, anterior to the lateral process

    

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

    

    

   1287. (4061) Q3-4186:

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

    

   1) Fixation with 0.062-inch K-wires

   3) Fixation with stainless steel mini-fragment screws

   2) Closed reduction

   5) Fixation with a stainless steel locking plate

   4) Fixation with titanium screws

    

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

    

    

   1288. (3329) Q3-4189:

   The plantar ecchymosis sign is:

    

   1) An indication of possible compartment syndrome

   3) An indication of possible Lisfranc fracture or sprain

   2) Related to a specific bacterial infection

   5) Requires immediate fasciotomy

   4) Described as a sign of plantar fascia rupture

    

   The plantar ecchymosis sign is described as an ecchymotic area on the plantar midfoot that is indicative of possible injury to the plantar tarsometatarsal ligaments.Correct Answer: An indication of possible Lisfranc fracture or sprain

    

    

   1289. (3330) Q3-4190:

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

    

   1) Dorsolateral subluxation

   3) Lateral subluxation

   2) Dorsal subluxation

   5) Plantar subluxation

   4) Medial subluxation

    

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

    

   1290. (3331) Q3-4191:

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

    

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

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

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

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

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

    

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

    

    

   1291. (3332) Q3-4192:

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

    

   1) Prolonged cast immobilization and non-weight bearing

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

   2) Pulsed electromagnetic fields

   5) Rigid carbon fiber shoe inserts

   4) Injection of demineralized bone matrix

    

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

    

    

   1292. (3333) Q3-4194:

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

    

   1) Two crossed screws from distal to proximal

   3) One large screw from posterior to anterior

   2) Two parallel screws inserted from distal to proximal

   5) One oblique screw from distal to proximal

   4) Two parallel screws from posterior to anterior

    

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

    

    

   1293. (3334) Q3-4195:

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

    

   1) One fracture line in the posterior facet

   3) Three fracture lines in the posterior facet

   2) Two fracture lines in the posterior facet

   5) Five fracture lines in the posterior facet

   1. Three fracture lines in the posterior facet

       

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

       

      1294. (3335) Q3-4196:

      The incidence of compartment syndrome following calcaneus fracture is:

       

      1) 5%

      3) 15%

      2) 10%

   2. 30%

4. 20%

    

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

    

    

   1295. (3336) Q3-4197:

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

    

   1) Early loss of fixation

   3) Syndesmotic irritation

   2) Greater wound healing complications

   5) Greater risk for nonunion

   4) Peroneal tendonitis or peroneal tendon lesions

    

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

    

    

   1296. (3337) Q3-4198:

   Displaced talar neck fractures should be treated:

    

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

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

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

   5) Emergently within 3 hours of injury

   4) Emergently within 1 hour of injury

    

   A retrospective review of 102 talar neck fractures that underwent open reduction internal fixation showed no decrease in the development of osteonecrosis in fractures that were treated earlier. The mean time to fixation was 3.4 days for patients who had development of osteonecrosis, compared with 5 days for patients who did not have development of osteonecrosis.Correct Answer: There is no correlation between emergent or urgent fixation of talar neck fractures and risk of talar avascular necrosis.

    

    

   1297. (3338) Q3-4200:

   Superficial peroneal nerve injury following ankle fracture:

    

   1) Does not occur with nonoperative treatment

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

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

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

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

    

   One hundred twenty patients with ankle fractures were evaluated. Symptomatic superficial peroneal nerve injury was identified in 21% of patients who underwent open reduction internal fixation and 9% of nonoperatively treated patients. AOFAS scores were decreased in patients with symptomatic superficial peroneal nerve injury. No injuries to the superficial peroneal nerve occurred in patients who underwent surgery involving a posterolateral approach to the fibula.Correct Answer: Can best be avoided during open reduction internal fixation with a posterolateral approach to the fibula

    

   1298. (3339) Q3-4201:

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

    

   1) The presence of medial tenderness on clinical examination

   3) The presence of significant medial swelling on clinical examination

   2) The presence of medial ecchymosis on clinical examination

   5) The presence of lateral malleolus tenderness

   4) Evidence of medial clear space widening on stress radiographs

    

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

    

    

   1299. (3340) Q3-4202:

   Varus malunion following talar neck fracture is best corrected by:

    

   1) Subtalar arthrodesis

   3) Deltoid ligament release and lateral ligament reconstruction

   2) Rotational calcaneal osteotomy with a bone block

   5) Lateral column lengthening

   4) Talar neck osteotomy with lengthening or by triple arthrodesis

    

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

    

    

   1300. (3341) Q3-4203:

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

    

   1) Bohlerâs angle <0°

   3) Workersâ compensation

   2) Sanders type IV fractures

   5) Female gender

   4) Initial nonoperative care

    

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

    

    

   1301. (3342) Q3-4204:

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

    

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

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

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

   5) Can be discharged with no further follow-up

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

    

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

    

   1302. (3343) Q3-4206:

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

    

   1) Quadratus plantae muscle

   3) Lateral plantar nerve, artery, and vein

   2) Posterior tibial nerve, artery, and vein

   5) 1st dorsal metatarsal artery

   4) Interossei muscles

    

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

    

    

   1303. (3344) Q3-4211:

   Time to radiographic fusion following arthroscopic ankle arthrodesis is:

    

   1) Longer than following an open technique arthrodesis

   3) The same as open technique

   2) Shorter than following an open technique arthrodesis

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

   4) Is affected by whether external bone stimulation is utilized

    

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

    

    

   1304. (3345) Q3-4213:

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

    

   1) Knee joint

   3) First metatarsophalangeal joint

   2) Naviculocuneiform joint

   5) Hindfoot joint

   4) Subtalar joint

    

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

    

    

   1305. (3346) Q3-4214:

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

    

   1) Amount of osteophytes resected during surgery

   3) Level of tibial and talar saw cuts

   2) Meticulous ligament balancing

   5) Size of implant

   4) Preoperative range of motion

    

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

    

   1306. (3347) Q3-4215:

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

    

   1) Is impossible if the fibula has been resected

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

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

   5) Requires custom made prosthetic implants

   4) Results in minimal gains in ankle range of motion

    

   This article studied the success rates of revising previous ankle fusions to ankle replacement. The authors found that if the etiology of a patientâs pain was unclear, the patients did poorly. Patients with prior fibula resection could still be revised to ankle replacement with allograft bone to support the lateral side of the implant. Range of motion following revision to arthroplasty was comparable to primary replacement.Correct Answer: Has a poor clinical success rate if there is no clear underlying cause of pain from the ankle fusion

    

    

   1307. (3348) Q3-4216:

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

    

   1) 0% of patients

   3) 50% of patients

   2) <25% of patients

   5) >75% of patients

   4) 75% of patients

    

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

    

    

   1308. (4062) Q3-4217:

   Clinical improvement following ankle distraction arthroplasty:

    

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

   3) Can take up to 5 years to reach maximal improvement

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

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

   4) Is not accompanied by improvement in radiographic joint space

    

   Distraction arthroplasty with an Ilizarov external fixator is usually associated with half of the clinical improvement occurring within the first year, and the other half happening over the next 5 years.Correct Answer: Can take up to 5 years to reach maximal improvement

    

    

   1309. (3349) Q3-4222:

   Isolated subtalar arthrodesis:

    

   1) Increases transverse tarsal joint over time

   3) Decreased talonavicular joint motion but increases calcaneocuboid joint motion

   2) Decreases talonavicular motion less than calcaneocuboid motion

   5) Increases subtalar motion

   4) Decreases talonavicular motion more than calcaneocuboid motion

    

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

    

   1310. (3350) Q3-4225:

   Which injury is likely to have a worse clinical outcome:

    

   1. A purely ligamentous Lisfranc injury

   2. A Lisfranc fracture-dislocation

       

      Purely ligamentous Lisfranc injuries have a worse clinical outcome than injuries associated with bony fractures.Correct Answer: A purely ligamentous Lisfranc injury

       

       

      1311. (3443) Q3-4368:

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

       

      1. Positive axial grind test on preoperative clinical examination

   3. Osteophytes over the dorsolateral head of the first metatarsal

      1. >50% of the cartilage on the metatarsal head remaining

5. Normal first metatarsophalangeal joint motion

1. Osteophytes over the dorsal aspect of the proximal phalanx

 

Coughlin and colleagues recommend that when pain with axial grind testing of the metatarsophalangeal joint is present or >50% loss of articular cartilage occurs intraoperatively, then first metatarsophalangeal arthrodesis should be performed.Correct Answer: Positive axial grind test on preoperative clinical examination

 

 

1312. (3452) Q3-4380:

The main blood supply to the talar body is from the:

 

1. Peroneal artery

3) Artery of the tarsal canal

2) Dorsalis pedis artery

5) 1st dorsal metatarsal artery

4) Artery of the sinus tarsi

 

The main blood supply to the body of the talus is the artery of the tarsal canal, which is a branch off the posterior tibial artery. The dorsalis pedis and the artery of the sinus tarsi supply the talar head.Correct Answer: Artery of the tarsal canal

 

 

1313. (3460) Q3-4392:

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

 

1) 6 weeks

3) 12 weeks

2) 9 weeks

5) 18 weeks

4) 16 weeks

 

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

 

1314. (3467) Q3-4404:

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

 

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

3) Are not at risk for causing joint infection

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

5) Cannot be olive wires because of a higher risk for pin-tract infection

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

 

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

9.3 mm and a maximum of 12.2 mm. There was a 100% communication between the distal tibia-fibula joint and the ankle joint.Correct Answer: Should remain >12.2 mm above the subchondral plate of the distal tibia

 

 

1315. (3470) Q3-4407:

Treatment of significant loss of height and posttraumatic arthritis following nonoperative treatment of calcaneus fractures should include:

 

1) Subtalar distraction bone block arthrodesis

3) Tibiotalocalcaneal arthrodesis

2) Corrective osteotomy

5) Custom orthotics with lateral heel posting

4) Custom Arizona ankle brace with heel lift

 

Management of late loss of height following calcaneus fracture is best addressed by a distraction arthrodesis of the subtalar joint using a wedge-shaped structural bone graft.Correct Answer: Subtalar distraction bone block arthrodesis

 

 

1316. (3471) Q3-4408:

Incisions made through blood-filled fracture blisters have:

 

1) A lower risk of wound healing problems than clear fluid-filled fracture blisters

3) The same ability to heal as clear fluid-filled fracture blisters

2) No increased risk of wound healing problems than through normal skin

5) Should be left open to heal by secondary intention

4) A higher risk of wound healing problems than clear fluid-filled fracture blisters

 

Biopsies of the edge of fracture blisters following ankle fracture show that blood-filled blisters represent a deeper injury than clear fluid-filled blisters. The dermis of clear blisters still showed some epithelial cells remaining, while the dermis of blood blisters showed no epithelial cells. Therefore, blood-filled blisters are more difficult to heal.Correct Answer: A higher risk of wound healing problems than clear fluid-filled fracture blisters

 

 

1317. (3472) Q3-4409:

Following triple arthrodesis, ankle range of motion is:

 

1) Unaffected

3) Decreased

2) Increased

5) Increases initially, but then returns to preoperative levels

4) Improves over time

 

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

1318. (3473) Q3-4410:

A Moberg procedure for hallux rigidus is:

 

1) An oblique first metatarsal shortening osteotomy

3) A medial closing wedge osteotomy of the proximal phalanx

2) An ostectomy of the medial eminence of the metatarsal

5) A lateral closing wedge osteotomy of the proximal phalanx

4) A dorsal closing wedge osteotomy of the proximal phalanx

 

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

 

 

1319. (3475) Q3-4413:

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

 

1) The presence of an incongruent ankle joint

3) The presence of an incongruent subtalar joint

2) The presence of a talonavicular dislocation

5) The presence of an associated talar body fracture

4) The presence of an associated talar body fracture

 

Hawkins type 1 fractures are nondisplaced. Hawkins type 2 fractures have an incongruent subtalar joint. Hawkins type 3 fractures have an incongruent ankle and subtalar joint. Hawkins type 4 fractures have the above injuries and incongruent talo-navicular joint.Correct Answer: The presence of a talonavicular dislocation

 

 

1320. (3476) Q3-4414:

First metatarsophalangeal prosthetic joint replacements:

 

1) Significantly increase joint range of motion

3) Provide less pain relief than first metatarsophalangeal arthrodesis

2) Have less complications than first metatarsophalangeal arthrodesis

5) Provide greater pain relief than first metatarsophalangeal arthrodesis

4) Have not been found to undergo osteolysis or loosening

 

First metatarsophalangeal joint replacement in this prospective comparative study performed poorly compared to arthrodesis. Patients with arthroplasties had greater pain and little improvement in range of motion.Correct Answer: Provide less pain relief than first metatarsophalangeal arthrodesis

 

 

1321. (3479) Q3-4418:

The optimal position for ankle arthrodesis is:

 

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

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

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

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

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

 

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

 

1322. (3480) Q3-4420:

Isolated talonavicular fusion:

 

1) Decreases subtalar motion by 25%

3) Locks subtalar motion

2) Decreases subtalar motion by 50%

5) Decreases subtalar motion by 10%

4) Has no effect on subtalar motion

 

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

 

 

1323. (3481) Q3-4421:

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

 

1) A spiral oblique fracture of the lateral malleolus

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

2) Anteroinferior tibiofibular ligament (AITFL) disruption

5) Anterior talo-fibular ligament disruption

4) Deltoid ligament disruption or medial malleolus fracture

 

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

 

 

1324. (3482) Q3-4422:

Isolated subtalar fusion:

 

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

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

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

5) Is associated with knee joint degenerative arthritis

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

 

In 48 subtalar fusions followed for 5 years, 36% of patients developed ankle arthritis and 41% of patients developed transverse tarsal joint arthritis.Correct Answer: Is associated with the development of both ankle and transverse tarsal joint arthritis

 

 

1325. (3488) Q3-4428:

The optimal position for hallux interphalangeal joint arthrodesis is:

 

1) 5° to 10° of plantarflexion

3) Neutral flexion

2) 5° to 10° of dorsiflexion

5) 10° of valgus

4) Slight supination of the toe

 

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

1326. (3501) Q3-4451:

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

 

1) Development of tarsometatarsal arthritis will not occur.

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

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

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

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

 

In a series of patients who underwent open reduction internal fixation of Lisfranc fracture dislocations, 25% of patients developed midfoot arthritis at final follow-up, but only half of these patients required eventual midfoot arthrodesis.Correct Answer: Tarsometatarsal arthritis may still arise in approximately 25% of patients.

 

 

1327. (3504) Q3-4455:

The maximal joint reactive force in the ankle is approximately:

 

1) Two times body weight

3) Five times body weight

2) Three times body weight

5) Eight times body weight

4) Seven times body weight

 

Stauffer and colleagues quantified ankle joint reactive force to be approximately 5 times body weight. This is a significant concern for prosthetic ankle arthroplasty because the implant surface area is relatively small over which these forces must be spread out.Correct Answer: Five times body weight

 

 

1328. (3510) Q3-4462:

Hallux rigidus is associated with:

 

1) Metatarsus primus elevatus

3) Long first metatarsal

2) First ray hypermobility

5) Bipartate sesamoid

4) Flat- or chevron-shaped metatarsal head

 

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

 

 

1329. (3742) Q3-7522:

Which nerve is NOT one of the terminal branches of Baxterâs nerve, also known as the first branch of the lateral plantar nerve:

 

1) Nerve to the medial calcaneal periosteum (sensory)

3) Nerve to the flexor digitorum brevis muscle (motor)

2) Lateral dorsal cutaneous nerve (sensory)

5) None of the above

4) Nerve to the abductor digiti minimi muscle (motor)

 

The three terminal branches of Baxterâs nerve are the nerve to the medial calcaneal periosteum, the nerve to the flexor digitorum brevis, and the nerve to the abductor digiti minimi. The lateral dorsal cutaneous nerve is a branch of the sural nerve.

Correct Answer: Lateral dorsal cutaneous nerve (sensory)

 

1330. (3814) Q3-7597:

A regimen of ankle bracing and supervised physical therapy:

 

1) Has no beneficial effect on stage II posterior tibial tendon dysfunction

3) Can significantly relieve pain and increase strength in stage II posterior tibial tendon dysfunction

2) Is helpful in relieving the pain symptoms associated with stage II posterior tibial tendon dysfunction but does not increase strength

5) Prevents patients from requiring surgery in only 11% of cases

4) Is only useful for postoperative rehabilitation after flexor digitorum longus tendon transfer and medial slide calcaneal osteotomy

 

In a study performed by Alvarez and colleagues, 47 patients with stage I or II posterior tibial tendon dysfunction were treated nonoperatively with either a hinged ankle-foot orthosis or foot orthosis and a supervised physical therapy program. After 10 therapy visits, 83% of patients had successful subjective and functional outcomes. Eighty-nine percent of patients were satisfied with the outcome of nonoperative treatment. This included significant improvement in visual analog scale scores and increased strength, concentrically and eccentrically. In this study, 11% of patients failed conservative treatment and required surgery.

 

Correct Answer: Can significantly relieve pain and increase strength in stage II posterior tibial tendon dysfunction

 

 

1331. (3815) Q3-7598:

The use of hyperbaric oxygen (HBO) in the treatment of problematic diabetic foot wounds has been shown to do all of the following except:

 

1) To increase the healing rate

3) To be potentially cost-effective when the costs of long-term care of a nonhealing wound and limb amputation are considered

2) To decrease the amputation rate

5) To increase the juxta-wound pO2

4) To be ineffective in changing the outcome of diabetic foot wounds

 

A meta-analysis of 12 studies showed that healing rates increased from 48% to 76%, and amputation rates decreased from 45% to 19% with the use of hyperbaric oxygen (HBO) and local wound care. In randomized controlled trials, wound area decreased significantly and days to healing decreased significantly in patients treated with HBO. The juxta-wound pO2 was also significantly increased in the HBO-treatment group.

 

Correct Answer: To be ineffective in changing the outcome of diabetic foot wounds

 

 

1332. (3816) Q3-7599:

The greatest insult to the vascular supply of the first metatarsal head during chevron bunionectomy with lateral release according to intraoperative laser Doppler blood flow measurements was:

 

1) During the lateral release

3) During the metatarsal osteotomy

2) During the adductor tenotomy

5) During skin incision

4) During the medial capsular release

 

Twenty patients were prospectively monitored with laser Doppler measurements of metatarsal head blood flow during chevron bunionectomy with lateral release. The greatest loss of blood flow occurred with the medial capsulotomy (45% decrease). The lateral release combined with the adductor tenotomy decreased the blood flow to the metatarsal head by 13%, and the metatarsal osteotomy decreased blood flow by an additional 13%. Total decrease in blood flow to the head was 71%. No patients developed avascular necrosis.

 

Correct Answer: During the medial capsular release

 

1333. (3817) Q3-7600:

In a randomized controlled trial comparing first metatarsophalangeal arthrodesis versus total joint replacement arthroplasty for end-stage hallux rigidus, all of the following statements are true except:

 

1) There was a significant improvement in functional outcome in the arthrodesis group compared to the arthroplasty group.

3) Following arthroplasty, patients tend to bear weight on the lateral border of the foot.

2) Following arthroplasty, there was a significant increase in dorsiflexion compared to preoperative status.

5) Fusion had a lower complication rate than arthroplasty.

1. The cost ratio was 2:1 in favor of arthrodesis.

    

   In the study by Gibson and Thomson, 38 fusions and 39 arthroplasties were prospectively compared at 2-year follow-up. There was an 82% improvement in the arthrodesis group and only a 45% improvement in the arthroplasty group. Fusion also had lower complication rates and lower cost. There was not a significant increase in first metatarsophalangeal joint dorsiflexion between preoperative and postoperative levels following total joint replacement.

    

   Correct Answer: Following arthroplasty, there was a significant increase in dorsiflexion compared to preoperative status.

    

    

   1334. (3818) Q3-7601:

   The nonunion rate for the Lapidus procedure (first tarsometatarsal arthrodesis) for the treatment of moderate to severe hallux valgus is:

    

   1) 2%

   3) 15%

   2) 7%

2. 25%

4) 20%

 

In a prospective cohort study following 105 Lapidus bunionectomies for 3.7 years, the nonunion rate was found to be 6.7%. The American Orthopaedic Foot & Ankle Society scores improved significantly, and loss of correction over 3.7 years was less than 1° for intermetatarsal and hallux valgus angles.

 

Correct Answer: 7%

 

 

1335. (3819) Q3-7602:

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

 

1. Should always traverse the distal tibia-fibula joint for optimal fixation

3) Are not at risk for causing joint infection

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

5) Should remain at least 5 mm above the subchondral plate of the distal tibia

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

 

In a cadaveric and in vivo study of the reflections of the ankle joint capsule, the distal tibia-fibula joint was found to communicate with the ankle joint capsule, thus representing a risk for ankle sepsis if it is penetrated by a transfixion wire. The anterolateral capsule displayed the most proximal reflection in all specimens.

 

Correct Answer: Should remain more than 12.2 mm above the subchondral plate of the distal tibia

 

1336. (3820) Q3-7603:

The best clinical outcome following a primarily ligamentous Lisfranc injury is with:

 

1) Protected weight-bearing and early range of motion in a removable boot

3) Open reduction and internal fixation of the Lisfranc injury

2) Non-weight bearing in a fiberglass cast

5) Primary repair of the ligaments

4) Primary arthrodesis of the Lisfranc injury

 

Forty-one patients were prospectively randomized into traditional open reduction internal fixation (ORIF) versus primary arthrodesis. The American Orthopaedic Foot & Ankle Society scores at 2-year follow-up were significantly better in the fusion group versus the ORIF group. Of the patients in the ORIF group, 25% later developed arthritis and were converted to fusions.

 

Correct Answer: Primary arthrodesis of the Lisfranc injury

 

 

1337. (3821) Q3-7604:

The clinical variable found to be associated with a higher risk of complications following open reduction and internal fixation of unstable ankle fractures in diabetic patients was:

 

1) Presence of a severe fracture pattern

3) Insulin-dependent diabetes mellitus

2) Presence of an open fracture

5) Presence of nephropathy

4) Peripheral neuropathy or vasculopathy

 

A retrospective Level IV study followed 84 patients with diabetes who underwent open reduction internal fixation of unstable ankle fractures. After analyzing multiple patient factors including sex, fracture pattern, open or closed injury, nephropathy, hypertension, vasculopathy, peripheral neuropathy, and diabetic control (insulin-dependent compared with non-insulin-dependent), the only factors that predicted a higher rate of complications were vasculopathy and peripheral neuropathy. There was a 12% rate of postoperative infection and an overall 14% rate of complications.

 

Correct Answer: Peripheral neuropathy or vasculopathy

 

 

1338. (3822) Q3-7605:

Which modality for the treatment of chronic insertional Achilles tendinopathy was shown to have the best clinical outcome:

 

1) Concentric Achilles tendon stretching

3) Short-term immobilization of the ankle in equinus

2) Eccentric Achilles tendon stretching

5) Topical anesthetic

4) Low-energy shockwave therapy

 

A randomized controlled trial compared recalcitrant insertional Achilles tendinopathy treated with eccentric heel cord stretching versus low-energy shockwave therapy. At 4 months, 28% of the stretching group and 64% of the shockwave therapy group reported complete relief of symptoms or greatly improved symptoms. All outcome measures showed favorable results with shockwave therapy.

 

Correct Answer: Low-energy shockwave therapy

 

1339. (3823) Q3-7606:

Urgent closed reduction of ankle fracture-dislocations using intraarticular lidocaine injection:

 

1) Provides a similar degree of analgesia compared to conscious sedation

3) Results in inferior reduction of ankle deformity compared to conscious sedation

2) Requires more time to perform the reduction and splint the leg than with conscious sedation

5) Is painful due to distension of the joint capsule

4) Requires frequent repeat reduction procedures due to persistent fracture malalignment

 

A prospective randomized study compared intraarticular lidocaine injection to conscious sedation for analgesia during reduction of ankle fracture-dislocations. There was no difference in the amount of analgesia provided by the two methods. Time for reduction and splinting was less in the local anesthetic group. Quality of reduction was similar in both groups.

 

Correct Answer: Provides a similar degree of analgesia compared to conscious sedation

 

 

1340. (3865) Q3-7648:

A tailorâs bunion is an abnormal prominence of the lateral aspect of the 5th metatarsal head. Similar to hallux valgus deformities, tailorâs bunions can be due to a widened intermetatarsal angle between the 4th and 5th metatarsal shafts. The normal 4-5 intermetatarsal angle is:

 

1) Less than 8°-9°

3) Less than 15°

2) Less than 12°

5) Less than 25°

4) Less than 20°

 

4-5 intermetarsal angle in normal feet averages 6.2 degrees. Different authors believe an abnormally wide 4-5 intermetatarsal angle to be anything greater than 8°-9°.

Correct Answer: Less than 8°-9°

 

 

1341. (3866) Q3-7649:

A 54-year-old woman with a 10-year history of type II diabetes mellitus develops a Wagner grade 2 ulceration under the first metatarsal head, which has not healed for 3 months. There is no gross cellulitis or drainage. A tagged white blood cell scan shows no signs of osteomyelitis, and noninvasive vascular studies reveal normal hemodynamics. She has failed wet-to-dry normal saline dressings and bacitracin ointment local wound care. The next step in treating this patientâs chronic ulcer is:

 

1) Application of hydro-colloid gel dressings

3) Application of a total contact cast by a qualified physician or cast technician

2) Use of a custom-made pressure off-loading plastizote insole

5) Amoxicillin/clavulanate potassium 875 mg twice daily

4) Regular debridment of the ulcer

 

The description of the ulcer indicates that it is not grossly infected and that there is no underlying bony involvement. According to evidence based medicine, the only treatments that are likely to be effective in the healing of diabetic foot ulcerations are topical growth factors, total contact casting, and for severely infected ulcers hyperbaric oxygen.

 

Correct Answer: Application of a total contact cast by a qualified physician or cast technician

 

1342. (3916) Q3-7796:

Which is the best match in surface topography when performing an osteochondral autograft transplantation procedure from the distal femur to the talar dome for an osteochondral lesion of the talus:

 

1) From the superior-medial femoral condyle to the antero-medial talar dome

3) From the superior-lateral femoral condyle to any position on the medial talar dome

2) From the inferior-medial femoral condyle to the postero-medial talar dome

5) From the inferior-lateral femoral condyle to the antero-medial talar dome

4) From the inferior-medial femoral condyle to the centro-medial talar dome

 

In a magnetic resonance imaging topography study looking for the best corresponding shape of the articular surface between the non-weightbearing femoral condyle and the medial talar dome, plugs from the supero-lateral femoral condyle had the best fit with osteochondral lesions of the medial talus in the anterior, central, and posterior zones.

 

Correct Answer: From the superior-lateral femoral condyle to any position on the medial talar dome

 

 

1343. (3918) Q3-7852:

The most frequent location for osteochondral lesions of the talar dome is:

 

1) Anterolateral talar dome (Raikin zone 3)

3) Lateral talar dome, mid-body (Raikin zone 6)

2) Posteromedial talar dome (Raikin zone 7)

5) Anteromedial talar dome (Raikin zone 1)

4) Medial talar dome, mid-body (Raikin zone 4)

 

A survey of 428 osteochondral lesions of the talus was undertaken using a nine zone anatomical grid system to determine the most frequent location in which these lesions occur. Results showed that 62% of lesions occurred in the medial talar dome and 34% over the lateral talar dome. The most frequent location along the medial dome was the mid-body of the talus. Medial lesions were larger in surface area as well as deeper than lateral lesions.

 

Correct Answer: Medial talar dome, mid-body (Raikin zone 4)

 

 

1344. (3919) Q3-7853:

Which gait parameters are significantly improved following first metatarsophalangeal arthrodesis for symptomatic hallux rigidus:

 

1) Maximal ankle push off power

3) Walking velocity

2) Stride length

5) Foot progression angle

4) Cadence

 

A prospective gait study was performed measuring various gait parameters 1 week prior to and 1 year following first metatarsophalangeal joint arthrodesis. The three significant changes in gait were increased maximal ankle push off power, increased single limb support time on the affected limb, and decreased step width. Stride length, walking velocity, and cadence were not significantly different after fusion.

 

Correct Answer: Maximal ankle push off power

 

1345. (3920) Q3-7855:

Which clinical or radiographic finding is not commonly associated with moderate or severe hallux valgus deformity in adults:

 

1) Positive family history

3) Oval or curved metatarsophalangeal joint on radiographs

2) Presence of bilateral bunion deformity

5) Achilles tendon contracture

4) Longer 1st metatarsal than 2nd metatarsal

 

A clinical series of 122 bunions was evaluated for demographic, etiologic, and radiographic findings associated with moderate to severe hallux valgus deformity. The following findings were reported:

 

 

83% of patients had a positive family history of bunions 84% of patients had bilateral bunion deformities

 

71% of patients had curved or oval-shaped metatarsophalangeal joints

 

 

71% of patients had a longer 1st metatarsal compared to the 2nd metatarsal by an average of 2.4 mm 11% of bunions were associated with an Achilles tendon contracture

Correct Answer: Achilles tendon contracture

 

 

1346. (3921) Q3-7856:

A 58-year-old runner has symptoms of chronic noninsertional Achilles tendinopathy for 8 months. Rest, ice, anti-inflammatory medications, and heel wedges have not helped. Which of the following treatments may help alleviate this patientâs symptoms:

 

1) Concentric Achilles tendon stretching

3) Intratendinous cortisone injection

2) Topical lidocaine patches

5) Oral fluorquinolone therapy

4) Topical glyceryl trinitrate

 

Noninsertional Achilles tendinosis is a noninflammatory degenerative condition that is common in middle-aged athletes. In a 3-year follow-up study examining the use of topical glyceryl trinitrate for Achilles tendinosis, patients were noted to have significantly less tendon tenderness and improved clinical scores compared to the placebo group. At 3 years, 88% of treated patients were asymptomatic. Novel nonoperative measures include sclerosing injections into the Achilles tendon with polidocanol and shock-wave therapy to the Achilles tendon.

 

Correct Answer: Topical glyceryl trinitrate

 

 

1347. (3922) Q3-7858:

When comparing complication rates following operative and nonoperative management of ankle fractures in the elderly (age 65-99):

 

1) Operatively managed patients have a higher mortality rate and a higher rehospitalization rate than conservatively managed patients.

3) Operatively managed patients have a lower mortality rate and a lower rehospitalization rate than conservatively managed patients.

2) Operatively managed patients have a higher mortality rate but a lower rehospitalization rate than conservatively managed patients.

5) Operatively managed patients have a high rate of revision of internal fixation, conversion to arthroplasty or arthrodesis, or amputation.

4) Operatively managed patients have a lower mortality rate but a higher rehospitalization rate than conservatively managed patients.

 

A study using the National Medicare Claims History System was performed looking at outcomes following ankle fracture in 33,704 elderly patients, specifically looking at mortality, rehospitalization, and the need for additional surgery. Researchers found that conservatively managed patients had a higher mortality rate up to 2 years following injury compared to patients who underwent open reduction internal fixation. Operatively treated patients had a higher rate of rehospitalization following their injury. Less than 1% of patients required revision of internal fixation, arthroplasty, arthrodesis, or amputation.

 

Correct Answer: Operatively managed patients have a lower mortality rate but a higher rehospitalization rate than conservatively managed patients.

 

1348. (3923) Q3-7861:

Exposure of tendons to ciprofloxacin in vitro causes all of the following except:

 

1) A decrease in fibroblast proliferation

3) A decrease in proteoglycan synthesis

2) An increase in proteoglycan synthesis

5) A decrease in collagen synthesis

4) An increase in matrix degrading proteolytic activity

 

Ciprofloxacin was shown to cause a decrease in fibroblast proliferation, proteoglycan synthesis, and collagen synthesis. Matrix degrading proteolytic activity was increased.

Correct Answer: An increase in proteoglycan synthesis

 

 

1349. (3924) Q3-7863:

Following first metatarsophalangeal joint cheilectomy for hallux rigidus, which patient parameter is NOT altered compared to preoperative values:

 

1) Shifting of plantar forefoot pressures medially toward the hallux

3) Increased first metatarsophalangeal joint dorsiflexion during gait

2) Increased active dorsiflexion of the first metatarsophalangeal joint

5) Increased hallux abduction

4) Decreased first metatarsophalangeal joint plantarflexion at rest

 

The resting position of the hallux in normal patients is 20° of dorsiflexion relative to the first metatarsal shaft. In patients with hallux rigidus, the resting position is decreased to 10° of dorsiflexion relative to the metatarsal shaft. This relatively plantarflexed position was not improved to a more normal value following cheilectomy.

 

Correct Answer: Decreased first metatarsophalangeal joint plantarflexion at rest

 

 

1350. (3925) Q3-7865:

The Brostrom lateral ligament reconstruction is a reliable technique for primary stabilization of ankle instability. The Gould modification of this technique uses which structure to reinforce the repair:

 

1) One half of the peroneus brevis

3) The calcaneofibular ligament

2) One half of the peroneus longus

5) The posterior inferior tibiofibular ligament

4) The inferior extensor retinaculum

 

The initial description of the Gould modification of the Brostrom procedure recommended âsuturing what one finds (there is always some ligament present) and reinforcing the anterior talofibular ligament repair with overlap of the nearby lateral talocalcaneal ligament plus the marginal ankle retinaculumâ.

 

Correct Answer: The inferior extensor retinaculum

 

1351. (3926) Q3-7868:

Following ankle injury, which radiographic parameter is indicative of syndesmotic instability:

 

1) Medial clear space greater than 2 mm

3) Syndesmotic overlap of less than 1 mm measured 1 cm above the ankle joint on the mortise view

2) Syndesmotic clear space greater than 5 mm measured 2 cm above the ankle joint on the anteroposterior (AP) view

5) Syndesmotic overlap of less than 1 mm measured 1 cm above the ankle joint on the AP view

4) Syndesmotic clear space greater than 5 mm measured 1 cm above the ankle joint on the mortise view

 

 

The normal radiographic findings of the syndesmosis on plain radiographs of the ankle are: Medial clear space less than or equal to 4 mm

 

 

Syndesmotic clear space less than 5 mm measured 1 cm above the ankle joint on the AP view of the ankle Syndesmotic overlap greater than 1 mm measured 1 cm above the ankle joint on the mortise view of the ankle

Correct Answer: Syndesmotic overlap of less than 1 mm measured 1 cm above the ankle joint on the mortise view

 

 

1352. (3927) Q3-7870:

In children between ages 7 and 11 with bilateral flexible flatfeet and without any pathologic findings, the use of custom-made orthotics or off-the-shelf orthotics demonstrate:

 

1) Significant improvement in motor proficiency compared to controls treated without orthotics

3) Significant improvement in exercise efficiency compared to controls treated without orthotics

2) Significant improvement in visual analog pain scores compared to controls treated without orthotics

5) No significant difference compared to controls with regards to motor proficiency, pain, exercise efficiency, or self-perception

4) Significant negative effects on the childâs self-perception compared to controls treated without orthotics

 

In a randomized controlled trial comparing children with flatfeet treated with custom orthotics, off-the-shelf orthotics, and no treatment, there were no differences in the above parameters found. The study concluded that no significant difference was found with regard to motor proficiency, pain, exercise efficiency, or self-perception.

 

Correct Answer: No significant difference compared to controls with regards to motor proficiency, pain, exercise efficiency, or self-perception

 

 

1353. (3928) Q3-7872:

Following open reduction and internal fixation of ankle fractures, early mobilization in a removable cast demonstrated:

 

1) Lower functional scores compared to non-weight bearing cast treatment at 9 and 12 weeks

3) Improved quality of life compared to non-weight bearing cast treatment at 6 months

2) Earlier return to work compared to non-weight bearing cast treatment

5) A lower postoperative rate of infection compared to non-weight bearing cast treatment

4) Lower costs in physical therapy following discontinuation of cast or boot

 

Patients treated with early mobilization in a removable custom fiberglass orthosis (non-weight bearing) had higher early functional scores, earlier return to work, but a higher rate of postoperative wound infection. There were no differences between the two groups with regard to the quality of life at 6 months or the costs of physical therapy.

 

Correct Answer: Earlier return to work compared to non-weight bearing cast treatment

 

1354. (3929) Q3-7874:

In comparing the clinical efficacy of intra-articular sodium hyaluronate injections vs triamcinolone injections for the treatment of hallux rigidus, which factor showed significantly better improvement in the sodium hyaluronate group:

 

1) Gait pain

3) Pain with passive mobilization

2) Pain at rest

5) Pain with palpation

4) Use of analgesics

 

In a prospective randomized study comparing sodium hyaluronate vs cortisone injections for hallux rigidus, gait pain and AOFAS scores were significantly better in the sodium hyaluronate-treated group. There was no significant difference between the two treatment groups with regard to rest pain, pain with mobilization, pain with palpation, and use of analgesics.

 

Correct Answer: Gait pain

 

 

1355. (3930) Q3-7875:

Which anatomical feature does not predispose patients to peroneal tendon dislocation:

 

1) Shallow peroneal groove

3) Peroneus quartus

2) Insufficient superior peroneal retinaculum

5) Varus heel alignment

4) Low-lying peroneus brevis muscle belly

 

A varus heel alignment would stabilize the peroneal tendons medially into the peroneal groove. Valgus heel alignment is associated with increased risk for peroneal tendon dislocation because this predisposes the tendons to move laterally out of the groove. The other anatomical features have all been implicated as risk factors for peroneal tendon dislocation.

 

Correct Answer: Varus heel alignment

 

 

1356. (3931) Q3-7876:

A 39-year-old man has a forced dorsiflexion injury while skiing. Radiographs taken in the emergency department show a small avulsion flake off the lateral surface of the fibula distally on the mortise view. This patient most likely has:

 

1) A lateral process of the talus fracture

3) An anterior process of the calcaneus fracture

2) An osteochondral fracture of the talus

5) A syndesmotic sprain

4) A peroneal tendon dislocation

 

A forced dorsiflexion injury, especially with skiing, is a common mechanism described for peroneal tendon dislocation. All of the diagnoses listed are potential injuries that can initially be mistaken for an ankle sprain. The flake avulsion off of the lateral border of the distal fibula is almost pathognomonic of a peroneal tendon dislocation injury.

 

Correct Answer: A peroneal tendon dislocation

 

1357. (3932) Q3-7877:

Which of the following is not considered to be a risk factor for peroneal tendon tears:

 

1) Shallow retromalleolar groove

3) Ligamentous laxity

2) Gastrocnemius-soleus contracture

5) Recurrent lateral ankle ligament instability

4) Varus hindfoot alignment

 

A shallow retrofibular groove and ligamentous laxity predispose to subluxation of the peroneal tendons causing attritional tears over the posterolateral fibular ridge. Varus hindfoot alignment places patients at risk for inversion sprains, which may cause trauma to the peroneal tendons when they are put on stretch. Heel chord contracture has not been implicated in the development of peroneal tendon tears.

 

Correct Answer: Gastrocnemius-soleus contracture

 

 

1358. (458) Q4-633:

The thoracic outlet syndrome is characterized by:

 

1) The invariable presence of abnormal congenital structures such as cervical ribs or costovertebral synestosis

3) A high incidence of vascular symptoms and a low incidence of neurological symptoms

2) Proximal compression of upper extremity neurologic and vascular structures at one of multiple

5) A frequently identifiable traumatic precipitant.

4) Compression of the subclavian vein between the anterior and middle scalene muscles

 

The thoracic outlet syndrome is a compressive neurovascular disorder of the upper extremity with many possible sites of entrapment. Abnormal congenital structures, macro-, and micro-trauma have all been implicated as possible mechanisms for the process, though none of these factors is an absolute requisite for the disorder. Neurologic symptoms are more common than vascular complaints. The subclavian vein passes anterior to the interscalene interval which contains the subclavian artery and the brachial plexus.Correct Answer: Proximal compression of upper extremity neurologic and vascular structures at one of multiple

 

 

1359. (459) Q4-635:

A typical presentation of thoracic outlet syndrome is likely to include:

 

1) An upper plexus constellation involving median nerve innervated muscles being the most common.

3) Venous obstruction presenting as edema and cyanosis progress to subclavian or axillary vein thrombosis.

2) Sensory loss and diminished strength at initial evaluation

5) Normal somatosensory evoked potentials in the affected extremity

4) Symptoms that are present at rest and alleviated by upper extremity acitivity

 

A lower plexus symptom constellation involving muscles supplied by the ulnar nerve is most typical of thoracic outlet syndrome. Objective signs of sensory loss and diminished strength are often not found. Somatosensory evoked potential abnormalities are common (74%), but are non-specific and may be seen in asymptomatic individuals. Although venous obstruction is rare, it may lead to subclavian or axillary vein thrombosis necessitating fibrinolytic treatment. Symptoms are usually exacerbated by upper extremity activities.Correct Answer: Venous obstruction presenting as edema and cyanosis progress to subclavian or axillary vein thrombosis.

 

 

1360. (460) Q4-636:

Primary treatment of thoracic outlet syndrome should include:

 

1) First rib resection with scalenectomy

3) Psychiatric evaluation

2) Claviculectomy

5) First rib resection without scalenectomy

4) Activity modification and shoulder girdle strengthening

 

Initial treatment of thoracic outlet syndrome is non-operative. Aggravating activities are modified and shoulder girdle strengthening is initiated. Surgery is considered for patients who have failed conservative therapy and suffer intractable pain, and for those who have significant neurologic or vascular deficits. Operative procedures must be tailored to the presumed pathological anatomy; there is no single best procedure.Correct Answer: Activity modification and shoulder girdle strengthening

 

1361. (461) Q4-637:

The term acrosyndactyly describes digits that are:

 

1) Joined by bone only

3) Joined proximally but separated distally

2) Joined by soft tissue only

5) Joined at the tips but separated proximally

4) Joined along the entire length of the web space

 

Acrosyndactyly describes digits that are joined distally but remain separated by a proximal cleft. Acrosyndactylized digits initially develop normal web spaces, but are subsequently joined by secondary events, such as the formation of constriction bands. In contrast to syndactylized fingers, which remain joined due to failure of formation of the web space between contiguous digits, acrosyndactyly may form between non-contiguous digits. Complex syndactyly involves a confluence of distal osseous and nail elements in addition to soft-tissue bridging. Simple syndactyly describes digits that are joined by soft tissue only. Finally, complete syndactyly refers to digits that are joined along their entire lengths, while incomplete syndactyly describes a web that extends more distally than usual, but not all the way to the finger tips.Correct Answer: Joined at the tips but separated proximally

 

 

 

1362. (462) Q4-638:

In normal development, the differentiation of the interdigital web space is influenced by which of the following factors:

 

1) Bone morphogenetic protein (BMP)

3) Interleukin-1 (IL-1)

2) Fibroblast growth factor-3 (FGF-3)

5) Thalidomide

4) Apical ectodermal ridge maintenance factor (AERMF)

 

The distal phalanges are composed of two germ cell layers. Ectodermal cells produce the tuft of the distal phalanx and the nail elements, while mesodermal cells form the epiphysis, physis, and metaphysis. Apical ectodermal ridge maintenance factor (AERMF) is a substance elaborated by the mesenchymal condensations between digits. When AERMF ceases to be produced, the apical ectodermal ridge begins to break apart. This in turn triggers the release of lysosomes which dissolve the mesenchymal connections between the developing digits, completing web space formation.Correct Answer: Apical ectodermal ridge maintenance factor (AERMF)

 

 

1363. (463) Q4-639:

Syndactyly may be isolated, it may be bilateral, or it may occur as part of a broader genetic syndrome. Which of the following syndromes are commonly associated with syndactyly:

 

1) Down syndrome (trisomy-21)

3) Marfan syndrome

2) Polandâs anomaly

5) Hunter syndrome

4) VATER association

 

Individuals afflected by Polandâs anomaly exhibit unilateral symbrachydactyly (simple syndactyly with short or absent middle phalanges), absent sternocostal head of the pectoralis major, and hypoplasia of the ipsilateral breast and nipple. Apertâs syndrome, the other syndrome most commonly associated with syndactyly, is characterized by complex acrosyndactyly of the hands and feet associated with premature closure of the cranial sutures. The features of the VATER association include Verterbral anomalies and or Ventricular septal defect, Anal atresia, T-E fistula, and Renal anomalies and or Radial dysplasia (pre-axial syndactyly is a possible but inconsistent feature). Individuals with Marfan syndrome exhibit arachnodactyly in addition to retinal detachments, lens subluxations, aortic dilatations/aneurysms, and tall stature with long, thin limbs. Hand manifestations of Down syndrome include short metacarpals and phalanges, clinodactyly, and abnormal crease patterns, but not syndactyly. Hunter syndrome (mucopolysaccharidosis II) is marked by stiffened joints and the development of a clawhand, but not by syndactyly.Correct Answer: Polandâs anomaly

 

 

1364. (464) Q4-640:

Surgical separation of syndactylized fingers produces two separate digits with an increase in total surface area. How are the gaps in coverage left by eliminating the common side between the two fingers best addressed:

 

1) Full-thickness skin graft

3) Fascio-cutaneous graft

2) Split-thickness skin graft

5) No graft is necessary; the defects will heal by secondary intention

4) Rotation flap

 

If syndactyly release is to be successful, contractures must be avoided at all costs. Tension-free closures are imperative to this effort. The surface area of two complete fingers is substantially greater than that of two fingers that share a common side, so primary closure of the skin on both sides of the new web is not possible without tension except in very proximal, incomplete syndactylies. For this reason, a strategy other than primary closure is necessary. Healing by secondary intention and split-thickness grafting are both prone to produce contracture. Fascio-cutaneous grafting and rotation flaps are unnecessary, since the defect is confined to the dermal layer. Full-thickness skin graft is least likely to contract, and thus is the material of choice for closing the separated digits.Correct Answer: Full-thickness skin graft

 

 

 

1365. (473) Q4-651:

The      of the brachial plexus emerge between the anterior middle scalane muscles:

 

1) Roots

3) Divisions

2) Trunks

5) Branches

4) Cords

 

After the roots emerge between the anterior scalene muscles, they merge to form trunks. The trunks branch into divisions and then merge into cords in the axilla. The cords branch into nerves.Correct Answer: Roots

 

 

1366. (474) Q4-653:

Dupuytren contracture is a progressive disease involving:

 

1) Proliferative fibrodysplasia of the flexor tendons in the palm.

3) A chronic inflammatory response with an increase in type 2 collagen in the flexor tendon sheath.

2) Pretendinous bands of the palmar aponeurosis which form nodules and cords causing metacarpophalangeal joint contracture.

5) A predilection for young women between the ages of 20 and 40 with exacerbation of symptoms during pregnancy.

4) Contracture beginning distally at the level of the distal interphalangeal joint and extending proximally as the disease progresses.

 

Dupuytren contracture involves proliferative fibrodysplasia of the subcutaneous palmar connective tissue. The flexor tendons are not involved. Pretendinous bands of the palmer aponeurosis form nodules and cords causing metacarpophalangeal joint contracture. The interphalangeal joint can be affected but only rarely is the distal interphalangeal joint involved. There is no inflammatory response but a proliferation of myofibroblasts with an increase in Type 3 collagen. The disease is most often seen in men between the ages of 40 and 60 years old and is associated with epilespy, alcoholism and diabetes. Carpal tunnel syndrome is often seen in young women and can be exacerbated by pregnancy.Correct Answer: Pretendinous bands of the palmar aponeurosis which form nodules and cords causing metacarpophalangeal joint contracture.

 

 

 

1367. (475) Q4-654:

Which of the following statements is true:

 

1) Spinnerâs sign is an early sign of anterior interosseous nerve compression.

3) The ligament of Strutherâs and the arcade of Strutherâs refer to the same structure.

2) Electromyography/nerve conduction velocity is usually normal in pronator syndrome.

5) The pain of pronator syndrome is dull aching in the proximal forearm that is worse with activity and awakens patients at night.

4) Forearm pronation is usually weak with anterior interosseous nerve syndrome.

 

Electromyography/nerve conduction velocity is usually normal in pronator syndrome, but abnormal in anterior interosseous nerve syndrome. The arcade of Struthers describes a possible point of compression of the ulnar nerve. The ligament of Struthers describes a possible point of compression of the median nerve. In AIN syndrome, forearm pronation may be weak due to weakness of the pronator quadratus, but the pronator teres is unaffected. There is no strict correlation between the pain of pronator syndrome and sleeplessness.Correct Answer: Spinnerâs sign is an early sign of anterior interosseous nerve compression.

 

1368. (476) Q4-655:

Initial treatment for De Quervain disease involves:

 

1) Occupational therapy with active range of motion and strengthening of the wrist extensors.

3) Steroid injection of the second dorsal compartment followed by range of motion exercises.

2) Surgical release of the extensor pollicis longus tendon as it wraps around Listerâs tubercle.

5) Surgical release of the first dorsal compartment.

4) Activity modification, steroid injection of the first dorsal compartment, followed by splinting full time for 3 to 4 weeks.

 

Initial treatment for De Quervain tenosynovitis involves rest and splinting with steroid injection into the first dorsal compartment. The splint should be worn as much as possible for 3 to 4 weeks. The extensor carpi radialis brevis has been implicated in lateral epicondulitis. The extensor pollicis longus can be a source of pain as it wraps over the wrist extensor giving the classic symptoms of intersection syndrome between the second and third dorsal compartments. Surgical release is only indicated in persistent cases that have failed conservative management. In 20% to 30% of cases, the first compartment is divided by longitudinal septations into two distinct tunnels. Care must be taken to identify and release both of these tunnels, as well as any multiple tendinous slips, when performing a surgical release.Correct Answer: Activity modification, steroid injection of the first dorsal compartment, followed by splinting full time for 3 to 4 weeks.

 

 

 

1369. (477) Q4-656:

The ulnar nerve arises from:

 

1) The lateral cord of the brachial plexus containing fibers from the C 6 and C 7 nerve roots.

3) The posterior cord of the brachial plexus containing fibers of the C 5 and C 6 nerve roots.

2) The medial cord of the brachial plexus containing fibers from the C 8 and T1 nerve roots.

5) The C 5 through C 7 nerve roots immediately before the upper trunk.

4) The lateral trunk of the brachial plexus containing fibers from C 7 through T1.

 

The ulnar nerve is the continuation of the medial cord of the brachial plexus containing fibers of the C 8 and T1 nerve roots. Radiculopathy at the C 8-T1 level may mimic a more distal compression of the nerve in the cubital tunnel. The axillary and radial nerves come off the posterior cord. There is no lateral trunk of the brachial plexus. The nerve to the rhomboids comes directly off of the C 5 nerve root and its presence is often helpful in differentiating pre-ganglionic from post-ganglionic lesions of the brachial plexus.

 

The lateral cord forms the musculocutaneous nerve. The medial cord forms the ulnar nerve. The medial and lateral cords form the median nerve. The radial nerve arises from the posterior cord.Correct Answer: The medial cord of the brachial plexus containing fibers from the C 8 and T1 nerve roots.

 

 

 

1370. (478) Q4-658:

Which of the following statements is true:

 

1) Posterior interosseous nerve syndrome and radial tunnel syndrome describe the same clinical syndrome with separate causes.

3) The posterior interosseous nerve contains both motor and sensory fibers.

2) The radial nerve spirals around the humeral shaft with the radial artery.

5) The most common site of proximal radial nerve compression is the leash of Henry.

4) Wartenberg's sign and Wartenberg's syndrome are both related to radial nerve compression.

 

The PIN contains motor fibers to the EDC, EDQP, ECU, APL, EPB, EPL, and EIP. Occasionally it gives motor fibers to the ECRB. It terminates with a sensory branch to the carpus and wrist capsule. There is, however, no cutaneous sensation.

In radial tunnel syndrome, the entire radial nerve is compressed, including a sensory component. The radial nerve passes posteriorly and laterally next to the humerus, but not with the radial artery. Wartenberg's sign is an isolated ulnar nerve palsy. This syndrome relates to the compression of the superficial branch of the radial nerve. The most common site of radial nerve compression is the arcade of Frohse.Correct Answer: The posterior interosseous nerve contains both motor and sensory fibers.

 

 

1371. (479) Q4-659:

The treatment of stenosing tenosynovitis should include all of the following except:

 

1) Release of the A1 pulley.

3) Splinting and nonsteroidal anti-inflammatory drugs (NSAIDs).

2) Release of the A1 pulley and flexor tendon tenosynovectomy.

5) Release of the A1 and A2 pulleys.

4) Steroid injections between the flexor tendon and the A1 pulley.

 

The A2 pulley should not be released as part of the treatment for trigger finger. Its presence, along with the A4 pulley, is important in maintaining efficient flexor tendon function. The pathology usually involves the A1 pulley and its release is usually all that is necessary.

 

Other modalities include NSAIDs, splinting, tenosynovectomy, and steroid injections. Correct Answer: Release of the A1 and A2 pulleys.

 

 

1372. (480) Q4-660:

Swan-neck deformity can be caused by which of the following:

 

1) Central slip rupture

3) Acute extensor tendon avulsion fracture

2) Flexor digitorum profundus avulsion fracture (Jersey finger)

5) Metaphalangeal (MP) arthroplasty

4) Dorsal proximal interphalangeal joint dislocation (middle phalanx dorsal to proximal phalanx)

 

A chronic mallet finger results in proximal retraction of the extensor mechanism and overpull of the central slip. Isolated central slip rupture does not cause this deformity. Rupture of the flexor digitorum sublimis can cause Swan-neck deformity. MP arthroplasty is not associated with this deformity. The sequalae of dorsal proximal interphalangeal joint dislocation (e.g., volar plate laxity or deficiency) leads to Swan-neck deformity.Correct Answer: Dorsal proximal interphalangeal joint dislocation (middle phalanx dorsal to proximal phalanx)

 

 

1373. (481) Q4-664:

Which of the following identifies the clinical finding of inadvertent hyperextension of the thumb metaphalangeal joint during attempted thumb-index finger pinch?

 

1) Froment's sign

3) Duchenne's sign

2) Jeanne's sign

5) Wartenberg's sign

4) Pollock's sign

 

Jeanne's sign identifies thumb metaphalangeal joint hyperextension of 10° to 15° with key pinch or gross grip.

Froment's sign refers to the exaggeration of thumb interphalangeal joint flexion during key punch by the flexor pollicis longus in ulnar nerve palsies.

Wartenberg's sign is the inability to adduct the extended small finger due to an ulnar nerve palsy. Duchenne's sign refers to clawing of the ring and small fingers.

Pollock's sign is the inability to flex the distal interphalangeal joints of the ring and small fingers in high palsies.Correct Answer: Jeanne's sign

 

 

1374. (482) Q4-665:

The Bunnell procedure to provide index finger abduction in ulnar nerve palsies refers to:

 

1) Transfer extensor indicis proprius (EIP) to the first dorsal interosseous

3) Transfer extensor pollicis brevis (EPB) to the first dorsal interosseous

2) Split and transfer EIP to the first dorsal interosseous and the adductor pollicis

5) Transfer flexor digitorum sublimis to the proximal phalanx of the thumb

4) Transfer EPB with EIP to the adductor pollicis

 

The Bunnell procedure transfers the EIP to the first dorsal interosseous. Answers B through E refer to the Omer technique, Bruner technique, Abreu technique, and Graham procedure or Riordan procedure, respectively.Correct Answer: Transfer extensor indicis proprius (EIP) to the first dorsal interosseous

 

 

1375. (565) Q4-784:

Ganglions most commonly arise from the:

 

1) Scapholunate interosseous ligament

3) Pisotriquetral joint

2) Scaphotrapezial joint

5) Flexor tendon sheath

4) Dorsal distal interphalangeal joint

 

Sixty percent to 70% of all ganglion cysts occur on the dorsum of the wrist. A majority of ganglions emanate from the scapholunate interosseous ligament. Volar wrist ganglions are prevalent in 16% to 20% of cases, followed by volar retinacular ganglions occurring at the metacarpophalangeal joints and proximal interphalangeal joints (7% to 12%), and mucous cysts presenting dorsally at the level of the joint.Correct Answer: Scapholunate interosseous ligament

 

 

1376. (566) Q4-785:

Pain from a dorsal carpal ganglion is caused by:

 

1) Tendinitis

3) Median nerve impingement

2) Posterior interosseous nerve impingement

5) Mass effect

4) Premalignant synovial degeneration

 

Dorsal carpal ganglions arising from the scapholunate interosseous ligament may expand to a large size without causing significant pain. Alternatively, small ganglions that compress the sensory terminus of the posterior interosseous nerve may be painful. The median nerve, on the volar side of the wrist, is not affected by dorsal ganglions. Dorsal carpal ganglions are benign. They have no potential for malignant degeneration and are not a significant cause of tendinitis.Correct Answer: Posterior interosseous nerve impingement

 

 

1377. (567) Q4-786:

Optimal treatment for a symptomatic ganglion is:

 

1) Observation

3) Aspiration

2) Closed rupture

5) Corticosteroid injection

4) Surgical excision

 

Surgical excision of a symptomatic ganglion, with removal of the entire ganglion stalk and a portion of the joint capsule at its base, reliably relieves pain and has a low recurrence rate (approximately 5%). Closed rupture, while potentially effective, has a recurrence rate of approximately 50%. Ganglions are prone to recur after aspiration, although 3 serial aspirations of a ganglion have been shown to reduce the recurrence rate to about 15%. The addition of corticosteroids to aspiration treatment has not been shown to provide any additional benefit. While observation of painless ganglions is certainly acceptable treatment given their benign prognosis, it is not considered the optimal course for a symptomatic lesion.Correct Answer: Surgical excision

 

1378. (568) Q4-787:

The following pair of tendons is affected in De Quervain disease:

 

1) Extensor pollicis longus and extensor pollicis brevis

3) Abductor pollicis brevis and extensor pollicis longus

2) Abductor pollicis longus and extensor pollicis longus

5) Abductor pollicis longus and extensor pollicis brevis

4) Opponens pollicis and abductor pollicis brevis

 

De Quervain disease affects the tendons in the first dorsal compartment, the extensor pollicis brevis and the abductor pollicis longus (consisting of 2 to 7 individual tendon slips). The extensor pollicis longus traverses the third dorsal compartment. The abductor pollicis brevis and the opponens pollicis are thenar muscles and do not lie within any of the dorsal compartments.Correct Answer: Abductor pollicis longus and extensor pollicis brevis

 

 

1379. (569) Q4-789:

Poor or incomplete resolution of symptoms following first dorsal compartment release for De Quervain disease would most likely occur as a result of:

 

1) Early return to activity

3) Abductor pollicis longus laceration

2) Superficial radial sensory nerve injury

5) Pseudoaneurysm in the radial artery

4) Incomplete release

 

The most common reason for recurrent or persistent symptoms of first dorsal compartment stenosis is failure to recognize and release a separate extensor pollicis brevis subsheath. The superficial radial sensory nerve may be injured in surgery for De Quervain disease, but the resulting neuroma is often more painful than the original symptoms and is of a different character. Abductor pollicis longus laceration would result in loss of radial abduction of the thumb. Early motion of the thumb is recommended following release of the first dorsal compartment.Correct Answer: Incomplete release

 

 

1380. (660) Q4-912:

When performing a tendon transfer to restore thumb index finger lateral pinch in an ulnar nerve palsy, which tendon, when transferred to the 1st dorsal interosseous provides the greatest power?

 

1) Flexor digitorum profundus (FDP)

3) Extensor digitorum communis (EDC)

2) Extensor indicis proprius (EIP)

5) Extensor carpi radialis lingus (ECRL)

4) Extensor carpi radialis brevis (ECRB)

 

The ECRB transfer gives the greatest return of power pinch due to the strength of this wrist motor. This transfer should be coupled with a thumb MP arthrodesis to provide the best results. The ideal pinch transfer is an extensor pollicis brevis to first dorsal interosseous with a metaphalangeal (MP) arthrodesis at the thumb. The FDP and EDC tendons are not good choices because they are not independent tendons. The EIP provides power, but the vector of the transfer is not ideal. Transfer of the ECRL would unbalance the wrist.Correct Answer: Extensor carpi radialis brevis (ECRB)

 

1381. (661) Q4-913:

In the diagnosis of a boutonniere deformity, a patient will not present with:

 

1) Laxity in the intrinsic system leading to passive hyperflexion of the distal interphalangeal joint, with the proximal interphalangeal joint held in extension.

3) Full extension at the proximal interphalangeal joint, with the wrist and metacarpophalangeal joint fully flexed but inability to extend the distal interphalangeal joint with the hand in this position.

2) Ecchymosis at the base of the middle phalanx, with a dorsal avulsion fragment from the middle phalanx base on the x-ray.

5) Pain and swelling over the metacarpophalangeal joint, with full flexion and extension over the proximal interphalangeal joint and distal interphalangeal joint.

4) Active hyperextension at the proximal interphalangeal joint, with full flexion at the distal interphalangeal joint, but no active flexion at the proximal interphalangeal joint.

 

A boutonniere deformity refers to a finger in which the PIP joint is in a flexed position and the DIP joint is in a hyperextended position. These deformities may be acute or chronic. With the exception of answer choice D, all of the other answers describe possible presentations of a patient with boutonniere deformity. A patient with active hyperextension at the PIP joint with full flexion at the DIP joint, but no active flexion at the PIP joint has a swan-neck deformity.Correct Answer: Active hyperextension at the proximal interphalangeal joint, with full flexion at the distal interphalangeal joint, but no active flexion at the proximal interphalangeal joint.

 

 

 

1382. (671) Q4-924:

In the diagnosis of a boutonniere deformity, a patient may present with:

 

1) Laxity in the intrinsic system leading to passive hyperflexion of the distal interphalangeal joint, with the proximal interphalangeal joint held in extension.

3) Full extension at the proximal interphalangeal joint, with the wrist and metacarpophalangeal joint fully flexed but inability to extend the distal interphalangeal joint with the hand in this position.

2) Flexion deformity of the PIP joint with ecchymosis at the base of the middle phalanx, with a dorsal avulsion fragment at the middle phalanx base on radiograph, as well as inability to actively extend the PIP joint.

5) Pain and swelling over the metacarpophalangeal joint, with full flexion and extension over the proximal interphalangeal joint and distal interphalangeal joint.

4) Active hyperextension at the proximal interphalangeal joint, with full flexion at the distal interphalangeal joint, but no active flexion at the proximal interphalangeal joint.

 

A bony boutonniere injury is a fracture of the base of middle phalanx with the central slip of the extensor mechanism attached. With this injury, the patient is unable to actively extend the PIP joint from its flexed position.Correct Answer: Flexion deformity of the PIP joint with ecchymosis at the base of the middle phalanx, with a dorsal avulsion fragment at the middle phalanx base on radiograph, as well as inability to actively extend the PIP joint.

 

 

1383. (1157) Q4-1521:

Horner syndrome includes all of the following except:

 

1) Miosis

3) Enophthalmos

2) Anhidrosis

4) Exophthalmos

 

 

Horner syndrome is due to disruption of sympathetic innervation and is characterized by enophthalmos not exophthalmos. Correct Answer: Exophthalmos

1384. (1158) Q4-1522:

Axonotmesis involves injury to which of the following structure:

 

1) Epineurium

3) Perineurium

2) Endoneurium

4) Axon

 

Axonotmesis as described in Seddon classification implies injury to the axon and myelin sheath. It is neurotmesis that involves injury to all the three layers.

Correct Answer: Axon

 

 

1385. (1159) Q4-1523:

All of the following may be seen with preganglionic lesion EXCEPT:

 

1) Horner syndrome

3) Positive Histamine test

2) Hemi-diaphragmatic palsy

4) Tinel sign

 

 

Tinel sign is seen with postganglionic lesions. Correct Answer: Tinel sign

 

1386. (1160) Q4-1524:

Weakness of which of the following muscles is not seen with root avulsion:

 

1) Rhomboids

3) Supraspinatus

2) Serratus anterior

4) Trapezius

 

Trapezius is innervated by spinal accessory nerve and thus will not be involved in a brachial plexus lesion. In the case of a preganglionic lesion, ALL muscles innervated by the nerve roots will be affected.

Correct Answer: Trapezius

 

 

1387. (1161) Q4-1525:

In obstetric brachial plexus injury, return of which of the following muscle by 3 months is considered an indicator of plexus recovery:

 

1) Biceps

3) Brachioradialis

2) Triceps

4) Latissimus

 

 

Biceps recovery at 3 months is considered the single most important indicator of recovery in obstetric plexus palsy. Correct Answer: Biceps

1388. (1162) Q4-1526:

A 15-year-old white boy presents to your office with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and says his neck was twisted away at the time of fall. He was seen at the local emergency department; skull, chest, cervical and thoracic spine, and shoulder x-rays showed no damage. There was no loss of consciousness and he has no chest pain or breathing difficulties. He was observed in the hospital until stable and was referred to follow up in the hand clinic at 4 weeks and scheduled for an electromyogram.

 

Clinical examination reveals weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature is preserved and he can grasp and release and pinch. Sensations are decreased along the distribution of axillary nerve. There is 3 cm wasting of his arm and 2 cm of his forearm. Tinel sign is positive around the clavicle. Horner signs are absent and his arm lies against the body. The EMG report shows fibrillation potentials in the weak muscles. The parents are concerned and say they have not seen any improvement. The boy reports that he is now able to flex his elbow. When asked to demonstrate you notice that he flexes his wrist and pronates his forearm to âswingâ his elbow into flexion.

 

The diagnosis of the boyâs condition is:

 

1) Brachial plexus neuropraxia

3) Brachial plexus neuritis

2) Erbâs palsy

4) C 5, C 6 disk herniations

 

The muscles involved have C 5, C 6 root innervations. There are multiple findings that rule out a preganglionic lesion: positive Tinel sign, functioning rhomboids and serratus anterior, absent Horner syndrome. The electromyogram finding confirms the clinical finding (it does not show subclinical involvement of any other muscle). Neuropraxia usually resolves in 6 weeks and EMG shows fibrillation, both of which are inconsistent with neuropraxia. Brachial plexus neuritis (Parsonage-Turner syndrome) has an acute presentation following a painful episode involving the whole arm. There is significant history of fall from an all terrain vehicle in this case.

 

Correct Answer: Erbâs palsy

 

 

1389. (1163) Q4-1527:

A 15-year-old white boy presents to your office with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and says his neck was twisted away at the time of fall. He was seen at the local emergency department; skull, chest, cervical and thoracic spine, and shoulder x-rays showed no damage. There was no loss of consciousness and he has no chest pain or breathing difficulties. He was observed in the hospital until stable and was referred to follow up in the hand clinic at 4 weeks and scheduled for an electromyogram.

 

Clinical examination reveals weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature is preserved and he can grasp and release and pinch. Sensations are decreased along the distribution of axillary nerve. There is 3 cm wasting of his arm and 2 cm of his forearm. Tinel sign is positive around the clavicle. Horner signs are absent and his arm lies against the body. The EMG report shows fibrillation potentials in the weak muscles. The parents are concerned and say they have not seen any improvement. The boy reports that he is now able to flex his elbow. When asked to demonstrate you notice that he flexes his wrist and pronates his forearm to âswingâ his elbow into flexion.

 

What is the level of lesion:

 

1) Postganglionic C 5, C 6

3) Posterior cord injury

2) Preganglionic C 5, C 6

4) Middle trunk

 

The muscles involved have C 5, C 6 root innervations. There are multiple findings that rule out a preganglionic lesion: positive Tinel sign, functioning rhomboids and serratus anterior, absent Horner syndrome. The electromyogram finding confirms the clinical finding (it does not show subclinical involvement of any other muscle). Neuropraxia usually resolves in 6 weeks and EMG shows fibrillation, which is inconsistent with neuropraxia. Brachial plexus neuritis (Parsonage-Turner syndrome) has an acute presentation following a painful episode involving the whole arm. There is significant history of fall from an all terrain vehicle in this case.

 

Correct Answer: Postganglionic C 5, C 6

 

1390. (1164) Q4-1528:

A 15-year-old white boy presents to your office with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and says his neck was twisted away at the time of fall. He was seen at the local emergency department; skull, chest, cervical and thoracic spine, and shoulder x-rays showed no damage. There was no loss of consciousness and he has no chest pain or breathing difficulties. He was observed in the hospital until stable and was referred to follow up in the hand clinic at 4 weeks and scheduled for an electromyogram.

 

Clinical examination reveals weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature is preserved and he can grasp and release and pinch. Sensations are decreased along the distribution of axillary nerve. There is 3 cm wasting of his arm and 2 cm of his forearm. Tinel sign is positive around the clavicle. Horner signs are absent and his arm lies against the body. The EMG report shows fibrillation potentials in the weak muscles. The parents are concerned and say they have not seen any improvement. The boy reports that he is now able to flex his elbow. When asked to demonstrate you notice that he flexes his wrist and pronates his forearm to âswingâ his elbow into flexion.

 

What is the least helpful test in further management of this patient:

 

1) Magnetic resonance imaging

3) Repeat electromyogram after 4 weeks

2) Computer tomography scan of the neck

4) Somatosensory evoked potential (SSEP)

 

Computer tomography scan of the cervical spine will not be of any use as it will neither show the pseudomeningoceles nor provide any information on brachial plexus. CT scan may be needed in case of a suspected neck injury but does not form part of a brachial plexus work up.

 

Correct Answer: Computer tomography scan of the neck

 

 

1391. (1165) Q4-1529:

A 15-year-old white boy presents to your office with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and says his neck was twisted away at the time of fall. He was seen at the local emergency department; skull, chest, cervical and thoracic spine, and shoulder x-rays showed no damage. There was no loss of consciousness and he has no chest pain or breathing difficulties. He was observed in the hospital until stable and was referred to follow up in the hand clinic at 4 weeks and scheduled for an electromyogram.

 

Clinical examination reveals weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature is preserved and he can grasp and release and pinch. Sensations are decreased along the distribution of axillary nerve. There is 3 cm wasting of his arm and 2 cm of his forearm. Tinel sign is positive around the clavicle. Horner signs are absent and his arm lies against the body. The EMG report shows fibrillation potentials in the weak muscles. The parents are concerned and say they have not seen any improvement. The boy reports that he is now able to flex his elbow. When asked to demonstrate you notice that he flexes his wrist and pronates his forearm to âswingâ his elbow into flexion.

 

The plan of management in this boy 5 months after injury with no clinical improvement should be:

 

1) Neurotization

3) Continued observation

2) Exploration and nerve grafting

4) Tendon transfers

 

Neurotization is appropriate in preganglionic lesions. Around 6 months with no evidence of recovery is ideal time for plexus exploration. Further observation will not change the picture and tendon transfers are reconstructive procedures, which are done at a later stage.

 

Correct Answer: Exploration and nerve grafting

 

1392. (1166) Q4-1530:

A 15-year-old white boy presents to your office with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and says his neck was twisted away at the time of fall. He was seen at the local emergency department; skull, chest, cervical and thoracic spine, and shoulder x-rays showed no damage. There was no loss of consciousness and he has no chest pain or breathing difficulties. He was observed in the hospital until stable and was referred to follow up in the hand clinic at 4 weeks and scheduled for an electromyogram.

 

Clinical examination reveals weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature is preserved and he can grasp and release and pinch. Sensations are decreased along the distribution of axillary nerve. There is 3 cm wasting of his arm and 2 cm of his forearm. Tinel sign is positive around the clavicle. Horner signs are absent and his arm lies against the body. The EMG report shows fibrillation potentials in the weak muscles. The parents are concerned and say they have not seen any improvement. The boy reports that he is now able to flex his elbow. When asked to demonstrate you notice that he flexes his wrist and pronates his forearm to âswingâ his elbow into flexion.

 

What will be the most important indication for an early exploration in this case:

 

1) Absence of biceps function at 3 months

3) Presence of âtrickâ movements

2) Absence of biceps function with return of extensor carpi radialis longus (ECRL) power at 4 months

4) Subluxation of humeral head on x-ray

 

An important indication for early exploration is recovery of a distally supplied muscle (ECRL â C 6) in the absence of a proximally supplied muscle (biceps â C 5). Trick movements are adaptive movements employed by the patient by recruiting other muscles (use of flexor-pronator as elbow flexors in this patient). Bony deformity is a late sequela and biceps recovery at 3 months is important in obstetric brachial palsy.

 

Correct Answer: Absence of biceps function with return of extensor carpi radialis longus (ECRL) power at 4 months

 

 

1393. (1167) Q4-1531:

A 15-year-old white boy presents to your office with inability to elevate his right shoulder and flex his elbow. He sustained a fall from an all-terrain vehicle 8 weeks ago. He landed on the right shoulder and says his neck was twisted away at the time of fall. He was seen at the local emergency department; skull, chest, cervical and thoracic spine, and shoulder x-rays showed no damage. There was no loss of consciousness and he has no chest pain or breathing difficulties. He was observed in the hospital until stable and was referred to follow up in the hand clinic at 4 weeks and scheduled for an electromyogram.

 

Clinical examination reveals weakness of deltoid, supraspinatus, infraspinatus, teres minor, biceps, brachialis, brachioradialis, and extensor carpi radialis longus. The remainder of his forearm musculature is preserved and he can grasp and release and pinch. Sensations are decreased along the distribution of axillary nerve. There is 3 cm wasting of his arm and 2 cm of his forearm. Tinel sign is positive around the clavicle. Horner signs are absent and his arm lies against the body. The EMG report shows fibrillation potentials in the weak muscles. The parents are concerned and say they have not seen any improvement. The boy reports that he is now able to flex his elbow. When asked to demonstrate you notice that he flexes his wrist and pronates his forearm to âswingâ his elbow into flexion.

 

The most important function that needs to be restored in this boy is:

 

1) Shoulder abduction

3) Elbow flexion

2) Shoulder elevation

4) Wrist extension

 

 

Elbow flexion is central to management of brachial plexus management because it serves the most important function of feeding. Correct Answer: Elbow flexion

1394. (1168) Q4-1532:

An 18-month-old boy is brought to your office for a clawing deformity of his right hand. The parents inform you that he was born full term after a difficult delivery complicated by shoulder dystocia. The boy weighed 9½ lbs at birth. The child had a brief episode of apnea with an APGAR score of 5 at birth and needed resuscitation and admission to the natal intensive care unit.

Parents recall having noted a bump on his right clavicle, which was tender and was diagnosed as clavicle fracture. They also noticed a week later that the child did not flex the fingers of his right hand. The neonatologist had informed them that the fracture is managed conservatively and the absence of finger flexion is due to the fracture and shall recover. They were warned that the recovery can be prolonged and can take up to 2 years. The boy has grown well and has achieved his milestones on time. His immunization is complete for his age.

 

You find a healthy, playful boy who tends to use his left hand to reach for objects. His right hand has extension at all the metacarpophalangeal (MCP) joints of the fingers while his proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints are flexed. His thumb is an adducted position and it is difficult to passively bring it to full abduction. There is obvious wasting of the hand and forearm. The child is able to move the arm well with no abnormalities noticed at the shoulder, elbow, and the wrist. The x-ray of his chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Horner Syndrome and the grasp reflex is absent.

 

The diagnosis of this boyâs condition is:

 

1) Erbâs palsy

3) Cerebrovascular accident

2) Klumpkeâs palsy

4) Ulnar and median combined nerve injury

 

This is a case of obstetric brachial plexus injury involving the C 8, T1 roots (Klumpke Palsy). Erbâs palsy involves upper roots only. Combined nerve injuries can present in a similar fashion; however, low ulnar and median nerve lesions will not have weakness of flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS).

 

History of large baby, shoulder dystocia and clavicle fracture point to a difficult labor. The most common type of brachial plexus injury related to birth is Erbâs palsy, which is usually associated with a breech presentation. Isolated Klumpkeâs palsy is rare, and involvement of C 8, T1 usually occurs as part of global plexus injury.

 

Correct Answer: Klumpkeâs palsy

 

 

1395. (1169) Q4-1533:

An 18-month-old boy is brought to your office for a clawing deformity of his right hand. The parents inform you that he was born full term after a difficult delivery complicated by shoulder dystocia. The boy weighed 9½ lbs at birth. The child had a brief episode of apnea with an APGAR score of 5 at birth and needed resuscitation and admission to the natal intensive care unit.

Parents recall having noted a bump on his right clavicle, which was tender and was diagnosed as clavicle fracture. They also noticed a week later that the child did not flex the fingers of his right hand. The neonatologist had informed them that the fracture is managed conservatively and the absence of finger flexion is due to the fracture and shall recover. They were warned that the recovery can be prolonged and can take up to 2 years. The boy has grown well and has achieved his milestones on time. His immunization is complete for his age.

 

You find a healthy, playful boy who tends to use his left hand to reach for objects. His right hand has extension at all the metacarpophalangeal (MCP) joints of the fingers while his proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints are flexed. His thumb is an adducted position and it is difficult to passively bring it to full abduction. There is obvious wasting of the hand and forearm. The child is able to move the arm well with no abnormalities noticed at the shoulder, elbow, and the wrist. The x-ray of his chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Horner Syndrome and the grasp reflex is absent.

 

The level of the lesion in this boyâs case is:

 

1) preganglionic lesion

3) lateral cord

2) postganglionic lesion

4) posterior cord

 

It is difficult to clinically differentiate between a pre- and post ganglionic lesion of C 8, T1 in a child. Absence of Hornerâs syndrome and hemi-diaphragmatic palsy in this case indicates that this is not a preganglionic lesion. Also, the ability of the child to hold his head suggests that the paravertebral muscles are functional as is true in postganglionic lesions.

 

Correct Answer: postganglionic lesion

 

1396. (1170) Q4-1534:

An 18-month-old boy is brought to your office for a clawing deformity of his right hand. The parents inform you that he was born full term after a difficult delivery complicated by shoulder dystocia. The boy weighed 9½ lbs at birth. The child had a brief episode of apnea with an APGAR score of 5 at birth and needed resuscitation and admission to the natal intensive care unit.

Parents recall having noted a bump on his right clavicle, which was tender and was diagnosed as clavicle fracture. They also noticed a week later that the child did not flex the fingers of his right hand. The neonatologist had informed them that the fracture is managed conservatively and the absence of finger flexion is due to the fracture and shall recover. They were warned that the recovery can be prolonged and can take up to 2 years. The boy has grown well and has achieved his milestones on time. His immunization is complete for his age.

 

You find a healthy, playful boy who tends to use his left hand to reach for objects. His right hand has extension at all the metacarpophalangeal (MCP) joints of the fingers while his proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints are flexed. His thumb is an adducted position and it is difficult to passively bring it to full abduction. There is obvious wasting of the hand and forearm. The child is able to move the arm well with no abnormalities noticed at the shoulder, elbow, and the wrist. The x-ray of his chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Horner Syndrome and the grasp reflex is absent.

 

Appropriate surgical management in this case should be:

 

1) Neurotization

3) Tendon transfers

2) Exploration and nerve grafting

4) Neurolysis

 

Neurotization has not been shown to produce successful results for lower root involvement and is performed for preganglionic lesions. At 18 months, exploration and nerve grafting must still be carried out. Neurolysis is reserved for cases in which the recovery is partial or plateaus. Tendon transfers in children younger than 3 years of age do not work as well. Younger children do not cooperate well in their rehabilitation and it is also difficult to decide upon the functioning motors for transfer.

 

Correct Answer: Exploration and nerve grafting

 

 

1397. (1171) Q4-1535:

An 18-month-old boy is brought to your office for a clawing deformity of his right hand. The parents inform you that he was born full term after a difficult delivery complicated by shoulder dystocia. The boy weighed 9½ lbs at birth. The child had a brief episode of apnea with an APGAR score of 5 at birth and needed resuscitation and admission to the natal intensive care unit.

Parents recall having noted a bump on his right clavicle, which was tender and was diagnosed as clavicle fracture. They also noticed a week later that the child did not flex the fingers of his right hand. The neonatologist had informed them that the fracture is managed conservatively and the absence of finger flexion is due to the fracture and shall recover. They were warned that the recovery can be prolonged and can take up to 2 years. The boy has grown well and has achieved his milestones on time. His immunization is complete for his age.

 

You find a healthy, playful boy who tends to use his left hand to reach for objects. His right hand has extension at all the metacarpophalangeal (MCP) joints of the fingers while his proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints are flexed. His thumb is an adducted position and it is difficult to passively bring it to full abduction. There is obvious wasting of the hand and forearm. The child is able to move the arm well with no abnormalities noticed at the shoulder, elbow, and the wrist. The x-ray of his chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Horner Syndrome and the grasp reflex is absent.

 

Which of the following set of investigations is most appropriate in this case:

 

1) Magnetic resonance imaging, electromyogram, histamine test

3) Computer tomography myelography, MRI, Somatosensory evoked potential

2) Manual muscle test (MMT), MRI, electromyogram

4) Somatosensory evoked potential, histamine test, EMG

 

In obstetric brachial palsies, it is important to confirm the level of lesion (pre- or postganglionic). Magnetic resonance imaging, computer tomography-myelogram or myelogram are comparable modalities. A manual muscle test is vital in documenting the muscle weakness as well as to assess progress on serial exams. SSEP is used intraoperatively and a histamine test usually does not form part of standard tests.

 

Correct Answer: Manual muscle test (MMT), MRI, electromyogram

 

1398. (1172) Q4-1536:

An 18-month-old boy is brought to your office for a clawing deformity of his right hand. The parents inform you that he was born full term after a difficult delivery complicated by shoulder dystocia. The boy weighed 9½ lbs at birth. The child had a brief episode of apnea with an APGAR score of 5 at birth and needed resuscitation and admission to the natal intensive care unit.

Parents recall having noted a bump on his right clavicle, which was tender and was diagnosed as clavicle fracture. They also noticed a week later that the child did not flex the fingers of his right hand. The neonatologist had informed them that the fracture is managed conservatively and the absence of finger flexion is due to the fracture and shall recover. They were warned that the recovery can be prolonged and can take up to 2 years. The boy has grown well and has achieved his milestones on time. His immunization is complete for his age.

 

You find a healthy, playful boy who tends to use his left hand to reach for objects. His right hand has extension at all the metacarpophalangeal (MCP) joints of the fingers while his proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints are flexed. His thumb is an adducted position and it is difficult to passively bring it to full abduction. There is obvious wasting of the hand and forearm. The child is able to move the arm well with no abnormalities noticed at the shoulder, elbow, and the wrist. The x-ray of his chest shows a healed clavicle fracture with no evidence of diaphragmatic paralysis. There is no evidence of Horner Syndrome and the grasp reflex is absent.

 

The goal of reconstructive surgery in this boy should include all of the following EXCEPT:

 

1) Thumb opposition

3) Thumb adduction

2) Widening of first web space

4) Thumb MP fusion

 

This child has already developed contractures of first web space, which probably will not respond to passive stretching. Fusion of MP joint is not needed as tendon transfers will be able to provide for lateral and tip pinch as well as opposition.

Correct Answer: Thumb MP fusion

 

 

1399. (1753) Q4-2150:

Which of the following lesions has the highest risk of malignant degeneration:

 

1) Maffucciâs syndrome

3) Solitary enchondroma

2) Ollierâs disease

5) None of the above

4) Multiple hereditary osteochondromatosis

 

Ollierâs disease (multiple enchondromatosis) is associated with deformities of the axial skeleton and larger, unilateral lesions. The combination of multiple enchondromatosis and venous-lymphatic vascular malformations (angiomas) is termed Maffucciâs syndrome. Maffucciâs syndrome is associated with a higher rate of degeneration into chondrosarcoma than in Ollierâs disease.

Malignant change of solitary lesions is rare, but a sudden increase in pain or size should raise suspicion of degeneration.Correct Answer: Maffucciâs syndrome

 

 

1400. (1754) Q4-2151:

The most common primary bone tumor of the hand is:

 

1) Enchondroma

3) Osteochondroma

2) Giant cell tumor

5) None of the above

4) Osteoid osteoma

 

Enchondromas account for more than 90% of primary bone tumors of the hand.Correct Answer: Enchondroma

 

1401. (1755) Q4-2152:

Prolonged nonsteroidal anti-inflammatory drugs (NSAIDs) cure which of the following lesions:

 

1) Osteosarcoma

3) Osteoblastoma

2) Osteoid osteoma

5) None of the above

4) Osteochondroma

 

An average 33-month course of treatment with NSAIDs cures osteoid osteoma. The prostaglandin E2 in osteoid osteoma is likely the reason for this response.Correct Answer: Osteoid osteoma

 

 

1402. (1756) Q4-2153:

The most common primary bone tumor in the hand is:

 

1) Enchondroma

3) Osteosarcoma

2) Osteochondroma

5) None of the above

4) Fibroma

 

Enchondroma preferentially occurs in the hand, most commonly in the phalanges and metacarpals, and is the most common primary tumor of bone found in the hand.Correct Answer: Enchondroma

 

 

1403. (1757) Q4-2154:

Which of the following statements regarding ganglions is false:

 

1) Surgery can lead to a decrease in range of motion.

3) Needle aspiration is diagnostic and therapeutic, although the rate of recurrence is high after this procedure.

2) Ganglions are filled with mucinous fluid that does not transilluminate.

5) Ganglions may be multilobulated.

4) Volar ganglion may arise in relation to the radial artery.

 

Transillumination is a hallmark of ganglions. Because of the location from which ganglia arise and the dissection performed during resection, a decrease in range of motion can be seen postoperatively. Needle aspiration is diagnostic and can be therapeutic, however, recurrence rates as high as 95% have been reported. Volar ganglia can often be intimately associated with the radial artery. Ganglia may often be multilobulated.Correct Answer: Ganglions are filled with mucinous fluid that does not transilluminate.

 

 

1404. (1758) Q4-2155:

Dorsal wrist ganglions originate from the:

 

1) Scapholunate ligament

3) Extensor digitorum communis (EDC) tendon

2) Dorsal capsule

5) Capitolunate joint

4) Dorsal carpal ligament

 

Dorsal wrist ganglia do not arise from the dorsal capsule, EDC tendon, capitolunate joint, or dorsal intercarpal ligament. Dorsal wrist ganglia arise from the scapholunate ligament. Some surgeons advocate excising a small rim of the scapholunate ligament to avoid recurrence.Correct Answer: Scapholunate ligament

 

1405. (1759) Q4-2156:

Ganglions of the distal interphalangeal (DIP) joints of the fingers are called:

 

1) Mucous cysts

3) Heberden nodes

2) Bouchard nodes

5) Retinacular cysts

4) Inclusion cysts

 

Ganglions arising at the DIP joints are called mucous cysts and ganglions from the flexor tendon in the palm are called retinacular cysts.

Bouchard nodes are osteophytes that develop at the proximal interphalangeal joint.

Heberden nodes are bony spurs at the dorsal aspect of the DIP joint and are present in osteoarthritis. Inclusion cysts are mobile, nonadherent to skin, and can occur anywhere on a hand.

Correct Answer: Mucous cysts

 

 

 

1406. (1760) Q4-2157:

Management of a mucous cyst entails:

 

1) Aspiration with injection of hyaluronidase

3) Excision and resection of osteophytes

2) Aspiration only

5) Arthrodesis of the distal interphalangeal joint

4) Aspiration with injection of steroids

 

Treatment of mucous cysts, which are ganglions of the distal interphalangeal joint associated with osteoarthritic changes, entails excision of the cyst and osteophyte resection of fusion.

Aspiration only or aspiration of the cyst with injection of hyaluronidase is not indicated or efficacious in the treatment of mucous cysts because the osteophyte must be addressed. Injection of steroids also fails to address the underlying cause of these cysts. Arthrodesis of the distal interphalangeal joint is not necessary in the treatment of typical mucous cysts.Correct Answer: Excision and resection of osteophytes

 

 

 

1407. (4047) Q4-2158:

A 30-year-old black woman presents with complaints of pain in the tip of her right index finger. The pain started approximately 6 months ago and becomes intense in cold weather. She also states that her nail on the index finger does not look as good as the others despite regular manicures. You notice a bluish discoloration and ridging of the nail. The nail is not split, but it appears clubbed. The patient does not have a history of respiratory or hemodynamic disease and appears healthy. The nail is exquisitely tender on pressure, but no mass is palpable. Two-point discrimination is intact and capillary refill is good. Radiographs do not reveal bony destruction, but you notice pressure indentation over the distal phalanx. The joint space is preserved, and the patient has full range of motion. The most likely diagnosis is:

 

1) Glomus tumor

3) Paronychia

2) Acute perinychia

5) Turret exostosis

4) Giant cell tumor

 

This patient presents with the classic triad of glomus tumor: sharp lancinating pain, point tenderness, and cold sensitivity. Localized bluish discoloration is also strongly suggestive of a glomus tumor.

Giant cell tumors can be found on the fingertip, however, a presentation of a giant cell tumor with these symptoms would be unusual. Mucous cysts would be part of the differential but does not cause a bluish discoloration or cold insensitivity. An acute paronychia would be painful and erythematous is infectious. A mucous cyst is not infectious. This classic triad does not describe a turret exotosis.Correct Answer: Glomus tumor

 

 

1408. (1761) Q4-2159:

A 30-year-old black woman presents with complaints of pain in the tip of her right index finger. The pain started approximately 6 months ago and becomes intense in cold weather. She also states that her nail on the index finger does not look as good as the others despite regular manicures. You notice a bluish discoloration and ridging of the nail. The nail is not split, but it appears clubbed. The patient does not have a history of respiratory or hemodynamic disease and appears healthy. The nail is exquisitely tender on pressure, but no mass is palpable. Two-point discrimination is intact and capillary refill is good. Radiographs do not reveal bony destruction, but you notice pressure indentation over the distal phalanx. The joint space is preserved, and the patient has full range of motion. The next step in management includes:

 

1) Ordering a magnetic resonance image

3) Ordering a computed tomography scan

2) Ordering a bone scan

5) Injecting the distal phalanx medullary canal with corticosteroid

4) Performing an excisional biopsy

 

This is a classic case of a glomus tumor with cold intolerance and nail deformity. Imaging studies often are inconclusive, although computed tomography scans may show cortical reaction. This patient is symptomatic and should receive definitive treatment. It should be noted that magnetic resonance imaging is increasingly helpful for nonclassical presentations of finger pain.Correct Answer: Performing an excisional biopsy

 

 

1409. (1762) Q4-2160:

A 30-year-old black woman presents with complaints of pain in the tip of her right index finger. The pain started approximately 6 months ago and becomes intense in cold weather. She also states that her nail on the index finger does not look as good as the others despite regular manicures. You notice a bluish discoloration and ridging of the nail. The nail is not split, but it appears clubbed. The patient does not have a history of respiratory or hemodynamic disease and appears healthy. The nail is exquisitely tender on pressure, but no mass is palpable. Two-point discrimination is intact and capillary refill is good. Radiographs do not reveal bony destruction, but you notice pressure indentation over the distal phalanx. The joint space is preserved, and the patient has full range of motion. Based on your clinical diagnoses, the histological findings will include which of the following:

 

1) Well-formed vascular channels with nonmyelinated nerve endings

3) Giant cells filled with inflammatory cells in the interstitium

2) Mucous islands with blood vessels

5) Amorphous calcium in pseudocapsule

4) Negatively birefringent cystals

 

Glomus tumors consist of well-formed vascular channels with nonmyelinated nerve endings. Glomus tumors are not associated with mucous islands or giant cells. Negatively birefringent crystals are found in patients with gout. The presentation of this patient does not suggest gout. Amorphous calcium in a pseudocapsule is diagnostic of calcinosis. Calcinosis occurs intracutaneoulsy or subcutaneously. These deposits can be tender but are not effected by changes in weather, as are glomus tumors.Correct Answer: Well-formed vascular channels with nonmyelinated nerve endings

 

 

1410. (1763) Q4-2161:

Glomus tumors are characterized by all of the following except:

 

1) Three-quarters of glomus tumors occur in the hand.

3) Glomera are neuromyoarterial apparatuses that regulate sympathetic outflow.

2) Pain, point tenderness, and cold sensitivity are clinically present.

5) None of the above

4) Persistence of symptoms for more than 3 months after excision is suggestive of recurrence.

 

Glomera are neuromyoarterial apparatuses that regulate temperature.Correct Answer: Glomera are neuromyoarterial apparatuses that regulate sympathetic outflow.