Free Orthopedic MCQs 2022, Dec, 16 | 12:00 am

ORTHOPEDIC MCQS ONLINE 015 FOOT AND ANKLE e

ORTHOPEDIC MCQS ONLINE 015FOOT and Ankle

CLINICAL SITUATION FOR QUESTIONS 1 THROUGH 4

A B

Figures 1a and 1b are the radiographs of a 17-year-old boy who planted his right foot while running and experienced immediate pain and an inability to bear weight.

Question 1 of 100

This injury is best treated with

closed reduction and percutaneous pinning.
a short-leg cast with closed reduction.
open reduction and internal fixation (ORIF) with Kirschner wires.
ORIF with screw and/or plate fixation.

PREFERRED RESPONSE: 4- ORIF with screw and/or plate fixation.

Question 2 of 100

The Lisfranc ligament extends from the

medial cuneiform to the first metatarsal bone.
medial cuneiform to the second metatarsal bone.
first metatarsal base to the second metatarsal base.
first metatarsal base to the medial cuneiform.

PREFERRED RESPONSE: 2- medial cuneiform to the second metatarsal bone.

Question 3 of 100

In Lisfranc injuries, the "fleck sign," when present, represents

calcification of the interosseous ligament.
a stable Lisfranc injury.
a small avulsion fracture of the first metatarsal base.
a small avulsion fracture of the second metatarsal base.

PREFERRED RESPONSE: 4- a small avulsion fracture of the second metatarsal base.

Question 4 of 100

In the evaluation of Lisfranc injuries, which radiographic studies should routinely be obtained?

MRI
Bilateral weight-bearing anteroposterior and lateral views of the foot with obliques
Stress radiographs under anesthesia
CT scan with 3-dimensional images

PREFERRED RESPONSE: 2- Bilateral weight-bearing anteroposterior and lateral views of the foot with obliques

DISCUSSION

It is estimated that as many as 20% of Lisfranc injuries are missed on initial radiographic examination. Weight-bearing bilateral radiographs should be performed routinely. CT scan, MRI, and stress radiographs performed under anesthesia may be needed in select cases. The Lisfranc ligament stabilizes the midfoot and consists of the dorsal and plantar oblique ligaments and the strong interosseous ligaments. All 3 extend from the base of the second metatarsal to the medial cuneiform. The “fleck sign" is a small avulsion fracture at the medial base of the second metatarsal, representing an avulsion of the Lisfranc ligament. The current treatment recommendation for displaced Lisfranc subluxations and dislocations is to perform ORIF with rigid fixation using either screws or plates and screws. Kirschner wire fixation may lead to recurrence after pin removal. Closed reduction and casting alone cannot permanently reduce the dislocation.

CLINICAL SITUATION FOR QUESTIONS 5 THROUGH 8

Figures 5a and 5b are the clinical photograph and AP radiograph of a 55-year-old woman who has a painful right forefoot deformity. There is no history of antecedent trauma. The 1-2 intermetatarsal angle is 17 degrees, and the hallux valgus angle is 35 degrees.

Question 5 of 100

The second-toe deformity is most accurately described as

hammer toe.
claw toe.
curly toe.
crossover toe.

PREFERRED RESPONSE: 4- crossover toe.

Question 6 of 100

The patient's painful great-toe deformity is best treated with

proximal metatarsal bunionectomy.
simple bunionectomy.
cheilectomy.
resection of base of proximal phalanx.

PREFERRED RESPONSE: 1- proximal metatarsal bunionectomy.

Question 7 of 100

Disruption of which anatomic structure is necessary for the second-toe pathology to occur?

Collateral ligaments
Intrinsic flexor tendons
Extrinsic extensor tendons
Plantar plate

PREFERRED RESPONSE: 4- Plantar plate

Question 8 of 100

On the morning of surgery the patient reports in the preop area that she has experienced skin breakdown over the second toe for 10 days. The extensor tendon is disrupted with an exposed proximal interphalangeal joint. She has been applying antibiotic ointment to the wound and denies fever or chills. What is the best plan of care?

Continue with plans for bunion and crossover toe correction.
Cancel the surgery and send the patient home with empiric oral medications.
Inform the patient that surgical joint debridement is necessary and the elective reconstructive surgery will be put on hold.
Swab the ulcer and admit the patient for peripherally inserted central catheter line placement and intravenous antibiotics.

PREFERRED RESPONSE: 3- Inform the patient that surgical joint debridement is necessary and the elective reconstructive surgery will be put on hold.

DISCUSSION

The clinical photograph shows a hallux valgus and a crossover toe deformity. The plantar plate must be damaged for a crossover toe deformity to develop. A moderately severe hallux valgus deformity without arthritic change is best treated with a bunionectomy with a proximal metatarsal osteotomy. The surgeon must assume that the open joint is at least colonized and at significant risk for postsurgical infection; consequently, it is best to cancel elective surgery, and surgical debridement of soft tissue and bone with deep cultures is recommended.

Question 9 of 100

Figure 9 is the radiograph of a 24-year-old amateur marathon runner who has ankle pain. She previously sustained a metatarsal stress fracture. In addition to asking about her training routine and the type of footwear she uses, the orthopaedic surgeon should inquire about this patient's history of nutrition and

genetics.
rheumatology.
menstruation.
cardiovascular health.

PREFERRED RESPONSE: 3- menstruation.

DISCUSSION

Several studies have reported an increased incidence of stress fractures in female athletes, including fractures of the foot and ankle in runners. The

female athlete triad describes a condition involving decreased bone density, anorexia, and amenorrhea. In addition to asking about this woman's exercise routine, the orthopaedic surgeon should obtain a comprehensive menstrual and dietary history in the context of multiple stress fractures. A review of genetics, rheumatology, and cardiovascular disorders is less likely to generate an etiology.

RESPONSES FOR QUESTIONS 10 THROUGH 13

Ankle replacement
Ankle fusion
Tibiotalocalcaneal fusion
Total contact cast
Intra-articular steroid injection

Match the appropriate treatment listed above with the patient scenario described below.

Question 10 of 100

A 28-year-old woman with bone-on-bone ankle arthritis, little deformity, and recalcitrant pain

Ankle replacement
Ankle fusion
Tibiotalocalcaneal fusion
Total contact cast
Intra-articular steroid injection

PREFERRED RESPONSE: 2- Ankle fusion

Question 11 of 100

A 56-year-old woman with diabetes, neuropathy, and an unbraceable ankle and hindfoot deformity

Ankle replacement
Ankle fusion
Tibiotalocalcaneal fusion
Total contact cast
Intra-articular steroid injection

PREFERRED RESPONSE: 3- Tibiotalocalcaneal fusion

Question 12 of 100

A 72-year-old man with a previous contralateral ankle fusion, rheumatoid arthritis, and 5 degrees of valgus; he has pursued nonsurgical treatment for 30 years and now has unrelenting pain

Ankle replacement
Ankle fusion
Tibiotalocalcaneal fusion
Total contact cast
Intra-articular steroid injection

PREFERRED RESPONSE: 1- Ankle replacement

Question 13 of 100

A 72-year-old man with diabetic neuropathy and 5 degrees of valgus talar tilt; he has pursued nonsurgical treatment for 30 years and now has unrelenting pain

Ankle replacement
Ankle fusion
Tibiotalocalcaneal fusion
Total contact cast
Intra-articular steroid injection

PREFERRED RESPONSE: 2- Ankle fusion

DISCUSSION

Arthritis of the ankle and hindfoot can pose challenges. Depending upon patient age, comorbidities, and alignment, a variety of surgical interventions may be offered. A total ankle replacement may be considered for patients older than 60 years of age who have minimal misalignment and low-demand lifestyles. In all other cases, ankle fusion must be considered. The nonsurgical care of ankle arthritis includes anti-inflammatory medication, intra-articular steroid injections, bracing with customized products such as the Arizona brace, or a molded foot and ankle orthosis.

Patients with diabetes and Charcot arthropathy may be treated nonsurgically with total-contact casting during acute and active or "hot" phases and accommodative shoes during consolidation and stable or "cool" phases. When the patient has recurrent ulcers or major anatomy changes, surgical intervention must be considered. Tibiotalocalcaneal fusion helps to realign the foot and ankle and make it more braceable in the setting of ankle and hindfoot Charcot disease.

Question 14 of 100

Figure 14 is a sagittal-cut MR image from the hindfoot of a 54-year-old woman who has had plantar heel pain for 3 months. There is no history of trauma. Her pain is worse when she rises and at the end of the day. Upon examination she has localizable tenderness over the plantar medial tubercle of the calcaneus. The Achilles is intact and nontender, and subtalar joint motion is full and painless. A Tinel test result is negative. What is the most likely diagnosis?

Calcaneal stress fracture
Hindfoot coalition
Insertional Achilles tendonitis
Plantar fasciitis

PREFERRED RESPONSE: 4- Plantar fasciitis

DISCUSSION

Plantar fasciitis is inflammation of the plantar fascia at its insertion onto the medial calcaneus. The T2-weighted sagittal MR image reveals thickening of the plantar fascia with no evidence of a calcaneal stress fracture, coalition, or inflammation of the insertion of the Achilles tendon.

CLINICAL SITUATION FOR QUESTIONS 15 THROUGH 18

Figures 15a through 15c are the initial injury radiographs of a 32-year-old man who sustained a closed injury to his right lower extremity after a fall from a curb. Initial examination reveals a swollen painful ankle with pain both medially and laterally at the level of the malleoli.

15A

Question 15 of 100

Following surgical stabilization and fixation of the distal fibula, what is the most appropriate next step?

Place a transsyndesmotic screw.
Perform an open repair of the deltoid ligament.
Perform a stress examination of the syndesmosis.
Close the wound and apply a short-leg splint.

PREFERRED RESPONSE: 3- Perform a stress examination of the syndesmosis.

Question 16 of 100

16A

Figures 16a through 16c are the postsurgical radiographs taken 3 months after surgical stabilization of the fracture and syndesmosis. The patient has no pain and symmetrical range of motion to the contralateral lower extremity. What is the most appropriate next step?

Removal of the transyndesmotic screw
Retention of hardware with progression of activity
Revision open reduction and internal fixation (ORIF) of the syndesmosis
Syndesmotic fusion

PREFERRED RESPONSE: 2- Retention of hardware with progression of activity

Question 17 of 100

One year after surgical fixation of the ankle (Figure 17) the patient has persistent pain within the ankle and wants the hardware removed. He should be counseled that after hardware removal he should expect

significant resolution of his pain and discomfort.
high risk of postoperative fibular fracture.
improvement in the range of motion.
no significant change in his symptoms.

PREFERRED RESPONSE: 4- no significant change in his symptoms.

Question 18 of 100

Which complication is most common after syndesmotic fixation?

Synostosis of the distal tibiofibular joint
Failure of fixation with subsequent loss of reduction
Malreduction of the distal tibiofibular joint
Posttraumatic ankle arthrosis

PREFERRED RESPONSE: 3- Malreduction of the distal tibiofibular joint

DISCUSSION

The injury radiographs reveal a supination external rotation IV ankle fracture with evidence of medial clear space widening exceeding 4 mm and an increase relative to the superior tibiotalar clear space. This indicates injury to the deltoid ligament and necessitates surgical reduction and fixation to restore and maintain ankle stability. Following stabilization of the fibula, an intraoperative stress examination of the syndesmosis such as an external rotation stress test under fluoroscopy or lateral pull on the fibula (the Cotton test) should be performed to determine the integrity of the syndesmosis. Radiographic evidence of tibiofibular clear space widening, medial clear space widening with external rotation, and lateral displacement of the distal fibula when pulled is consistent with syndesmotic injury. In contrast to the presurgical stress test, once the fibula has been reduced and stabilized lateral talar translation can occur only if the syndesmosis is injured in addition to the deltoid ligament. Failure of the syndesmotic screw without evidence of malalignment of the mortise and a pain-free ankle are not indications for further surgery because these patients have satisfactory outcomes when compared to those who have intact or removed screws. Hardware removal following fibula ORIF is indicated when patients have pain directly related to hardware prominence. Resolution of joint pain or stiffness is not a reliable outcome following hardware removal. Although fibular fracture can occur, this is a rare complication. Malreduction of the syndesmosis is the most common complication following ORIF of the syndesmosis and is improved with direct visualization; however, malreduction still may occur with direct visualization.

Question 19 of 100

Figure 19 is the clinical photograph of a 54-year-old man who underwent a total ankle replacement (TAR). Three weeks after surgery he has increasing pain and a deep wound as seen in the photograph. What is the best next step?

Remove the total ankle and place an antibiotic spacer
Debride and exchange polyethylene
Perform a below-the-knee amputation
Convert to a fusion with an intercalary allograft

PREFERRED RESPONSE: 2- Debride and exchange polyethylene

DISCUSSION

The patient is 3 weeks out from TAR. The wound is erythematous, and the tendon is visible. At 3 weeks this is an acute wound breakdown. The preferred treatment is a return to the operating room, an exchange of the polyethylene because the wound appears deep enough to go down to the joint, and a flap for coverage. Removal of the total ankle and placement of an antibiotic spacer should be considered in the settings of subacute (6 weeks postop) or chronic infection following TAR. A below-the-knee amputation may be considered with a failed salvage or a chronically infected TAR. Conversion to a fusion may be considered in situations in which the wound bed is not infected. In this case, there is concern for ongoing active infection, and an intercalary allograft is not appropriate.

Question 20 of 100

Figures 20a and 20b are the radiographs of a 56-year-old woman who runs a horse farm. She has a 2-year history of increasing ankle pain and swelling without previous treatment. Which treatment is most appropriate at this time?

- Nonsteroidal anti-inflammatory drugs (NSAIDs) and bracing
- Ankle fusion
- Ankle arthroscopy and cheilectomy
- Ankle distraction arthroplasty

PREFERRED RESPONSE: 1 - Nonsteroidal anti-inflammatory drugs (NSAIDs) and bracing

DISCUSSION

This patient has end-stage ankle arthritis. A short course of NSAIDs may provide pain and inflammation relief. Bracing with either an ankle-foot orthosis or Arizona brace can reduce pain by offloading the ankle joint. Ankle fusion is a reliable procedure for treatment of end-stage ankle arthritis and is especially recommended for active people after it is determined that nonsurgical measures no longer provide adequate relief. Arthroscopic debridement and cheilectomy may be indicated for bony impingement and mild arthritis with little articular cartilage loss. The long-term results of ankle distraction arthroplasty are not yet well defined but likewise would be reserved for scenarios in which nonsurgical measures no longer provide adequate relief. The patient must be able to wear a thin-wire external fixator for 3 months.

Question 21 of 100

Figure 21 is the intraoperative fluoroscopic image of a 40-year-old man who felt a pop during a twisting injury to his right ankle. He underwent open reduction and internal fixation (ORIF) of a bimalleolar ankle fracture. During the surgery the medial and lateral malleoli fractures were reduced and rigidly was internally fixed. Following fracture fixation, which additional test is recommended to ensure mortise stability?

Thompson
Cotton
Squeeze
Anterior drawer

PREFERRED RESPONSE: 2- Cotton

DISCUSSION

Following ORIF of a known osseous injury, stress testing of the syndesmosis is recommended, especially for pronation-external rotation injuries. The Cotton test applies a laterally directed force to the fibula to assess for widening of the distal tibiofibular joint space. A positive Cotton test result indicates that syndesmotic stabilization is indicated. The Thompson test is used to determine Achilles tendon integrity. The squeeze test is a clinical, not intraoperative, assessment of syndesmotic injury. The anterior drawer test assesses the integrity of the anterior talofibular ligament.

CLINICAL SITUATION FOR QUESTIONS 22 THROUGH 25

Figure 22 is a lateral radiograph of a 56-year-old woman who arrives at the emergency department with a midfoot injury that occurred 4 weeks ago. Her

medical history is positive for diabetes mellitus, hypertension, and dialysis-dependent chronic renal failure. She is a household ambulator. Her midfoot is red, swollen, and deformed. The redness decreases with elevation. Her white blood cell count is 5600/µL (reference range [rr], 4500-11000/µL) and her erythrocyte sedimentation rate is 15 mm/h (rr, 0-20 mm/h).

Question 22 of 100

What is the most appropriate diagnosis?

Osteomyelitis
Osseous tumor
Stress fracture
Charcot foot

PREFERRED RESPONSE: 4- Charcot foot

Question 23 of 100

What is the most appropriate treatment?

Bone biopsy
Total-contact casting
Double upright ankle foot orthosis
Empiric antibiotics

PREFERRED RESPONSE: 2- Total-contact casting

Question 24 of 100

Glucose control assessment is best achieved by ordering which blood test?

Random glucose
Fasting glucose
Hemoglobin A1C
Prealbumin

PREFERRED RESPONSE: 3- Hemoglobin A1C

Question 25 of 100

The mechanism for the osseous destruction is attributable to

avascular necrosis.
tumor invasion.
hypervascularity.
infection.

PREFERRED RESPONSE: 3- hypervascularity.

DISCUSSION

This scenario is a classic example of the development of Charcot foot. A red, swollen, deformed foot without ulceration suggests neuroarthropathy. Normal inflammatory marker findings, no history of fever or chills, and radiographs demonstrating bone loss support the diagnosis. Limb elevation with dramatic reduction in erythema is also characteristic of this disease process and does not occur with infection. Total-contact casting is the cornerstone of treatment for acute Charcot disease. Hemoglobin A1C is an indicator of glucose averaged over a 3-month period, providing the most reliable indication of a patient's ongoing glucose control. The pathophysiology of bone destruction is believed to be hypervascularity of bone. Infection and Charcot disease may develop simultaneously, but the combination is rare.

Question 26 of 100

Contracture of which structure causes hammertoe deformity?

Extensor digitorum longus tendon
Extensor digitorum brevis tendon
Flexor digitorum longus tendon
Flexor digitorum brevis tendon

PREFERRED RESPONSE: 3- Flexor digitorum longus tendon

DISCUSSION

A patient with a flexible hammertoe deformity has the deformity while standing, but practically no deformity when seated with the foot in equinus. The metatarsophalangeal joint is not involved. The deformity is created by contracture of the flexor digitorum longus tendon.

Question 27 of 100

A 10-year-old boy reports heel pain with sporting activities. An examination demonstrates gastrocnemius contracture and tenderness at the calcaneal apophysis. Radiographs are unremarkable. What is the best next step?

MRI
Surgical intervention
Activity modification
Cast immobilization

PREFERRED RESPONSE: 3- Activity modification

DISCUSSION

Sever disease, or calcaneal apophysitis, is best treated with activity modification that includes rest, restriction from sports and running, and Achilles tendon stretching exercises. The diagnosis is clinical (rendering MRI study unnecessary) and the course is usually self-limited, obviating the need for surgery. Occasionally, children with severe symptoms may benefit from a short period of cast or fracture brace immobilization.

Question 28 of 100

Figure 28 is the radiograph of a 25-year-old soccer player who twisted her left ankle 1 week ago. She has pain and swelling over the anterolateral ankle and there is ecchymosis over the lateral ankle. She has these muscle group findings: anterior tibial tendon-right 5/5, left 5/5; posterior tibial tendon-right

5/5, left 5/5; peroneals-right 5/5, left 4/5; Achilles-right 5/5, left 5/5. What is the best next diagnostic or treatment step?

Stress radiographs
Surgical resection of the fragment with lateral ligament reconstruction
Physical therapy for peroneal strengthening and proprioceptive training
Ankle arthroscopy for debridement

PREFERRED RESPONSE: 3- Physical therapy for peroneal strengthening and proprioceptive training

DISCUSSION

Thousands of ankle sprains occur in the United States every day. Most affected patients do not have serious sequelae associated with their injury. In this case, a young athlete sprained her ankle. Her only area of tenderness is isolated to the anterior talofibular ligament. She also has associated weakness. The radiograph shows an os subfibulare; this is an entity that she likely was born with. There is no indication of bony pain, and it is too soon to test for instability; consequently, no further imaging is required. Considering the nature of the sprain and her weakness, physical therapy with proprioceptive training and peroneal strengthening would be most beneficial.

CLINICAL SITUATION FOR QUESTIONS 29 THROUGH 33

Figures 29a and 29b are the weight-bearing radiographs of a 49-year-old woman who has had several months of increasing pain and deformity in her left foot. She points to her plantar medial arch as her area of greatest pain; however, she also has pain just distal to the tip of the distal fibula. Her pain worsens with walking or navigating stairs. Upon examination she has a flexible unilateral pes planus deformity with increased heel valgus and forefoot abduction. She is unable to perform a single heel raise.

29A

Question 29 of 100

Which primary underlying pathologic finding is causing her symptoms?

Spring ligament tear
Gastrocnemius contracture
Tarsal coalition
Posterior tibial tendon dysfunction

PREFERRED RESPONSE: 4- Posterior tibial tendon dysfunction

Question 30 of 100

Injury to which ligament is commonly seen in this condition?

Cervical
Calcaneonavicular (spring)
Deltoid
Interosseous

PREFERRED RESPONSE: 2- Calcaneonavicular (spring)

Question 31 of 100

In addition to physical therapy, what is the best course of treatment at this time?

Steroid injection
Platelet-rich plasma injection
Ankle-foot orthosis
Foot orthosis with a lateral post

PREFERRED RESPONSE: 3- Ankle-foot orthosis

Question 32 of 100

Which surgical procedure should be considered after 6 months of unsuccessful nonsurgical treatment?

Calcaneal osteotomy with bone graft and flexor digitorum longus tendon transfer
Subtalar fusion
Triple arthrodesis
Ankle arthrodesis

PREFERRED RESPONSE: 1- Calcaneal osteotomy with bone graft and flexor digitorum longus tendon transfer

Question 33 of 100

Figure 33 is the preoperative photograph of the patient's forefoot with the heel taken out of valgus. Which procedure will best address this forefoot deformity (which cannot be passively corrected by the examiner)?

First tarsometatarsal joint fusion
Gastrocnemius musculotendonous recession
Subtalar arthroereisis
Dorsal opening-wedge osteotomy of the medial cuneiform

PREFERRED RESPONSE: 4- Dorsal opening-wedge osteotomy of the medial cuneiform

DISCUSSION

The most common cause of acquired adult flatfoot deformity (AAFD) is dysfunction of the posterior tibial tendon. Tearing of the calcaneonavicular (spring) ligament and gastrocnemius contracture results from longer-standing attenuation of the posterior tibial tendon. Tarsal coalitions typically cause rigid flatfoot deformity. The calcaneonavicular ligament comprises superomedial and inferomedial bands. More than 70% of patients with AAFD have tearing of the superomedial band. Tearing of the inferior band is seen less commonly. Deltoid ligament insufficiency can be seen in long-standing valgus foot deformity. Initial treatment should start with ankle-foot orthosis bracing and physical therapy.

The radiographs reveal loss of arch, significant uncoverage of the talar head by the navicular, and lack of significant arthritis. Fusion procedures are not indicated considering the patient's flexible deformity and the absence of hindfoot arthritis. Realignment osteotomy must be combined with flexor digitorum longus tendon transfer to successfully alleviate this patient's symptoms. Lateral column lengthening will correct the forefoot abduction and talonavicular subluxation. A medial sliding osteotomy can achieve additional correction and decompress subfibular impingement. A dorsal opening plantar flexion (Cotton) osteotomy of the medial cuneiform is an adjunct procedure that is needed to balance the foot in cases of residual forefoot varus, as seen in the clinical photograph.

Question 34 of 100

Which stress fracture location is reported most frequently among ballet dancers?

Base of the second metatarsal
Base of the fifth metatarsal
Tibial sesamoid
Central third of the tarsal navicular

PREFERRED RESPONSE: 1- Base of the second metatarsal

DISCUSSION

Stress fractures are a frequent overuse injury among professional ballet dancers. The most common location is at the proximal metaphyseal-diaphyseal junction of the second metatarsal. Repetitive stress injuries and fractures of the tibial sesamoid, tarsal navicular, and base of the fifth metatarsal occur among other athletes.

Question 35 of 100

Figure 35 is the radiograph of a 37-year-old woman who began having right forefoot pain about 4 weeks ago after increasing her daily running mileage. She denies any specific injury. Upon examination she has tenderness over the medial forefoot with mild swelling. In addition to her activity level, what is the primary etiology of the radiograph finding?

Osteoporosis
Hallux valgus deformity
Hallux rigidus
A relatively long second metatarsal

PREFERRED RESPONSE: 4- A relatively long second metatarsal

DISCUSSION

Stress fractures are the result of physiological bone response to increased stress. Increased stress on bone triggers an increase in remodeling, which begins with resorption of bone at the site of stress. Ongoing stress can overwhelm bone strength, resulting in a fracture. In the foot this most commonly is seen in the second metatarsal at the junction of the middle and distal thirds. Contributing factors to increased loading of the second metatarsal include hallux valgus (decreased hallux loading transfers to the second metatarsal head), hallux rigidus (offloading of the hallux attributable to pain increases second metatarsal loading), and a long second metatarsal (increased duration of contact during push-off in the stance phase).

Question 36 of 100

Which radiographic abnormality most accurately serves as a predictor of ankle syndesmosis disruption?

Medial clear space equal to the superior clear space on the anteroposterior (AP) view
Tibiofibular overlap exceeding 6 mm on the AP view
Tibiofibular clear space exceeding 6 mm on AP view
Talocrural angle symmetric to the opposite side

PREFERRED RESPONSE: 3- Tibiofibular clear space exceeding 6 mm on AP view

DISCUSSION

Normal syndesmotic relationships include a tibiofibular clear space smaller than 6 mm on both AP and mortise views. In a 1989 cadaveric study by Harper and Keller, a tibiofibular clear space exceeding 6 mm on both the AP and mortise views was the most reliable predictor of early syndesmotic widening. Tibiofibular overlap is measured 1 cm proximal to the plafond. Normal values exceed 6 mm or 42% of the width of the fibula on the AP view, or 1 mm on the mortise view. Proximal fibula fracture can occur in isolation without syndesmotic injury, frequently after direct trauma. The medial clear space is the distance between the lateral border of the medial malleolus and the medial border of the talus and is measured at the level of the talar dome. In the mortise view with the ankle in neutral dorsiflexion, the medial clear space should be equal to or smaller than the superior clear space between the talar dome and the tibial plafond. ?A normal medial clear space may be present with syndesmotic injury and consequently lacks sensitivity and specificity.

CLINICAL SITUATION FOR QUESTIONS 37 THROUGH 40

A 41-year-old man sustained a twisting injury while running up stairs 4 weeks ago. He was treated in an ankle brace and has been bearing weight since the injury occurred. He has no history of ankle problems, but he now has ankle pain, swelling, and instability. The pain is aggravated by stairs, and the instability is worse on unlevel ground. Radiographs do not show a fracture.

Question 37 of 100

What is the appropriate treatment at this time?

Begin a structured proprioceptive-based rehabilitation program and use a brace as needed.
Discontinue the brace and start aggressive range-of-motion physical therapy.
Use a short-leg weight-bearing cast for 4 weeks.
Maintain nonweight-bearing status on crutches for 4 weeks.

PREFERRED RESPONSE: 1- Begin a structured proprioceptive-based rehabilitation program and use a brace as needed.

Question 38 of 100

38A

Three months later this patient has continued swelling and giving-way episodes. Figures 38a and 38b are his stress radiographs. This study indicates laxity in which ligament?

Anterior talofibular
Calcaneal fibular
Posterior talofibular
Lateral talocalcaneal

PREFERRED RESPONSE: 1- Anterior talofibular

Question 39 of 100

39A

The continued pain and instability 4 months after injury are likely related to which finding on the presurgical MR images in Figures 39a through 39d?

Peroneal brevis tear
Osteochondral lesion of the talus
Loose body in the posterior ankle
Tear of the calcaneal-fibular ligament

PREFERRED RESPONSE: 2- Osteochondral lesion of the talus

Question 40 of 100

40A

Figures 40a and 40b are this patient's intraoperative arthroscopic images. The abnormality seen here illustrates which of the patient's clinical findings?

Instability on unlevel ground
Ankle pain and swelling
Anterior laxity on lateral radiographs
Osteochondral lesion of the talus on MR imaging

PREFERRED RESPONSE: 2- Ankle pain and swelling

DISCUSSION

Ankle sprains are the most common musculoskeletal injury; however, most of these sprains do not progress to chronic instability. Initial injuries are treated with RICE (rest, ice, compression, elevation), range of motion, weight bearing

as tolerated, and proprioceptive therapy. Lace-up ankle braces are most effective during the subacute period after a sprain. Structured physical therapy focused on proprioception is recommended for 6 weeks. Examination findings for ankle ligament instability are unreliable because of associated subtalar joint motion. Casting is not as effective as functional rehabilitation. Stress radiographs are recommended, but a clear pathologic range of measurements is not defined. Generalized ligament laxity can result in false-positive findings of instability; therefore, contralateral stress radiographs are often necessary for comparison. The difference in anterior drawer measurement between both ankles should not exceed 5mm. Likewise, the difference in talar tilt measurement between both ankles should be 5 or fewer degrees. Patients with mechanical symptoms, a joint effusion, or continued pain may have an intra-articular pathology such as a loose body or osteochondral lesion. Ankle instability can exist without ligamentous laxity. Symptoms of chronic instability can result from osteochondral lesions of talus, peroneal tendon pathology, loose bodies, anterior ankle impingement, and fracture nonunions. Although there is not sufficient evidence to recommend arthroscopy prior to all ligament reconstructions, arthroscopy is recommended when other pathology is suspected.

Question 41 of 100

Which nerve is not included in a standard popliteal nerve block?

Sural nerve
Saphenous nerve
Superficial peroneal nerve
Deep peroneal nerve

PREFERRED RESPONSE: 2- Saphenous nerve

DISCUSSION

A standard popliteal nerve block is performed with the patient prone. The injection aims for the area at, or close to, the peroneal and tibial nerves. The sural nerve branches distal to the injection site, so this nerve and the superficial peroneal, deep peroneal, and tibial nerves are covered with the injection. The saphenous nerve is in an anteromedial location at knee level and is not close enough to the area covered by the posterior injection to be included in the analgesic effect.

CLINICAL SITUATION FOR QUESTIONS 42 THROUGH 44

42A

Figures 42a and 42b are the radiographs of a 32-year-old man with an accessory navicular, pes planovalgus deformity, and an associated gastrocnemius contracture. He has been treated with custom orthotics and a physical therapy program for several years and has progressed to stage II posterior tibial tendon dysfunction (PTTD). This patient is now interested in surgery. Tendon reconstruction with bony procedure to correct alignment, medializing calcaneal osteotomy with lateral column lengthening, and a subtalar arthroereisis implant are discussed with the patient.

Question 42 of 100

Which complication associated with subtalar arthroereisis devices for treatment of flexible flatfoot deformity is most common?

Fracture of the talus
Osteonecrosis of the calcaneus
Persistent pain in the sinus tarsi
Attritional rupture of the flexor digitorum longus (FDL) tendon

PREFERRED RESPONSE: 3- Persistent pain in the sinus tarsi

Question 43 of 100

43A

Figures 43a and 43b are the postsurgical radiographs. Which tendon transfer is most appropriate for this patient's treatment?

Peroneus longus
Plantaris
Flexor hallucis longus
FDL

PREFERRED RESPONSE: 4- FDL

Question 44 of 100

Os naviculare is present in which percentage of normal feet?

1- 1% to 2%

2- 10% to 14%

3- 25% to 30%

4- 40% to 50%

PREFERRED RESPONSE: 2- 10% to 14%

DISCUSSION

Accessory navicular is found in 10% to 14% of normal feet, is generally asymptomatic, and involves 3 radiographic types. Type I represents a small ossicle embedded within the posterior tibial tendon, type II is larger with a synchondrosis, and type III is fused to the navicular tuberosity. Approximately 50% of patients with symptoms have flexible flatfoot; however, os naviculare is not directly associated with pes planovalgus deformity.

Subtalar arthroereisis describes the use of a sinus tarsi plug or implant to restrict eversion of the subtalar joint. This surgical procedure has been used in combination with tendon reconstruction for treatment of flexible flatfoot deformity. Known complications of subtalar arthroereisis include persistent sinus tarsi pain, foreign body reaction, implant failure, and osteonecrosis of the talus.

The FDL tendon travels within the same compartment adjacent to the posterior tibial tendon and is the most commonly used tendon transfer for treatment of stage II PTTD (strength characteristics are similar). The plantaris has inferior tendon strength to the FDL, and the peroneus longus travels in a different compartment than the FDL.

Question 45 of 100

B C

D E

Figures 45a through 45c are the MR images of a 22-year-old woman who has had 6 months of ankle pain related to activities of daily living. She recently completed a course of cast immobilization and protected weight bearing without symptom resolution. Figures 45d and 45e are the intraoperative arthroscopy images after minimal probing. What is the most appropriate treatment?

Ankle fusion
Arthroscopic debridement and drilling
Retrograde drilling and bone grafting
Malleolar osteotomy and osteochondral grafting

PREFERRED RESPONSE: 4- Malleolar osteotomy and osteochondral grafting

DISCUSSION

The MR images reveal a large cystic medial talar dome osteochondral lesion (OCL) in a patient who has failed nonsurgical treatment. Ankle fusion is inappropriate because the patient has an otherwise normal ankle. Arthroscopic debridement and drilling are appropriate for smaller (< 1.5 cm sq) noncystic lesions. Retrograde drilling and bone grafting is an option in the treatment of cystic OCL if the cartilage surface is intact; however, intraoperative arthroscopy images show that this patient's cartilage surface is unstable. Osteochondral allografts and autografts are effective in the treatment of large cystic talar dome OCLs but are not appropriate for the initial surgical treatment of smaller lesions like this one.

Question 46 of 100

A 32-year-old woman has had progressive left foot pain over the first metatarsophalangeal (MTP) joint. Footwear is becoming problematic. There is full range of motion of the first MTP with medial eminence pain. Her weightbearing radiograph reveals a hallux valgus angle (HVA) of 35 degrees and a 1-2 intermetatarsal angle (IMA) of 10 degrees. What is the best next step?

Distal metatarsal osteotomy
Distal soft-tissue reconstruction
Proximal metatarsal osteotomy
Lapidus bunionectomy

PREFERRED RESPONSE: 1- Distal metatarsal osteotomy

DISCUSSION

Patients with painful progressive hallux valgus are surgical candidates. Presurgical evaluation includes radiographic examination. The IMA between the first and second metatarsals as well as the HVA must be measured. If the IMA is smaller than 15 degrees and the HVA is smaller than 35 degrees, a distal osteotomy is preferred. Distal soft-tissue reconstruction is only useful for IMAs smaller than 11 degrees and HVAs smaller than 25 degrees. Proximal osteotomies and the Lapidus bunionectomy are reserved for larger hallux valgus deformities with IMAs exceeding 15 degrees and HVAs exceeding 35 degrees.

RESPONSES FOR QUESTION 47 THROUGH 50

Observation
Arizona brace
Medial arch support
Casting
Hindfoot fusion

Select the most appropriate initial treatment from the list above to address each of the conditions described below.

Question 47 of 100

An 8-year-old boy with pes planus that reconstitutes with heel-rise; his mother brought him in for evaluation because he seems to be "tripping a lot".

Observation
Arizona brace
Medial arch support
Casting
Hindfoot fusion

PREFERRED RESPONSE: 1- Observation

Question 48 of 100

A 37-year-old woman has had persistent right lateral ankle pain after sustaining a minor sprain 5 months ago. She has a sense of instability on

uneven ground. Physical therapy has not helped. She is tender along the peroneal tendons and in the sinus tarsi. She has a negative anterior drawer test result for the ankle and no tenderness over the anterior lateral malleolus. She also has bilateral pes planus that persists with heel rise.

Observation
Arizona brace
Medial arch support
Casting
Hindfoot fusion

PREFERRED RESPONSE: 4- Casting

Question 49 of 100

A 15-year-old high school basketball player has pain over a medial midfoot prominence on his right foot. There has been no trauma and no specific treatment. He has bilateral flexible pes planus and pain with inversion against resistance on the right. His pain is disrupting or preventing his daily and sports activities.

Observation
Arizona brace
Medial arch support
Casting
Hindfoot fusion

PREFERRED RESPONSE: 4- Casting

Question 50 of 100

A 69-year-old woman has rigid painful left pes planus that has become less symptomatic with casting. She has multiple comorbidities and is not a good surgical candidate. She has failed a trial of activity without any supports.

Observation
Arizona brace
Medial arch support
Casting
Hindfoot fusion

PREFERRED RESPONSE: 2- Arizona brace

DISCUSSION

Treatment for pes planus revolves around 2 clinical parameters: pain and rigidity. In the absence of pain, no intervention is warranted because there are no other symptoms that can reasonably be linked to the foot shape. Flexible pes planus (that corrects with heel rise) is usually normal and does not cause symptoms, but it can be associated with a symptomatic accessory navicular, in which case the patient may have pain over the medial navicular from either traction by the tibialis posterior or the act of rubbing against the medial shoe counter. Rigid pes planus is most frequently associated with a tarsal coalition, which classically presents in late adolescence but can become symptomatic for the first time in adults. The initial treatment for painful pes planus, whether flexible or rigid, is immobilization, usually in a walking cast. This often is sufficient to relieve symptoms on a permanent basis. Surgery should be contemplated only when this treatment fails. Adult-acquired flatfoot is most commonly attributable to tibialis posterior tendon dysfunction. In stage 3, the pes planus is rigid. If it is painful, surgical treatment, which consists of a triple arthrodesis, may be considered. However, if medical constraints or patient preference preclude surgery, an Arizona brace can provide sufficient support to reduce symptoms to an acceptable level to perform activities of daily living.

CLINICAL SITUATION FOR QUESTIONS 51 AND 52

Figure 51a demonstrates the sneaker wear pattern and Figures 51b and 51c are the weight-bearing radiographs of a 20-year-old National Collegiate Athletic Association Division I basketball player. Throughout his college career he has experienced pain in the lateral aspect of his right foot. He has been treated with a clamshell orthotic, but this preseason his pain is worse than ever. Upon examination he has tenderness to palpation over the fifth metatarsal and his peroneal strength is 5/5 bilaterally

Question 51 of 100

What is the primary concern regarding resolution of this fracture?

Overload of the lateral foot column
Tendon pull on the fragments
Blood supply to this area
Patient activity level

PREFERRED RESPONSE: 3- Blood supply to this area

Question 52 of 100

Which treatment option will most reliably achieve long-term success?

Dwyer osteotomy
Surgical fixation with a solid screw
Surgical fixation with a cannulated screw
Iliac crest bone graft with plate fixation

PREFERRED RESPONSE: 2- Surgical fixation with a solid screw

DISCUSSION

There are 3 types of fifth metatarsal fractures. Zone 1 is an avulsion fracture. Zone 2 fractures, also known as Jones fractures, occur in the watershed area of the fifth metatarsal. A fracture must exit the intermetatarsal articulation between the fourth and fifth metatarsals to be considered a Jones fracture. Zone 3 fractures are distal to the articulation in the diaphysis of the fifth metatarsal. Jones fractures are associated with a 15% to 20% nonunion rate with nonsurgical care. Surgical intervention is preferred in athletic patients. Fixation with a solid screw is mechanically stronger than fixation with a cannulated screw. Nonunions or failure of hardware can be attributable to inadequate fixation or an unrecognized varus heel alignment leading to lateral column overload.

Question 53 of 100

Figure 53 is a coronal-cut CT scan of a 63-year-old woman who has a longstanding pes planus. She is seen for lateral ankle discomfort. Upon examination she is tender over the sinus tarsi and distal to the fibula. She has painless passive hindfoot eversion with 5/5 eversion strength. The most appropriate diagnosis is

subtalar arthritis.
middle-facet coalition.
lateral impaction syndrome.
calcaneonavicular coalition.

PREFERRED RESPONSE: 3- lateral impaction syndrome.

DISCUSSION

With the use of CT scans, adults with symptomatic flatfoot deformity have been noted to develop subluxation of the talocalcaneal joint with resulting lateral hindfoot pain. Impingement of the talus and calcaneus in the sinus tarsi and/or between the tip of the fibula and the calcaneus may occur. This impingement is known as lateral impaction syndrome. Hindfoot motion is painless; therefore, this patient does not have symptomatic subtalar arthritis. Middle facet and calcaneonavicular coalitions are not present (hindfoot motion is present).

Question 54 of 100

Figure 54 is the lateral radiograph of a 55-year-old man who is evaluated for a 2-year history of pain and stiffness of his right metatarsophalangeal (MTP) joint. Upon examination he has dorsal bossing, severe crepitation, and pain

with passive range of motion. There is pain with the "grind" test. Dorsiflexion is limited to 0 degrees. No sesamoid tenderness is present. What is the most appropriate surgical treatment?

Chevron bunionectomy
Cheilectomy and removal of loose body
MTP arthrodesis
Resection of proximal phalanx

PREFERRED RESPONSE: 3- MTP arthrodesis

DISCUSSION

The radiograph reveals end-stage degenerative changes of the first MTP joint with a dorsal loose body. MTP arthritis and decreased joint dorsiflexion is referred to as hallux rigidus. A chevron bunionectomy is used to correct hallux valgus deformity without arthritis. The cheilectomy is used in lesser degrees of joint destruction. Resection of the proximal phalanx results in a floppy toe and is generally not recommended.

CLINICAL SITUATION FOR QUESTIONS 55 THROUGH 58

Figures 55a and 55b are the anteroposterior and lateral radiographs of a 57-year-old man who fell off of a ladder 10 days ago and landed on his left foot. He is now unable to weight bear on the left. He has no history of trauma to this foot, and his medical history is unremarkable. Upon examination his left foot is swollen and tender. Pulses and sensation are intact.

A B

Question 55 of 100

What is the most likely diagnosis?

Fracture dislocation of the Lisfranc joint
Fracture dislocation of the Chopart joint
Fracture dislocation of the subtalar joint
Complex fracture dislocation of the midtarsal articulations

PREFERRED RESPONSE: 2- Fracture dislocation of the Chopart joint

Question 56 of 100

What is the most appropriate initial treatment?

Primary arthrodesis
Attempted closed reduction in the office
Attempted closed reduction under anesthesia with possible open reduction
Splinting to comfort level and progressive weight bearing as tolerated

PREFERRED RESPONSE: 3- Attempted closed reduction under anesthesia with possible open reduction

Question 57 of 100

If a closed reduction is attempted, which structure most likely will prevent a reduction?

Tibialis anterior tendon
Tibialis posterior tendon
Peroneus brevis tendon
Peroneus longus tendon

PREFERRED RESPONSE: 2- Tibialis posterior tendon

Question 58 of 100

After full healing from this injury, which option most likely will help to optimize this patient's activities?

Extra-depth shoes
Rocker-bottom soles
Figure-of-8 soft-ankle brace
A patellar-tendon-bearing brace

PREFERRED RESPONSE: 2- Rocker-bottom soles

DISCUSSION

Midfoot fracture dislocations typically occur after a fall from a height or a motor vehicle collision involving severe dorsiflexion loading of the foot from a brake pedal or the floorboards. The deformity that results may be subtle because the subluxation may be a valgus or varus rotation around the midfoot rather than pure dorsiflexion. Early recognition and reduction is indicated to minimize secondary complications such as nerve injury or vascular compromise. Closed reduction usually necessitates formal anesthesia in an operating room to permit adequate relaxation and reduction. In many cases, satisfactory reduction can be accomplished closed, but the surgeon must be prepared to perform an open reduction if needed. The most common reason for failed closed reduction is that the talar head is caught by the tibialis posterior tendon (under which the talar head has protruded). This acts as a Chinese finger trap, preventing relocation by the usual distraction followed by

a plantar flexion maneuver. In these cases, open reduction is performed through a dorsomedial incision through which the tibialis posterior is retracted medially, allowing reduction of the talonavicular joint. The joints usually require pinning to maintain stability during healing. The long-term prognosis for these injuries is guarded because many patients develop degenerative changes in the Chopart joint. If symptomatic arthritis develops, helpful external supports are designed to limit sagittal motion at the joint (for example, carbon fiber inserts or rocker-bottom soles).

Question 59 of 100

Which lower extremity muscle is first weakened in Charcot-Marie-Tooth (CMT) disease?

Peroneus brevis
Peroneus longus
Foot intrinsics
Tibialis anterior

PREFERRED RESPONSE: 3- Foot intrinsics

DISCUSSION

Although many of the lower extremity muscles may be affected in CMT, those innervated by the longest axons have been shown to be affected first. In the lower extremity the muscles innervated by the longest axons are the intrinsic foot muscles. The tibialis anterior and the peroneus brevis may be severely affected but not before the foot intrinsics. The peroneus longus typically is spared, resulting in the cavus.

CLINICAL SITUATION FOR QUESTIONS 60 THROUGH 63

Figure 60 is the standing radiograph of a 27-year-old man who played football throughout his teen years. During those years, he noted that he had less mobility of his left foot and ankle. He twisted his left foot and ankle 8 months ago and has tried over-the-counter nonsteroidal anti-inflammatory drugs and a brace. He now has pain and edema in the left sinus tarsi area. Upon examination the following arcs of motion are identified: ankle dorsiflexion-right, 5 degrees/left, 5 degrees; ankle plantar flexion-right, 30 degrees/left 30 degrees; foot inversion-right, 10 degrees/left, 5 degrees; foot eversion-right, 10 degrees/left 5 degrees.

Question 60 of 100

What are the most common locations of the pathology?

Calcaneocuboid and talocalcaneal joints
Talonavicular and calcaneocuboid joints
Talonavicular and calcaneonavicular joints
Talocalcaneal and calcaneonavicular joints

PREFERRED RESPONSE: 4- Talocalcaneal and calcaneonavicular joints

Question 61 of 100

What is the origin of this patient's pathology?

Traumatic
Genetic
Arthritic
Attritional

PREFERRED RESPONSE: 2- Genetic

Question 62 of 100

After a review of the images, it appears the appropriate next diagnostic step should be

MRI.
CT scan.
bone scan.
ultrasound.

PREFERRED RESPONSE: 2- CT scan.

Question 63 of 100

The patient undergoes further testing and it is discovered that the lesion encompasses 70% of the joint. What is the best next treatment option?

Arthroscopic debridement
Subtalar arthroereisis
Subtalar fusion
Lesion resection

PREFERRED RESPONSE: 3- Subtalar fusion

DISCUSSION

A tarsal coalition is an abnormal connection of 2 or more bones in the foot. Although tarsal coalitions are present at birth, children and adults typically do not show signs of the disorder until early adolescence or later. The exact incidence of the disorder is hard to determine; however, it is caused by a gene mutation that affects cells that produce the tarsal bones. The 2 most common locations for tarsal coalitions are between the calcaneus and the navicular or between the talus and the calcaneus. It is estimated that 1 out of every 100 people may have a tarsal coalition. In 50% of cases, both feet are affected. Tarsal coalitions are rarely discovered until symptoms arise. Symptoms may include stiff and painful feet, a rigid flatfoot, or increased pain or a limp with high-level activities. Upon examination, symptoms may include tenderness in the area of the coalition, loss of motion, rigid flat feet, and arthritic changes of the joint. Imaging studies begin with radiographs. A CT scan can provide bony detail for imaging tarsal coalitions and determining the extent of the coalition and any accompanying degenerative change. MRI can provide details of the soft tissues. Treatment includes nonsurgical care including rest, orthotics, a temporary boot or cast, and injections. Surgical options include resection with interposition of muscle or fatty tissue from another area of the body or fusions when large (exceeding 50% of the joint), more severe coalitions are encountered.

Question 64 of 100

Figures 64a through 64c are the MR images and radiograph of an active 30-year-old man who has been treated for pain in his subtalar joint for 6 months. He has had casting, physical therapy, and bracing but continues to have activity-limiting pain. An injection into the subtalar joint under fluoroscopic guidance temporarily relieved his pain. His best surgical option at this time is

resection of the coalition bar.
subtalar fusion.
medial sliding calcaneal osteotomy.
Dwyer osteotomy.

PREFERRED RESPONSE: 2- subtalar fusion.

DISCUSSION

When contemplating the causes of subtalar joint degeneration in young patients, an unstable tarsal coalition should be considered in the absence of antecedent trauma. Initial treatment with casting is appropriate because this intervention can relieve symptoms for many patients. There are 2 surgical options for a symptomatic tarsal coalition: bar resection or completion fusion. Risk factors for a poor outcome after bar resection are adult age and a bar that encompasses more than 50% of the middle facet of the subtalar joint. Because this patient has both risk factors, the appropriate procedure is a subtalar fusion.

Question 65 of 100

What is a risk factor for interdigital neuroma?

Female gender
Increased mobility between the third and fourth rays
Achilles tendon contracture
Prolonged standing at work

PREFERRED RESPONSE: 1- Female gender

DISCUSSION

The only proven risk factor for development of an interdigital neuroma is female gender, which likely is related to the use of fashionable shoes that force plantar flexion of the metatarsal heads and secondary hyperdorsiflexion of the metatarsophalangeal joints. The other factors listed have not been proven to cause interdigital neuroma, as well as mediolateral compression of the forefoot.

Question 66 of 100

Which Morton neuroma histology is most common?

Perineural fibrosis
Wallerian degeneration
Distal axonopathy
Segmental demyelination

PREFERRED RESPONSE: 1- Perineural fibrosis

DISCUSSION

Morton neuroma is a compressive neuropathy of the interdigital nerves of the forefoot that most commonly is noted in the third web space. Perineural fibrosis is commonly noted on microscopic examination of resected tissue. This accounts for the relatively higher failure rate of neuroma decompression by transection of the intermetatarsal ligament as opposed to resection. Wallerian degeneration is seen following axonal transection in the distal part of the nerve. Distal axonopathy is degeneration of the axon and myelin and is associated with "stocking-glove" distribution neuropathy. Segmental demyelination is characterized by breakdown of myelin with an intact axon

and is associated with lead poisoning and hereditary sensory motor neuropathy.

Question 67 of 100

A patient sustained a puncture wound to the plantar aspect of his foot. He was wearing shoes and socks at the time of the injury. Systemic antibiotic administration with specific coverage for which bacterial species (in addition to Staphylococcus aureus) should be instituted?

Escherichia coli
Mycobacterium marinum
Pseudomonas
Clostridium

PREFERRED RESPONSE: 3- Pseudomonas

DISCUSSION

Puncture wounds sustained through a shoe and sock increase risk for Pseudomonas infection. Clostridium are associated with soil-contaminated wounds. Mycobacterium marinum is associated with injuries sustained within water.

Question 68 of 100

Figure 68 is the radiograph of a 33-year-old runner who recently decided to begin running barefoot on trails. Since his transition to running without shoes 3 months ago, he has been having pain in the second metatarsophalangeal (MTP) joint. He feels like he is walking on a stone, notes edema in the ball of his foot, and has started to see a deviation of the second toe. What is the most likely etiology of these symptoms and findings?

Tear of the plantar plate
Second MTP joint synovitis
Second metatarsal stress fracture
Flexor tendonitis

PREFERRED RESPONSE: 1- Tear of the plantar plate

DISCUSSION

Lesser-toe plantar plate injuries are becoming increasingly recognized. Patients typically have an increase in pain, a positive Lachman test result upon examination, and deviation of the MTP joint. On radiograph, MTP subluxation can be appreciated. Nonsurgical treatment with a metatarsal pad may be attempted. Many patients who have surgery will have a partial or full tear of the plantar plate. The repair necessitates reinsertion of the plantar plate to the base of the proximal phalanx.

Question 69 of 100

Figure 69 is the radiograph of a 9-year-old who has posterior hindfoot pain while running. What is the most likely diagnosis?

Kohler disease
Thiemann disease
Freiberg infraction
Sever disease

PREFERRED RESPONSE: 4- Sever disease

DISCUSSION

Sever disease is a traction apophysitis at the Achilles tendon insertion on the calcaneus. Plain radiographs may be unremarkable for this condition. Other osteochondroses of the foot include Kohler disease (tarsal navicular), Freiberg infraction (lesser metatarsal head), and Thiemann disease (great toe phalanx).

Question 70 of 100

A 62-year-old runner injured his right ankle 8 weeks ago. He has ongoing lateral ankle pain and swelling that did not improve with 4 weeks of immobilization and 4 weeks of physical therapy. MR images demonstrate a longitudinal tear of the peroneus brevis tendon. Treatment should involve

peroneus brevis tendon repair.
peroneus longus to peroneus brevis tenodesis.
6 weeks in short-leg cast.
platelet-rich plasma injection.

PREFERRED RESPONSE: 1- peroneus brevis tendon repair.

DISCUSSION

Additional nonsurgical treatment is not beneficial for peroneal tendon tears. Early repair of longitudinal tears reduces risk for progression to a full-thickness tear that would necessitate peroneus brevis to peroneus longus tenodesis. Platelet-rich plasma has no role in peroneal tendon tears.

RESPONSES FOR QUESTIONS 71 THROUGH 75

Lapidus procedure
First metatarsophalangeal (MTP) joint arthrodesis and lesser metatarsal head resection
Proximal first metatarsal osteotomy
Distal first metatarsal chevron osteotomy
Biplanar distal first metatarsal osteotomy

Match the appropriate surgical procedure listed above with the clinical scenario described below.

Question 71 of 100

Figure 71 is the radiograph of a 67-year-old patient with rheumatoid arthritis who has experienced 6 months of increasing pain, swelling, and foot deformity. Anti-inflammatory medications, orthotics, and extra-depth shoes fail to provide sufficient relief.

Lapidus procedure
First metatarsophalangeal (MTP) joint arthrodesis and lesser metatarsal head resection
Proximal first metatarsal osteotomy
Distal first metatarsal chevron osteotomy
Biplanar distal first metatarsal osteotomy

PREFERRED RESPONSE: 2- First metatarsophalangeal (MTP) joint arthrodesis and lesser metatarsal head resection

Question 72 of 100

Figure 72 is the radiograph of a 58-year-old active woman with progressive medial first MTP joint pain, particularly with shoe wear and increased activity. The patient has no hypermobility.

Lapidus procedure
First metatarsophalangeal (MTP) joint arthrodesis and lesser metatarsal head resection
Proximal first metatarsal osteotomy
Distal first metatarsal chevron osteotomy
Biplanar distal first metatarsal osteotomy

PREFERRED RESPONSE: 3- Proximal first metatarsal osteotomy

Question 73 of 100

A 44-year-old patient who has had a proximal first metatarsal osteotomy has recurrent pain and difficulty wearing many types of shoes. Radiographs show a large 1-2 intermetatarsal angle (IMA).

Lapidus procedure
First metatarsophalangeal (MTP) joint arthrodesis and lesser metatarsal head resection
Proximal first metatarsal osteotomy
Distal first metatarsal chevron osteotomy
Biplanar distal first metatarsal osteotomy

PREFERRED RESPONSE: 1- Lapidus procedure

Question 74 of 100

Figure 74 is the radiograph of a 31-year-old woman with a painful bunion deformity that has failed nonsurgical treatment.

Lapidus procedure
First metatarsophalangeal (MTP) joint arthrodesis and lesser metatarsal head resection
Proximal first metatarsal osteotomy
Distal first metatarsal chevron osteotomy
Biplanar distal first metatarsal osteotomy

PREFERRED RESPONSE: 4- Distal first metatarsal chevron osteotomy

Question 75 of 100

25-year-old man has had a painful bunion deformity since childhood. Nonsurgical treatment has failed. Weight-bearing radiographs reveal a congruent hallux valgus (HV) with a large distal metatarsal articular angle (DMAA) and a normal 1-2 IMA. There is no arthritis or first tarsometatarsal joint or hypermobility.
1. Lapidus procedure
2. First metatarsophalangeal (MTP) joint arthrodesis and lesser metatarsal head resection
3. Proximal first metatarsal osteotomy
4. Distal first metatarsal chevron osteotomy
5. Biplanar distal first metatarsal osteotomy
  
  PREFERRED RESPONSE: 5- Biplanar distal first metatarsal osteotomy
  
  DISCUSSION
  
  Most cases of HV should initially be treated nonsurgically. When indicated, the decision to pursue surgical treatment of HV is dependent on a variety of factors including presence of arthritis, joint stability/ligamentous laxity, congruence of the first MTP joint, and severity of deformity. Mild congruent HV may be treated with a distal chevron osteotomy. A distal soft-tissue procedure may be added if the deformity is incongruent. Moderate to severe HV deformities may be treated with proximal first metatarsal osteotomies such as the crescentic, Ludloff, or scarf osteotomy. Larger HV deformities are almost always associated with incongruent HV angles, and they necessitate a distal soft-tissue procedure to realign the first MTP joint. Fusion of the first MTP joint
  
  is indicated in cases of severe HV deformity or associated osteoarthritis or rheumatoid arthritis. The Lapidus procedure, an arthrodesis of the first metatarsal-medial cuneiform joint, has been a success when used to treat patients with first-ray instability (hypermobility) or as a salvage procedure for those who have bunion recurrence after previous surgery. A biplanar distal chevron osteotomy is indicated for congruent HV deformities involving a large DMAA (the angle measured between the slope of the articular surface of the first metatarsal head and the longitudinal axis of the first metatarsal).
  
  RECOMMENDED READINGS
  
  Coughlin MJ, Jones CP. Hallux valgus and first ray mobility. A prospective study. J Bone Joint Surg Am. 2007 Sep;89(9):1887-98. PubMed PMID: 17768183. View Abstract at PubMed Robinson AH, Limbers JP. Modern concepts in the treatment of hallux valgus. J Bone Joint Surg Br. 2005 Aug;87(8):1038-45. Review. PubMed PMID: 16049235. View Abstract at PubMed
  
  Coetzee JC, Wickum D. The Lapidus procedure: a prospective cohort outcome study. Foot Ankle Int. 2004 Aug;25(8):526-31. PubMed PMID: 15363372. View Abstract at PubMed Coughlin MJ, Mann RA. Hallux valgus. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. Philadelphia, PA: Mosby-Elsevier; 2007:230-236.
  
  CLINICAL SITUATION FOR QUESTIONS 76 THROUGH 79
  
  Figures 76a through 76c are the clinical photograph and radiographs of a 48-year-old man with a 10-year history of diabetes who has an open wound on his left foot. He had neither previous trauma nor earlier similar occurrences. His diabetes is well controlled, with a hemoglobin A1c level of 6.7% (reference range, 4%-7%). His examination is notable for well-perfused feet with intact pulses and intact sensation to light touch. There is mild tenderness over the left forefoot. The erythema in the forefoot does not resolve with elevation. The head of the fifth metatarsal can be probed through the wound.
  
  A
C

Question 76 of 100

What is the most common underlying etiology for this condition in this clinical setting?

Microvascular disease
Poorly controlled blood glucose
Sensory neuropathy
Chronic renal failure

PREFERRED RESPONSE: 3- Sensory neuropathy

Question 77 of 100

If nonsurgical treatment of this wound fails, the most likely cause for failure is

poor tolerance to casting.
poorly controlled blood glucose.
inappropriate choice of antibiotics.
underlying osteomyelitis.

PREFERRED RESPONSE: 4- underlying osteomyelitis.

Question 78 of 100

If surgery is necessary, what is the most appropriate procedure?

Below-knee amputation
Debridement of all infected tissue with primary closure
Debridement of all infected tissue with free-flap closure
Debridement of all infected tissue and a negative-pressure dressing for the resulting wound

PREFERRED RESPONSE: 4- Debridement of all infected tissue and a negative-pressure dressing for the resulting wound

Question 79 of 100

After the patient's wound has healed, which intervention is critical to prevent future ulceration?

A well-fitted prosthesis on the left
Making sure he wears large shoes to decrease pressure on his feet
A bilateral ankle-foot orthoses fitting
Custom-molded soft shoe inserts

PREFERRED RESPONSE: 4- Custom-molded soft shoe inserts

DISCUSSION

The most common etiology for plantar ulcers in patients with diabetes is neuropathy; 80% of these patients have adequate vascularity. The pathobiology is increased pressure applied on skin that lacks protective sensation (detected by lack of sensation to Semmes-Weinstein monofilament 5.07). The presence of sensation to light touch is not predictive of ulcer risk, but absent Semmes-Weinstein sensation at 5.07 carries a 30% risk for developing an ulcer. Intact light touch sensation does not rule out loss of protective sensation, and, therefore, does not rule out sensory neuropathy. The grading of an ulcer primarily depends on the existence of deep infection, either an abscess or osteomyelitis. In the presence of deep infection, formal surgical debridement is required. The surgery should be limited to the tissues

that are compromised, without an attempt at primary closure (which increases risk for recurrent infection). Negative-pressure dressings are a significant advance in postsurgical treatment by permitting delayed healing without further surgical intervention. Once healed, the key to preventing recurrent ulceration is the use of orthopaedic shoes with custom-molded soft inserts that accommodate the contours of the feet. This is particularly true when surgery has removed a portion of the foot; the foot otherwise will shift in a shoe that does not include a custom molded insert incorporating a filler that occupies the space left by the surgical resection.

Question 80 of 100

Which repair technique for an osteochondral lesion of the medial talus shoulder produces hyaline cartilage that is similar to native cartilage and will not degrade over time?

Autologous osteochondral transplantation
Arthroscopic bone marrow stimulation
Chondroplasty
Osteochondral allograft transplantation

PREFERRED RESPONSE: 1- Autologous osteochondral transplantation

DISCUSSION

Autologous osteochondral transplantation (typically involving tubular grafts harvested from the knee) has been shown to replace a talar defect with viable hyaline cartilage. The results over the medium term show good clinical outcomes, and MRI studies reveal cartilage repair similar to native cartilage. Chondroplasty and arthroscopic bone-marrow stimulation are both associated with good clinical results for smaller lesions, but these techniques develop fibrocartilaginous repair tissue composed of type I collagen instead of hyaline cartilage. Osteochondral transplantation of fresh allografts performed less than 14 days after harvest contains high chondrocyte viability. Few clinical studies report long-term results, but radiographic studies demonstrate high rates of collapse and resorption. Joint space narrowing has been noted in 60% of ankles treated with bulk grafts after an average of 44 months. Autologous chondrocyte implantation (both periosteum-covered and matrix-associated techniques) has been shown to create hyaline cartilage in some studies, but fibrocartilage creation has been reported in others.

Question 81 of 100

What is the most common turf toe mechanism of injury?

Hyperdorsiflexion of the first metatarsophalangeal (MTP) joint and axial load with the foot fixed in equinus
Hyperdorsiflexion of the first MTP joint with valgus thrust
Hyperplantarflexion of the first MTP joint axial load with the foot fixed in equinus
Hyperplantarflexion of the first MTP joint with valgus thrust

PREFERRED RESPONSE: 1- Hyperdorsiflexion of the first metatarsophalangeal (MTP) joint and axial load with the foot fixed in equinus

DISCUSSION

Turf toe, or capsuloligamentous injury to the first MTP joint, most commonly is caused by an axial load being applied to a fixed, dorsiflexed great toe with the heel off the ground. The external force causes further dorsiflexion of the great toe, leading to injury to the capsuloligamentous complex. A less common mechanism of turf toe is hyperplantarflexion of the great toe with valgus stress, which is seen in beach volleyball players.

Question 82 of 100

Figures 82a and 82b are the clinical photograph and radiograph of a 60-year-old man with a 30-year history of diabetes complicated by borderline chronic

renal failure, heart failure controlled by medication, and bilateral lower extremity neuropathy. He is currently wheelchair bound because of his cardiopulmonary limitations, but uses his legs for transfers. He has had a progressive left ankle deformity that has progressed to the point at which he cannot use his leg for pivot transfers. He is adamant that something should be done to improve his living situation. Which surgical option can best achieve his goal of using the leg for transfers?

Local debridement of the ankle with long-term bracing
Attempted fusion using a multiplanar external fixation
Attempted fusion using an intramedullary rod
Attempted fusion using screw fixation

PREFERRED RESPONSE: 3- Attempted fusion using an intramedullary rod

DISCUSSION

The indications for surgery in a Charcot joint are an unbraceable deformity or recurrent ulceration despite use of adequate bracing. Any significant varus/valgus deformity of the ankle or hindfoot (as in this patient) is unbraceable, whereas midfoot Charcot deformities usually can be treated nonsurgically. The goal of surgery is to provide a stable aligned foot and ankle to permit activities and reduce risk for recurrent ulceration. This does not mean that there has to be a radiographic fusion because many patients with diabetes achieve a stable nonunion without pain. The only surgical construct that will provide long-term inherent stability and alignment in this situation is use of a hindfoot fusion rod. It provides better stability and purchase than screw fixation and can be left in indefinitely (unlike an external fixator).

CLINICAL SITUATION FOR QUESTIONS 83 THROUGH 87

Figures 83a and 83b are the clinical photographs of a 42-year-old woman with a BMI of 31 who has had a 1-year history of right heel pain.

Question 83 of 100

Pain and tenderness at location 2 on Figures 83a and 83b is most consistent with which diagnosis?

Baxter's nerve entrapment.
Plantar fasciitis.
Tarsal tunnel syndrome.
Fat pad atrophy.

PREFERRED RESPONSE: 2- Plantar fasciitis.

Question 84 of 100

What is the most appropriate initial diagnostic test for plantar heel pain?

MRI
Ultrasound
Weight-bearing plain radiographs
Inflammatory arthritis serology

PREFERRED RESPONSE: 3- Weight-bearing plain radiographs

Question 85 of 100

What is the strongest risk factor for plantar fasciitis?

Female gender
African American ancestry
BMI higher than 30
Weight lifting and body building

PREFERRED RESPONSE: 3- BMI higher than 30

Question 86 of 100

What is the most reliable nonsurgical treatment for plantar fasciitis?

High-impact loading exercise
Corticosteroid injection
Platelet-rich plasma (PRP) injection
Plantar fascia stretching

PREFERRED RESPONSE: 4- Plantar fascia stretching

Question 87 of 100

Which surgical procedure should be considered for treatment of chronic plantar fasciitis?

Endoscopic or open plantar fasciotomy
Heel spur excision
Achilles tendon lengthening
Extensile approach, medial and plantar, to include release of tarsal tunnel and complete plantar fasciotomy

PREFERRED RESPONSE: 1- Endoscopic or open plantar fasciotomy

DISCUSSION

Imaging studies in the evaluation of plantar fasciitis should always include weight-bearing foot radiographs to reveal alignment and exclude calcaneal stress fracture, tumor, subtalar arthritis, and insertional posterior spurs. MRI is occasionally indicated in problematic cases. Ultrasound can be helpful to evaluate thickening and disease in the proximal plantar fascia. Ultrasound is quick and much more cost effective than MRI. Laboratory screenings to evaluate inflammatory arthritis are indicated only for patients with bilateral heel pain who may be more likely to have systemic disease.

In the nonsurgical treatment of plantar fasciitis, high-impact loading exercises may make the condition worse. Corticosteroid injections may provide short-term relief only and can occasionally cause plantar fascia rupture. They should be used with caution. PRP injections are expensive and currently not covered by insurance. Studies have not demonstrated long-term pain relief with PRP. Plantar fascia-specific stretching has been shown more effective than Achilles tendon stretching alone.

Surgical treatment is indicated for fewer than 5% of patients. It is not necessary to resect the heel spur because the spur is not attached to the plantar fascia and rarely contributes to a patient's pain. The open extensile approach is associated with a much longer recovery than the open or endoscopic approaches and is no longer justified. Multiple studies have demonstrated the efficacy of endoscopic and open plantar fasciotomy techniques.

Question 88 of 100

A 45-year-old woman with grade II adult-acquired flatfoot deformity has pain on the lateral side of her foot just distal to the tip of the fibula. Which component of a comprehensive flatfoot reconstruction most likely will address the deformity responsible for this pain?

Spring ligament reconstruction
Lateral column lengthening
Medial-displacing calcaneal osteotomy
Medial cuneiform opening-wedge osteotomy

PREFERRED RESPONSE: 3- Medial-displacing calcaneal osteotomy

DISCUSSION

Patients develop lateral ankle pain with progression of adult-acquired flatfoot deformity. This is associated with increased hindfoot valgus deformity. Calcaneal fibular impingement has been considered the primary cause of this pain. Studies demonstrate that arthrosis of the posterior facet of the subtalar joint strongly correlates with lateral pain in adult-acquired flatfoot deformity. Both conditions are related to hindfoot valgus deformity. Although lateral column lengthening is a powerful tool for correction of flatfoot deformity, its effect on hindfoot deformity is less defined. Lateral column lengthening provides better correction of the longitudinal arch of the midfoot and realignment of the medial column than other osteotomies. A medializing calcaneal osteotomy has a significant linear effect on hindfoot valgus alignment. Spring ligament reconstruction and medial cuneiform opening-wedge osteotomies have less effect on hindfoot alignment than the medial calcaneal slide.

Question 89 of 100

Figures 89a through 89c are the radiographs of a 35-year-old woman who has had 7 years of progressive ankle pain. She experiences stiffness and pain despite the use of an ankle-foot orthosis. Examination reveals pain along the anterior tibiotalar joint without tenderness to the subtalar or talonavicular joints. What is the most appropriate surgical intervention?

Total ankle arthroplasty (TAA)
Ankle arthrodesis
Tibiotalocalcaneal arthrodesis
Anterior tibial exostectomy with Achilles lengthening

PREFERRED RESPONSE: 2- Ankle arthrodesis

DISCUSSION

This patient has isolated posttraumatic ankle arthritis with significantly decreased ankle range of motion that is best treated with an isolated ankle arthrodesis to eliminate pain. Because this patient is younger than 50 years of age and has limited presurgical range of motion, she is not a candidate for ankle arthroplasty. Additionally, TAA outcomes among patients who have a posttraumatic etiology are worse than for those with osteoarthritis. Tibiotalocalcaneal arthrodesis is suited for patients with associated subtalar

arthritis or rigid hindfoot deformity that necessitates correction. Anterior tibial exostectomy will not resolve the underlying arthritic pain and is not indicated.

Question 90 of 100

Which structure is the primary stabilizer of the lesser metatarsophalangeal (MTP) joint?

Flexor digitorum brevis
Flexor digitorum longus
Plantar plate
Collateral ligament

PREFERRED RESPONSE: 3- Plantar plate

DISCUSSION

Synovitis of the second MTP occurs in association with instability of the joint. This can be idiopathic or secondary to an external deforming force (such as a hallux valgus or shoe wear causing a claw toe). The primary stabilizer of the MTP joint for translation in the vertical plane is the plantar plate. The flexor digitorum brevis flexes the MTP joint, and the flexor digitorum longus flexes

all joints of the toe. The collateral ligaments are primary stabilizers in the transverse plane and secondary stabilizers in the sagittal plane.

CLINICAL SITUATION FOR QUESTIONS 91 THROUGH 95

Figure 91a is the sagittal plane ultrasound of the second web space of a 48-year-old woman who has noted burning pain in the ball of her right foot for 2 years. The pain intermittently radiates into her second and the third toes. Figure 91b shows the surgical procedure and Figure 91c is the pathologic specimen.

Question 91 of 100

The cause of this patient's symptoms most likely is

pigmented villonodular synovitis (PVNS).
lipoma.
ganglion.
interdigital neuroma.

PREFERRED RESPONSE: 4- interdigital neuroma.

Question 92 of 100

The most appropriate pedorthic management of symptomatic interdigital neuroma involves

a metatarsal pad.
a dancer's pad.
a custom foot orthosis.
a medial heel wedge.

PREFERRED RESPONSE: 1- a metatarsal pad.

Question 93 of 100

Open or endoscopic decompression of interdigital neuroma is predicated on the hypothesis that interdigital neuromas represent a compression neuropathy from which anatomic structure?

Lumbrical tendon
Interosseous muscle
Intermetatarsal ligament
Plantar plate

PREFERRED RESPONSE: 3- Intermetatarsal ligament

Question 94 of 100

The primary advantage of the plantar approach for resection of interdigital neuromas is

a less painful scar.
a lower infection rate.
better access to the neuroma.
earlier weight bearing.

PREFERRED RESPONSE: 3- better access to the neuroma.

Question 95 of 100

The most common complication associated with corticosteroid injection for the treatment of interdigital neuroma is

Infection
Chronic regional pain syndrome (CRPS)
Hammertoe deformity
Hives

PREFERRED RESPONSE: 3- Hammertoe deformity

DISCUSSION

Interdigital neuromas represent perineural fibrosis of the intermetatarsal nerve most commonly seen in the second and third web spaces. The photographs depict a neuroma in the second web space, which is less common than in the third space. Its hypoechoic appearance is characteristic on ultrasound. PVNS occurs in joints. Lipomas are fatty tumors. A ganglion cyst can occasionally occur adjacent to a nerve, but it has a cystic appearance.

The most popular theory on the etiology of interdigital neuromas is compression neuropathy by the intermetatarsal ligament. The plantar approach for the resection of interdigital neuromas has become more popular, especially for recurrent neuromas. The major advantage is better visualization and access to the neuromas.

Infection and allergic reactions such as hives are rare after steroid injection. CRPS is not known to occur in this setting. Hammertoe formation can occur, especially after multiple steroid injections into an interdigital neuroma.

CLINICAL SITUATION FOR QUESTIONS 96 THROUGH 98

Figure 96 is the anteroposterior projection foot radiograph of a 35-year-old woman who is injured in a high-speed motorcycle collision. Her assessment reveals an isolated injury. Her pulses are palpable and her neuromotor examination is intact. There is tenting of skin with ecchymosis over the second metatarsal. The foot is extremely swollen but not tense. Passive toe range of motion is painless.

Question 96 of 100

The most appropriate urgent orthopaedic intervention involves

splinting in situ with serial compartment checks.
urgent closed reduction and splinting with serial compartment checks.
closed reduction and percutaneous fixation when the operating room is available.
emergency foot fasciotomy.

PREFERRED RESPONSE: 2- urgent closed reduction and splinting with serial compartment checks.

Question 97 of 100

Six months after surgical repair, the patient reports that when tapping over her central midfoot incision, paresthesias to the third and fourth toes occur. What is the most likely diagnosis?

Complex regional pain syndrome (CRPS)
Laceration of the deep peroneal nerve
Neuritis of the superficial peroneal nerve
Scar hypersensitivity

PREFERRED RESPONSE: 3- Neuritis of the superficial peroneal nerve

Question 98 of 100

The patient returns 1 year later to report curling of her toes and numbness on the plantar surface of her foot. What is the most likely cause of this condition?

CRPS
Plantar fasciitis
Plantar fibromatosis
Subclinical compartment syndrome

PREFERRED RESPONSE: 4- Subclinical compartment syndrome

DISCUSSION

Radiographs reveal a Lisfranc fracture dislocation with fractures of the first and second metatarsals. Tenting of skin that is over a bony prominence is an orthopaedic emergency. The fracture dislocation should be reduced without delay. There is no evidence of compartment syndrome of the foot, but this may develop and monitoring is necessary. Toe deformity may develop on a delayed basis because of the subclinical presentation. Nerve irritation is not uncommon with dorsal midfoot surgical incisions. A positive Tinel test result over the midfoot in the distribution of the superficial common peroneal nerve is consistent with a stretch injury to this nerve. CRPS is usually associated with multiple nerve distributions and autonomic nerve findings such as cold hypersensitivity and hyperhidrosis.

Question 99 of 100

Figure 99 is the radiograph of an 18-year-old National Collegiate Athletic Association Division I basketball player who jumped for a basket. After

landing, he was unable to put weight on his left great toe. He developed pain, swelling, and ecchymosis maximally around the sesamoids. When assessing stability of the first metatarsophalangeal joint, he appears to have more laxity on the left. What is the best next step?

Standing radiographs of the right foot
MRI of the foot
Carbon fiber insole with a Morton extension
Surgery for reconstruction

PREFERRED RESPONSE: 1- Standing radiographs of the right foot

DISCUSSION

This patient jumped on his forefoot and landed with pain in his great toe. His radiograph shows possible increased space between the sesamoids and the base of the phalanx. A comparison radiograph on the other side will reveal if this position is normal for this patient. If findings are asymmetric, turf toe injury is a possibility based on this patient's symptoms and mechanism of injury.

Question 100 of 100

Video 100 is the presurgical lateral ankle examination of a 45-year-old woman who has had pain and discomfort for 2 years along the posterolateral ankle following a sudden dorsiflexion injury. She notes occasional clicking and popping, and she has not experienced resolution of her symptoms despite immobilization and physical therapy. Examination reveals a stable ankle-to-anterior drawer and inversion stress testing. No strength deficit is noted, but

she has apprehension with resisted eversion. MR images do not reveal evidence of tendonosis or tear. The most appropriate surgical intervention is

imbrication of the lateral collateral ligaments with reinforcement with the extensor retinaculum (modified Brostrom procedure).
peroneal tendon synovectomy and tubularization of the peroneus brevis.
groove deepening of the fibula with imbrication of the peroneal retinaculum.
excision of the peroneus brevis with tenodesis of the proximal stump to the peroneus longus.

PREFERRED RESPONSE: 3- groove deepening of the fibula with imbrication of the peroneal retinaculum.

DISCUSSION

This patient has a clear history of dorsiflexion injury complicated by chronic peroneal tendon dislocation. The symptoms and findings are consistent with dislocation in this particular case. Groove deepening of the posterior fibula with associated imbrication of the peroneal retinaculum is the most effective surgical procedure. Associated synovitis or tendonosis should be addressed. However, failure to deepen the groove and imbricate the retinaculum will result in continued discomfort. Consequently, both responses that involve isolated tendon surgery are not appropriate. Associated subjective instability can be noted in these patients. The examination is critical to determine the stability of the lateral collateral complex, which is intact in this case (so

imbrication is not indicated). A sense of apprehension is a common examination finding because patients sense that the peroneals will subluxate with resisted eversion. Placement of the examiner's hands on the peroneals to stabilize the tendons should relieve this apprehension. A patient may not be able to voluntarily dislocate the tendon. Dynamic ultrasound is the most sensitive radiographic examination for detection of dislocation. Intrasheath peroneal subluxation may also occur and is treated similarly.

ORTHOPEDIC MCQS ONLINE 015 FOOT AND ANKLE e

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