Multiple Choice Questions

Foot & Ankle

Please use the comments section at the bottom of the page if you have any query or feedback about any of the questions.

 

37. 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:

A) Ankle instability is present
B) Subtalar instability is present.
C) Ankle and subtalar instability are present.
D) Generalized ligamentous laxity is present. 
E) No determination of instability can be made from this picture

Correct Answer: E

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

Author: Rajesh Bahadur Lakhey

 

36. 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:

A) Ankle arthrodesis
B) Arthroscopy of the ankle with drilling of the osteochondral defect
C) Osteoarticular autograft procedure
D) Cartilage cell harvest with staged debridement of the talus and cartilage cell implantation
E) Osteoarticular allograft procedure

Correct Answer: B

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.

Author: Rajesh Bahadur Lakhey

35. 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:

A) An unrecognized Lisfranc injury
B) Posterior tibial tendon rupture
C) Rupture of the spring ligament
D) Idiopathic tarsometatarsal arthritis
E) Calcaneonavicular tarsal coalition

Correct Answer: D

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.

Author: Rajesh Bahadur Lakhey

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

A) Lisfranc ligament
B) Long plantar ligament C) Talocalcaneal ligament
D) Calcaneonavicular ligament
E) Anterior talofibular ligament

Correct Answer: C

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

Author: Rajesh Bahadur Lakhey

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

A) Midswing
B) Midstance
C) Toe off
D) Heelstrike
E) First one-third of stance

Correct Answer: B

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.

Author: Rajesh Bahadur Lakhey

32. A patient sustains a fracture of the anterior process of the calcaneus. 

What ligament is responsible for avulsion of this bone:

A) Short plantar 
B) Long plantar 
C) Anterior talofibular
D) Calcaneofibular 
E) Bifurcate

Correct Answer: E

The bifurcate ligament extends from the anterior process of the calcaneus to the cuboid and navicular. In certain plantarflexion and inversion injuries of the hindfoot, the ligament, which is strong, will avulse the anterior process of the calcaneus.

Author: Rajesh Bahadur Lakhey

31. After surgery to the hallux, a patient complains of burning and numbness along the medial aspect of the first metatarsal. The numbness extends from the medial cuneiform distally to the midportion of the first metatarsal and junction of the plantar and dorsal skin. 

The nerve involved with the pain is the:

A) Intermediate dorsal cutaneous branch superficial peroneal 
B) Medial cutaneous branch deep peroneal
C) Medial cutaneous branch superficial peroneal
D) Dorsal cutaneous branch medial plantar 
E) Intermediate cutaneous branch deep peroneal 

Correct Answer: C

Explanation: The branches of the various sensory nerves of the foot are important to understand. The normal and aberrant topographic anatomy is important in any foot surgery, and management of posttraumatic neuritis is contingent upon an understanding of the anatomy

Author: Rajesh Bahadur Lakhey

30. A 65-year-old woman presents for treatment of a painful flatfoot condition. On examination, the hindfoot is in marked valgus and a rupture of the posterior tibial tendon is noted. The recommended treatment is a transfer of the flexor digitorum longus tendon and a medial translational osteotomy of the calcaneus. 

The rationale for the osteotomy includes all of the following except:

A) To increase the ground reaction forces medially
B) ) To make the Achilles tendon vector lateral to the axis of the subtalar joint 
C) To improve the weight bearing tripod effect of the foot
D) To augment the flexor transfer medially
E) To decrease the valgus force of the gastrocnemius on the hindfoot

Correct Answer: B

A medial translational osteotomy of the calcaneus shifts the axis of the Achilles tendon insertion medial to the axis of the subtalar joint. In doing so, the lateralizing force of the gastrocnemius on the heel is lessened and the medial tendon shift augments the strength of the flexor digitorum longus transfer and improves the mechanical efficiency of the foot by altering the ground reaction forces.

Author: Rajesh Bahadur Lakhey

 

29. A 49-year-old woman has had swelling in the posterior aspect of the ankle for 5 years (Slide). The pain is focal and does not radiate. She notes that pain is worse with activity, exercise, and shoe wear. Which of the following is not an acceptable treatment for this patient:

A) Short leg cast immobilization
B) High heel shoe with no heel counter
C) Debridement of the insertion of the Achilles tendon
D) Osteotomy of the calcaneus
E) Achilles stretching exercises and physical therapy modalities including corticosteroid application

Correct Answer: D

Explanation: Insertional Achilles tendinopathy is aggravated by a hard heel counter on the shoe, a flat shoe, or exercise without stretching. Therapy modalities are effective for treatment of this condition. If patients do not respond to nonoperative measures, then surgery with debridement of the Achilles tendon and posterior calcaneus may be required. Osteotomy of the calcaneus (as opposed to ostectomy) is not an effective treatment.

Author: Rajesh Bahadur Lakhey

 

28. A 22-year-old collegiate basketball player presents for treatment of a stress fracture of the base of the fifth metatarsal at the junction of the metaphysis and diaphysis. The fracture was treated operatively, and the patient returned to playing basketball. Three months later, it was apparent that a repeat fracture was present. The fracture was treated with screw removal and a repeat screw fixation. Four months later, after a successful basketball season, he sustained a repeat stress fracture of the metatarsal. On examination, he has a mild cavovarus foot configuration with normal ankle range of motion. Inversion is 15° and eversion is 5°. The base of the fifth metatarsal is prominent.

The most likely cause for the repeat fracture is

A) Abnormal ankle biomechanics
B) Chronic unrecognized ankle instability 
C) A varus heel 
D) Bone sclerosis of the fifth metatarsal base
E) Chronic avascularity of the fifth metatarsal base 

Correct Answer: C

The most common cause of recurrent injury to the fifth metatarsal is unrecognized varus heel deformity. Surgeons must also check for ankle instability, which may be present in this patient.

A varus heel, ankle instability, and injury to the fifth metatarsal are associated with recurrent deformity.

Author: Rajesh Bahadur Lakhey

 

27. A 23-year-old man sustains an injury to his foot when falling off a ladder. The foot is grossly twisted inward, and the talonavicular joint is dislocated with the talar head penetrating through the extensor brevis muscle. The dislocation is reduced. 

The likelihood of this resulting in avascular necrosis of the talus is:

A) Rare
B) 20% 
C) 40%
D) 70% 
E) 100%

Correct Answer: A

Medial peritalar dislocation does not result in avascular necrosis of the talus. The development of subtalar arthritis is more likely

Author: Rajesh Bahadur Lakhey

 

 26. A 43-year-old construction worker sustained a work-related injury to his foot 7 months ago. He was initially treated with cast immobilization and limited weight bearing. He has lateral foot pain and inability to walk comfortably. He has limited walking endurance. Upon examination, pain is present laterally along the course of the peroneal tendons, and no motion of the subtalar joint is present.

The recommendation is:

A) Physical therapy followed by job modification 
B) Shoe modification and orthotic support 
C) Nonsteroidal medication, and ankle foot orthoses
D) Injection of the peroneal tendons with cortisone 
E) Subtalar arthrodesis

 

Correct Answer: E

A worker who sustains a calcaneus fracture must be returned to the work force as soon as possible. Although these alternatives for treatment may be considered in the patient with limited activity and low demands, the longer the time from injury to salvage surgery with arthrodesis, the less likely it is that the injured worker will ever return to gainful employment. Therefore, subtalar arthrodesis should be performed.

Author: Rajesh Bahadur Lakhey

 

25. You are commencing a repair of an acute rupture of the Achilles tendon that occurred 8 days previously in a 32- year-old recreational tennis player. Fibrillation of the tendon ends is noted. 

The following is most important to maximize the ultimate outcome of the repair:

A) Resection of the frayed tendon end, and end-to-end apposition
B) Incorporation of the plantaris tendon in the repair 
C) Repair of the tendon with the foot in slight equinus
D) Augmentation of the repair with a facial turn down flap
E) Repair with the tendon ends at normal resting tension

Correct Answer: E

Repair of the Achilles tendon at its normal resting length is critical. The frayed tendon ends should not be excised, since this will force a repair with the foot in equinus. The resting tension of the repair can be compared with the position of the opposite limb that should be prepared into the operative field.

Author: Rajesh Bahadur Lakhey

 

24. The nerve most likely to be at risk during surgical exposure when performing a triple arthrodesis is the:

A) Sural 
B) Lateral cutaneous branch superficial peroneal
C) Intermediate cutaneous branch superficial peroneal 
D) Lateral plantar 
E) Dorsalis pedis

Correct Answer: A

The sural nerve has a variable path in the distal leg, but lies immediately adjacent to the peroneal tendons on the lateral side of the foot. The lateral incision used to expose the subtalar and calcaneocuboid joints is adjacent to this nerve.

Author: Rajesh Bahadur Lakhey

 

23. The radiograph of a 22-year-old woman with ankle pain and instability is presented. She has noted this problem for 10 years, and it appears to be worsening. The opposite ankle is not symptomatic. She has not had any previous treatment for foot or ankle problems.

The cause of this ankle deformity is most likely to be associated with which of the following conditions:

A) Recurrent ankle instability
B) Congenital bimalleolar dysplasia 
C) Subtalar fusion
D) Talar growth arrest
E) Fibular hemimelic syndrome

Correct Answer: E

This patient has a ball and socket ankle, which results from limited motion of the hindfoot during early childhood, either from extensive tarsal coalition, premature hindfoot arthrodesis, or trauma. The condition most commonly associated with a ball and socket ankle is a form of hemimelia of the fibula with lateral ray deficiencies and associated tarsal coalition of which the latter is usually extensive.

Author: Rajesh Bahadur Lakhey

 

22. A 14-year-old boy presents for treatment of a painful foot, which has been present for 2 years. He has limited his athletic activities. He has similar symptoms in the opposite foot, although not as severe. On clinical examination, the alignment and appearance of the foot are normal; motion of the foot and ankle is good; and some discomfort is present in the sinus tarsi. Standard radiographs, of which the lateral view is presented, include anteroposterior, lateral, and oblique views. Because the diagnosis is unclear, more imaging studies are required. 

The next study to obtain is:

A) External oblique views of the foot
B) Axial views of the subtalar joint (Harris)
C) Oblique views of the subtalar joint (Broden) 
D) Internal oblique views of the midfoot 
E) Inclined views of the talonavicular joint (Canale)

Correct Answer: B

The radiograph demonstrates changes in the subtalar joint suggestive of a middle facet coalition. Note the sclerosis of the joint surface. Although a computed axial tomography scan may be helpful, standard axial views of the subtalar joint (Harris) taken in the plane of the joint are usually diagnostic of tarsal coalition. Motion of the subtalar joint may be normal in the adolescent with a tarsal coalition

Author: Rajesh Bahadur Lakhey

21. A 52-year-old man presents for evaluation and treatment of a painful flatfoot deformity. While playing tennis 2 years ago, he felt a tearing sensation in his foot and ankle. Since that time, he notes that the arch of his foot has become progressively flatter. Upon examination, he has a flatfoot inability to perform a single heel rise and weak inversion strength. He desires to have this deformity corrected. At surgery, the posterior tibial tendon is grossly normal in appearance. 

The most likely source of his deformity is:

A) Rupture of the Achilles tendon
B) Rupture of the peroneus longus tendon 
C) Rupture of the plantar fascia
D) Rupture of the spring ligament
E) Rupture of the inferolateral long plantar ligament

Correct Answer: D

A rupture of the spring ligament, the talonavicular capsule, or the deltoid ligament should be looked for in the patient with an acquired flatfoot following trauma. Intratendinous tear of the posterior tibial tendon is also possible.

Author: Rajesh Bahadur Lakhey

 

20. The most common complication of arthrodesis of the proximal interphalangeal (PIP) joint is:

A) Claw toe deformity
B) Mallet toe deformity 
C) Hammer toe deformity
D) Curly toe deformity
E) Instability of metatarsophalangeal (MP) joint

Correct Answer: B

With arthrodesis of the proximal interphalangeal joint (PIP), the long flexor tendon that remains intact flexes the toe at the metatarsophalangeal (MP) joint and also at the distal interphalangeal (DIP) joint, thus the development of a mallet toe deformity.

Author: Rajesh Bahadur Lakhey

 

19. A 43-year-old woman has had a 2-year history of ankle pain. Her ankle pain is associated with swelling, decreased activities, and limited range of motion. Upon examination, diffuse warmth and swelling of the ankle are noted. Radiographs and a clinical picture are presented.

The most likely diagnosis is:

A) Rheumatoid arthritis
B) Gout 
C) Septic arthritis
D) Synovial sarcoma 
E) Pigmented villonodular synovitis (PVNS)

Correct Answer: A

Although pigmented villonodular synovitis (PVNS), infection, or gout may cause inflammatory changes on both sides of the ankle joint, the most likely cause of this inflammatory arthropathy is rheumatoid arthritis. Note the cystic changes, the synovial hypertrophy, and the joint inflammation

Author: Rajesh Bahadur Lakhey

 

18. A patient presents for treatment in your emergency department following an injury that he sustained 4 hours earlier. His foot was run over by a piece of heavy industrial equipment. On examination, he has pain in the foot, a displaced fracture of the second metatarsal, a 3-cm area of severe contusion over the forefoot, and numbness of the dorsal surface of the foot. 

The next examination that you recommend is:

A) Measurement of compartment pressures in the foot
B) Magnetic resonance imaging of the tarsometatarsal joint
C) Computerized axial tomography of the midfoot
D) Doppler evaluation of the foot pulses
E) Laser Doppler flowmetry 

Correct Answer: A

Because of his history, this patient may have a compartment syndrome of the foot. Although other studies may be relevant as part of his evaluation, a compartment syndrome mandates emergency treatment. Vascular evaluation, including laser Doppler flowmetry is unreliable in diagnosing compartment syndrome. Imaging studies may be performed as part of the surgical work-up, but they are not indicated at this time.

Author: Rajesh Bahadur Lakhey

 

17. The nerve commonly associated with painful heel syndrome is the:

A) Medial plantar nerve
B) Lateral plantar nerve
C) First branch of the lateral plantar nerve 
D) Calcaneal nerve
E) Deep peroneal nerve

Correct Answer: C

Explanation:The first branch of the lateral plantar nerve (occasionally referred to as the nerve to the abductor digiti quinti) is occasionally involved in pathologic painful heel syndrome and plantar fasciitis.

Author: Rajesh Bahadur Lakhey

 

16. A 23-year-old woman with juvenile rheumatoid arthritis presents for treatment of painful forefoot deformity. Painful hallux valgus is present and is associated with dislocation of the lesser metatarsophalangeal joints. 

The recommended surgical treatment is:

A) Bunionectomy, first metatarsal osteotomy, and arthroplasty of the lesser metatarsophalangeal joints 
B) Resection arthroplasty (Keller procedure) of the first metatarsophalangeal joint and arthroplasty of the lesser metatarsophalangeal joints
C) Arthrodesis hallux metatarsophalangeal joint and resection of the lesser metatarsal heads 
D) Bunionectomy, first metatarsal osteotomy, and resection of the lesser metatarsal heads 
E) Resection of all of the metatarsal heads

Correct Answer: C

Explanation: Although resection arthroplasty of the first metatarsalphalangeal (MP) joint is a commonly practiced procedure, it is less likely to be a reliable operation in younger patients and is associated with an increased incidence of hallux deformity. A bunionectomy may be an alternative provided the first MP joint is healthy, although this may not be sufficient in the long term for patients with rheumatoid arthritis.

Author: Rajesh Bahadur Lakhey

 

15. A 37-year-old construction worker presents for evaluation and treatment of a painful stiff foot. He has noticed the stiffness for approximately 12 years, and particularly feels the stiffness when he is working on uneven ground surfaces. Upon clinical and radiographic examination, he is noted to have a calcaneonavicular coalition without any peritalar arthritis. 

Your recommended treatment is:

A) Triple arthrodesis
B) Subtalar arthrodesis
C) Resection of the coalition
D) Calcaneal osteotomy 
E) Calcaneocuboid and talonavicular arthrodesis

Correct Answer: C

Although arthrodesis has proved reliable with respect to managing tarsal coalition in the adult, resection of a calcaneonavicular coalition should be performed whenever possible. This procedure is preferable to a triple arthrodesis. A subtalar arthrodesis would be applicable as treatment for a middle facet coalition in the adult.  

Author: Rajesh Bahadur Lakhey

 

14.  A 13-year-old girl is seen in clinic for bunion. She is asymptomatic but has a hallux valgus angle of 29°, an intermetatarsal angle of 15°, and a medial prominence over the first metatarsal head. The family asks whether anything can be done to prevent future problems with the foot. 

You recommend:

A) Osteotomy of the first metatarsal base
B) Hemiepiphyseodesis of the medial physis of the first metatarsal 
C) Double osteotomy of the first metatarsal
D) Mitchell osteotomy
E) Shoe modifications if symptoms develop 

Correct Answer: E

Bunions may often be treated conservatively, and it is impossible to predict which ones will later develop symptoms. Surgical reconstruction of bunions in adolescents has a higher rate of recurrence than in adults in many reported series. For all of these reasons, nonoperative treatment is preferred for asymptomatic patients.

Author: Fouad Chaudery

 

13. Which of the following conditions is not associated with an increased risk of congenital vertical talus ?

A) Cerebral palsy
B) Myelomeningocele
C) Arthrogryposis
D) Nail patella syndrome
E) Larsen syndrome 

Correct Answer: A

Patients with cerebral palsy do not have an increased risk of congenital vertical talus, but they may develop an acquired neuromuscular vertical talus.

• Patients with myelomeningocele have approximately a 5% to 10% risk of vertical talus, far above that of the general population. • Arthrogryposis is associated with an increased risk of vertical talus.
• Nail patella syndrome and Larsen syndrome are associated with an increased risk of vertical talus.

Author: Fouad Chaudery

 

12. Which of the following conditions is not associated with an increased risk of congenital vertical talus?

A) Sacral agenesis
B) Cerebral palsy
C) Myelomeningocele
D) ArthrogryposisV
E) Nail patella syndrome

Correct Answer: B

Patients with cerebral palsy do not have an increased risk of congenital vertical talus, but they may develop an acquired neuromuscular vertical talus.

• Patients with myelomeningocele have approximately a 5% to 10% risk of vertical talus, far above that of the general population. • Arthrogryposis is associated with an increased risk of vertical talus.
• Nail patella syndrome is associated with an increased risk of vertical talus.
• Sacral agenesis is associated with an increased risk of vertical talus.

Author: Fouad Chaudery

 

11. Prior to treatment, this pathologic finding characterizes clubfoot:

A) The talar head and neck are deviated medially. 
B) The dome of the talus is flattened.
C) The navicular is positioned more laterally than normal.
D) The foot has a rocker deformity.
E) The tendoachilles inserts in a more lateral position than normal.

Correct Answer: A

The talar head and neck are deviated medially. This deformity cannot be corrected surgically but may improve with growth.

• The dome of the talus is not originally flattened, but it may become this way after repeated manipulation.
• The navicular is positioned more medially than normal and may touch the medial malleolus.
• The foot has either a normal arch or a cavus deformity (the opposite of a rocker bottom). The rocker bottom foot may develop as a result of over-vigorous manipulation of a clubfoot against a tight heelcord.
• The tendoachilles inserts are more medially positioned than normal on the calcaneus

Author: Fouad Chaudery

 

10. A 15-year-old basketball player has mild scoliosis, pes planus, pectus carinatum, and long slender fingers. In order to determine if he has Marfan syndrome and should be allowed to continue playing basketball.

It is most useful to order a:

A) Cardiac echo 
B) Magnetic resonance image of the lumbosacral spine 
C) Slit lamp examination
D) Chest radiograph
E) Dermal fibroblast assay 

Correct Answer: A

A cardiac echo will give information about enlargement of the ascending aorta, as well as the valves. This is the most important information for activity recommendations and patient prognosis.

• A magnetic resonance image (MRI) of the lumbosacral spine will either rule in or out dural ectasia, but a MRI has no clinical importance for activity recommendations.
• A slit lamp examination is not as important as a cardiac echo in making sport recommendations.
• A chest radiograph may be helpful, if the patient is suspected of having a pneumothorax.
• A dermal fibroblast assay is useful in assessing collagen, such as in osteogenesis imperfecta, but it is not helpful in diagnosing Marfan syndrome.

Author: Fouad Chaudery

 

9. Which ancillary test is not helpful in the diagnosis of Charcot-Marie-Tooth disease (CMT):

A) Electromyography (EMG)
B) Nerve conduction velocity (NCV)
C) Nerve biopsy
D) Muscle biopsy
E) Muscle enzymes

Correct Answer: E

Charcot-Marie-Tooth disease (CMT) is a neuropathic process resulting in muscle atrophy, therefore, muscle enzyme studies will not be helpful.

• Electromyography (EMG) will confirm the diagnosis by displaying increased amplitude and duration of signals, both of which are indicative of a neuropathic process.
• Nerve conduction velocity (NCV) will also confirm the diagnosis by displaying decreased motor and sensory conduction velocities.
• Nerve biopsy can be helpful by showing loss of myelinated fibers and fibrosis.
• Muscle biopsy will show diffuse atrophy, fibrosis, and adipose tissue within muscle.

Author: Fouad Chaudery

 

8. A 7-year-old boy presents with bilateral high arches. His parents report that they are having difficulty finding shoes that comfortably fit him. The patient denies any foot pain. The father had similar problems with his feet and was diagnosed with a “mild” neurologic condition. On exam, the child has bilateral pes cavus with a supple hindfoot. 

Treatment of the feet at this time should consist of:

A) Soft tissue procedures alone
B) Soft tissue procedures and calcaneal osteotomy
C) Triple arthrodesis 
D) Bracing 
E) Observation

Correct Answer: A

The child has a supple deformity secondary to Charcot-Marie-Tooth disease that will progress if untreated. Soft tissue procedures, which may consist of claw toe correction, plantar release, and possibly tendon transfer, are recommended for children younger than 8 years old who have a supple hindfoot.

• The calcaneal osteotomy is reserved for patients with a rigid hindfoot.
• Triple arthrodesis is a salvage procedure reserved for a fixed, painful foot in older children.
• Bracing and observation are not preferred options due to the progressive nature of the disease, and the lack of ability to apply corrective forces to the foot in cavus.

Author: Fouad Chaudery

 

7. The most common cause of an indirect injury to the Lisfranc joint occurs through which mechanism:

A) Compression
B) Hyperdorsiflexion
C) Axial load of a plantarflexed foot
D) Supination and external rotation
E) Pronation and adduction

Correct Answer: C

The indirect mechanism of injury involves axial loading of a plantarflexed foot. This type of mechanism is commonly cited in soccer, basketball, and gymnastics. The most frequent pattern in the indirect mechanism is failure of the weaker dorsal tarsometatarsal ligaments in tension with dorsal dislocation of the metatarsals .

Author: Fouad Chaudhry

 

6. Initial management of a symptomatic Haglund’s deformity in a runner consists of:

A) Intratendinous steroid injection 
B) Debridement of the tendon 
C) Excision of the posterosuperior calcaneal prominence 
D) Heel lift and soft shoe counter 
E) A firm heel counter and medial heel wedge 

Correct Answer: D

Haglund’s deformity is characterized by a prominence about the posterosuperior calcaneus that can lead to retrocalcaneal bursitis and Achilles tendon injury just proximal to its insertion. The initial treatment involves relieving pressure from the affected area with a heel lift and soft heel counter. Resistant cases may benefit from excision of the prominence and debridement of the bursa and tendon. 

Author: Fouad Chaudhry

 
 

 

5. The extensor hallucis longus muscle is innervated by which of the following nerve roots:

A) L1
B) L2
C) L3
D) L4
E) L5

Correct Answer: E

Remember that the L5 nerve root innervates the following muscles:
• Extensor hallucis longus
• Extensor digitorum longus and brevis
• Gluteus medius

Author: Fouad Chaudhry

 
 

 

4. The skin on the medial aspect of the leg and great toe is innervated by which of the following nerve roots: 

A) L2
B) L3
C) L4
D) L5
E) S1

Correct Answer: C

Explanation:  Remember:
• L4 Medial aspect of the leg, foot, and great toe
• L5 Lateral aspect of the leg and toes 2 to 4
• S1 Lateral aspect of the fifth toe 

Author: Fouad Chaudhry

 

 

3. A 46y old man fell 20 feet and sustained the injury shown in the figure attached. The injury is closed; however, the soft tissues are swollen and ecchymotic with blisters. 

The most appropriate initial management should consist of 

A) long leg cast.
B) a short leg cast.
C) immediate open reduction and internal fi xation.
D) a temporizing spanning external fi xator.
E) primary ankle fusion.

 

 

Correct Answer: D

Explanation: Although this is a fracture of the medial and lateral malleoli, the degree of displacement and comminution of the medial dome indicate that this injury is similar to a pilon fracture. Initial management should consistent of stabilization to allow for soft-tissue healing. The use of temporizing spanning external fi xation should be the initial step, fol-lowed by limited or more extensive open reduction and internal fi xation when the soft-tissue status will allow. Initial placement in either a short or long leg cast does not provide the needed stability and does not allow for care and monitoring of soft tissues. In addition, maintaining reduction of the talus may be very diffi cult. Immediate open reduction and internal fi xation through an injured soft-tissue envelope adds the risk of diffi culties with incision healing and a higher risk of deep infection. In the acute setting, a primary ankle fusion through this soft-tissue envelope is not indicated.

Author: Salam Al-Abayachi

 

2. 36y woman sustained a tarsometatarsal joint fracture-dislocation in a motor vehicle accident. The patient is treated with ORIF. 

What is the most common complication?

A) Posttraumatic arthritis
B) Infection
C) Fixation failure
D) Malunion
E) Nonunion

Correct Answer: A

The most common complication associated with tarsometatarsal joint injury is posttrau-matic arthritis. In one series, symptomatic arthritis developed in 25% of the patients and half of those went on to fusion. In another series, 26% had painful arthritis. 

Initial treatment should consist of shoe modifi cation, inserts, and anti-infl ammatory drugs. Fusion is reserved for failure of nonsurgical manage-ment. Hardware failure may occur, but it is clinically unimportant.

Author: Salam Al-Abayachi


1. A 50-year-old patient presents with a 2 month history of midfoot pain after a twisting injury to their foot, which has now been diagnosed as a late Lisfranc injury. 

Lisfranc injury - Wikipedia

Which of the following is TRUE about tarsometatarsal arthrodesis in this situation?

A) It is best performed across all tarso-metatarsal joints
B) It is a good option in late diagnosis of this injury
C) It will allow this patient to mobilise fully weight bearing from day one post-surgery
D) It is best performed through a lateral approach
E) It is part of the ‘Triple arthrodesis’ procedure

Correct Answer : B

While the 1st-3rd tarsometatarsal joints are relatively immobile the 4th and 5th are mobile allowing accomodation to rough ground. As such arthrodesis of these joint is generally not well tolerated. However in a foot with either painful malunion or degeneration arthrodesing the 1st - 3rd joints may provide sustained pain relief and return to activity.

Post-operative management usually requires a period of non-weight-bearing and the conventional approach is dorsally.

The role of reduction and internal fixation of Lisfranc fracture–dislocations: a systematic review of the literature. Stavlas et al. Int Orthop. 2010 Dec;34(8):1083-91. doi: 10.1007/s00264-010-1101-x

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