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.

 

65. A magnetic resonance image (MRI) of the right foot of a 16-year-old female cross-country runner is presented. The patient complains of progressive pain in her right foot. 

Recommended initial management should include:

A) Excisional biopsy
B) A period of nonweight bearing with further workup including nutritional and endocrine evaluation
C) Resumption of activities as tolerated
D) Open reduction internal fixation
E) Incisional biopsy

Correct Answer: B

The MRI demonstrates a stress fracture of the second metatarsal. Appropriate initial management includes a period of nonweight bearing, as well as assessment of risk factors for additional stress fractures such as poor nutrition and
amenorrhea.

Author: Rajesh Bahadur Lakhey

 

64. The initial recommended treatment for a grade 3 acute lateral ankle sprain is:

A) Acute lateral ankle reconstruction
B) Acute lateral ankle repair (modified Brostrom)
C) Functional bracing and rehabilitation
D) Nonweight bearing cast for 3 months
E) Weight bearing cast for 6 weeks

Correct Answer: C

A review of 12 prospective studies comparing surgery, casting, and functional bracing with early range of motion revealed 75% to 100% excellent or good results regardless of treatment. The final recommendation was functional
bracing.

Author: Rajesh Bahadur Lakhey

 

63. With regard to the level of athletics, which group of patients can be expected to have less satisfactory results after lateral ankle repair using a modified Brostrom technique:

A) Professional dancers
B) Recreational athletes
C) Non-athletes
D) Professional athletes
E) All groups can be expected to have similar success

Correct Answer: E

In a series of 28 ankles undergoing a modified Brostrom repair for lateral ankle instability, there were no significant differences in outcome whether the patients were professional dancers, athletes, or non-athletes.

Author: Rajesh Bahadur Lakhey

 

62. Isolated subtalar fusion:

A) Is not associated with development of ankle or transverse tarsal joint arthritis
B) Is associated only with development of transverse joint arthritis, but the ankle joint is spared
C) Is associated only with development of ankle arthritis, but the transverse tarsal joints are spared
D) Is associated with the development of both ankle and transverse tarsal joint arthritis
E) Is associated with knee joint degenerative arthritis

Correct Answer: D

In 48 subtalar fusions followed for 5 years, 36% of patients developed ankle arthritis and 41% of patients developed transverse tarsal joint arthritis

Author: Rajesh Bahadur Lakhey

 

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

A) Is impossible if the fibula has been resected
B) Is a dependable procedure with a rate of complications similar to primary ankle replacement
C) Has a poor clinical success rate if there is no clear underlying cause of pain from the ankle fusion
D) Results in minimal gains in ankle range of motion
E) Requires custom made prosthetic implants 

Correct Answer: C

This article studied the success rates of revising previous ankle fusions to ankle replacement. The authors found that if the etiology of a patient’s pain was unclear, the patients did poorly. Patients with prior fibula resection could still be revised to ankle replacement with allograft bone to support the lateral side of the implant. Range of motion following revision to arthroplasty was comparable to primary replacement.

Author: Rajesh Bahadur Lakhey

 

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

A) A spiral oblique fracture of the lateral malleolus
B) Anteroinferior tibiofibular ligament (AITFL) disruption
C) Posteroinferior tibiofibular ligament (PITFL) disruption or posterior malleolus fracture 
D) Deltoid ligament disruption or medial malleolus fracture
E) Anterior talo-fibular ligament disruption

Correct Answer: D

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

Author: Rajesh Bahadur Lakhey

 

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

A) The presence of medial tenderness on clinical examination 
B) The presence of medial ecchymosis on clinical examination 
C) The presence of significant medial swelling on clinical examination 
D) Evidence of medial clear space widening on stress radiographs
E) The presence of lateral malleolus tenderness 

Correct Answer: D 

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

Author: Rajesh Bahadur Lakhey

 

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

A) Peroneal artery
B) Dorsalis pedis artery
C) Artery of the tarsal canal
D) Artery of the sinus tarsi
E) 1st dorsal metatarsal artery

Correct Answer: C

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

Author: Rajesh Bahadur Lakhey

 

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

A) Prolonged cast immobilization and non-weight bearing
B) Pulsed electromagnetic fields
C) Continued use of a fracture boot with protected weight-bearing
D) Injection of demineralized bone matrix
E) Rigid carbon fiber shoe inserts

Correct Answer: B

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

Author: Rajesh Bahadur Lakhey

 

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

A) Dorsolateral subluxation
B) Dorsal subluxation
C) Lateral subluxation
D) Medial subluxation
E) Plantar subluxation 

Correct Answer: A

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

Author: Rajesh Bahadur Lakhey

 

55. A Moberg procedure for hallux rigidus is:

A) An oblique first metatarsal shortening osteotomy
B) An ostectomy of the medial eminence of the metatarsal 
C) A medial closing wedge osteotomy of the proximal phalanx
D) A dorsal closing wedge osteotomy of the proximal phalanx 
E) A lateral closing wedge osteotomy of the proximal phalanx

Correct Answer: D

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

Author: Rajesh Bahadur Lakhey

 

54. Triple arthrodesis is associated with

A) Long-term clinical stability with respect to pain relief
B) High rates of nonunion 
C) Worse patient satisfaction when ankle arthritis is present
D) Development of ankle arthritis over time 
E) No increased risk for ankle arthritis

Correct Answer: D

Explantation: 

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

Author: Rajesh Bahadur Lakhey

 

53. Following triple arthrodesis, ankle range of motion is

A) Unaffected 
B) Increased
C) Decreased
D) Improves over time
E) Increases initially, but then returns to preoperative levels

Correct Answer: C

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

Author: Rajesh Bahadur Lakhey

 

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

A) Should be managed with a postoperative shoe and early physical therapy until the tenderness resolves
B) Should be splinted and kept non-weight bearing until nontender
C) Should be protected in a cast boot with early weight bearing to tolerance
D) Requires open reduction internal fixation to prevent long-term arthritis
E) Can be discharged with no further follow-up

Correct Answer: B

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

Author: Rajesh Bahadur Lakhey

 

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

A) Amount of osteophytes resected during surgery
B) Meticulous ligament balancing
C) Level of tibial and talar saw cuts
D) Preoperative range of motion
E) Size of implant

Correct Answer: D 

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

Author: Rajesh Bahadur Lakhey

 

50. Varus malunion following talar neck fracture is best corrected by:

A) Subtalar arthrodesis
B) Rotational calcaneal osteotomy with a bone block
C) Deltoid ligament release and lateral ligament reconstruction
D) Talar neck osteotomy with lengthening or by triple arthrodesis 
E) Lateral column lengthening

Correct Answer: D

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

Author: Rajesh Bahadur Lakhey

 

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

A) 6 weeks
B) 9 weeks
C) 12 weeks 
D) 16 weeks
E) 18 weeks

Correct Answer: B

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

Author: Rajesh Bahadur Lakhey

 

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

A) Early loss of fixation
B) Greater wound healing complications 
C) Syndesmotic irritation
D) Peroneal tendonitis or peroneal tendon lesions
E) Greater risk for nonunion

Correct Answer: D

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

Author: Rajesh Bahadur Lakhey

 

47. The incidence of compartment syndrome following calcaneus fracture is:

A) 5%
B) 10%
C) 15%
D) 20%
E) 30%

Correct Answer: B

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

Author: Rajesh Bahadur Lakhey

 

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

A) One fracture line in the posterior facet
B) Two fracture lines in the posterior facet 
C) Three fracture lines in the posterior facet
D) Four fracture lines in the posterior facet
E) Five fracture lines in the posterior facet

Correct Answer: B

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

Author: Rajesh Bahadur Lakhey

 

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

A) Fixation with 0.062-inch K-wires
B) Closed reduction
C) Fixation with stainless steel mini-fragment screws
D) Fixation with titanium screws
E) Fixation with a stainless steel locking plate

Correct Answer: D

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

Author: Rajesh Bahadur Lakhey

 

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

A) No improvement in pain scores occurred at 4 or 12 weeks. 
B) No improvement in pain scores occurred at 4 weeks, but significant improvement occurred at 12 weeks.
C) Pain scores significantly improved at 4 and 12 weeks. 
D) Pain scores improved, but function did not improve. 
E) Although pain scores improved, less than 50% of the patients were satisfied

Correct Answer: C

Explantation: 

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

Results

Pain Visual Analog Scale (VAS)
 Pre-treatment VAS 9.2 standard deviation (SD) 0.7
 Post-treatment VAS (4 weeks) 3.4 SD 1.9 (P<.05)
 Post-treatment VAS (12 weeks) 2.4 SD dev 1.8 (P<.05)

RAND Score Physical functioning
 Pre-treatment 40.4 SD 1.3
 Post-treatment (4 weeks) 91.5 SD 11.5 (P<.05)
 Post-treatment (12 weeks) 91.5 SD 10.6 (P<.05)

RAND Score Pain
 Pre-treatment 3.3 SD dev 1.1
 Post-treatment (4 weeks) 88.6 SD 16 (P<.05)
 Post-treatment (12 weeks) 90.0 SD 11.6 (P<.05)

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

Author: Rajesh Bahadur Lakhey

 

43. Which of the following muscles raises the arch of the foot during dorsiflexion:

A) Posterior tibial tendon
B) Peroneus longus tendon 
C) Plantar aponeurosis 
D) Gastroc-soleus complex
E) Anterior tibial tendon

Correct Answer: C

Remember that the plantar aponeurosis increases the arch height.

 As the toes dorsiflex, they function as a windlass mechanism.

 The plantar aponeurosis
Origination: Plantar aspect of calcaneus
Insertion: Base of the toe flexor mechanism

Author: Rajesh Bahadur Lakhey

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

A) Abductor hallucis, flexor digitorum brevis, quadratus plantae 
B) Flexor hallucis brevis, adductor hallucis, flexor digiti, minimi
C) Abductor, hallucis, flexor digitorum brevis, abductor digiti minimi
D) Quadratus plantae, lumbricals
E) Abductor hallucis, quadratus plantae, lumbricals 

Correct Answer: C

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

First Layer
Abductor hallucis MPN (S2,S3) abducts and flexes
Flexor digitorum brevis MPN (S2,S3) flexes lateral four digits
Abductor digit minimi LPN (S2,S3) abducts and flexes fifth digit

Second Layer
Quadratus plantae LPN (S2,S3) flexes lateral. four digits
Lumbricals Medial one: MPN flex MTPJ, ext PIP, DIP Lateral three: LPN

Third Layer
Flexor hallucis brevis MPN (S2, S3) flex MTPJ
Adductor hallucis LPN (S2, S3) abducts first digit
Flexor digiti minimi LPN (S2, S3) flex MTPJ

Fourth Layer
Plantar interossei LPN (S2,S3) adducts digits flex MTPJ
Dorsal interossei LPN (S2,S3) adducts digits flex MTPJ

 

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

 

Author: Rajesh Bahadur Lakhey

 

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

A) Superficial 
B) Medial 
C) Calcaneal 
D) Adductor
E) First interosseus

Correct Answer: C

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

Author: Rajesh Bahadur Lakhey

 

40. A 26-year-old woman presents for treatment, and the motion in the subtalar joint is normal. Ankle arthritis is noted radiographically. In a preoperative discussion, she states the desire to have as mobile a foot as possible, wear high heel shoes, and participate in realistic exercise activities. You perform an ankle arthrodesis. 

What is the ideal position for the arthrodesis:

A) 10° of dorsiflexion, 5° of valgus, and neutral rotation
B) Neutral dorsiflexion, 15° of valgus, and neutral rotation 
C) 10° of plantarflexion, 10° of valgus, and neutral rotation
D) 10° of plantarflexion, neutral valgus, and 10° of external rotation
E) Neutral dorsiflexion, 5° of valgus, and neutral rotation

Correct Answer: E

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

Author: Rajesh Bahadur Lakhey

 

39. A patient underwent an arthrodesis of the hallux metatarsophalangeal joint for correction of painful arthritis (Slide 1 and Slide 2). She remains symptomatic and cannot walk without pain.

The most likely cause for her pain is:

A) Fusion of the hallux in too much plantarflexion
B) Fusion of the hallux in too much dorsiflexion
C) Fusion of the hallux in too much varus
D) Removal of too much bone in the metatarsophalangeal joint during fusion, leading to claw hallux
E) Removal of too much bone in the metatarsophalangeal joint during fusion, leading to lesser toe metatarsalgia

Correct Answer: C

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

Author: Rajesh Bahadur Lakhey

 

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

Which of the following is the most accurate diagnosis:

A) A ganglion of the anterior ankle
B) Synovial sarcoma 
C) Pigmented villonodular synovitis
D) A rupture of the anterior tibial tendon
E) An accessory extensor hallucis longus

Correct Answer: D

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

Author: Rajesh Bahadur Lakhey

 

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 

D) Calcaneonavicular ligament

E) Anterior talofibular ligament
C) Talocalcaneal 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

Leave a Reply

Your email address will not be published.