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5. OITE > Foot and Ankle 2016 > Flashcards

Foot and Ankle 2016 Flashcards

1
Q

1. Figures 1a through 1d are the weight-baring radiographs of a 76-year old mand who has a rigid, painful foot deformity. Examination reveals he has a severe planovalgus foot position. In addition to addressing the soft-tissue contracture, which surgical plan offers appropriate correction while minimizing potential soft-tissue complications?

  1. Isolated talonavicular arthrodesis through a medial approach
  2. Isolated subtalar arthrodesis througha lateral approach
  3. Subtalar and talonavicular arthrodesis througha medial approach
  4. Triple arthrodeisis through a medial approach
  5. Triple arthrodeisis througha 2-incision approach
A
  1. Subtalar and talonavicular arthrodesis througha medial approach
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2
Q

16. Figures 16a through 16c are the saggital and axial proton densitiy images and figure 16d is the MRI sagittal short tau inversion recover MR image of a 60-year old man who has had ankle pain for several months. There is tenderness to palpation approximately 3-4 cm above the top of the calcaneus. Which form of exercise most consistently and effectively addresses this condition?

  1. Eccentric
  2. Isometric
  3. Plyometric
  4. Isotonic
  5. Concentric
A
  1. Eccentric

(Achilles tendinopathy)

  • Eccentric contraction - causes muscle to elongate in response to greater opposing force
  • Concentric - causes muscle to shorten, generating force
  • Isotonic Contractions - generate force by changing the length of the muscle; can be either eccentric or concentric
  • Plyometric - Muscle exerts maximum force in short intervals of time (ie jumping)
  • Isometric - Muscle contraction without changing length (vs Isotonic)
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3
Q

31. Figures 31a through 31c are the weight-baring radiographs of an active 32-year old man who has lateral foot pain that is most notable with high-impact activity. There is no history of trauma or giving way episode. He has full heel cord flexibility and is able to perform a single-leg heel rise. Coleman block test findings are positive. His physical therapist told him he has “fallen arches” and recommended custom inserts. Which orthosis is optimal in this scenario?

  1. Semirigid insert with a medial post and medial arch support
  2. Soft, full-length closed cell polyethelyne foam inlay
  3. Lateral heel and sole wedge with a first metatarsal head recess
  4. Full-length stell shank with a rocker-bottom sole
  5. Carbon shank witha Morton’s exten
A
  1. Lateral heel and sole wedge with a first metatarsal head recess

Condition depicted is mild cavovarus foot.

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4
Q

46. Figures 46a through 46c are the radiograph and MR images of a 55-year-old woman who had immediate pain after hearing a pop while twisting her ankle. What is the most appropriate surgical treatment?

  1. Lateral ligmanet reconstruction
  2. Lateralizing calcanues osteotomy
  3. Superior peroneal retinaculum (SPR) repair
  4. Microfracture of the talus
  5. Deltoid Repair
A
  1. Superior peroneal retinaculum (SPR) repair

(Can see subluxation and edema around the superficial peroneal tendon.)

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5
Q

54. Figure 54a through 54c are the current standing radiographs of a 48-year-old woman who sustained an open talar neck fracture-dislocation 2 years ago. She experiences consistent pain in her ankle with weight-baring activities adn has failed nonsurgical treatment. What is the most prudent treatment method?

  1. Distraction arthroplasty
  2. Ankle arthrodesis
  3. Osteochondral allograft
  4. Arthroscopic debridement and implant removal
  5. Total ankle arthroplasty
A
  1. Ankle arthrodesis
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6
Q

69. Figure 69a is a latearl weight-baring radiograph of a 55-year old woman with diabetes who has an 18-month history unilateral plantar heel pain. She has recieved 5 injections during the last year to address plantar fasciitis. She has deep, central, nonradiating heel pain that is worse when barefoot and resolves when she walks on her toes. She has tenderness to palpation at the central aspect of her heel. Figures 69b and 69c are proton density (PD) and short tau inversion (STIR) sagittal MRI findings. What is the most appropriate next step?

  1. Non-weightbaring activity for 3-4 weeks followed by a gradual return to activity.
  2. Partial plantar fasciotomy
  3. Decompression of the first branch of the lateral plantar nerve
  4. Physical therapy for Achilles tendon stretching and modalities
  5. External heel padding
A
  1. External Heel Padding

RECOMMENDED READINGS

Lareau CR, Sawyer GA, Wang JH, DiGiovanni CW. Plantar and medial heel pain: diagnosis and management. J Am Acad Orthop Surg. 2014 Jun;22(6):372-80. doi: 10.5435/JAAOS-22-06-372. Review. PubMed PMID: 24860133.

Johnson JE, Klein SE, Putnam RM. Corticosteroid injections in the treatment of foot & ankle disorders: an AOFAS survey. Foot Ankle Int. 2011 Apr;32(4):394-9. doi: 10.3113/FAI.2011.0394. PubMed PMID: 21733442.

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7
Q

80. Which structure is most at risk when the anterolateral ankle arthroscopy portal is established?

  1. Deep peroneal nerve
  2. Dorsalis pedis artery
  3. Extensor digitorm longus tendon
  4. Distial tibial articular surface
  5. Superficial peroneal nerve
A
  1. Superficial peroneal nerve.
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8
Q

93. Figures 93a through 93c are the weight-baring radiographs of a 58-year-old man who has hindfoot pain. He has a remote history of a calcaneal fracture treated with a closed reduction and casting. He exhibits minimal hindfoot motion and lacks 10 degrees of ankle dorsiflexion compared to the contralateral side. What is the most appropriate treatment method?

  1. In situ subtalar arthrodesis
  2. Lateral wall extostectomy
  3. Hindfoot arthrodesis
  4. Romash osteotomy with subtalar joint salvage
  5. Subtalar bone block arthrodesis
A
  1. Subtalar bone block arthrodesis.

RECOMMENDED READINGS

Carr JB, Hansen ST, Benirschke SK. Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle. 1988 Oct;9(2):81-6. PubMed PMID: 3066724.

Clare MP, Lee WE 3rd, Sanders RW. Intermediate to long-term results of a treatment protocol for calcaneal fracture malunions. J Bone Joint Surg Am. 2005 May;87(5):963-73. PubMed PMID: 15866957.

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9
Q

105. After satisfactorily obtaining and confirming reduction of this fracture (Figures 105a through 105c), what is the next step in evaluation of this fracture pattern.

  1. Stress radiographs to assess ligaments
  2. Gravity external rotation stress view
  3. Knee radiographs
  4. CT scan through the ankle
  5. Foot radiographs
A
  1. CT scan through the ankle
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10
Q

117. Figures 117a through 117c are the radiographs of a 32-year-old recreational soccer players who has chronic posterolateral ankle pain. She has stiffness during activity and increased pain when pushing off, but has no had episodes of giving way. An examination reveals her ankle and hindfoot range fo motion are normal, but she has pain with maximum ankle plantarflexion. there is no tenderness at the distal lateral calf. Neurovascular examination findings are normal. Anti-inflammatory drugs, physical therapy, and activity modification have been unsuccessful. An injection into her subtalar joint provided minimal improvement. MRI sequence scans are shown in Videos 117d and 117e. What is the most appropriate next step?

  1. Peroneal debridement and repair
  2. Arthroscopy of the subtalar joint
  3. Excision of an anomalous soleus muscle
  4. Excision of a symptomatic os trigonum
  5. Decompression of the sural nerve at teh lateral ankle
A
  1. Exicision of a symptomatic os trigonum
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11
Q

130. A 22-year-old woman has an equinus contracture. She was involved in a motor vehicle collision 1 year ago in which she sustained a humeral shaft fracture, iliac wing fracture, and closed-head injury, which necessitated prolonged rehabilitation. Ankle dorsiflexion is to 10 degrees shy of neutral with her knee in extension and in flexion, without full tension on the Achilles, and despite extensive physical therapy. Treatment should consist of:

  1. Fascial turndown/flexor hallicus longus (FHL) transfer
  2. The Strayer Procedure
  3. The Baumann Procedure
  4. Hoke triple-cut Achilles Lengthening
  5. Posterior Capsular Release/Open Achilles lengthening
A
  1. Posterior Capsular Release/Open Achilles lengthening

RECOMMENDED READINGS

Chen L, Greisberg J. Achilles lengthening procedures. Foot Ankle Clin. 2009 Dec;14(4):627-37. doi: 10.1016/j.fcl.2009.08.002. Review. PubMed PMID: 19857837.

Barske HL, DiGiovanni BF, Douglass M, Nawoczenski DA. Current concepts review: isolated gastrocnemius contracture and gastrocnemius recession. Foot Ankle Int. 2012 Oct;33(10):915-21. doi: DOI: 10.3113/FAI.2012.0915. Review. PubMed PMID: 23050719.

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12
Q

147. Figures 147a and 147b are the weight-bearing radiographs of a 45-year-old laborer with a history of hallux rigidus who has persistent foot pain despite undergoing surgery 1 year ago. He has pain with weight bearing that is refractory to shoe modifications. He has stiffness through the first metatarsophalangeal (MTP) joint, a positive axial grind test result, and tenderness to palpation of the dorsal midfoot. In addition to stabilization of the second metatarsal, treatment should include

  1. dorsal cheilectomy.
  2. distraction bone block arthrodesis.
  3. Moberg-type phalanx osteotomy.
  4. capsular interposition arthroplasty.
  5. first MTP hemiarthroplasty.
A
  1. distraction bone block arthrodesis.
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13
Q

158. A collegiate basketball player sustained the hyperextension injury shown in Figures 158a through 158c. What is the preferred treatment?

  1. First metatarsophalangeal (MTP) joint arthrodesis
  2. Direct plantar plate repair
  3. Taping of the first MTP joint and physical therapy
  4. Sesamoidectomy
  5. Plantar flexion casting of the first ray
A
  1. Direct plantar plate repair
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14
Q

179. Figures 179a and 179b are the anteroposterior and lateral radiographs of a 43-year-old man who is seen 1 year after undergoing hallux valgus correction on his right foot. His medial great toe pain resolved after surgery, but he reports a persistent feeling that he is walking on a marble under his central forefoot. His neurovascular examination findings are normal. There is a mild callous under his second metatarsal head. Tenderness to palpation is isolated to the plantar aspect of the second metatarsophalangeal (MTP) joint. There is 50% subluxation of the joint with a drawer test. What is the most appropriate next step?

  1. Corticosteroid injection in the second web space
  2. Foot orthotics with metatarsal pads
  3. Nonweight-bearing activity for 3 weeks or until walking is pain free
  4. Shaving of the callus and maintenance with a pumice stone
  5. Immobilization in a stiff-soled shoe
A
  1. Foot orthotics with metatarsal pads
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15
Q

193. Figures 193a and 193b are the weight-bearing foot radiographs of a 48-year-old man who has had progressive, atraumatic posterolateral ankle pain for several years. An examination reveals tenderness behind his distal fibula, and a Coleman block test result is negative. His subtalar and first tarsometatarsal joints have normal motion. Figures 193c and 193d are his MRI ankle findings. He has attempted bracing, activity modification, nonsteroidal anti-inflammatory drugs, and physical therapy without success. What is the best next step?

  1. Debridement and repair of the peroneus brevis tendon and a lateralizing calcaneal osteotomy
  2. Debridement and repair of the peroneus longus tendon and a lateralizing calcaneal osteotomy
  3. Debridement and repair of the peroneus longus tendon and a dorsiflexion osteotomy of the

first metatarsal

  1. Achilles tendon lengthening and triple arthrodesis
  2. Lateral column lengthening, flexor digitorum longus transfer, and Achilles tendon lengthening
A
  1. Debridement and repair of the peroneus longus tendon and a lateralizing calcaneal osteotomy
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16
Q

200. Figure 200 is a weight-bearing radiograph of a 70-year-old woman with diabetes mellitus who has a neuropathic plantar ulcer in the region of her first metatarsal head. An examination reveals peripheral granulation tissue, neutral dorsiflexion, and exposed tendon but no exposed bone. Which intervention will allow for ulcer healing, decrease risk for recurrence, and maintain function?

  1. Topical application of a honey-impregnated dressing
  2. Total-contact casting
  3. Tendo-Achilles lengthening with total-contact casting
  4. Metatarsal head resection
  5. Transmetatarsal amputation
A
  1. Tendo-Achilles lengthening with total-contact casting
17
Q

211. Figures 211a through 211c are the standing radiographs of a 63-year-old man who has chronic ankle pain and drainage 1 year after sustaining an open ankle fracture-dislocation. He denies recent fevers, chills, or constitutional signs. There is clear fluid drainage from an anteromedial wound at the ankle joint line. In addition to implant removal, definitive treatment should consist of

  1. hindfoot arthrodesis.
  2. ankle arthrodesis.
  3. arthroscopic irrigation and debridement.
  4. wound debridement and antibiotic beads.
  5. saucerization and staged arthrodesis.
A
  1. saucerization and staged arthrodesis.

RECOMMENDED READINGS

Anakwenze OA, Milby AH, Gans I, Stern JJ, Levin LS, Wapner KL. Foot and ankle infections: diagnosis and management. J Am Acad Orthop Surg. 2012 Nov;20(11):684-93. doi: 10.5435/JAAOS-20-11-684. Review. PubMed PMID: 23118134.

Baumhauer JF, Lu AP, DiGiovanni BF. Arthodesis of the infected ankle and subtalar joint. Foot Ankle Clin. 2002 Mar;7(1):175-90. Review. PubMed PMID: 12380388.

18
Q

216. Figures 216a through 216c are the anteroposterior and lateral weight-bearing radiographs of a 19-year-old woman with chronic bilateral hallux valgus deformities. She reports pain over the medial eminence that limits her shoe wear choices and recreational activities. Examination reveals tenderness over the medial prominence. Her range of motion is normal. Wide toe box shoes, pads, and oral anti-inflammatory drugs have not provided relief, and a decision is made to proceed with surgical treatment. The hallux valgus angle is 34 degrees, and the 1-2 intermetatarsal angle (IMA) is 16 degrees. In addition to some form of proximal correction, which distal procedure is necessary to achieve adequate correction?

  1. Reduction of IMA with a mini-tightrope bunionectomy procedure
  2. Medially based closing-wedge osteotomy of the first metatarsal
  3. Akin osteotomy at the base of the proximal phalanx
  4. Complete lateral soft-tissue release with sesamoid excision
  5. Distal Chevron osteotomy of the first metatarsal
A
  1. Medially based closing-wedge osteotomy of the first metatarsal
19
Q

222. A 41-year-old woman sustained an inversion ankle sprain 6 months ago. She has continued to experience pain with standing and walking and giving-way sensations on uneven ground. She exhibits tenderness to palpation along the anterior ankle joint line, normal ankle and hindfoot motion, and stable anterior drawer and calcaneal inversion test results. What is the best next step?

  1. Cortisone injection
  2. Initiate nonsteroidal anti-inflammatory drugs (NSAIDs)
  3. Proprioception and peroneal strengthening
  4. Lace-up ankle bracing
  5. Custom arch supports
A
  1. Proprioception and peroneal strengthening
20
Q

251. Figures 251a through 251c are the weight-bearing radiographs of a 19-year-old man who was involved in a high-speed motor vehicle collision 6 months ago. Radiographs taken at the time of the incident were read as “negative.” He has continued to experience pain with weight bearing and states that his “foot turns outward.” What is the best next step?

  1. Flatfoot reconstruction with tendon transfer, calcaneal osteotomy, and Achilles lengthening
  2. Triple arthrodesis and Achilles lengthening
  3. Closed reduction and percutaneous pinning
  4. Sinus tarsi implant
  5. Open reduction and primary midfoot arthrodesis
A
  1. Open reduction and primary midfoot arthrodesis

RECOMMENDED READINGS

Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006 Mar;88(3):514-20. PubMed PMID: 16510816.

Sangeorzan BJ, Veith RG, Hansen ST Jr. Salvage of Lisfranc’s tarsometatarsal joint by arthrodesis. Foot Ankle. 1990 Feb;10(4):193-200. PubMed PMID: 2307374.

21
Q

260. Figures 260a and 260b are the radiographs of a 38-year-old man who fell from his bicycle and now has ankle pain. His skin is intact; distal pulses are Dopplerable but biphasic. What is the most appropriate next step?

  1. CT scan
  2. Vascular surgery consult
  3. Closed reduction
  4. Ankle brachial index
  5. MRI
A
  1. Closed reduction
22
Q

268. Figures 268a through 268c are the current standing radiographs of a 39-year-old woman who wants a second opinion 6 months after undergoing surgical treatment performed elsewhere for an ankle fracture dislocation. She has persistent ankle pain with weight bearing and was told by her treating physician that she would require further surgery. What is the most appropriate revision surgery for this patient?

  1. Total ankle arthroplasty
  2. Revision fixation of the fibula and medial malleolus
  3. Revision fixation of the medial malleolus
  4. Revision fixation of the syndesmosis and medial malleolus
  5. Ankle arthrodesis
A
  1. Revision fixation of the fibula and medial malleolus

RECOMMENDED READINGS

Chu A, Weiner L. Distal fibula malunions. J Am Acad Orthop Surg. 2009 Apr;17(4):220-30. Review. PubMed PMID: 19307671.

Perera A, Myerson M. Surgical techniques for the reconstruction of malunited ankle fractures. Foot Ankle Clin. 2008 Dec;13(4):737-51, ix. doi: 10.1016/j.fcl.2008.09.005. Review. PubMed PMID: 19013406.

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