Foot & Ankle Speciality Exam No.6 Flashcards
(OBQ15.157) A patient suffers a midfoot crush injury at work (Figure A). When comparing treatment strategies, which of the following is true? Review Topic
QID:5842
FIGURES:
A http://upload.orthobullets.com/question/5842/images/slide1.jpg
1- Operative versus nonperative management would make no difference because this is a workplace injury
2- Arthrodesis should be considered as a salvage procedure only if ORIF fails
3- Rigid fixation of the 4th and 5th TMTs is the most important goal of primary arthrodesis or ORIF
4- Primarily ligamentous patterns have better outcomes with primary arthrodesis than with ORIF
5- Suture fixation alone of this pattern will have equal outcomes to ORIF without the need for hardware removal
1- Operative versus nonperative management would make no difference because this is a workplace injury
2- Arthrodesis should be considered as a salvage procedure only if ORIF fails
3- Rigid fixation of the 4th and 5th TMTs is the most important goal of primary arthrodesis or ORIF
4- Primarily ligamentous patterns have better outcomes with primary arthrodesis than with ORIF
5- Suture fixation alone of this pattern will have equal outcomes to ORIF without the need for hardware removal
For primarily ligamentous Lisfranc dislocations, primary arthrodesis has been shown to have the best clinical outcomes when compared to ORIF.
The Lisfranc joint is inherently stable, as the articulation of the 2nd metatarsal (MT) base forms the keystone of the transverse tarsal arch. The medial and middle columns three tarsometatarsal (TMT) articulations of the Lisfranc joint have little motion and allow a rigid lever arm for propulsion during gait. Meanwhile, the lateral column, comprised of the 4th and 5th TMTs, have considerably more mobility and function to accommodate the foot on uneven terrain. Therefore, rigid fixation of the 1-3 TMTs is an essential component of fixing traumatic Lisfranc instability, and what little motion is lost is not morbid to the patient. Furthermore, since healing of the ligaments is less reliable than bony healing in the setting of rigid fixation, primary arthrodesis has been shown to have better outcomes than ORIF for purely ligamentous variants.
(OBQ10.250) A diaphyseal fifth metatarsal osteotomy is the optimal surgical treatment for which of the following patients who has failed nonsurgical management? Review Topic
QID:3355
1- 28-year-old woman with a Jones fracture nonunion
2- 50-year-old woman with a physiologic bow to the 5th metatarsal and a lateral prominence of the 5th metatarsal head
3- 54-year-old woman with a widened 4-5 intermetatarsal angle and a lateral prominence of the 5th metatarsal head
4- 35-year-old woman with prominent lateral condyle of her 5th metatarsal head, without bowing of the metatarsal and with normal 4-5 intermetatarsal angle
5- 60-year-old woman with rheumatoid arthritis and a plantar plate rupture
1- 28-year-old woman with a Jones fracture nonunion
2- 50-year-old woman with a physiologic bow to the 5th metatarsal and a lateral prominence of the 5th metatarsal head
3- 54-year-old woman with a widened 4-5 intermetatarsal angle and a lateral prominence of the 5th metatarsal head
4- 35-year-old woman with prominent lateral condyle of her 5th metatarsal head, without bowing of the metatarsal and with normal 4-5 intermetatarsal angle
5- 60-year-old woman with rheumatoid arthritis and a plantar plate rupture
A bunionette, “tailor’s bunion”, is a lateral prominence of the fifth metatarsal head, as seen in the photo in illustration A. Illustration B shows a standard bunion and a bunionette on the same forefoot.
Usually a large 4-5 intermetatarsal (IM) angle and varus of the metatarsophalangeal joint are associated with the tender prominence, but not always. Conservative measures include wide toe boxed shoes and pads. Surgical treatment is fairly rare and only appropriate when nonoperative measures fail. A simple lateral eminence resection alone is indicated when the 4-5 IM angle is normal, but there is risk of recurrence and for overresection. A distal chevron osteotomy is reliable for those with a lateral bow to the fifth metatarsal, but a diaphyseal osteotomy of the 5th is needed if the 4-5 IM angle is widened.
Baumhauer et al. actually state that they favor distal chevron osteotomies in most cases because there is more reliable union in the more vascular distal regions than in the diaphysis.
However, Cohen et al. argue that adequate correction can rarely be achieved without a diaphyseal osteotomy when the 4-5 IM angle is increased.
Incorrect Answers:
Answer 1: Osteotomies are not generally used to treat Jones fracture nonunions.
Answer 2: The patient in scenario 2 would be best treated with a distal chevron osteotomy.
Answer 4: The woman in scenario 4 could be treated with lateral eminence resection alone.
Answer 5: Rheumatoid patients with plantar plate rupture can be treated with metatarsal head excision but not with diaphyseal osteotomies.
http://upload.orthobullets.com/question/3355/images/bunionette%20photo.jpg
http://upload.orthobullets.com/question/3355/images/bunionette%20xray.jpg
(OBQ10.193) Which of the following best describes the physical examination test demonstrated in Figure A? Review Topic
QID:3285
FIGURES:
A
1- Silfverskiöld test used to differentiate gastrocnemius tightness from achilles tendon contracture
2- Thompson test used to differentiate soleus tightness from achilles tendon contracture
3- Coleman test used to differentiate soleus tightness from achilles tendon contracture
4- Silfverskiöld test to differentiate soleus tightness from achilles tendon contracture
5- Thompson test to differentiate gastrocnemius tightness from achilles tendon contracture
1- Silfverskiöld test used to differentiate gastrocnemius tightness from achilles tendon contracture
2- Thompson test used to differentiate soleus tightness from achilles tendon contracture
3- Coleman test used to differentiate soleus tightness from achilles tendon contracture
4- Silfverskiöld test to differentiate soleus tightness from achilles tendon contracture
5- Thompson test to differentiate gastrocnemius tightness from achilles tendon contracture
The Silfverskiöld test differentiates gastrocnemius tightness from an achilles tendon contracture by evaluating ankle dorsiflexion with the knee extended and then flexed. Increased ankle dorsiflexion with knee flexion indicates gastrocnemius tightness. This occurs because the gastrocnemius relaxes with knee flexion as the muscle spans the knee joint and the soleus does not. If there is no difference in dorsiflexion with flexion of the knee, then an achilles tendon contracture is present.
(OBQ15.130) A 32-year-old female patient with hallux valgus underwent a proximal first metatarsal osteotomy with distal soft-tissue release. What preoperative radiographic measurements for hallux valgus was most likely for this surgical technique to be utilized, in terms of hallux valgus angle (HVA), 1-2 intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA)? Review Topic
QID:5815
1- HVA=30°, IMA=9°, DMAA=16°
2- HVA=25°, IMA=10°, DMAA=8°
3- HVA=35°, IMA=9°, DMAA=10°
4- HVA=35°, IMA=16°, DMAA=10°
5- HVA=50°, IMA=18°, DMAA=15°
1- HVA=30°, IMA=9°, DMAA=16°
2- HVA=25°, IMA=10°, DMAA=8°
3- HVA=35°, IMA=9°, DMAA=10°
4- HVA=35°, IMA=16°, DMAA=10°
5- HVA=50°, IMA=18°, DMAA=15°
A proximal first MT osteotomy with distal soft-tissue release is indicated in moderate to severe hallux valgus deformity (HVA = 26-40), increased intermetatarsal angles (IMA > 13 degrees), and congruent distal metatarsal articular angle (DMAA <15).
Hallux valgus deformities that require surgical correction are indicated in symptomatic patients with an IMA > 10° and HVA of > 20°. Distal metatarsal osteotomies are typically performed in patients with mild disease (HVA < 40°, IMA < 13°). Biplanar distal osteotomies are indicated when the distal metatarsal articular angle (DMAA) is greater than 15. Proximal osteotomies are indicated when the IMA is greater than 13°.
http://upload.orthobullets.com/question/5815/images/disorders-of-the-hallux-24-728.jpg
Incorrect Answers:
Answer 1: HVA=30° is considered a moderate deformity; IMA=9° is considered normal; DMAA=16° is considered as incongruent. Therefore the best operative treatment of this deformity would be biplanar distal MT osteotomy (as this also corrects DMAA).
Answer 2: HVA=25° is considered mild deformity, IMA=10° is considered normal; DMAA=8° is considered as congruent MTPJ. Therefore the best operative treatment of this deformity would be distal MT osteotomy +/- soft-tissue work (e.g. Chevron, Mitchell, etc.)
Answer 3: HVA=35° is considered moderate/severe deformity; IMA=10° is considered normal; DMAA=10° is considered as congruent MTPJ. Therefore the best operative treatment of this deformity would be distal osteotomy.
Answer 5: HVA=50° is considered severe deformity; IMA=18° is considered increased; DMAA=15° is considered as incongruent. Therefore the best operative treatment of this deformity would be proximal and distal (biplane) MT osteotomy (as this also corrects DMAA).
(SBQ12FA.24) In comparison with a percutaneous technique for repair of a ruptured Achilles tendon, an open technique will result in: Review Topic
QID:3831
1- Decreased incidence of sural nerve injury
2- Greater calf circumference at one year
3- Decreased rate of rerupture
4- Increased rate of postoperative wound complications
5- Decreased scarring at the incision site
1- Decreased incidence of sural nerve injury
2- Greater calf circumference at one year
3- Decreased rate of rerupture
4- Increased rate of postoperative wound complications
5- Decreased scarring at the incision site
Open repair of a ruptured Achilles tendon is associated with a higher complication rate than percutaneous repair.
Trials directly comparing open versus percutaneous techniques of Achilles repair have failed to show a difference in functional outcome or re-rupture rate. However, minimally invasive techniques have resulted in lower rates of minor complications such as superficial wound infection.
Aktas et al. prospectively compared 40 patients treated surgically for acute Achilles tendon rupture. Half were treated with Krakow end-to-end suturing, half were treated percutaneously. They found that functional outcomes were equal, but the percutaneous group had more favorable rates of local skin tenderness, scar adhesions, scar thickness and tendon thickness.
Gigante et al. randomized 40 consecutive patients with acute Achilles rupture to receive either open or percutaneous repair. They found two minor complications (delayed wound healing) in the open group and one failed repair in the percutaneous group. They concluded that both techniques produced equal results, but that the percutaneous technique was favored due to decreased surgical time and fewer cutaneous complications.
Incorrect answers:
Answers 1-3. No statistically significant difference in rates of sural nerve injury, calf circumference or re-rupture has been demonstrated when comparing open and percutanous techniques of Achilles repair.
Answer 5. Percutaneous, not open, technique has been shown to result in decreased local scarring.
(OBQ14.1) A 42-year-old women underwent the procedure seen in Figure A. What pre-operative radiographic measurements for hallux valgus would be most appropriate for this surgical technique, in terms of hallux valgus angle (HVA), Intermetatarsal angle (IMA), and hallux valgus interphalangeus angle (HVI)? Review Topic
QID:5411
FIGURES:
A http://upload.orthobullets.com/question/5411/images/op.jpg
1- HVA=30, IMA=15, HVI=9
2- HVA=50, IMA=18, HVI=12
3- HVA=20, IMA=9, HVI=14
4- HVA=15, IMA=10, HVI=8
5- HVA=30, IMA=12, HVI=9
1- HVA=30, IMA=15, HVI=9
2- HVA=50, IMA=18, HVI=12
3- HVA=20, IMA=9, HVI=14
4- HVA=15, IMA=10, HVI=8
5- HVA=30, IMA=12, HVI=9
Figure A shows a AP foot radiograph of a distal chevron osteotomy procedure. The most appropriate radiographic measurements for this technique would be a hallux valgus angle (HVA)=30, Intermetatarsal angle (IMA)=12, and hallux valgus interphalangeus angle (HVI)=9.
Hallux valgus deformities that require surgical correction are indicated in symptomatic patients with an IMA > 10° and HVA of > 20°. Distal metatarsal osteotomy (Chevron) includes a lateral translation of the metatarsal head after osteotomy. Distal chevron osteotomies are typically performed in patients with mild disease (HVA<40, IMA <13). This procedure may be combined with proximal phalanx osteotomy (Akin-medial closing wedge osteotomy) if the hallux valgus interphalangeus angle (HVI) >10.
Incorrect Answers:
Answer 1: An IMA angle >13 would require a proximal metatarsal osteotomy.
Answer 2: A HVA>40 and IMA>13 would require a proximal and distal metatarsal osteotomy or Lapidus procedure plus Akin.
Answer 3: A HVI>10 would require a proximal phalanx osteotomy. The HVA and IMA are normal.
Answer 4: HVA=15, IMA=10, HVI=8 are within normal limits. No corrective procedure would be indicated.
(OBQ11.68) The anterior drawer test with the ankle in 20 degrees of plantarflexion most effectively tests for injury or laxity or which of the following ligaments shown in Figure A? Review Topic
QID:3491
FIGURES:
A http://upload.orthobullets.com/question/3491/images/lateral%20ligaments%20of%20ankle%20question.jpg
1 - A
2- B
3- C
4- D
5- E
1 - A
2- B
3- C
4- D
5- E
Answer choice B points to the anterior talofibular ligament (ATFL). The ATFL is the most common ligament injured with ankle sprains and occurs most often with the foot in slight plantar flexion. Plantar flexion of the foot causes the ATFL to become parallel with the axis of the foot and become taut.
Maffulli et al, in his study on the on the management of acute and chronic ankle instability, concluded that acute lateral ankle ligament injuries are very common and can result in chronic instability if left untreated. Conservative measures includes functional rehabilitation which is the management of choice for acute and chronic injuries. Surgical intervention is best reserved for high-demand athletes.
Illustration A shows the orientation of the ATFL, along with the other foot and ankle ligaments. Illustration B shows the ankle anterior drawer test can show injury of the ATFL and is performed by doing an anterior drawer of the talus with the foot in slight plantar flexion. Illustration C, shows a radiographic example of anterior translation of the talus during an anterior drawer exam. The video V is a link to a video demonstrating this exam maneuver.
(SBQ12FA.13) A 42-year-old female sustains the injury exhibited in Figure A. Fluoroscopic images are exhibited in Figure B following open reduction and internal fixation. Should she go on to develop tibiotalar arthritis and fail conservative management for this, which of the following treatment modalities has the highest success rate? Review Topic
QID:3820
FIGURES:
A http://upload.orthobullets.com/question/3820/images/figure_a.jpg
B
http://upload.orthobullets.com/question/3820/images/figure_b.jpg
1 - Isolated osteochondral allograft transplantation
2- Interpositional soft tissue replacement
3 - Tibiotalar fusion
4- Arthroscopic debridement and microfracture
5- Tibiotalocalcaneal fusion
1 - Isolated osteochondral allograft transplantation
2- Interpositional soft tissue replacement
3 - Tibiotalar fusion
4- Arthroscopic debridement and microfracture
5- Tibiotalocalcaneal fusion
In the treatment of ankle arthritis, tibiotalar fusion is the most reliable in reducing pain and improving function. In comparison to the other options, data supports fusion as the most successful option.
Zwipp et al. retrospectively reviewed 94 patients who underwent tibiotalar fusion with cancellous screws. At mean follow-up of 5 years, all patients had significant improvements in outcome scores, high union rates, and no reoperations/fusions at adjacent joint locations.
Baker et al. reviewed outcomes of 45 consecutive patients with BMI over 30 undergoing total ankle replacement (TAR) and noted no significant failures or reoperation rates. While strict criteria were utilized to indicate TAR, the authors do not consider high BMI a contraindication if other criteria are met.
Meehan et al. reports on 11 patients who underwent osteochondral allograft replacement. At 2-year follow-up, 5/11 had allograft failure and required repeat allografting procedures. All eventually went on to union and improvements in outcome scores, however, the authors caution that more research is needed before widespread application.
Figure A exhibits ankle fracture dislocation. Figure B depicts definitive fixation for the fracture shown in Figure A.
Incorrect answers:
Answers 1,2,4,5: When compared to fusion, all other procedures lack the evidence to support its reliable success, especially at mid-term and long-term follow-up.
(SBQ12FA.15) An active 70-year-old female presents to your office with increasing foot pain over the last several years. She enjoys walking however is limited to 2 blocks due to pain. Her pain is greatest with “push off”. She has attempted shoe wear modifications, orthotics, physical therapy and non steroidal anti-inflammatories with limited relief of her symptoms. Her current weight bearing radiographs are seen in Figures A, B and C. What is the most appropriate treatment at this time? Review Topic
QID:3822
FIGURES:
A http://upload.orthobullets.com/question/3822/images/pta_midfoot_ap._jpg.jpg
B http://upload.orthobullets.com/question/3822/images/pta_midfoot_lateral.jpg
C
1- Platelet rich plasma injection
2- Proximal medial opening wedge of first metatarsal
3- Dorsal exostectomy of the midfoot
4- Midfoot arthrodesis
5- Double calcaneal osteotomy with lateral column lengthening
1- Platelet rich plasma injection
2- Proximal medial opening wedge of first metatarsal
3- Dorsal exostectomy of the midfoot
4- Midfoot arthrodesis
5- Double calcaneal osteotomy with lateral column lengthening
The patient’s history and imaging are consistent with atraumatic midfoot arthritis. She has failed non operative management and the best option for treatment is now midfoot arthrodesis.
Atraumatic midfoot arthritis, similar to postraumatic deformity, results in pain with propulsive activities, typically combined with collapse of the longitudinal arch and/or abduction deformity. Non surgical treatment options include shoe wear modifications (mid foot rocker), arch support orthotics, activity modifications, physical therapy and medications. In patients that fail these modalities, midfoot arthrodesis is indicated to relieve pain and restore the functional anatomy of the medial column of the foot.
Jung et al reviewed the management of patients with symptomatic midfoot arthritis. The authors define subtypes of patients with atraumatic arthritis including hallux valgus, pes planovaglus (abduction deformity) and rocker bottom (longitudinal collapse). Significant improvement was seen in radiographic parameters and functional outcome scores (AOFAS midfoot, FFI) with corrective midfoot arthrodesis.
(SBQ12FA.27) A 29-year-old slightly overweight male comes for evaluation of heel pain that he has had for 7 months without associated trauma. He recently began running to lose weight and reports completing approximately 10 miles per week. He has tried anti-inflammatory medications as well as a stretching program that you feel has been appropriately directed at his condition. Physical examination reveals no pain with heel squeeze and no Tinel sign, however he is tender at the area indicated in Figure A. Which of the pictured orthoses is the most effective next treatment? Review Topic
QID:3834
FIGURES:
A http://upload.orthobullets.com/question/3834/images/foot.jpg
B http://upload.orthobullets.com/question/3834/images/figure_b.jpg
C http://upload.orthobullets.com/question/3834/images/figure_c.jpg
D http://upload.orthobullets.com/question/3834/images/figure_d.jpg
E http://upload.orthobullets.com/question/3834/images/figure_e.jpg
F http://upload.orthobullets.com/question/3834/images/figure_f.jpg
1- Figure B
2- Figure C
3- Figure D
4- Figure E
5- Figure F
1- Figure B
2- Figure C
3- Figure D
4- Figure E
5- Figure F
The patient has chronic plantar fasciitis. A dorsiflexion night splint is the only orthosis with demonstrated effectiveness in treating chronic plantar fasciitis.
The mainstay of treatment of plantar fasciitis is non-operative. A plantar fascia-specific stretching program is the first line of treatment. Pre-fabricated orthotics are generally preferred to custom-made because of decreased cost and no clear benefit of custom orthoses. Although many inserts are used to treat plantar fasciitis, only the dorsiflexion night splint has demonstrated effectiveness for chronic plantar fasciitis.
Figure A shows the typical location of pain and tenderness found in patients with plantar fasciitis. Figure B shows gel heel cusions. Figure C shows a full length prefabricated shoe insert. Figure D shows a Morton’s extension orthotic insert. Figure E shows a dorsiflexion splint. Figure F shows and insert with a recessed area to accommodate first ray plantarflexion.
Incorrect answers:
Answers 1 and 2. Though often used to treat plantar fasciitis, gel heel cushions and full length prefabricated inserts have not demonstrated effectiveness in chronic plantar fasciitis.
Answer 3. A Morton’s extension orthotic would be more appropriate to treat pathology of the first ray metatarso-phalangeal joint
Answer 5. A recessed first ray would be appropriate to accommodate a cavus foot.
(OBQ15.147) A 25-year-old ballerina complains of right forefoot pain of insidious onset 2 months after starting practice for a major performance. On initial examination, there is tenderness along the shaft of the second metatarsal. She is not able to perform a single-leg heel rise. Initial radiographs are shown in Figure A. Radiographs taken 2 weeks later are shown in Figure B. What is the next best step? Review Topic
QID:5832
FIGURES:
A http://upload.orthobullets.com/question/5832/images/fig_a.jpg
B http://upload.orthobullets.com/question/5832/images/fig_b.jpg
1- Biopsy
2- Observation
3- Protected weight-bearing
4- MRI
5- Bone scan
1- Biopsy
2- Observation
3- Protected weight-bearing
4- MRI
5- Bone scan
This patient has right second metatarsal shaft stress fracture. These fractures will heal if the fracture site is stabilized. Protected weight-bearing will provide stability and minimize pain.
Stress fractures arise when there is a disruption of the balance between accumulation of microdamage and bone repair. Stress fractures occur in watershed areas where there is poor blood supply and areas of high stress. Pain is typically insidious (2-3 weeks) and may correlate with a change in training habits. Radiographs typically lag behind clinical symptoms by weeks. Repeat radiographs 2 weeks later may reveal the fracture.
Shindle et al. reviewed stress fractures about the tibia, foot and ankle. They recommend elucidating a history including endocrinopathies, autoimmune and eating disorders, depression, malabsorption, bariatric surgery, and dietary history. Management depends on the fracture location. High-risk fractures (anterior tibia, navicular, proximal fifth metatarsal, medial malleolus) may require surgery in high level athletes who need to return to sport early.
(OBQ15.69) A 45-year-old female presents with persistent ankle pain 9 years after total ankle arthroplasty. Radiographs at the 3, 6 and 9 year (current) time point are shown in Figures A through C respectively. The workup for infection is negative. What is the next best step? Review Topic
QID:5754
FIGURES:
A http://upload.orthobullets.com/question/5754/images/fig_a.jpg
B http://upload.orthobullets.com/question/5754/images/fig_b.jpg
C http://upload.orthobullets.com/question/5754/images/fig_c.jpg
1- Revision of the talar component and polyethylene exchange
2- Revision of the tibial component and polyethylene exchange
3- Revision of both talar and tibial components and polyethylene exchange
4- Tibiotalocalcaneal (TTC) arthrodesis
5- Tibiotalocalcaneal (TTC) arthrodesis with structural allograft
1- Revision of the talar component and polyethylene exchange
2- Revision of the tibial component and polyethylene exchange
3- Revision of both talar and tibial components and polyethylene exchange
4- Tibiotalocalcaneal (TTC) arthrodesis
5- Tibiotalocalcaneal (TTC) arthrodesis with structural allograft
—
This patient has progressive progressive talar bone loss and talar component subsidence, and violation of the subtalar joint (STJ) after total ankle arthroplasty (TAA). TTC arthrodesis is necessary, and femoral head bulk allograft is necessary to make up for bone loss and restore height.
TAA has a higher rate of reoperation (up to 30%) and lower 5-year survival (up to 60%) than TKA and THA. Loss of bone stock leaves fusion as the treatment of choice. The subtalar joint should be included if there is insufficient talar bone stock, or if talar component subsidence crosses the STJ, or if there is pre-existing STJ arthrosis. Structural bone graft options include the Campbell technique (tricortical iliac crest wedges), femoral head allograft, and fresh-frozen distal tibial allograft. For large talar losses, femoral head allograft is the graft of choice.
Berkowitz et al (2012). reviewed the decision making process after failed TAA. They state that the 4 key points are: (1) rule out infection, (2) decide if fusion can be limited to the ankle joint or involve both ankle and STJ, (3) decide which bone graft and (4) which internal fixation to use.
(SBQ12FA.54) Which of the following findings would most likely be found in a patient with synovitis of the second metatarsalphalangeal (MTP) joint? Review Topic
QID:3861
1- Less pain when barefoot
2- Pain and a click when compression applied to the forefoot from medial and lateral
3- No pain with toe range of motion
4- More pain when barefoot
5- Pain when compression applied to the web space between the second and third rays
1- Less pain when barefoot
2- Pain and a click when compression applied to the forefoot from medial and lateral
3- No pain with toe range of motion
4- More pain when barefoot
5- Pain when compression applied to the web space between the second and third rays
The pain of synovitis of the second MTP joint is worse when barefoot.
Synovitis of the second MTP joint must be differentiated from Morton’s interdigital neuroma. Although the pain of each may localize to a similar area, physical exam findings can help differentiate the two. Additionally, Morton’s Neuroma is more likely to occur in the third interspace. If the pain is located more in the second interspace, second MTP synovitis/metatarsalgia needs to be considered. The distinction is important because corticosteroid injection may be an appropriate treatment for neuroma but may cause or worsen instability in the case of synovitis. Instability can lead to deformity, including dorsal subluxation of the MTP joint and cross-over toe deformity
Kaz et al. reviewed 169 patients treated for cross-over deformity of the second toe to identify factors associated with this deformity. They found that cross-over second toe was associated with hallux valgus and first MTP arthritis. A positive drawer sign was a reliable exam finding in this cohort (present in 112 patients).
Incorrect answers:
Answer 1. MTP synovitis pain is typically worse when barefoot. Patients with interdigital neuroma may have less pain when barefoot.
Answers 2 and 5. These findings are characteristic of Morton’s interdigital neuroma.
Answer 3. Toe range of motion is typically painful with synovitis. It may be painless in the case of interdigital neuroma.
(SBQ12FA.36) A 43-year-old female presents with a painful right 2nd toe. On examination, she has a rigid flexion contracture of the second proximal interphalangeal (PIP) joint, with neutral position of the metatarsophalangeal (MTP) joint. The deformity does not correct with foot plantarflexion. What is the most appropriate sequence of treatment options? Review Topic
QID:3843
1- Dorsal PIP joint padding, shoe modification, PIP resection arthroplasty
2- Plantar PIP joint padding, PIP resection arthroplasty, MTP capsular release
3- Dorsal PIP joint padding, shoe modification, extensor tenotomy, metatarsal head excision
4- Plantar PIP joint padding, shoe modification, PIP resection arthroplasty
5- Dorsal PIP joint padding, extensor tenotomy, PIP resection arthroplasty
1- Dorsal PIP joint padding, shoe modification, PIP resection arthroplasty
2- Plantar PIP joint padding, PIP resection arthroplasty, MTP capsular release
3- Dorsal PIP joint padding, shoe modification, extensor tenotomy, metatarsal head excision
4- Plantar PIP joint padding, shoe modification, PIP resection arthroplasty
5- Dorsal PIP joint padding, extensor tenotomy, PIP resection arthroplasty
The patient presents with a rigid 2nd hammertoe. The most appropriate progression of treatment is padding the dorsum of the PIP joint, modification of shoe wear, followed by PIP resection arthroplasty if conservative treatment fails. Extensor tenotomy/lengthening may be performed concomitantly to address MTP dorsiflexion contracture.
Rigid hammertoe deformity is characterized by fixed PIP flexion which does not correct with foot plantarflexion. It is associated with neutral to slight MTP extension, and variable position of the DIP. Persistent deformities are symptomatic from dorsal pressure to the PIP joint, which is why padding and shoe modification are first line of treatment.
(OBQ15.105) A 45-year-old woman with diabetic neuropathy is referred to your office for the Wagner grade 3 heel ulcer shown in Figure A. Her BMI is 42kg/m2. She is mostly homebound and rarely ventures outside the house. The dorsalis pedis pulse is palpable but the posterior tibial pulse is not. Both pulses are audible on Doppler ultrasound examination. She has had 3 previous ulcer debridements by a referring orthopedist. She has no constitutional symptoms and blood glucose levels and insulin requirements have not changed recently. Which treatment will maximize the chance of healing and minimize metabolic demand? Review Topic
QID:5790
FIGURES:
A http://upload.orthobullets.com/question/5790/images/fig_a_heel.jpg
B http://upload.orthobullets.com/question/5790/images/fig_b.jpg
1- Partial calcanectomy and wound closure by secondary intention
2- Partial calcanectomy and primary wound closure
3- Total calcanectomy and partial talectomy
4- Below-knee amputation
5- Revascularization
1- Partial calcanectomy and wound closure by secondary intention
2- Partial calcanectomy and primary wound closure
3- Total calcanectomy and partial talectomy
4- Below-knee amputation
5- Revascularization
This patient has a recalcitrant heel ulcer with visible bone (presumed osteomyelitis, OM). Partial calcanectomy (PC) and primary wound closure (or delayed primary closure)(often over a drain) is indicated. This maximizes the chance of healing while minimally changing oxygen expenditure and metabolic demand.
Heel ulcers with OM are difficult to treat. Skin grafts are not stable enough to withstand shear. Options include (1) below knee amputation (BKA) with the disadvantages of increased energy requirements and need for assistive devices, (2) debridement with free muscle flap, with the disadvantages of long recovery, donor site morbidity and footware fitting difficulties. The aim of a PC is debridement and tension-free primary wound closure (to prevent recurrent breakdown). Part (or all) of the Achilles insertion may need to be resected (and reattached). Healing will be delayed in patients with MRSA, poor nutrition (albumin <3g/dl), PVD and large ulcers with Wagner grade = 3.
Bollinger et al. reviewed 22 patients with heel wounds treated with PC instead of BKA. All patients healed their wounds although 12 had delayed healing (especially those with diabetes). They conclude that PC is a viable alternative for patients with large heel ulcers. They emphasize postoperative equinus splinting to prevent a calcaneus deformity
