A 44-year-old male with long standing insulin dependent diabetes complains of a non-healing plantar foot ulcer. The ulcer is shown in Figure A. The second metatarsal head can be probed at the base of the wound, and he lacks plantar sensation. Laboratory work-up for infection is negative. Which of the following is the best initial treatment?
Ray resection and primary wound closure
Oral antibiotics and local wound care
Local wound care and non-weight bearing in a removable boot
Surgical debridement, dressing changes, and IV antibiotics
MRI of the foot to evaluate for underlying osteomyelitis
A 67% rate of osteomyelitis with bone being probed does NOT mean that one can "assume" that there is osteomyelitis in this case. There is also a 33% chance that the patient does not have it. Therefore imaging would certainly be of value. Poorly designed question in my opinion.Source: your didactic materials: "67% of ulcers that probe to bone have osteomyelitis"
Lisfranc Injuries - Anatomy Review & History of Injury
So how did a gynaecologist get a foot injury named after him. And what on earth is it anyhow. This is a quick run through the relevant anatomy that you need to understand this injury.
thanks so much
A 32-year-old dancer presents with right-sided posteromedial ankle pain. Her symptoms worsen during the "demi-pointe" position. MRI scan is shown in Figure A. Which of the following physical exam findings is most consistent with this diagnosis?
Reproduction of pain with percussion of the posterior tibial nerve
Painful crepitus of tendon with passive motion at great toe
Posterior ankle pain with forced passive plantar flexion
Medial ankle pain with resisted inversion
Foot drop with weakness of dorsiflexion
Your didactic materials state that the physical exam may show: "pain with forced plantarflexion of the ankle" but does not differentiate that this finding is specifically indicative of impingement as distinct from other problems with the tendon. Perhaps a little elaboration in that section would be helpful. Thanks.
A 17-year-old tennis player sustained an ankle sprain 4 weeks ago and now complains of painful popping posterior to the lateral malleolus. What physical exam will reproduce his symptoms?
External rotation stress test
Resisted plantar flexion
The didactic materials state that the test involves resisted dorsiflexion AND eversion:"the sensation of apprehension or subluxation with active dorsiflexion and eversion against resistance cause subluxation/dislocation and apprehension"Thus the choice between the answers dorsifflexion and eversion is impossible. Please edit didactic materials or the question to be consistent. Thanks.
In the retromalleolar groove, as shown in Figure A, what is the relationship of the peroneus brevis tendon to the peroneus longus tendon?
The peroneus longus tendon is not in the groove
The peroneus brevis tendon is not in the groove
Yes, thus the question is poor.
Asymptomatic Medial Talar Dome OCD in a 17M (C2741)
17 / M - A 17 year old male presented to sports clinic for assessment after twisting his ankle while playing soccer two days earlier. Prior to this recent episode, his ankle was completely asymptomatic.
XRays were taken, which revealed an OCD lesion of the medial talar dome. He was referred for an MRI. Images are shown.
How would you manage this patient's OCD lesion?
This case needs a CT scan. The history is acute and IF there is a large subchondral bone fragment I would consider fixing it.
A healthy 42-year-old male has a 2-year history of worsening hindfoot pain that is refractory to therapy and orthotics. Physical exam reveals a flexible planovalgus foot with an equinus contracture. He is unable to perform a single limb heel rise on the affected side. In addition to a flexor digitorum longus tendon transfer to the navicular, which of the following operative procedures is indicated?
Gastrocnemius lengthening only
Triple arthrodesis and gastrocnemius lengthening
Subtalar arthrodesis and gastrocnemius lengthening
Lateralizing calcaneal osteotomy, medial column lengthening, and gastrocnemius lengthening
Medializing calcaneal osteotomy, lateral column lengthening, and gastrocnemius lengthening
Medializing calcaneal osteotomies protect the repair. Lateral lengthening osteotomy would be done for a IIb case, but unfortunately this question does not give us enough information on talar head uncoverage and forefoot abduction to know whether that should be done or not. Also the question states that there is a equinus contracture but does not tell us whether we are dealing with a gastroc contracture or an Achilles tendon contracture, thus it is unclear whether Achilles or gastroc lengthening is need. Physical exam testing info is not provided. Poorly written question in my opinion.
You are seeing a 60-year-old male for pain in his great toe that has increased in severity over the past year despite the use of an insole with a Morton's extension. His great toe plantar/dorsiflexion range of motion is limited to a 35 degree arc with pain at the extremes of motion. Radiographs are seen in Figures A & B. What treatment do you suggest?
Cheilectomy and joint debridement
1st MTP resection artrhoplasty (Keller procedure)
1st MTP fusion
Clear grade 3 to my assessment, therefore fusion is indicated. Clinical data and xray do not match the prososed explanation of the answer.
Br J Sports Med. 2015 Oct;49(20):1329-35. Epub 2015 Aug 17.
What is the greatest advantage of surgical repair of an acute Achilles tendon rupture with early range of motion compared to non-operative treatment with immobilization in a short-leg cast for 6 weeks?
Lower rate of infection
Higher rate of normal skin sensation
Better skin cosmesis
Lower rate of dehiscence
Lower rate of re-rupture
Anonymous - we do keep up on the latest articles and have the help from our users, who also post new articles that may agree or disagree with certain concepts on the site. This question was purposefully written to compare surgery and conservative management with casting, not early functional rehab. It does appear that early functional rehab helps the operative patients as well:Early functional rehabilitation or cast immobilisation for the postoperative management of acute Achilles tendon rupture? A systematic review and meta-analysis of randomised controlled trials.McCormack R, Bovard JBr J Sports Med. 2015 Oct. pii: bjsports-2015-094935. doi: 10.1136/bjsports-2015-094935. 49. (20). :1329-35PMID: 26281836 (Link to Abstract)
i hope the test makers are reading the latest articles bc it has been well know so far that Sx has lower rates of rerupture, however the recent papers on no significant difference can definitely complicate things if both options appear in the choices. good question though
Which of the following best describes the physical examination test demonstrated in Figure A?
Silfverskiöld test used to differentiate gastrocnemius tightness from achilles tendon contracture
Thompson test used to differentiate soleus tightness from achilles tendon contracture
Coleman test used to differentiate soleus tightness from achilles tendon contracture
Silfverskiöld test to differentiate soleus tightness from achilles tendon contracture
Thompson test to differentiate gastrocnemius tightness from achilles tendon contracture
The gastrocnemius and soleus muscles (calf muscles) unite into one band of tissue, which becomes the Achilles tendon at the low end of the calf. ---->WHY are we talking about gastroc versus achilles??<----- knee Extended both gastroc and soleus contractures, flexed we take away the gastroc influence and assess the Soleus contractures. Is there a paper against this also? very confused now!
A 45-year-old male presents with complaints that his left foot "slaps" on the floor when he tries to ambulate. He reports a remote history of playing rugby 7 months ago when an opposing player fell on his plantarflexed left ankle. He denies constitutional symptoms. On physical examination he has weak dorsiflexion and increased fatigue with walking. He is able to achieve 15 degrees of passive dorsiflexion with the knee in full extension and 20 degrees of dorsiflexion with his knee in 90 degrees of flexion. A sagittal T2 MRI is shown in Figure A and axial MRI images are shown in Figures B and C. Which of the following is the MOST appropriate next step in management?
Surgical reconstruction with posterior tibial tendon transfer and gastrocnemius recession
MRI of the proximal tibiofibular joint for evaluation of ganglion cyst and EMG of the peroneal nerve
Primary surgical repair with gastrocnemius recession
Chest CT, skeletal survey, hematology profile, and referral to an orthopaedic oncologist for biopsy of the mass
Surgical reconstruction with plantaris tendon interposition augmentation
I don't know. I've seen and heard of attendings doing a split PT to AT transfer for drop/slap foot problem. prevents slap foot and lowers plantarflexory force a bit as well. What are your thoughts on this??
A diabetic ulcer shown in Figure A probes down to bone when a cotton-tipped applicator is used. What is the approximate likelihood this patient has osteomyelitis?
clinically speaking, I've never gotten a negative OM on MRI after +probe to bone test. 5 should be correct
A 40-year-old female presents to the physician for an initial visit with a 5-month history of plantar medial heel pain. She notices it immediately on getting out of bed in the morning, but the pain improves after a few steps. The pain is exacerbated throughout her workday to the point where she is unable to finish her work shift. Figure A shows a lateral radiograph of the affected heel. Which of the following is the most appropriate initial management?
Walker boot immobilization with full weightbearing for 4 weeks
Corticosteroid injection to the plantar fascia
Surgical release of 50% of the plantar fascia
Heel spur resection
Achilles stretching exercises
i had suferred from this. And with the Achiles stretching every morning after wake up and place Ice 3 times a day for 10-15 minutes, it will be recovered for about 2 weeks.
Acta Ortop Bras. 2016 Jan-Feb;24(1):52-4.
Orthop Traumatol Surg Res. 2013 Sep;99(5):593-9. Epub 2013 Jul 8.
There's a few studies on viscosupplementation of the ankle, and if you look at the recent review below, as well as several of the case series, like the 2nd article, there appears to be an improvement with viscosupplementation, but limited to no great comparative data exists on showing that this is better than other conservative methods.VISCOSUPPLEMENTATION IN ANKLE OSTEOARTHRITIS: A SYSTEMATIC REVIEW.Faleiro TB, Schulz Rda S, Jambeiro JE, Tavares A, Delmonte FM, Daltro Gde CActa Ortop Bras. 2016 Jan-Feb. doi: 10.1590/1413-785220162401139470. 24. (1). :52-4PMID: 26997916 (Link to Abstract)Viscosupplementation of the ankle: a prospective study with an average follow-up of 45.5 months.Lucas Y Hernandez J, Darcel V, Chauveaux D, Laffenêtre OOrthop Traumatol Surg Res. 2013 Sep. pii: S1877-0568(13)00109-6. doi: 10.1016/j.otsr.2013.02.008. 99. (5). :593-9PMID: 23845277 (Link to Abstract)
what are the roles of intraarticular injections of viscosupplemnations and steroids in ankle arthritis?
Sesamoid Injuries of the Hallux
Mistake in Anatomy: adductor connects to fibular sesamoid not tibial and abductor to tibial not fibular.