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A 60-year-old woman with a history of well-controlled diabetes and hypertension sustained a fall into a ditch yesterday and presents with persistent left ankle pain and deformity. The injury is closed, and the patient is neurovascularly intact. Injury films are shown in Figures A and B. An unsuccessful attempt at reduction in the emergency department with sedation was made. What is the cause of failure of closed reduction?
Subacute nature of fracture
Incarceration of the deltoid ligament
Incarceration of the fibula behind the posterolateral ridge of tibia
Entrapment of the flexor hallucis longus (FHL) tendon
Entrapment of the extensor digitorum brevis (EDB)
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A 40-year-old man fell off of a ladder at work sustaining the injury shown in Figures A and B. On examination, his skin is intact, but the pulses in his foot are absent. Following closed reduction and splinting, what would be the next best step?
Vascular surgery consultation
Surgical exploration and stabilization
A 33-year-old female sustains the injury shown in Figure A as the result of a fall off a chair, and subsequently undergoes operative stabilization of her injury. Which of the following is most correlated with positive outcomes when treating this injury?
Subchondral debridement of any osteochondral defect
Repair of medial ligamentous structures
Casting or splinting in a neutral position postoperatively
Anatomic reduction of the syndesmosis
Which of the following ankle fractures seen in Figures A-E most likely occurred as a result of abduction of the foot relative to the tibia?
A 40-year-old male patient sustains a bimalleolar ankle fracture and undergoes open reduction and internal fixation. Four months later, he returns for follow-up with mild ankle discomfort, and a radiograph is shown in Figure A. What is the most appropriate next step in treatment?
Syndesmosis sagittal plane reduction and fixation
Syndesmosis coronal plane reduction and fixation
Osteotomy and revision of the fibula and syndesmosis
Retrieval of osteochondral fragment
Revision plating of the fibula and syndesmosis reduction and fixation.
Figure A shows an isolated left ankle injury in an active 48-year-old recreational hockey player. Past medical history includes insulin dependent diabetes mellitus for 35 years. On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. His pedal pulses are palpable. Of the following options, what would be the recommended treatment?
Closed reduction and casting for 6 weeks
Closed reduction and casting for 12 weeks
Open reduction and internal fixation with restricted weight bearing for 2 weeks
Open reduction and internal fixation with restricted weight bearing for 6 weeks
Open reduction and internal fixation with restricted weight bearing for 12 weeks
A 27-year-old man presents to the emergency department with an ankle fracture. CT scans note anteromedial marginal impaction. Which radiograph (Figures A-E) would best correlate with this finding?
Surgical fixation with absolute stability would be most appropriate for which of the following fracture patterns?
An otherwise healthy 45-year-old female slips and falls with immediate right ankle pain. Stress examination of the right ankle is shown in Figure A. Which of the following is the most important for achieving a satisfactory outcome following open reduction internal fixation for this injury?
Weight-bearing before 3 weeks.
Medial clear space >5mm
Talocrural angle of 83 degrees
Tibiofibular clear space of >6mm
Talar tilt of >5 degrees
A 45-year-old male with long-standing diabetes sustains the injury shown in Figure A. He has a BMI of 38, established peripheral neuropathy, and his most recent HbA1c is 8.8. What is the most appropriate definitive management option of Figures B through F?
A 28-year-old male sustained an ankle injury 3 months ago, and was treated with closed management and splinting; a current x-ray is shown in Figure A. Which of the following is the most important factor in deciding between a joint sacrificing and a joint preserving operation for this patient at this time?
Workers' Compensation involvement
Date of injury
Degree of tibiotalar arthritis
Degree of deformity
A 34-year-old female requests a second opinion following open reduction internal fixation (ORIF) of her left ankle three weeks ago. Which of the following is most appropriate step based on Figures A and B?
Progressive weightbearing in 3-4 weeks based on radiographs
Deltoid ligament repair vs reconstruction
Revision ORIF of fibula with lengthening
Revision ORIF of fibula and syndesmosis
Removal of syndesmotic screws in 3-6 months
A 25-year-old male sustains an ankle fracture dislocation and undergoes open reduction and internal fixation. He returns to clinic five months following surgery complaining of continued ankle pain and instability with weight bearing. His immediate post-operative AP radiograph is seen in Figure A. Which of the following could have prevented this patient from developing persistent pain?
Deep deltoid ligament repair
Quadricortical syndesmotic screw fixation
Restoration of fibular length and rotation
Lateral collateral ligament complex repair
Use of two syndesmotic screws
In an isolated ankle syndesmotic injury, the fibula is unstable in the incisura fibularis of the tibia. In what direction is the fibula most unstable?
Equivalent instability in all axes
A 34-year-old man sustains a twisting injury to his left ankle playing soccer. Radiographs from the ER are provided in figures A and B. Four hours later, he undergoes open reduction internal fixation. An intraoperative fluoroscopy image is provided in figure C. Which of the following is the best method to assess the integrity of the syndesmosis?
Measurement of medial clear space widening
Measurement of the tibiofibular overlap
Anterior drawer test with comparison to the contralateral ankle
External rotation stress radiograph
Evaluation of the syndesmosis on preoperative CT scan
A 32-year-old female sustains the injury shown in Figure A. What is the most reliable method to evaluate the competence of the deltoid ligament?
Medial ankle tenderness
Medial ankle ecchymosis
Stress radiography of the ankle
Canale view radiograph
A 32-year-old laborer reports left ankle pain and deformity. History reveals that he sustained a left ankle fracture 2 years ago and was treated with closed reduction and casting. Radiographs are shown in Figures 25a through 25c. What is the most appropriate management?
Bracing and physical therapy
Intra-articular injection of steroids into the ankle joint, bracing, and physical therapy
Intra-articular injection of hyaluronic acid product into the ankle joint, bracing, and physical therapy
Corrective osteotomy of the fibula and medial malleolus with reconstruction of the syndesmosis if unstable
In the Lauge-Hansen classification system, a pronation-abduction ankle fracture has what characteristic fibular fracture pattern?
Transverse fracture below the level of the syndesmosis
Short oblique fracture running from anteroinferior to posteriosuperior
Short oblique fracture running from posteroinferior to anteriosuperior
Comminuted fracture at or above the level of the syndesmosis
An 18-year-old football player presents to the emergency department after sustaining an ankle injury. His radiograph is shown in figure A. What is the most appropriate definitive treatment?
Open reduction and internal fixation of the medial malleolus with syndesmosis reduction and suture-button repair
Repair of the anterior talo-fibular ligament
Open reduction internal fixation of the fibula with syndesmosis reduction and suture-button repair
Open reduction internal fixation of the medial malleolus and fibula
Open reduction internal fixation of the fibula and medial malleolus with syndesmosis reduction and suture-button repair
Presence of diabetes-induced peripheral neuropathy has been shown to be an independent risk factor for postoperative complications of which of the following injuries?
Distal radius fractures
Distal femoral fractures
A 34-year-old male falls off of a ladder and sustains the ankle injury shown in Figure. Which of the following is unique with this particular ankle fracture pattern and must be recognized by the operating surgeon to optimize outcomes?
Marginal impaction of the anteromedial tibial plafond
Deltoid ligament tear
Posterolateral osteochondral lesion of the talus
In which of the following radiographs of different types of ankle fractures should the medial malleolus be treated with screw fixation directed parallel to the ankle joint?
A 31-year-old male sustains an irreducible ankle fracture-dislocation with the foot maintained in an externally rotated position. An AP and lateral radiograph are shown in figures A and B respectively. The attempted post reduction AP and lateral are shown in C and D. What structure is most likely preventing reduction?
Anterior-inferior tibiofibular ligament
Posterior-inferior tibiofibular ligament
Peroneus brevis tendon
Posterolateral ridge of the tibia
Flexor hallucis longus tendon
Following operative repair of lower extremity long bone and periarticular fractures, what is the time frame for patients to return to normal automobile braking time?
6 weeks after initiation of weight bearing
4 weeks postoperatively
8 weeks from the date of injury
Once full range of motion of the ankle and knee exist
At the time of bony union
A 25-year-old man sustains a twisting injury to his ankle. His radiograph is shown in Figure A. Which of the following is the most appropriate method to assess the competency of his deltoid ligament?
Anterior drawer test
Internal rotation stress radiograph
Palpation of the medial ankle in the region of the deltoid
Inversion stress radiograph
A 68-year-old female sustains a closed ankle fracture and is treated with open reduction and internal fixation. Her postoperative radiographs are shown in Figure A. Widening of the tibia-fibular clear space with external rotation stress would be a result of injury of which structure?
Anterior ankle joint capsule
Anterior talofibular ligament
Posterior tibial tendon
A 35-year-old male with a pronation abduction ankle injury would have which of the following radiographs?
A 19-year-old male sustains the injury shown in Figure A while skiing. Injury to what structure should be evaluated intraoperatively during fixation of the fibula?
Appropriate treatment of the bimalleolar ankle fracture shown in Figure A includes which of the following?
Bridge plating of the fibula with oblique medial malleolar screws
Antiglide plating of the fibula with oblique medial malleolar screws
Intramedullary fibular screw with medial malleolar tension banding
Fibular plating with open correction of plafond impaction with medial malleolar antiglide plate
Fibular plating with open correction of syndesmosis and oblique medial malleolar screws
The Cotton test evaluates which of the following structures?
Lateral ulnar collateral ligament of the elbow
After undergoing the treatment seen in Figure A, when should a patient be expected to safely operate the brakes of an automobile?
2 -4 weeks
The Lauge-Hansen classification of ankle fractures identifies characteristic fracture patterns based on mechanism of injury. What is the mechanism for the fracture pattern shown in Figure A?
What is the most appropriate plating technique utilized for the medial malleolus fracture typically seen in a displaced supination-adduction ankle fracture?
Tension band plating
The talocrural angle of an ankle mortise x-ray is formed between a line perpendicular to the tibial plafond and a line drawn:
perpendicular to the medial clear space
parallel to the talar body
between the tips of the malleoli
perpendicular to the shaft of the fibular
parallel to the subtalar joint
A 34-year-old woman twists her right ankle stepping off the city bus. An AP ankle radiograph is provided in Figure A. Which of the following statements accurately describe this radiograph?
The tibiofibular overlap is less than 3 mm
The fibula demonstrates a Weber C fracture pattern
The tibiofibular clear space is less than 4 mm
The fracture is consistent with a Lauge-Hansen pronation-external rotation injury pattern
The medial clear space is greater than 5 mm
When comparing the fibular plating techniques shown in Figures A and B, the plate position shown in Figure B is associated with which of the following?
Decreased rate of hardware prominence
Increased risk of intra-articular screw penetration
Increased peroneal tendinitis
Coupled with reduction of the syndesmosis, which of the following interventions is most important when surgically addressing the ankle malunion shown in Figure A?
Placement of an osteochondral allograft
Fibular lengthening osteotomy
Calcaneofibular ligament release
Medial malleolar shortening osteotomy
Deltoid ligament imbrication
A 32-year-old taxi driver sustains a displaced supination external rotation ankle injury after slipping off of a curb. He subsequently undergoes surgical fixation, and a post-operative radiograph is shown in Figure A. At the eight-week postoperative visit, you are asked to fill out a return to work form. How long from today’s visit will his braking time be expected to return to normal?
Two weeks ago
One week from now
Three weeks from now
Six weeks from now
Eight weeks from now
A 33-year-old male is involved in a motor vehicle accident and suffers a right pilon fracture. Which of the bone fragments labeled on the distal tibia in the axial CT scan shown in Figure A is attached to the posterior inferior tibiofibular ligament?
C and B
A and D
A 32-year-old female sustained a bimalleolar ankle fracture and was treated with open reduction and internal fixation four months ago. A radiograph of her ankle is shown in Figure A. Recommended management should consist of?
Physical therapy for ambulation assistance and proprioception training
Short leg bracing
Revision open reduction and internal fixation with open syndesmosis reduction
Addition of syndesmosis screw from fibula to tibia
Open medial ankle ligament reconstruction