Summary Ankle fractures are very common injuries to the ankle which generally occur due to a twisting mechanism. Diagnosis is made with orthogonal radiographs of the ankle. Treatment can be nonoperative or operative depending on fracture displacement, ankle stability, syndesmosis injury, and patient activity demands. Etiology Injury patterns isolated medial malleolus fracture isolated lateral malleolus fracture bimalleolar and bimalleolar-equivalent fractures posterior malleolus fractures Bosworth fracture-dislocations open ankle fractures associated syndesmotic injuries isolated syndesmosis injury Anatomy Biomechanics deltoid ligament (deep portion) primary restraint to anterolateral talar displacement fibula acts as buttress to prevent lateral displacement of talus Imaging Radiographs recommended views AP lateral mortise external rotation stress most appropriate stress radiograph to assess competency of deltoid ligament more sensitive to injury than medial tenderness, ecchymosis, or edema gravity stress radiograph is equivalent to manual stress radiograph full-length tibia, or proximal tibia radiographs important to rule out Maisonneuve-type fracture findings syndesmotic injury decreased tibiofibular overlap measure at point of maximum overlap normal >6 mm on AP view normal >1 mm on mortise view it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements increased medial clear space normal ≤ 4 mm on mortise or stress view medial clear space of >5mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption increased tibiofibular clear space measure clear space 1 cm above joint normal <6 mm on both AP and mortise views lateral malleolus fractures talocrural angle measured by bisection of line through tibial anatomical axis and another line through the tips of the malleoli shortening of lateral malleoli fractures can lead to increased talocrural angle talocrural angle is not 100% reliable for estimating restoration of fibular length can also utilize the realignment of the medial fibular prominence with the tibiotalar joint posterior malleolus fractures double contour sign misty mountains sign spur sign Classification Lauge-Hansen based on foot position and force of applied stress/force has been shown to predict the observed (via MRI) ligamentous injury in less than 50% of operatively treated fractures Lauge-Hansen Classification Supination - Adduction (SAD) 1. Talofibular sprain or distal fibular avulsion2. Vertical medial malleolus and impaction of anteromedial distal tibia Supination - External Rotation (SER) 1. Anterior tibiofibular ligament sprain2. Lateral short oblique fibula fracture (anteroinferior to posterosuperior)3. Posterior tibiofibular ligament rupture or avulsion of posterior malleolus4. Medial malleolus transverse fracture or disruption of deltoid ligament Pronation - Abduction (PAB) 1. Medial malleolus transverse fracture or disruption of deltoid ligament2. Anterior tibiofibular ligament sprain3. Transverse comminuted fracture of the fibula above the level of the syndesmosis Pronation - External Rotation (PER) 1. Medial malleolus transverse fracture or disruption of deltoid ligament2. Anterior tibiofibular ligament disruption3. Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint4. Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Anatomic / Descriptive isolated medial malleolar isolated lateral malleolar bimalleolar trimalleolar Bosworth fracture-dislocation (posterior dislocation of the fibula behind incisura fibularis) Danis-Weber (location of fibular fracture) A - infrasyndesmotic (generally not associated with ankle instability) B - transsyndesmotic C - suprasyndesmotic AO / ATA 44A - infrasyndesmotic 44B - transsyndesmotic 44C - suprasyndesmotic Treatment Nonoperative short-leg walking cast/boot indications isolated nondisplaced medial malleolus fracture or tip avulsions isolated lateral malleolus fracture with < 3mm displacement and no talar shift bimalleolar fracture if elderly or unable to undergo surgical intervention posterior malleolar fracture with < 25% joint involvement or < 2mm step-off Operative open reduction internal fixation indications any talar displacement displaced isolated medial malleolar fracture displaced isolated lateral malleolar fracture bimalleolar fracture and bimalleolar-equivalent fracture posterior malleolar fracture with > 25% or > 2mm step-off Bosworth fracture-dislocations open fractures malleolar nonunions technique goal of treatment is stable anatomic reduction of talus in the ankle mortise 1 mm shift of talus leads to 42% decrease in tibiotalar contact area see fracture patterns below for specific treatment outcomes overall success rate of 90% prolonged recovery expected (2 years to obtain final functional result) significant functional impairment often noted anatomic reduction is considered the most important factor for a satisfactory outcome worse outcomes with: smoking decreased level of education alcohol use presence of medial malleolar fracture ORIF superior to closed treatment of bimalleolar fractures in Lauge-Hansen supination-adduction fractures, restoration of marginal impaction of the anteromedial tibial plafond leads to optimal functional results after surgery postoperative rehabilitation time for proper braking response time (driving) returns to baseline at nine weeks for operatively treated ankle fractures braking travel time is significantly increased until 6 weeks after initiation of weight bearing in both long bone and periarticular fractures of the lower extremity Isolated Medial Malleolus Fracture Nonoperative short leg walking cast or cast boot indications nondisplaced fracture and tip avulsions deep deltoid inserts on posterior colliculus symptomatic treatment often appropriate Operative ORIF indications any displacement or talar shift technique lag screw fixation lag screw fixation stronger if placed perpendicular to fracture line antiglide plate with lag screw best for vertical shear fractures tension band fixation utilizing stainless steel wire fixation of medial malleolus fracture for transverse pattern, lag by technique using 3.5 fully-threaded screw is biomechanically superior to lag by design using 4.0 partially-threaded screws Isolated Lateral Malleolus Fracture Nonoperative short leg walking cast vs cast boot indications if intact mortise, no talar shift, and < 3mm displacement classically fractures with more than 4-5 mm of medial clear space widening on stress radiographs have been considered unstable and need to be treated surgically recent studies have shown the deep deltoid may be intact with up to 8-10 mm of widening on stress radiographs if the mortise is well reduced, results from operative and non-operative treatment are similar Operative Open reduction and internal fixation (ORIF) indications if talar shift or > 3 mm of displacement can be treated operatively if also treating an ipsilateral syndesmosis injury plate placement lateral lag screw fixation with neutralization plating bridge plate technique posterior antiglide technique lag screw fixation with neutralization plating most common disadvantage of using posterior antiglide plating is peroneal irritation if the plate is placed too distally posterior antiglide plating is biomechanically superior to lateral plate placement the stiffest fixation construct for the fibula is a locking plate intramedullary retrograde screw placement isolated lag screw fixation possible if fibula is a spiral pattern and screws can be placed at least 1 cm apart post-operative care period of immobilization usually 4-6 weeks after ORIF duration of immobilization should be doubled in diabetic patients Medial and Lateral (Bimalleolar) Fracture Nonoperative total contact casting indications elderly or unable to undergo surgical intervention Operative ORIF indications any lateral talar shift fibula technique need to fix with one of the options listed in section above medial malleolus technique fixation options cancellous lag screws bicortical screws tension band wiring antiglide plate to treat a vertical medial malleolus fracture orient screws parallel to joint for vertical medial malleolar fracture (Lauge-Hansen supination-adduction fracture pattern) Functional Bimalleolar Fracture (deltoid ligament tear with fibular fracture) Operative ORIF of lateral malleolus indications examination has been shown to be largely unreliable in predicting medial injury can see significant lateral translation of the talus in this pattern technique not necessary to repair medial deltoid ligament only need to explore medially if you are unable to reduce the mortise see isolated fibular fracture techniques above Posterior Malleolar Fracture Nonoperative short leg walking cast vs cast boot indications < 25% of articular surface involved evaluation of percentage should be done with CT, as plain radiology is unreliable < 2 mm articular stepoff syndesmotic stability Operative ORIF indications > 25% of articular surface involved > 2 mm articular stepoff syndesmosis injury technique approach posterolateral approach interval between FHL and the peroneals posteromedial approach decision of approach will depend on fracture lines and need for fibular fixation fixation anterior to posterior lag screws to capture fragment (if nondisplaced) posterior to anterior lag screw and buttress plate antiglide plate syndesmosis injury stiffness of syndesmosis restored to 70% normal with isolated fixation of posterior malleolus (versus 40% with isolated syndesmosis fixation) stress examination of syndesmosis still required after posterior malleolar fixation posteroinferior tibiofibular ligament may remain attached to posterior malleolus and syndesmotic stability may be restored with isolated posterior malleolar fixation Bosworth Fracture-Dislocation Overview rare fracture-dislocation of the ankle where the fibula becomes entrapped behind the tibia and becomes irreducible posterolateral ridge of the distal tibia hinders reduction of the fibula Operative open reduction and fixation of the fibula in the incisura fibularis indicated in most cases Hyperplantarflexion Variant Overview fracture-dislocation of the ankle due to hyperplantarflexion main feature is a vertical shear fracture of the posteromedial tibial rim "spur sign" is a double cortical density at the inferomedial tibial metaphysis Operative fixation of posteromedial and posterior fragments with antiglide plating Open Ankle Fracture Operative emergent operative debridement and ORIF indicated if soft tissue conditions allow primary closure at the index procedure can be performed in appropriately-selected Gustilo-Anderson grade I, II, and IIIA open fractures in otherwise healthy patients sustaining low-energy injuries without gross contamination external fixation indications soft tissue conditions and overall patient characteristics Associated Syndesmotic Injury Overview suspect injury in all ankle fractures most common in Weber C fracture patterns fixation usually not required when fibula fracture within 4.5 cm of plafond up to 25% of tibial shaft fractures will have ankle injury (highest rate with distal 1/3 spiral fractures) Evaluation measure clear space 1 cm above joint it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements lateral stress radiograph has more interobserver reliability than an AP/mortise stress film best option is to assess stability intraoperatively with abduction/external rotation stress of dorsiflexed foot instability of the syndesmosis is greatest in the anterior-posterior direction Treatment syndesmotic screw or suture fixation indications widening of medial clear space tibiofibular clear space (AP) greater than 5 mm tibiofibular overlap (mortise) narrowed any postoperative malalignment or widening should be treated with open debridement, reduction, and fixation technique length and rotation of fibula must be accurately restored outcomes are strongly correlated with anatomic reduction placing reduction clamp on midmedial tibial ridge and the lateral fibular ridge at the level of the syndesmosis (1-2 cm proximal to mortise) will achieve the most reliable anatomic reduction "Dime sign"/Shentons line to determine length of fibula open reduction required if closed reduction unsuccessful or questionable one or two cortical screw(s) or suture devices 2-4 cm above joint, angled posterior to anterior 20-30 degrees lag technique not desired maximum dorsiflexion of ankle not required during screw placement (can't overtighten a properly reduced syndesmosis) postoperative screws should be maintained in place for at least 8-12 weeks must remain non-weight bearing, as screws are not biomechanically strong enough to withstand forces of ambulation controversies number of screws 1 or 2 most commonly reported number of cortices 3 or 4 most commonly reported size of screws 3.5 mm or 4.5 mm screws implant material (stainless steel screws, titanium screws, suture, bioabsorbable materials) suture devices are more forgiving on reduction need for hardware removal no difference in outcomes seen with hardware maintenance (breakage or loosening) or removal at 1 year outcome may be worse with maintenance of intact screws malreduction of isolated syndesmotic injuries improves with screw removal Diabetic Ankle Fractures (with or without Neuropathy) Risks prolonged healing high risk of hardware failure high risk of infection Enhanced fixation multiple quadricortical syndesmotic screws (even in the absence of syndesmotic injury) tibiotalar Steinmann pins or hindfoot nailing ankle spanning external fixation augment with intramedullary fibula K-wires stiffer, more rigid fibular plates (instead of 1/3 tubular plates) compression plates small fragment locking plates Delay weightbearing maintain non-weightbearing postop for 8-12 weeks (instead of 4-8 weeks in normal patients) Nonoperative treatment Stable unimalleolar ankle fractures Increased risk for: Charcot arthropathy Loss of reduction (greatest risk) Infection Complications Wound problems (4-5%) Deep infections (1-2%) up to 20% in diabetic patients largest risk factor for diabetic patients is presence of peripheral neuropathy Malunion high suspicion for articular impaction of the tibial plafond in supination-adduction injuries, which should be addressed at the time of surgery corrective osteotomy requires obtaining anatomic fibular length and mortise correction for optimal outcomes Post-operative stiffness Loss of dorsiflexion with posterior fixation Post-traumatic arthritis rare with anatomic reduction and fixation
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Ankle Simple Bimalleolar Fracture ORIF with 1/3 Tubular Plate and Cannulated Screw of Medial Malleol Orthobullets Team Trauma - Ankle Fractures Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Ankle Isolated Lateral Malleolus Fracture ORIF with Lag Screw Orthobullets Team Trauma - Ankle Fractures
QUESTIONS 1 of 96 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ18FA.20) A 35-year-old morbidly obese female presents with global right ankle pain and significant swelling after a misstep over one of her cats on the stairs. She is unable to bear weight, but the skin is intact. Injury films are shown in Figures A through D. What is the internervous plane through which direct anatomic reduction and fixation of both fractures could best be achieved? QID: 211319 FIGURES: A B C D Type & Select Correct Answer 1 Deep peroneal nerve, sural nerve 5% (79/1600) 2 Deep peroneal nerve, tibial nerve 12% (188/1600) 3 Superficial and deep peroneal nerves 5% (75/1600) 4 Superficial peroneal nerve, tibial nerve 67% (1065/1600) 5 There is no true internervous plane 11% (181/1600) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (SBQ18FA.13) A 32-year-old soccer player presents with severe right ankle pain and inability to bear weight after sustaining a slide-tackle injury during a game. Radiographs are shown in Figures A and B. Given the nature of his injury, he is taken for surgical reduction and fixation. Following medial malleolar fixation, the syndesmosis is addressed. All of the following are true regarding the most appropriate intra-operative technique for anatomic syndesmotic reduction EXCEPT: QID: 211242 FIGURES: A B Type & Select Correct Answer 1 The axis of the reduction clamp should parallel the anatomic trans-syndesmotic angle 13% (222/1668) 2 The lateral tine of the clamp should be seated just posterior to the lateral malleolar ridge 32% (530/1668) 3 The medial tine should be placed on the anterior third of the tibia on a true lateral fluoroscopic view of the ankle 20% (330/1668) 4 The reduction clamp should be placed 1-2cm proximal to the tibial plafond 17% (281/1668) 5 The surgeon should apply judicious compression under fluoroscopic visualization to avoid over-compression of the syndesmosis 17% (284/1668) L 5 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (SBQ18FA.19) A 42-year-old male who works as a professional clown presents with severe ankle pain and gross deformity after tripping and falling over his props at a children’s birthday party. His radiograph is shown in Figure A. Following fixation of the medial and lateral malleolar fractures, the syndesmosis is assessed and is found to be persistently unstable. All of the following are true regarding posterior malleolar fixation EXCEPT: QID: 211308 FIGURES: A Type & Select Correct Answer 1 Fixation of the posterior malleolus obviates the need for syndesmotic fixation in most cases 16% (271/1729) 2 Fixation of the posterior malleolus remains biomechanically inferior to trans-articular syndesmotic fixation 61% (1053/1729) 3 Functional and radiographic outcomes following posterior malleolar fixation are at least equivalent if not superior to those following syndesmotic fixation 9% (147/1729) 4 Non-anatomic fixation of the posterior malleolus will compromise syndesmotic fixation 7% (117/1729) 5 The syndesmosis is often incompletely injured in the setting of a posterior malleolar fracture 7% (117/1729) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ18.94) A 26-year-old male recreational basketball player sustained an ankle injury 6 months prior. He continues to complain of ankle pain and instability. Current imaging is shown in Figures A & B. Imaging of the proximal fibula is unremarkable and there is little concern for syndesmotic injury. What is the next best step in treatment? QID: 212990 FIGURES: A B Type & Select Correct Answer 1 Open reduction and internal fixation (ORIF) with autograft 80% (1556/1937) 2 Fragment excision 0% (7/1937) 3 Obtain stress radiographs 13% (243/1937) 4 Physical therapy and management of symptoms 2% (37/1937) 5 Percutaneous skeletal fixation 4% (81/1937) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ18.29) A 63-year-old patient presents with right ankle pain after a fall down four stairs. Figures A and B are the radiographs of the injury. The patient reports a history of diabetes mellitus type 2 and peripheral neuropathy with a most recent hemoglobin A1c of 9.8. The injury is reduced and placed in a well-padded bivalved cast. The patient is then discharged with outpatient follow-up without DVT prophylaxis. Twelve weeks later, the patient presents to the clinic for the first time in the same bivalved cast. The has remained non-weight bearing and the bottom of the cast confirms this. What is the expected outcome at this point? QID: 212925 FIGURES: A B Type & Select Correct Answer 1 Charcot arthropathy 12% (230/1916) 2 Diabetic foot ulcer 18% (349/1916) 3 Deep vein thrombosis 10% (183/1916) 4 Elevation of A1c 2% (32/1916) 5 Fracture displacement 58% (1110/1916) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ18FA.18) 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? QID: 211297 FIGURES: A B Type & Select Correct Answer 1 Subacute nature of fracture 1% (12/1660) 2 Incarceration of the deltoid ligament 16% (264/1660) 3 Incarceration of the fibula behind the posterolateral ridge of tibia 64% (1059/1660) 4 Entrapment of the flexor hallucis longus (FHL) tendon 16% (271/1660) 5 Entrapment of the extensor digitorum brevis (EDB) 3% (44/1660) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ16.260) 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? QID: 9022 FIGURES: A B Type & Select Correct Answer 1 Re-evaluate pulses 95% (3199/3353) 2 Vascular surgery consultation 0% (14/3353) 3 CT angiogram 2% (71/3353) 4 Formal angiogram 0% (11/3353) 5 Surgical exploration and stabilization 1% (20/3353) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ14.216) 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? QID: 5626 FIGURES: A Type & Select Correct Answer 1 Immediate weightbearing 0% (11/2365) 2 Subchondral debridement of any osteochondral defect 6% (132/2365) 3 Repair of medial ligamentous structures 1% (22/2365) 4 Casting or splinting in a neutral position postoperatively 4% (84/2365) 5 Anatomic reduction of the syndesmosis 89% (2095/2365) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.137) 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? QID: 4772 FIGURES: A B C D E Type & Select Correct Answer 1 A 6% (244/4099) 2 B 58% (2390/4099) 3 C 10% (413/4099) 4 D 2% (99/4099) 5 E 23% (933/4099) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ13.87) 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? QID: 4722 FIGURES: A Type & Select Correct Answer 1 Syndesmosis sagittal plane reduction and fixation 15% (498/3239) 2 Syndesmosis coronal plane reduction and fixation 6% (191/3239) 3 Osteotomy and revision of the fibula and syndesmosis 59% (1895/3239) 4 Retrieval of osteochondral fragment 2% (79/3239) 5 Revision plating of the fibula and syndesmosis reduction and fixation. 17% (546/3239) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ13.54) 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? QID: 4689 FIGURES: A Type & Select Correct Answer 1 Closed reduction and casting for 6 weeks 1% (26/4541) 2 Closed reduction and casting for 12 weeks 1% (50/4541) 3 Open reduction and internal fixation with restricted weight bearing for 2 weeks 2% (77/4541) 4 Open reduction and internal fixation with restricted weight bearing for 6 weeks 15% (671/4541) 5 Open reduction and internal fixation with restricted weight bearing for 12 weeks 81% (3691/4541) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ13.261) 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? QID: 4896 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 5% (170/3476) 2 Figure B 5% (163/3476) 3 Figure C 2% (69/3476) 4 Figure D 86% (3006/3476) 5 Figure E 2% (53/3476) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12TR.104) Surgical fixation with absolute stability would be most appropriate for which of the following fracture patterns? QID: 4019 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 12% (245/2119) 2 Figure B 75% (1579/2119) 3 Figure C 3% (55/2119) 4 Figure D 3% (72/2119) 5 Figure E 7% (144/2119) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (SBQ12FA.77) 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? QID: 3884 FIGURES: A Type & Select Correct Answer 1 Weight-bearing before 3 weeks. 7% (121/1787) 2 Medial clear space >5mm 7% (117/1787) 3 Talocrural angle of 83 degrees 75% (1333/1787) 4 Tibiofibular clear space of >6mm 9% (160/1787) 5 Talar tilt of >5 degrees 3% (47/1787) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (SBQ12FA.12) 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? QID: 3819 FIGURES: A B C D E F Type & Select Correct Answer 1 Figure B 1% (17/2308) 2 Figure C 2% (42/2308) 3 Figure D 8% (196/2308) 4 Figure E 82% (1882/2308) 5 Figure F 7% (155/2308) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (SBQ12FA.3) 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? QID: 3810 FIGURES: A Type & Select Correct Answer 1 Workers' Compensation involvement 5% (93/1840) 2 Gender 0% (9/1840) 3 Date of injury 3% (53/1840) 4 Degree of tibiotalar arthritis 81% (1493/1840) 5 Degree of deformity 10% (184/1840) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.127) 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? QID: 4487 FIGURES: A B Type & Select Correct Answer 1 Progressive weightbearing in 3-4 weeks based on radiographs 2% (115/4782) 2 Deltoid ligament repair vs reconstruction 9% (450/4782) 3 Revision ORIF of fibula with lengthening 9% (453/4782) 4 Revision ORIF of fibula and syndesmosis 76% (3613/4782) 5 Removal of syndesmotic screws in 3-6 months 2% (119/4782) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.17) 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? QID: 3440 FIGURES: A Type & Select Correct Answer 1 Deep deltoid ligament repair 1% (51/3873) 2 Quadricortical syndesmotic screw fixation 3% (126/3873) 3 Restoration of fibular length and rotation 92% (3552/3873) 4 Lateral collateral ligament complex repair 0% (12/3873) 5 Use of two syndesmotic screws 3% (98/3873) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ10.40) 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? QID: 3128 Type & Select Correct Answer 1 Anterior-posterior 58% (1146/1982) 2 Medial-lateral 24% (467/1982) 3 Proximal-distal 2% (43/1982) 4 Varus-valgus 13% (262/1982) 5 Equivalent instability in all axes 2% (42/1982) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ10.121) 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? QID: 3215 FIGURES: A B C Type & Select Correct Answer 1 Measurement of medial clear space widening 4% (54/1348) 2 Measurement of the tibiofibular overlap 5% (65/1348) 3 Anterior drawer test with comparison to the contralateral ankle 1% (20/1348) 4 External rotation stress radiograph 88% (1182/1348) 5 Evaluation of the syndesmosis on preoperative CT scan 1% (15/1348) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ10.5) 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? QID: 3093 FIGURES: A Type & Select Correct Answer 1 Medial ankle tenderness 3% (57/2065) 2 Medial ankle ecchymosis 1% (14/2065) 3 Squeeze test 1% (14/2065) 4 Stress radiography of the ankle 95% (1964/2065) 5 Canale view radiograph 0% (4/2065) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE09FA.55) 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? QID: 6743 FIGURES: A B C Type & Select Correct Answer 1 Bracing and physical therapy 1% (4/591) 2 Intra-articular injection of steroids into the ankle joint, bracing, and physical therapy 1% (4/591) 3 Intra-articular injection of hyaluronic acid product into the ankle joint, bracing, and physical therapy 0% (1/591) 4 Ankle fusion 15% (87/591) 5 Corrective osteotomy of the fibula and medial malleolus with reconstruction of the syndesmosis if unstable 83% (490/591) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.173) In the Lauge-Hansen classification system, a pronation-abduction ankle fracture has what characteristic fibular fracture pattern? QID: 2986 Type & Select Correct Answer 1 Transverse fracture below the level of the syndesmosis 9% (181/2014) 2 Short oblique fracture running from anteroinferior to posteriosuperior 10% (202/2014) 3 Short oblique fracture running from posteroinferior to anteriosuperior 5% (96/2014) 4 Comminuted fracture at or above the level of the syndesmosis 75% (1512/2014) 5 Wagstaff fracture 0% (10/2014) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ09.204) 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? QID: 3017 FIGURES: A Type & Select Correct Answer 1 Open reduction and internal fixation of the medial malleolus with syndesmosis reduction and suture-button repair 2% (27/1185) 2 Repair of the anterior talo-fibular ligament 0% (1/1185) 3 Open reduction internal fixation of the fibula with syndesmosis reduction and suture-button repair 1% (11/1185) 4 Open reduction internal fixation of the medial malleolus and fibula 5% (56/1185) 5 Open reduction internal fixation of the fibula and medial malleolus with syndesmosis reduction and suture-button repair 91% (1080/1185) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ09.259) Presence of diabetes-induced peripheral neuropathy has been shown to be an independent risk factor for postoperative complications of which of the following injuries? QID: 3072 Type & Select Correct Answer 1 Distal radius fractures 1% (10/1023) 2 Patella fractures 0% (1/1023) 3 Metatarsal fractures 8% (84/1023) 4 Ankle fractures 90% (919/1023) 5 Distal femoral fractures 0% (5/1023) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ09.17) 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? QID: 2830 FIGURES: A Type & Select Correct Answer 1 Marginal impaction of the anteromedial tibial plafond 76% (1774/2344) 2 Syndesmosis diastasis 6% (134/2344) 3 Deltoid ligament tear 3% (62/2344) 4 Posterolateral osteochondral lesion of the talus 14% (326/2344) 5 Fibular overlengthening 2% (37/2344) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ09.52) 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? QID: 2865 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 88% (1215/1381) 2 Figure B 4% (55/1381) 3 Figure C 3% (36/1381) 4 Figure D 3% (35/1381) 5 Figure E 2% (32/1381) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ09.121) 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? QID: 2934 FIGURES: A B C D Type & Select Correct Answer 1 Anterior-inferior tibiofibular ligament 5% (53/972) 2 Posterior-inferior tibiofibular ligament 5% (48/972) 3 Peroneus brevis tendon 12% (112/972) 4 Posterolateral ridge of the tibia 34% (332/972) 5 Flexor hallucis longus tendon 43% (420/972) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ09.70) 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? QID: 2883 Type & Select Correct Answer 1 6 weeks after initiation of weight bearing 75% (628/838) 2 4 weeks postoperatively 2% (16/838) 3 8 weeks from the date of injury 8% (69/838) 4 Once full range of motion of the ankle and knee exist 11% (91/838) 5 At the time of bony union 3% (27/838) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.103) 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? QID: 489 FIGURES: A Type & Select Correct Answer 1 Anterior drawer test 1% (20/1976) 2 External rotation stress radiograph 89% (1768/1976) 3 Internal rotation stress radiograph 2% (32/1976) 4 Palpation of the medial ankle in the region of the deltoid 3% (64/1976) 5 Inversion stress radiograph 3% (56/1976) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.210) 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? QID: 596 FIGURES: A Type & Select Correct Answer 1 Anterior ankle joint capsule 0% (4/2188) 2 Syndesmosis 97% (2130/2188) 3 Anterior talofibular ligament 2% (37/2188) 4 Posterior tibial tendon 0% (2/2188) 5 Calcaneofibular ligament 0% (5/2188) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ08.93) A 35-year-old male with a pronation abduction ankle injury would have which of the following radiographs? QID: 479 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 6% (155/2420) 2 Figure B 16% (386/2420) 3 Figure C 4% (107/2420) 4 Figure D 71% (1715/2420) 5 Figure E 2% (47/2420) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ08.81) 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? QID: 467 FIGURES: A Type & Select Correct Answer 1 Deltoid ligament 4% (46/1030) 2 Syndesmosis 93% (960/1030) 3 Proximal fibula 1% (8/1030) 4 Calcaneofibular ligament 1% (7/1030) 5 Posterior tibial tendon 0% (4/1030) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ07.223) Appropriate treatment of the bimalleolar ankle fracture shown in Figure A includes which of the following? QID: 884 FIGURES: A Type & Select Correct Answer 1 Bridge plating of the fibula with oblique medial malleolar screws 3% (33/1086) 2 Antiglide plating of the fibula with oblique medial malleolar screws 7% (75/1086) 3 Intramedullary fibular screw with medial malleolar tension banding 1% (11/1086) 4 Fibular plating with open correction of plafond impaction with medial malleolar antiglide plate 77% (837/1086) 5 Fibular plating with open correction of syndesmosis and oblique medial malleolar screws 11% (123/1086) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ07.39) The Cotton test evaluates which of the following structures? QID: 700 Type & Select Correct Answer 1 Calcaneofibular ligament 2% (25/1209) 2 Lateral ulnar collateral ligament of the elbow 2% (19/1209) 3 Ligamentum flavum 0% (2/1209) 4 Anterior talofibular ligament 4% (43/1209) 5 Ankle syndesmosis 92% (1115/1209) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ07.88) After undergoing the treatment seen in Figure A, when should a patient be expected to safely operate the brakes of an automobile? QID: 749 FIGURES: A Type & Select Correct Answer 1 6 weeks 18% (170/932) 2 2 -4 weeks 2% (18/932) 3 6 months 4% (39/932) 4 8-9 weeks 52% (486/932) 5 3 months 23% (216/932) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ06.140) 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? QID: 326 FIGURES: A Type & Select Correct Answer 1 Supination-External Rotation 6% (76/1174) 2 Pronation-External Rotation 2% (18/1174) 3 Pronation-Abduction 3% (34/1174) 4 Supination-Adduction 86% (1015/1174) 5 Supination-Abduction 2% (25/1174) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ06.250) What is the most appropriate plating technique utilized for the medial malleolus fracture typically seen in a displaced supination-adduction ankle fracture? QID: 261 Type & Select Correct Answer 1 Tension band plating 4% (35/943) 2 Antiglide plating 86% (810/943) 3 Bridge plating 2% (20/943) 4 Neutralization plating 7% (64/943) 5 Submuscular plating 1% (10/943) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ06.85) The talocrural angle of an ankle mortise x-ray is formed between a line perpendicular to the tibial plafond and a line drawn: QID: 196 Type & Select Correct Answer 1 perpendicular to the medial clear space 1% (21/1740) 2 parallel to the talar body 17% (302/1740) 3 between the tips of the malleoli 77% (1337/1740) 4 perpendicular to the shaft of the fibular 1% (12/1740) 5 parallel to the subtalar joint 3% (60/1740) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic