Introduction 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, 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 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 Class Sequence Supination - Adduction (SA) Talofibular sprain or distal fibular avulsion Vertical medial malleolus and impaction of anteromedial distal tibia Supination - External Rotation (SER) Anterior tibiofibular ligament sprain Lateral short oblique fibula fracture (anteroinferior to posterosuperior) Posterior tibiofibular ligament rupture or avulsion of posterior malleolus Medial malleolus transverse fracture or disruption of deltoid ligament Pronation - Abduction (PA) Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament sprain Transverse comminuted fracture of the fibula above the level of the syndesmosis Pronation - External Rotation (PER) Medial malleolus transverse fracture or disruption of deltoid ligament Anterior tibiofibular ligament disruption Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint 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 General 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 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 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 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 ORIF indications if talar shift or > 3 mm of displacement can be treated operatively if also treating an ipsilateral syndesmosis injury technique open reduction and plating 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 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 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 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 technique fibula need to fix with one of the options listed in section above medial malleolus 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 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 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 operative syndesmotic screw 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 ridge and the fibular ridge at the level of the syndesmosis willa chieve 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) 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) 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 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 Post-traumatic arthritis rare with anatomic reduction and fixation corrective osteotomy requires anatomic fibular and mortise correction for optimal outcomes 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
Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the 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 guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Ankle Isolated Lateral Malleolus Fracture ORIF with Lag Screw Orthobullets Team Trauma - Ankle Fractures
QUESTIONS 1 of 78 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 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Review Topic QID: 4722 FIGURES: A 1 Syndesmosis sagittal plane reduction and fixation 20% (475/2423) 2 Syndesmosis coronal plane reduction and fixation 5% (127/2423) 3 Osteotomy and revision of the fibula and syndesmosis 56% (1348/2423) 4 Retrieval of osteochondral fragment 3% (68/2423) 5 Revision plating of the fibula and syndesmosis reduction and fixation. 16% (390/2423) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ08.103) A 25-year-old man sustains a twisting injury to his ankle. His radiograph is shown in Figure A. What is the most appropriate method to assess the competency of his deltoid ligament? Review Topic QID: 489 FIGURES: A 1 Anterior drawer test 1% (14/1267) 2 External rotation stress radiograph 88% (1120/1267) 3 Internal rotation stress radiograph 2% (23/1267) 4 Palpation of the medial ankle in the region of the deltoid 4% (50/1267) 5 Inversion stress radiograph 3% (39/1267) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 This is an AAOS Self assessment question. Orthobullets was not involved into the editorial process, and does not have the ability to alter. If you prefer to hide SAE questions on topics simply turn them off in your Content Settings (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? Review Topic QID: 6743 FIGURES: A B C 1 Bracing and physical therapy 1% (1/124) 2 Intra-articular injection of steroids into the ankle joint, bracing, and physical therapy 1% (1/124) 3 Intra-articular injection of hyaluronic acid product into the ankle joint, bracing, and physical therapy 0% (0/124) 4 Ankle fusion 18% (22/124) 5 Corrective osteotomy of the fibula and medial malleolus with reconstruction of the syndesmosis if unstable 80% (99/124) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 5 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 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Review Topic QID: 3128 1 Anterior-posterior 55% (708/1299) 2 Medial-lateral 23% (297/1299) 3 Proximal-distal 2% (26/1299) 4 Varus-valgus 18% (235/1299) 5 Equivalent instability in all axes 2% (24/1299) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 1 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 (OBQ04.49) 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 tibiofibular ligament? Review Topic QID: 110 FIGURES: A 1 A 1% (8/1292) 2 B 5% (60/1292) 3 C and B 2% (20/1292) 4 D 32% (416/1292) 5 A and D 60% (772/1292) ML 5 Select Answer to see Preferred Response PREFERRED RESPONSE 4 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 (OBQ09.173) In the Lauge-Hansen classification system, a pronation-abduction ankle fracture has what characteristic fibular fracture pattern? Review Topic QID: 2986 1 Transverse fracture below the level of the syndesmosis 11% (151/1404) 2 Short oblique fracture running from anteroinferior to posteriosuperior 9% (131/1404) 3 Short oblique fracture running from posteroinferior to anteriosuperior 4% (53/1404) 4 Comminuted fracture at or above the level of the syndesmosis 75% (1054/1404) 5 Wagstaff fracture 1% (8/1404) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 4689 FIGURES: A 1 Closed reduction and casting for 6 weeks 1% (23/3974) 2 Closed reduction and casting for 12 weeks 1% (47/3974) 3 Open reduction and internal fixation with restricted weight bearing for 2 weeks 2% (71/3974) 4 Open reduction and internal fixation with restricted weight bearing for 6 weeks 15% (582/3974) 5 Open reduction and internal fixation with restricted weight bearing for 12 weeks 81% (3229/3974) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.204) 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? Review Topic QID: 3017 FIGURES: A 1 Open reduction and internal fixation of the medial malleolus with syndesmosis reduction and suture-button repair 2% (14/706) 2 Repair of the anterior talo-fibular ligament 0% (1/706) 3 Open reduction internal fixation of the fibula with syndesmosis reduction and suture-button repair 1% (8/706) 4 Open reduction internal fixation of the medial malleolus and fibula 5% (33/706) 5 Open reduction internal fixation of the fibula and medial malleolus with syndesmosis reduction and suture-button repair 92% (647/706) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (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? Review Topic QID: 326 FIGURES: A 1 Supination-External Rotation 6% (47/729) 2 Pronation-External Rotation 2% (12/729) 3 Pronation-Abduction 3% (24/729) 4 Supination-Adduction 86% (625/729) 5 Supination-Abduction 2% (17/729) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 4896 FIGURES: A B C D E 1 Figure A 5% (147/2906) 2 Figure B 5% (135/2906) 3 Figure C 2% (56/2906) 4 Figure D 86% (2510/2906) 5 Figure E 2% (46/2906) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 3072 1 Distal radius fractures 1% (3/542) 2 Patella fractures 0% (0/542) 3 Metatarsal fractures 12% (63/542) 4 Ankle fractures 87% (474/542) 5 Distal femoral fractures 0% (2/542) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ07.223) Appropriate treatment of the bimalleolar ankle fracture shown in Figure A includes which of the following? Review Topic QID: 884 FIGURES: A 1 Bridge plating of the fibula with oblique medial malleolar screws 3% (20/618) 2 Antiglide plating of the fibula with oblique medial malleolar screws 8% (48/618) 3 Intramedullary fibular screw with medial malleolar tension banding 2% (10/618) 4 Fibular plating with open correction of plafond impaction with medial malleolar antiglide plate 75% (463/618) 5 Fibular plating with open correction of syndesmosis and oblique medial malleolar screws 12% (74/618) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 4487 FIGURES: A B 1 Progressive weightbearing in 3-4 weeks based on radiographs 2% (98/4235) 2 Deltoid ligament repair vs reconstruction 9% (371/4235) 3 Revision ORIF of fibula with lengthening 10% (430/4235) 4 Revision ORIF of fibula and syndesmosis 76% (3202/4235) 5 Removal of syndesmotic screws in 3-6 months 3% (106/4235) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 3215 FIGURES: A B C 1 Measurement of medial clear space widening 4% (33/869) 2 Measurement of the tibiofibular overlap 5% (45/869) 3 Anterior drawer test with comparison to the contralateral ankle 1% (12/869) 4 External rotation stress radiograph 88% (763/869) 5 Evaluation of the syndesmosis on preoperative CT scan 1% (8/869) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ07.39) The Cotton test evaluates which of the following structures? Review Topic QID: 700 1 Calcaneofibular ligament 3% (18/643) 2 Lateral ulnar collateral ligament of the elbow 2% (15/643) 3 Ligamentum flavum 0% (2/643) 4 Anterior talofibular ligament 3% (21/643) 5 Ankle syndesmosis 91% (587/643) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (OBQ07.88) After undergoing the treatment seen in Figure A, when should a patient be expected to safely operate the brakes of an automobile? Review Topic QID: 749 FIGURES: A 1 6 weeks 17% (103/604) 2 2 -4 weeks 2% (12/604) 3 6 months 5% (29/604) 4 8-9 weeks 53% (319/604) 5 3 months 23% (139/604) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 2830 FIGURES: A 1 Marginal impaction of the anteromedial tibial plafond 75% (1483/1977) 2 Syndesmosis diastasis 6% (123/1977) 3 Deltoid ligament tear 2% (45/1977) 4 Posterolateral osteochondral lesion of the talus 15% (295/1977) 5 Fibular overlengthening 1% (27/1977) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (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? Review Topic QID: 2865 FIGURES: A B C D E 1 Figure A 87% (716/825) 2 Figure B 5% (41/825) 3 Figure C 3% (22/825) 4 Figure D 3% (25/825) 5 Figure E 2% (18/825) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ05.89) 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? Review Topic QID: 975 FIGURES: A B 1 Increased stiffness 7% (71/1046) 2 Increased strength 5% (55/1046) 3 Decreased rate of hardware prominence 6% (66/1046) 4 Increased risk of intra-articular screw penetration 67% (703/1046) 5 Increased peroneal tendinitis 14% (150/1046) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 2934 FIGURES: A B C D 1 Anterior-inferior tibiofibular ligament 6% (31/555) 2 Posterior-inferior tibiofibular ligament 4% (24/555) 3 Peroneus brevis tendon 12% (64/555) 4 Posterolateral ridge of the tibia 30% (166/555) 5 Flexor hallucis longus tendon 48% (269/555) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 2883 1 6 weeks after initiation of weight bearing 74% (397/540) 2 4 weeks postoperatively 1% (6/540) 3 8 weeks from the date of injury 9% (48/540) 4 Once full range of motion of the ankle and knee exist 12% (64/540) 5 At the time of bony union 4% (20/540) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ06.250) What is the most appropriate plating technique utilized for the medial malleolus fracture typically seen in a displaced supination-adduction ankle fracture? Review Topic QID: 261 1 Tension band plating 4% (22/567) 2 Antiglide plating 83% (473/567) 3 Bridge plating 2% (14/567) 4 Neutralization plating 9% (49/567) 5 Submuscular plating 1% (8/567) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ04.243) 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? Review Topic QID: 1348 FIGURES: A 1 Physical therapy for ambulation assistance and proprioception training 2% (10/523) 2 Short leg bracing 2% (8/523) 3 Revision open reduction and internal fixation with open syndesmosis reduction 80% (420/523) 4 Addition of syndesmosis screw from fibula to tibia 14% (72/523) 5 Open medial ankle ligament reconstruction 2% (9/523) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ06.115) Lateral malleolus fractures can be treated with a variety of techniques, including posterior antiglide plating or lateral neutralization plating. What is an advantage of using lateral neutralization plating instead of posterior antiglide plating? Review Topic QID: 301 1 Decreased joint penetration of distal screws 1% (14/1006) 2 Increased rigidity 4% (45/1006) 3 Decreased need for delayed hardware removal 2% (18/1006) 4 Decreased peroneal irritation 88% (882/1006) 5 Improved distal fixation 4% (43/1006) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 3093 FIGURES: A 1 Medial ankle tenderness 3% (45/1487) 2 Medial ankle ecchymosis 1% (9/1487) 3 Squeeze test 1% (11/1487) 4 Stress radiography of the ankle 95% (1414/1487) 5 Canale view radiograph 0% (3/1487) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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: Review Topic QID: 196 1 perpendicular to the medial clear space 1% (16/1248) 2 parallel to the talar body 21% (257/1248) 3 between the tips of the malleoli 74% (922/1248) 4 perpendicular to the shaft of the fibular 1% (10/1248) 5 parallel to the subtalar joint 3% (42/1248) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (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? Review Topic QID: 596 FIGURES: A 1 Anterior ankle joint capsule 0% (4/1864) 2 Syndesmosis 98% (1818/1864) 3 Anterior talofibular ligament 2% (31/1864) 4 Posterior tibial tendon 0% (0/1864) 5 Calcaneofibular ligament 0% (4/1864) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ04.23) 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? Review Topic QID: 134 FIGURES: A 1 Two weeks ago 12% (83/709) 2 One week from now 47% (335/709) 3 Three weeks from now 10% (68/709) 4 Six weeks from now 23% (164/709) 5 Eight weeks from now 8% (57/709) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (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? Review Topic QID: 3440 FIGURES: A 1 Deep deltoid ligament repair 1% (34/3363) 2 Quadricortical syndesmotic screw fixation 3% (93/3363) 3 Restoration of fibular length and rotation 93% (3122/3363) 4 Lateral collateral ligament complex repair 0% (8/3363) 5 Use of two syndesmotic screws 2% (78/3363) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ05.205) Coupled with reduction of the syndesmosis, which of the following interventions is most important when surgically addressing the ankle malunion shown in Figure A? Review Topic QID: 1091 FIGURES: A 1 Placement of an osteochondral allograft 2% (37/1842) 2 Fibular lengthening osteotomy 64% (1181/1842) 3 Calcaneofibular ligament release 2% (45/1842) 4 Medial malleolar shortening osteotomy 1% (19/1842) 5 Deltoid ligament imbrication 30% (554/1842) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ08.93) A 35-year-old male with a pronation abduction ankle injury would have which of the following radiographs? Review Topic QID: 479 FIGURES: A B C D E 1 Figure A 6% (126/1968) 2 Figure B 16% (318/1968) 3 Figure C 5% (89/1968) 4 Figure D 71% (1389/1968) 5 Figure E 2% (38/1968) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ06.28) 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? Review Topic QID: 139 FIGURES: A 1 The tibiofibular overlap is less than 3 mm 15% (176/1161) 2 The fibula demonstrates a Weber C fracture pattern 6% (64/1161) 3 The tibiofibular clear space is less than 4 mm 62% (719/1161) 4 The fracture is consistent with a Lauge-Hansen pronation-external rotation injury pattern 15% (169/1161) 5 The medial clear space is greater than 5 mm 3% (30/1161) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (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? Review Topic QID: 467 FIGURES: A 1 Deltoid ligament 5% (28/604) 2 Syndesmosis 93% (559/604) 3 Proximal fibula 1% (6/604) 4 Calcaneofibular ligament 0% (3/604) 5 Posterior tibial tendon 0% (3/604) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 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
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