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Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC.
A 25-year-old male is running and trips over a curb, sustaining a twisting injury to his ankle. He notes obvious deformity to his ankle. He is taken to the nearest trauma center by ambulance, where the injury is noted to be closed and his neurovascular status intact. Radiographs reveal a trimalleolar ankle fracture/dislocation. After closed reduction and splinting in the emergency department, he is scheduled for open reduction and internal fixation the following day. A CT scan of the ankle is obtained and based on these findings, you plan to place the patient prone and perform dual posterolateral and medial approaches to address all of the fracture fragments. Reduction and stable fixation of the posterior malleolus is important to restore the function of which structure seen in Figures A/B?
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Figure A is the radiograph of a 55-year-old female who is a poorly-controlled diabetic with neuropathy and peripheral vascular disease (PVD) that underwent ankle open reduction internal fixation (ORIF) two years ago at an outside facility. She was noncompliant with her immediate postoperative weight-bearing instructions and went on to fixation failure. She subsequently underwent revision ORIF with bone grafting soon after as seen in Figure B. One year ago, she underwent hardware removal secondary to irritation. Current radiographs are seen in Figure C. She complains of continued pain in the ankle which is not manageable with non-surgical treatments and would like to proceed with surgical treatment. She asks if limb salvage is an option for her. Which surgery is most indicated at this time?
Below knee amputation
Re-revision ORIF with bone grafting
Supramalleolar osteotomy and total ankle arthroplasty
Figures A-C are the radiographs of a 26-year-old male who presents to the emergency department following a motocross accident. Two attempts at a closed reduction by the on-call orthopedic resident were unsuccessful. Figures D and E are the pre-operative axial CT-images that were obtained. The patient undergoes surgical fixation seen in Figure F. Limitations in post-operative dorsiflexion is likely influenced by which of the following?
Fracture extension to the posteromedial rim
Initial displacement of the fibula fracture
Posterior fixation of the fibula and posterior malleolus
Initial talar subluxation
Inability to reduce the ankle
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?
Deep peroneal nerve, sural nerve
Deep peroneal nerve, tibial nerve
Superficial and deep peroneal nerves
Superficial peroneal nerve, tibial nerve
There is no true internervous plane
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:
The axis of the reduction clamp should parallel the anatomic trans-syndesmotic angle
The lateral tine of the clamp should be seated just posterior to the lateral malleolar ridge
The medial tine should be placed on the anterior third of the tibia on a true lateral fluoroscopic view of the ankle
The reduction clamp should be placed 1-2cm proximal to the tibial plafond
The surgeon should apply judicious compression under fluoroscopic visualization to avoid over-compression of the syndesmosis
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:
Fixation of the posterior malleolus obviates the need for syndesmotic fixation in most cases
Fixation of the posterior malleolus remains biomechanically inferior to trans-articular syndesmotic fixation
Functional and radiographic outcomes following posterior malleolar fixation are at least equivalent if not superior to those following syndesmotic fixation
Non-anatomic fixation of the posterior malleolus will compromise syndesmotic fixation
The syndesmosis is often incompletely injured in the setting of a posterior malleolar fracture
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?
Open reduction and internal fixation (ORIF) with autograft
Obtain stress radiographs
Physical therapy and management of symptoms
Percutaneous skeletal fixation
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?
Diabetic foot ulcer
Deep vein thrombosis
Elevation of A1c
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)
Radiographs of a 32-year-old male show a lateral malleolus fracture as well as a spur sign on the mortise view. Figure A is an axial CT scan of the plafond. What is the most appropriate treatment of this patient's fracture?
ORIF fibula and anterior to posterior screw placement for posterior malleolus via lateral approach to fibula
ORIF fibula, stress ankle and syndesmotic fixation if widening via lateral approach to fibula
ORIF fibula with buttress plating of posterior malleolus via posterolateral approach
ORIF fibula with buttress plating of posterior malleolus via posteromedial approach
ORIF fibula, stress ankle and syndesmotic fixation if widening via posterolateral approach
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