Module 5 Surgical Criteria

November 2010 ABPOPPM In-training Exam Page 1 of 50
Module 2: Surgical Criteria
A 12 year-old male is presented with the digital deformity shown by the "x". He reports no pain but is
embarrassed to be seen barefooted by his peers. The digital deformity is fixed and rigid. Past medical and
developmental history is unremarkable.
Which of the following is the most appropriate course of action?
A. Defer treatment until apophyses are fully closed

B. Soft tissue tendon release at the MTPJs
C. Soft tissue tendon release at the IP joints
D. Arthroplasty at the DIP joints
E. Arthroplasty at the PIP joints
Correct Answer: D
Suggested Readings:
Coughlin MJ, Mann RA. Lesser toe deformities. In (Mann RA, Coughlin MJ, eds.): Surgery of foot and ankle,
Sixth Edition. Mosby, St. Louis, 1992, pp. 341-412. Hansen ST. Functional reconstruction of the foot and
ankle. Lippincott Williams & Wilkins, Philadelphia, 2000, pp. 235-236.
A patient is scheduled for arthroplasties of the second and fifth toes as well as a bunionectomy with distal
osteotomy and screw fixation. Radiographs are shown.
Which of the following constitutes the most appropriate intraoperative sequencing?
A. Bunionectomy; then arthroplasty fifth; then arthroplasty second

B. Bunionectomy; then arthroplasty second; then arthroplasty fifth
C. Arthroplasty fifth, then arthroplasty second then bunionectomy
D. Order of procedures is irrelevant; surgeon's preference
Correct Answer: C
Suggested Readings:
McGlamry's Comprehensive Textbook of Foot and Ankle Surgery Alan S. Banks, Michael S. Downey, Dennis
E. Martin, and Stephen J. Miller; Jun 2001 Easley M. Medicolegal aspects of foot and ankle surgery. Clin
Orthop Rel Res 433:77-81, 2005. Shurnas P, Coughlin M. Recall of the risks of forefoot surgery after informed
consent. Foot and Ankle Int 24(12):904-8, 2003.
Which of the following procedures would best relieve the problem of the Tailor's bunion seen in the illustration
of an otherwise healthy 32 year-old male?
A. Dorsal V-osteotomy
B. Dorsal wedge osteotomy
C. Plantar conylectomy
D. Austin osteotomy of the fifth metatarsal head
E. Fifth metatarsal head resection

Correct Answer: D

Suggested Readings:
J Pontious, JW Brook, and HJ Hillstrom Tailor's bunion. Is fixation necessary? J Am Podiatr Med Assoc 1996
86: 63-73 DG Shrum, DC Sprandel, and H Marshall Triplanar closing base wedge osteotomy for tailor's bunion
J Am Podiatr Med Assoc 1989 79: 124-127

The radiographic findings demonstrate an intermetatarsal angle of 15 ° and the proximal articular set angle
(PASA) is measured at 18 °.
Which of the following procedures is LEAST effective in the long term correction of the HAV deformity
shown?
A. McBride with closing base wedge osteotomy

B. Mitchell
C. Bicorrectional Austin
D. Reverdin-Laird
Correct Answer: B
Suggested Readings:
Gerbert J. Textbook of Bunion Surgery, third edition. WB Saunders Co, p 129, 2001.
Kernozek TW, Sterriker SA. Chevron (Austin) distal metatarsal osteotomy for hallux valgus: comparison or
pre and postsurgical characteristics. Foot Ankle 23:503-508, 2002
The surgical procedure depicted includes the correction of a severely contracted hammertoe, second, and a
second MTPJ release.
The associated Kirschner wire fixation is best utilized to accomplish which of the following?
A. Obtain correction
B. Avoid valgus rotation
C. Prevent plantarflexion deformity
D. Maintain correction
E. Ensure fusion
Correct Answer: D
Suggested Readings:
Coughlin M. Second metatarsophalangeal joint instability in the athlete. Foot and Ankle 1993, 14:309.
Jenkin WM. Approach to the Patient with Ankle and Foot Pain. In: Imboden JB, Hellman DB and Stone JH,
editors. Current Rheumatology Diagnosis and Treatment, Lange Medical Books 2004. Chapter 7 pp. 63-64.
Surgical syndactyly is most useful in which of the following conditions?
A. Hallux abductus
B. Flexible hammertoe
C. Claw toe
D. Mallet toe
E. Flail toe

Correct Answer: E

Suggested Readings:
Myerson MS, Jung HG. The role of toe flexor-to-extensor transfer in correcting metatarsophalangeal joint
instability of the second toe. Foot Ankle Int 2005; 26(9):675-9. Renato J. Giorgini, Tomasz Rostkowski, and
Christopher Japour Desyndactylization of the First and Second Toes Using Full-Thickness Autologous Skin
Graft from the Ankle J Am Podiatr Med Assoc 2006 96: 513-517
A 22 year-old male who fell off a ladder while repairing a window presents with the radiographic findings
shown.
Assuming the patient is stable and other pathology has been ruled out, which of the following is the most
appropriate treatment for this patient?
A. Apply a short leg, weight bearing cast

B. Open reduction and internal fixation
C. Initiate early mobilization
D. Allow ambulation in a surgical shoe
E. Adhesive tape immobilization; changed weekly

Correct Answer: B

Suggested Readings:
Schon LC: Decision-making for the athlete: the leg, ankle, and foot in sports. In Myerson MS (ed), Foot and
Ankle Disorders, WB Saunders Company, Philadelphia, 2000. Stone DA, Kamenski R, Shaw J, Nachazel KMJ,
Conti SF, Fu FH: Dance. In Fu FH, Stone DA (eds), Sports Injuries, 2nd Ed, Lippincott Williams & Wilkins,
Philadelphia, 2001.
A young child failed earlier casting for the condition seen below. Release of the abductor hallucis with medial
naviculo-cuneiform and cuneiform-first metatarsal capsulotomy is being considered.
Which of the following is an appropriate indication for surgery?
A. Spontaneous reduction is occurring too slowly

B. Familial history of hallux valgus
C. Pain or shoe wear problems
D. Older sibling had rectus foot at the same age
Correct Answer: C
Suggested Readings:
TA Griffiths and SJ Palladino M tatarsus adductus and selected radiographic measurements of the first ray in
normal feet J Am Podiatr Med Assoc 1992 82: 616-622. Asirvatham R, Stevens PM: Idiopathic forefoot
adduction deformity: Medial capsulotomy and abductor hallucis lengthening for resistant and severe
deformities. J Pediatr Orthop 1997;17:496.
A 7 year-old male who is three days S/P injury is presented to the ED with the abscess shown. He was playing
barefooted in the park and stepped on a shard of glass.
Which of the following is the most appropriate treatment at the present time?
A. Order appropriate systemic antibiotic therapy

B. Order appropriate topical antibiotic therapy
C. Apply rest, ice, compression and elevation
D. Perform incision and drainage
E. Order a CBC and sedimentation rate

Correct Answer: D

Suggested Readings:
Stapp MD, Taylor RP. Edema, Hematoma, and Infection. In: Banks AS, Downey MS, Martin DE, Miller SJ,
eds. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, 3rd ed. Philadelphia: Lippincott
Williams & Wilkins, 2001:1997-2015. Brian K. Wagner, Jeffrey D. Martone, Harry Conte, Melissa Hill, and
Karuna Kusan Complications of a Cat Bite J Am Podiatr Med Assoc 2006 96: 455-457
A 44 year-old male injures a previously asymptomatic os trigonum while playing soccer with his teenage son.
He was aware of the presence of the os trigonum as an incidental finding noted on a radiograph taken 12 years
earlier.
Which of the following is the most likely mechanism of the injury?
A. Forced plantarflexion
B. Forced dorsiflexion
C. Inversion
D. Eversion
E. Supination-adduction
Correct Answer: A
Suggested Readings:
O Kose, AN Okan, MO Durakbasa, K Emrem, NC Islam Fracture of the os trigonum: a case report Journal of
Orthopaedic Surgery 2006;14(3):354-6 Anthony Morgan, Peter S. Kim, and Robert A. Christman
Radiographic Anatomy of the Talus J Am Podiatr Med Assoc 2003 93: 449-480.
A 13 year-old male is presented for acute pain in the left ankle of several days duration. There is no history of
trauma, and he is otherwise in good health. Past Medical history includes a series of "colds" over the past few
winter months causing him to miss school.
Based on the information given and the MRI shown, which of the following is the most likely diagnosis?
A. Brodie's abcess
B. Unicameral bone cyst
C. Osteosarcoma
D. Interosseous lipoma
E. Osteochondritis dessicans
Correct Answer: A
Suggested Readings:
Amin MU, Shafique M, Jalil J, Nafees M, Khan S. Brodie's abscess--an uncommon cause of leg pain. J Coll
Physicians Surg Pak. 2008 Mar;18(3):183-4. Stapp MD, Taylor RP. Edema, Hematoma, and Infection. In:
Banks AS, Downey MS, Martin DE, Miller SJ, eds. McGlamry’s Comprehensive Textbook of Foot and Ankle
Surgery, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001:1997-2015.
A 13 year-old boy is presented with ankle pain sustaned after jumping down from a 6 foot wall and landing
directly on his foot. Examination reveals the pain to be localized to the ankle. Radiographs (shown) indicate
the apophysis appears to be compressed as compared to the opposite foot.
The radiographic findings are most consistent with which of the following Salter-Harris fractures?
A. Type I
B. Type II
C. Type III
D. Type IV
E. Type V

A.
Correct Answer: D

Suggested Readings:
Oguz Poyanli, Koray Unay, Kaya Akan, Korhan Ozkan, and Ender Ugutmen Distal Tibial Epiphyseal Fracture
(Tillaux) and Capsular Interposition J Am Podiatr Med Assoc 2009 99: 435-437. WH Simon, R Floros, H
Schoenhaus, and RM Jay Juvenile fracture of tillaux. A distal tibial epiphyseal fracture J Am Podiatr Med
Assoc 1989 79: 295-299.
The radiographs shown are for a patient who underwent a closing base wedge osteotomy with insertion of an
intramedullary rod.
Which of the following best describes the purpose of this fixation device?
A. Aligns and stabilizes the osteotomy

B. Produces compression along the entire bone
C. Allows earlier weight bearing
D. Reduces healing time
E. Stabilizes the metatarsal cuneiform joint
Correct Answer: A
Suggested Readings:
Mary L. Forte, PhD, DC, Beth A. Virnig, PhD, MPH, Lynn E. Eberly, PhD, Marc F. Swiontkowski, MD, Roger
Feldman, PhD, Mohit Bhandari, MD, MSc, FRCSC and Robert L. Kane, MD Provider Factors Associated with
Intramedullary Nail Use for Intertrochanteric Hip Fractures The Journal of Bone and Joint Surgery
(American). 2010;92:1105-1114. Matthew R. Bong, MD, Frederick J. Kummer, PhD, Kenneth J. Koval, MD
and Kenneth A. Egol, MD Intramedullary Nailing of the Lower Extremity: Biomechanics and Biology J Am
Acad Orthop Surg, Vol 15, No 2, February 2007, 97-106
A 52 year-old school teacher who underwent bilateral bunionectomy 3 years ago now complains of pain in the
right first MTPJ, and demonstrates a diffuse, painful lesion under the ball of her right foot.
Which of the following is the most likely etiology of her right foot discomfort?
A. Arthritic joint changes

B. Malunion of the osteotomy
C. Latent osteomyelitis
D. Short first metatarsal
E. Exuberant bone formation
Correct Answer: D
Suggested Readings:
Allen J. Selner, Marc D. Selner, Robert P. Cyr, and Wanlop Noiwangmuang Revisional Hallux Abducto Valgus
Surgery Using Tricorrectional Bunionectomy J Am Podiatr Med Assoc 2004 94: 341-346 Alan R. Bryant, Paul
Tinley, and Joan H. Cole Plantar Pressure and Radiographic Changes to the Forefoot After the Austin
Bunionectomy J Am Podiatr Med Assoc 2005 95: 357-365
A 24 year-old female presents with the second toe as shown and accompanying radiographic findings. She fell
off her bicycle while riding barefoot 2 weeks earlier. Her second toe is still painful and does not demonstrate a
rectus resting position.
Which of the following is the most likely diagnosis?
A. Avulsion of the extensor tendon at the distal phalanx

B. Occult fracture of the distal phalanx
C. Hematoma
D. Septic joint
E. Rupture of lateral collateral ligament of the DIP joint
Correct Answer: A
Suggested Readings:
Lorne A. Zielaskowski and Jane Pontious Extensor Hallucis Longus Tendon Rupture Repair Using a Fascia
Lata Allograft J Am Podiatr Med Assoc 2002 92: 467-470. Arian Mowlavi, Jamie Schall, Bradon J. Wilhelmi
Extensor hallucis longus tenorrhaphy by using the Massachusetts General Hospital repair Journal of Foot and
Ankle Surgery November 2004 (Vol. 43, Issue 6, Pages 412-418)
A 32 year-old female presents with hallux limitus secondary to dropping a bowling ball on her foot several
years ago. Examination reveals no evidence of metatarsus primus elevatus. There is first MTPJ pain on the end
range of dorsiflexion but no radiographic evidence of articular disease.
If surgery is elected, which of the following procedures is most appropriate for the clinical presentation?
A. Implant arthroplasty
B. Cheilectomy
C. First MTPJ arthrodesis
D. Arthrosurface cap procedure
E. OAT cartilage replacement
Correct Answer: B
Suggested Readings:
Thomas S. Roukis The Need for Surgical Revision After Isolated Cheilectomy for Hallux Rigidus: A Systematic
Review Journal of Foot and Ankle Surgery September 2010 (Vol. 49, Issue 5, Pages 465-470) Wieske
Beertema, Wiebe F. Draijer, Johannes J. van Os, Peter Pilot A Retrospective Analysis of Surgical Treatment in
Patients With Symptomatic Hallux Rigidus: Long-Term Follow-Up Journal of Foot and Ankle Surgery July
2006 (Vol. 45, Issue 4, Pages 244-251)
A one-third tubular plate is used in conjunction with a lag screw for the repair of a lateral malleolar fracture .
Which of the following is the function of this plate?
A. Static compression plate

B. Dynamic compression plate
C. Neutralization plate
D. Buttressing plate

Correct Answer: C
Suggested Readings:
Himanshu Sharma, Shaishav Bhagat, John DeLeeuw, Frans Denolf In Vivo Comparison of Screw versus Palte
and Screw Fixation for First Metatarsophalangeal Arthrodesis: Does Augmentation of Internal Compression
Screw Fixation Using a Semi- Tubular Plate Shorten Time to Clinical and Radiologic Fusion of the First
Metatarsophalangeal Joint (MTPJ)? Journal of Foot and Ankle Surgery January 2008 (Vol. 47, Issue 1, Pages
2-7) Grace D, Delmonte R, Catanzariti AR, Hofbauer M. Modified Lapidus arthrodesis for adolescent hallux
abducto valgus. J Foot Ankle Surg 38:8–13, 1999.
A 32 year-old roofer sustained the injury shown in the radiographs 2 years ago. He now complains of pain in
activities of daily living and is unable to work.
Which of the following is the most appropriate surgical treatment for this patient?
A. Partial calcanectomy
B. Dwyer calcaneal osteotomy
C. Tarsal arthrodesis
D. Subtalar arthroresis
E. Open reduction and internal fixation
Correct Answer: C
Suggested Readings:
Justin T. Johnson, John M. Schuberth, Sean D. Thornton, Jeffrey C. Christensen Joint Curettage Arthrodesis
Technique in the Foot: A Histological Analysis Journal of Foot and Ankle Surgery
September 2009 (Vol. 48, Issue 5, Pages 558-564) Bruce Lehnert, Christine Gosch, George E Sims A plantar
approach for fixation of subtalar joint arthrodesis Journal of Foot and Ankle Surgery January 2004 (Vol. 43,
Issue 1, Pages 67-69)
A 39 year-old woman sustained a laceration which was poorly repaired in a local ED. Two years later the scar
is unsightly and painful. A "Z-plasty" repair is planned.
Which of the following must be considered in performing a "Z-plasty"?
A. The central limb of the Z should be perpendicular to the line of contracture

B. All arms should be of equal length
C. The greater the angle the greater the length of the arms
D. The depth of the incision should not penetrate the dermis
E. The point of the flap must be closed with absorbable suture
Correct Answer: B
Suggested Readings:
Samantha E. Bark, L. Marie Keplinger, Andrew J. Meyr Precise Intraoperative 60° Skin Z-plasty, 01 February
2010 Journal of Foot and Ankle Surgery March 2010 (Vol. 49, Issue 2, Pages 191-193) ME Crawford and GL
Dockery Use of Z-skin plasty in scar revisions and skin contractures of the lower extremity J Am Podiatr Med
Assoc 1995 85: 28-35.
A 72 year-old patient with severe rheumatoid arthritis underwent a pan-metatarsal head resection, as shown.
Which of the following is the primary indication for this procedure?
A. Restores digital function

B. Realigns digital position
C. Alleviates pain
D. Prevents progression of arthritis
E. Reduces the possibility of osteomyelitis
Correct Answer: C
Suggested Readings:
Richard O. Jones, Darren Payne, Brent A. Clark Simple method of exacting a desired parabola for pan
metatarsal head resection Journal of Foot and Ankle Surgery September 2002 (Vol. 41, Issue 5, Pages 342-
345) L Hodor and BM Dobbs Pan metatarsal head resection. A review and new approach J Am Podiatr Med
Assoc 1983 73: 287-292.
A 72 year-old female is seen 4 hours after having slipped off a curb and sustained the intra-articular fracture
shown in the accompanying radiograph.
Which of the following is the most appropriate treatment for this injury?
A. Insert a drain to prevent hemarthrosis

B. Attempt closed reduction and percutaneous pinning
C. Apply long-leg non-weight bearing cast
D. Excise fracture fragment
E. Initiate early mobilization and surgical shoe
Correct Answer: B
Suggested Readings:
Tim Schepers, Esther M.M. van Lieshout, Abida Z. Ginai, Paul G.H. Mulder, Martin J. Heetveld, Peter Patka
Calcaneal Fracture Classification: A Comparative Study Journal of Foot and Ankle Surgery March 2009 (Vol.
48, Issue 2, Pages 156-162) Tim Schepers, Martin J. Heetveld, Paul G.H. Mulder, Peter Patka Clinical Outcome
Scoring of Intra-articular Calcaneal Fractures , 31 March 2008 Journal of Foot and Ankle Surgery May 2008
(Vol. 47, Issue 3, Pages 213-218)
A 35 year-old male presents with a painful, recurrent osteochondroma as show in the radiograph. He underwent
surgery for the condition 6 months earlier with a nail-sparing fishmouth incision.
Which of the following is most appropriate at this time?
A. Distal amputation of digit

B. Repeat fishmouth incision
C. Total nail plate matrixectomy
D. Nail avulsion and lift nail bed for exposure
E. Laser ablatement of bone
Correct Answer: D
Suggested Readings:
Molly Schnirring-Judge, Jared Visser Resection and Reconstruction of an Osteochondroma of the Hallux: A
Review of Benign Bone Tumors and a Description of an Unusual Case Journal of Foot and Ankle Surgery July
2009 (Vol. 48, Issue 4, Pages 495-505) Frederick N. Day, Claudia Ruggieri, Calvin Britton Recurrent
osteochondroma Journal of Foot and Ankle Surgery March 1998 (Vol. 37, Issue 2, Pages 162-164)
A 60 year-old female with a history of rheumatoid arthritis presents with a painful, deformed right foot as
shown. Past medical history is significant for long-term high dose corticosteroid use. There are no other medical
contraindications for the planned reconstructive foot surgery.
Which of the following is most appropriate concerning her corticosteroid regimen?
A. Discontinue the medication pre-operatively

B. Reduce corticosteroid dosage 2 days post-operatively
C. Maintain the same dosage and regimen of corticosteroids
D. Reduce corticosteroid dosage 1 week pre-operatively and 1 week post-operatively
E. Increase corticosteroid dosage on the day of surgery
Correct Answer: E
Suggested Readings:
Robert L. Haynie, Jamie Yakel Perioperative management of the rheumatoid patient Journal of Foot and Ankle
Surgery March 1996 (Vol. 35, Issue 2, Pages 94-100) Benjamin J.R.F. Bolland, Philip S. Sauvé, Graeme R.
Taylor Rheumatoid Forefoot Reconstruction: First Metatarsophalangeal Joint Fusion Combined with Weil’s
Metatarsal Osteotomies of the Lesser Rays Journal of Foot and Ankle Surgery March 2008 (Vol. 47, Issue 2,
Pages 80-88)
The individual depicted suffered extensive partial thickness burns of her feet and legs bilaterally. Rapid
assessment of the total body surface affected is required.
Which of the following surgical principles will aid in the determination?
A. Harris Benedict equation

B. Rule of Nines
C. Kayser-Fleeischer rule
D. Rule of 72’s
E. McBurneys equation
Correct Answer: B
Suggested Readings:
Neal S. Schoen, Lawrence J. Gottlieb, Lawrence S. Zachary Distribution of pedal burns by source and depth
Journal of Foot and Ankle Surgery May 1996 (Vol. 35, Issue 3, Pages 194-198) Pham TN, Cancio LC, Gibran
NS: American Burn Association Practice Guidelines Burn Shock Resuscitation. J Burn Care Res 2008; 29:257–
266
A patient is scheduled for a flatfoot correction incorporating an opening calcaneal osteotomy with allograft.
Which of the following is an advantage of an allograft over an autograft?
A. More effective incorporation

B. Larger size of available bone
C. Easier accessibility
D. Decreased possibility of rejection
E. Greater assurance of being disease free
Correct Answer: C
Suggested Readings:
Glenn M. Weinraub, Catherine Cheung Efficacy of allogenic bone implants in a series of consecutive elective
foot procedures Journal of Foot and Ankle Surgery March 2003 (Vol. 42, Issue 2, Pages 86-89) Shannon M.
Rush, Graham A. Hamilton, Lynn M. Ackerson Mesenchymal Stem Cell Allograft in Revision Foot and Ankle
Surgery: A Clinical and Radiographic Analysis Journal of Foot and Ankle Surgery March 2009 (Vol. 48, Issue
2, Pages 163-169)
A 42 year-old male with a long standing history of gout presents with a gouty tophus, as shown.
Which of the following most justifies consideration for excision of the tophus?
A. Tophus interferes with tendon function

B. Tophus encroaches on nerves, causing symptoms
C. Serum uric acid is above 8.0 mg/dL
D. Surrounding area is indurated
E. Tophus is the result of secondary gout
Correct Answer: B
Suggested Readings:
Choi HIK, Mount DB, Reginato AM. Pathogenesis of gout. Ann Intern Med 2005; 143(7):499-516. William A.
Larmon M.D. and James F. Kurtz M.D. The Surgical Maleagement of Chronic Tophaceous Gout, Journal of
Bone and Joint Surgery, 1958;40:743-772.
A 54 year-old female is evaluated 72 hours post Austin bunionectomy with absorbable fixation. She has had no
pain, is afebrile and the bandage is intact. Examination reveals minimal edema and the hallux is rectus, with
pain free range of motion. Radiographs taken this visit are shown.
What is the most appropriate course of action at this time?
A. Encourage non-weight bearing

B. Perform closed reduction
C. Re-evaluate in 72 hours
D. Return to the OR for ORIF
E. Evaluate further after bony union
Correct Answer: D
Suggested Readings:
Matthew S. Rockett, Larry R. Goss; Midshaft First-Ray Osteotomies for Hallux Valgus; Clinics in Podiatric
Medicine and Surgery;April 2005 (Vol. 22, Issue 2, Pages 169-195) Jeff Hetmale, Kevin D. Myer ;The Distal
Metatarsal Osteotomy for the Treatment of Hallux Valgus Clinics in Podiatric Medicine and Surgery April
2005 (Vol. 22, Issue 2, Pages 143-167)
An 47 year-old female complains of right first MTPJ pain with activity of daily living in all closed shoes. She
is asymptomatic in sandals. Past medical history includes a pacemaker implanted several years earlier.
Medications include coumadin, HCTZ and Fosamax on a regular basis. Examination reveals hallux range of
motion of 50 ° of dorsiflexion and 20 ° of plantarflexion without crepitus. Radiographs and clinical photo are
shown.
Which of the following is the most appropriate recommendation for this patient?
A. Advise only non-restrictive shoes, such as sandals

B. Accommodative orthotic
C. Functional orthotic
D. Cheilectomy
Correct Answer: D
Suggested Readings:
Thomas S. Roukis Outcomes after Cheilectomy with Phalangeal Dorsiflexory Osteotomy for Hallux Rigidus: A
Systematic Review , Journal of Foot and Ankle Surgery September 2010 (Vol. 49, Issue 5, Pages 479-487) Tim
Harrison, Ernest Fawzy, Feroz Dinah, Simon Palmer; Prospective Assessment of Dorsal Cheilectomy for Hallux
Rigidus Using a Patient-reported Outcome Score , Journal of Foot and Ankle Surgery May 2010 (Vol. 49, Issue
3, Pages 232-237)
A 27 year-old female presents with a congenitally overlapping fifth toe, as shown, complaining of pain in all
shoes. Past surgical history includes prior arthroplasty at the PIP joint through a "V" to "Y" skin incision, which
offered no relief.
Which of the following surgical procedures would best address the current deformity?
A. Amputation of the digit

B. MTPJ and PIP joint arthrodesis
C. Extensor tenotomy and transposition skin "Z-plasty"
D. Flexor brevis transfer
Correct Answer: C
Suggested Readings:
James L. Thomas, Edwin L. Blitch, D. Martin Chaney, Kris A. Dinucci, Kimberly Eickmeier, Laurence G.
Rubin, Mickey D. Stapp, John V. Vanore; Diagnosis and Treatment of Forefoot Disorders. Section 1: Digital
Deformities Clinical Practice Guideline Forefoot Disorders Panel, Journal of Foot and Ankle Surgery
March 2009 (Vol. 48, Issue 2, Pages 230-238) GOHAR A. SALAM, M.D., D.O., and JANKI P. AMIN, M.D.
The Basic Z-Plasty Am Fam Physician. 2003 Jun 1;67(11):2329-2332.
A 57 year-old male presents with the deformity shown. He is unable to wear normal shoe gear due to pain in
the second toe. Examination reveals 60 ° of dorsiflexion at the first MTPJ with 10 ° of plantarflexion, with
pain-free range of motion. There are no significant medical risk factors contraindicating surgery. An outpatient
procedure is planned.
Which of the following procedures is most appropriate for this patient?
A. Arthroplasty of the second digit

B. Plantar plate repair of the second MTPJ
C. Arthrodesis of the first MTPJ and the second digit
D. Arthrodesis of the second digit and first ray realignment
Correct Answer: D
Suggested Readings:
Neal M. Blitz ; The Versatility of the Lapidus Arthrodesis; Clinics in Podiatric Medicine and Surgery
July 2009 (Vol. 26, Issue 3, Pages 427-441) Philip Basile, Emily A. Cook, Jeremy J. Cook; Immediate Weight
Bearing Following Modified Lapidus Arthrodesis , 20 July 2010 ;Journal of Foot and Ankle Surgery;September
2010 (Vol. 49, Issue 5, Pages 459-464)
A 47 year-old female is seen 72 hours post Austin bunionectomy reporting significant discomfort throughout
the foot when dorsiflexing of the hallux but not when plantarflexing it. She is unable to bear weight due to pain.
Examination reveals significant swelling from the digits through the midfoot. No drainage is noted and she is
afebrile. Radiographs are shown.
Which of the following most likely accounts for the discomfort?
A. Hematoma
B. Infection
C. Acute sesamoiditis
D. Inappropriate fixation
Correct Answer: D
Suggested Readings:
Matthew S. Rockett, Larry R. Goss; Midshaft First-Ray Osteotomies for Hallux Valgus; Clinics in Podiatric
Medicine and Surgery;April 2005 (Vol. 22, Issue 2, Pages 169-195) Jeff Hetmale, Kevin D. Myer ; The Distal
Metatarsal Osteotomy for the Treatment of Hallux Valgus Clinics in Podiatric Medicine and Surgery April 2005
(Vol. 22, Issue 2, Pages 143-167)
You consult on a 39 year-old female with pain sub right first metatarsal head of 6 weeks duration. The referring
podiatrist is considering dorsiflexory osteotomy of the first metatarsal to correct the problem. Radiograph and
clinical photo are shown.
Which of the following is the appropriate recommendation for this patient?
A. Proceed with surgery as planned

B. Perform sesamoidectomy rather than osteotomy
C. Address metatarsus adductus to correct the problem
D. Alter shoe gear and re-evaluate in 6 weeks
Correct Answer: D
Suggested Readings:
Bruce E. Cohen; Hallux Sesamoid Disorders;Foot and Ankle Clinics;March 2009 (Vol. 14, Issue 1, Pages 91-
104) Thomas S. Roukis; Central Metatarsal Head-Neck Osteotomies: Indications and Operative Techniques;
Clinics in Podiatric Medicine and Surgery April 2005 (Vol. 22, Issue 2, Pages 197-222)
The patient shown complains of continual swelling in the left ankle area 7 years post ORIF for the fracture seen
in the accompanying radiograph. Examination reveals pain free ankle range of motion, with 10 ° of dorsiflexion
and 10 ° of plantarflexion with the knee both flexed and extended.
Which of the following is the most appropriate treatment for this patient?
A. Prescribe a diuretic
B. Repair widened syndesmosis
C. Remove all implants
D. Perform ankle arthrodesis
Correct Answer: C
Suggested Readings:
O L Brown, D R Dirschl, W T Obremskey Incidence of hardware-related pain and its effect on functional
outcomes after open reduction and internal fixation of ankle fractures.J Orthop Trauma;May 2001 (Vol. 15,
Issue 4, Pages 271-4) Maleuel Leyes, Raúl Torres, Pedro Guillén; Complications of open reduction and internal
fixation of ankle fractures; Foot and Ankle Clinics; March 2003 (Vol. 8, Issue 1, Pages 131-147)
A 27 year-old male presents with the lesions shown. They appeared insidiously 2 months ago, are not painful or
raised but have become larger. They are found nowhere else on his body. His medical history is unremarkable.
Which of the following biopsy techniques is most appropriate to evaluate these lesions?
A. Excisional
B. Incisional
C. Shave
D. Needle
Correct Answer: B
Suggested Readings:
Evelien Ton, Aike A. Kruize; How to perform and analyse biopsies in relation to connective tissue diseases;
Best Practice & Research Clinical Rheumatology; April 2009 (Vol. 23, Issue 2, Pages 233-255) Bennett DR,
Wasson D, MacArthur JD, McMillen MA. The effect of misdiagnosis and delay in on clinical outcome in
melanomas of the foot. J Am Coll Surg 1994 Sep; 179(3):279-84. Ng JC, Swain S, Dowling JP, Wolfe R,
Simpson P, Kelly JW; The Impact of Partial Biopsy on Histopathologic Diagnosis of Cutaneous Melanoma:
Experience of an Australian Tertiary Referral Service; Arch Dermatol. 2010;146:234-239
A 52 year-old female who underwent "bunion surgery" 3 years earlier complains of pain sub left second
metatarsal head.
In addition to lengthening the first metatarsal, which of the following procedures best addresses the sub-second
pain?
A. Arthrodesis of the first MTPJ

B. Arthroplasty of the second digit
C. Second metatarsal head resection
D. Second metatarsal osteotomy
Correct Answer: D
Suggested Readings:
Thomas S. Roukis; Central Metatarsal Head-Neck Osteotomies: Indications and Operative Techniques; Clinics
in Podiatric Medicine and Surgery April 2005 (Vol. 22, Issue 2, Pages 197-222) Hugo R. Perez, Leon K. Reber,
Jeffrey C. Christensen The Role of Passive Plantar Flexion in Floating Toes Following Weil Osteotomy Journal
of Foot and Ankle Surgery; November 2008 (Vol. 47, Issue 6, Pages 520-526)
In evaluating a 48 year-old sedentary female for an "ankle sprain" after slipping on ice, a unicameral bone cyst
is noted as an incidental finding on radiograph. There is no pain. The patient’s BMI is 17.65.
Which of the following is the most appropriate treatment for the bone cyst?
A. Repeat film in 6 months

B. Excision and pack with cortical bone chips
C. Aspiration with 16 gauge needle
D. Total body MR study
Correct Answer: A
Suggested Readings:
Glaser, DL. DormalesJP, Stanton RP, DavidsonRS Surgical Maleagement of Calcaneal Unicameral Bone
Cysts. Clin Ortop Related Res. 1999 Mar;(360):231-7. Treatment of a Unicameral Bone Cyst of Calcaneus with
Endoscopic Curettage and Percutaneous Filling with Corticocancellous Allograft; Cengiz Yıldırım, Mahir
Mahiroğulları, Mesih Kuşkucu, İbrahim Akmaz, Kenan Keklikci Journal of Foot and Ankle Surgery January
2010 (Vol. 49, Issue 1, Pages 93-97)
A 22 year-old male who has had repeated episodes of paronychia of the left hallux nail presents 5 days after
being stepped on while playing basketball.
A. Radiograph to rule out phalangeal fracture

B. Remove entire nail plate to evaluate for laceration
C. Excise ingrowing nail and resolve infection
D. Begin antibiotics and saline soaks TID
Correct Answer: C
Suggested Readings:
Carina L E Gerritsma-Bleeker, Joost M Klaase, Robert H Geelkerken, Jo Hermales, Rob J van Det Partial
matrix excision or segmental phenolization for ingrowing toenails. Arch Surg March 2002 (Vol. 137, Issue 3,
Pages 320-5) Schelto Kruijff, Robert J. van Det, Gretha T. van der Meer, Inez C.M.A.E. van den Berg, Job van
der Palen, Robert H. Geelkerken Partial Matrix Excision or Orthonyxia for Ingrowing Toenails Journal of the
American College of Surgeons January 2008 (Vol. 206, Issue 1, Pages 148-153)
A 53 year-old female who is 3 years post forefoot reconstructive surgery complains of right first MTPJ pain in
all shoe gear. Crepitus is noted with first MTPJ range of motion.
Which of the following is most appropriate for the patient at this time?
A. Cartilagenous realignment procedure of first metatarsal

B. Joint destructive procedure
C. Excision of exuberant bone along metatarsal shaft
D. Callus distraction of short first metatarsal
Correct Answer: B
Suggested Readings:
Lawrence A. Ford, Graham A. Hamilton Procedure Selection for Hallux Valgus Clinics in Podiatric Medicine
and Surgery July 2009 (Vol. 26, Issue 3, Pages 395-407) Christopher Nicholas, Alison D. Silhanek, Fiona G.
Connolly, Charles M. Lombardi The Effect of First Metatarsophalangeal Arthrodesis on Transverse Plane
Deviation of the Second Toe: A Retrospective Radiographic Study Journal of Foot and Ankle Surgery
September 2005 (Vol. 44, Issue 5, Pages 365-376)
A 47 year-old female who is 1 year post first ray procedure for a callus sub first metatarsal head was told that
the plate (shown) may require removal after a year. She currently has no pain.
A. Remove implant as was suggested

B. Remove only the long proximal screw
C. Leave implant and re-evaluate in a year
D. Leave implant and stabilize foot with a functional orthotic
Correct Answer: C
Suggested Readings:
O L Brown, D R Dirschl, W T Obremskey Incidence of hardware-related pain and its effect on functional
outcomes after open reduction and internal fixation of ankle fractures.J Orthop Trauma;May 2001 (Vol. 15,
Issue 4, Pages 271-4) Maleuel Leyes, Raúl Torres, Pedro Guillén; Complications of open reduction and internal
fixation of ankle fractures; Foot and Ankle Clinics; March 2003 (Vol. 8, Issue 1, Pages 131-147)
A 94 year-old female presents with subungual pain on the third toe for the past year. Medical history includes
cardiomyopathy and early Alzheimer’s disease. There is no drainage or ascending cellulitis. ABI is 0.65.
Radiograph is shown.
Which of the following is most appropriate for the pathology shown?
A. Needle biopsy
B. MRI
C. Tc-99 bone scan
D. Excise lesion

Correct Answer: D
Suggested Readings:
Ritchard C. Rosen; Digital Amputations Clinics in Podiatric Medicine and Surgery
July 2005 (Vol. 22, Issue 3, Pages 343-363) Robert G. Atnip ; Toe and Partial Foot Amputations Operative
Techniques in General Surgery; June 2005 (Vol. 7, Issue 2, Pages 67-73)
This 37 year-old female who underwent an Austin bunionectomy with Akin osteotomy and second metatarsal
head osteotomy now complains of pain beneath the third metatarsal head. Clinical presentation and radiographs
are shown.
Which of the following is most appropriate in managing her third metatarsal pain?
A. Metatarsal head resection

B. Repeated steroid injections
C. Metatarsal osteotomy
D. Third MTPJ arthrodesis
Correct Answer: C
Suggested Readings:
Jonathan B Feibel, Christopher L Tisdel, Brian G Donley; Lesser metatarsal osteotomies: A biomechanical
approach to metatarsalgia; Foot and Ankle Clinics; September 2001 (Vol. 6, Issue 3, Pages 473-489) Vincent
James Sammarco, Jorge Acevedo Stability and fixation techniques in first metatarsal osteotomies Foot and
Ankle Clinics; September 2001 (Vol. 6, Issue 3, Pages 409-432)
72 hours after injuring his left foot while stepping off a curb a 24 year-old male presents with pain and swelling
on the lateral aspect of the foot. Examination reveals ecchymosis and tenderness about the base of the fifth
metatarsal to palpation with associated pain traveling laterally up the leg. Radiograph is shown.
Which of the following is most appropriate in managing this patient?
A. Begin protected weight bearing in supportive shoe

B. Short leg weight bearing cast
C. Non-weight bearing with crutches
D. Schedule ORIF within 10 days
Correct Answer: C
Suggested Readings:
Donald E. Buddecke, Matthew A. Polk, Eric A. Barp; Metatarsal Fractures; Clinics in Podiatric Medicine and
Surgery ; ctober 2010 (Vol. 27, Issue 4, Pages 601-624) Gary B. Fetzer, Rick W. Wright; Metatarsal Shaft
Fractures and Fractures of the Proximal Fifth Metatarsal; Clinics in Sports Medicine; January 2006 (Vol. 25,
A transpositional Z-plasty is scheduled to redirect a scar and add length.
Based on the illustration, which of the following is correct regarding the greatest gain in length?
A. 30 degree angle provides the greatest gain in length

B. 45 degree angle provides the greatest gain in length
C. 60 degree angle provides the greatest gain in length
D. All three provide the same gain
Correct Answer: C
Suggested Readings:
Gohara A. Salam,, M.D., D.O., and Janki P Amin, M.D. The Basic Z-Plasty Am Fam
Physician. 2003 Jun 1;67(11):2329-2332. Samaletha E. Bark, L. Marie Keplinger, Andrew J. Meyr; Precise
Intraoperative 60° Skin Z-plasty, 01 February 2010 Journal of Foot and Ankle Surgery; March 2010 (Vol. 49,
A 47 year-old male with DM1 undergoes repeated ulceration on the plantar aspect of his foot in the area shown.
The area has broken down 3 times in the past year and has been healed 3 times through off-loading in a total
contact cast. Osseous pathology has been ruled out.
Which of the following is most appropriate to prevent future recurrence of the ulceration?
A. Gastrocnemius recession
B. Split thickness skin graft
C. Free flap of myocutaneous tissue
D. Fourth metatarsal head resection
Correct Answer: A
Suggested Readings:
Neal M. Blitz, Shannon M. Rush; The Gastrocnemius Intramuscular Aponeurotic Recession: A Simplified
Method of Gastrocnemius Recession; Journal of Foot and Ankle Surgery; March 2007 (Vol. 46, Issue 2, Pages
133-138) Amaleda Meszaros, Gage Caudell The Surgical Management of Equinus in the Adult Acquired
Flatfoot; Clinics in Podiatric Medicine and Surgery; October 2007 (Vol. 24, Issue 4, Pages 667-685)
A 22 year-old college exchange student presents with the lesion shown, which first appeared 6 weeks ago. You
suspect Kaposi’s sarcoma.
Which of the following is the next most appropriate step in managing the patient?
A. Immediate referral to oncologist

B. Full body PET scan
C. HIV testing
D. Biopsy of lesion
Correct Answer: D
Suggested Readings:
David M Aboulafia; Kaposi’s sarcoma; Clinics in Dermatology; May 2001 (Vol. 19, Issue 3, Pages 269-283)
Robert A. Schwartz, Giuseppe Micali, Maria Rita Nasca, Laura Scuderi; Kaposi’s sarcoma: A continuing
conundrum Journal of the American Academy of Dermatology August 2008 (Vol. 59, Issue 2, Pages 179-206)
A 27 year-old morbidly obese patient presents with the lesions shown. Several are painful, have been present
for 2 years and are increasing in number. Laboratory findings reveal normal serum uric acid and serum
cholesterol.
Which of the following is the most appropriate course of action for these lesions?
A. Inject with soluble steroid and local anesthesia

B. Needle biopsy
C. Excise painful lesions
D. Order 24-hour urine
Correct Answer: C
Suggested Readings:
F Montgomery, A Fioriti Piezogenic pedal papules: treated by resection and hernial closure The Foot;
September 1998 (Vol. 8, Issue 3, Pages 171-172) What walked into the office today—A brief review of
podiatric dermatology; Journal of the American Academy of Dermatology; March 2005 (Vol. 52, Issue 3,
Supplement, Page P64)
A 32 year-old male presents with unilateral rear foot pain since childhood. The pain is not relieved by oral
medication or orthotic control. Radiograph is shown. CT scan confirmed the pathology shown on radiograph.
Which of the following is the most appropriate treatment for this patient?
A. Short leg NWB cast immobilization

B. Excision of C-N bar and interposition of fat
C. Injection of long acting steroid into C-N articulation
D. Rearfoot arthrodesis
Correct Answer: D
Suggested Readings:
Klaus J. Kernbach Tarsal Coalitions: Etiology, Diagnosis, Imaging, and Stigmata Clinics in Podiatric Medicine
and Surgery; January 2010 (Vol. 27, Issue 1, Pages 105-117) Klaus J. Kernbach, Neal M. Blitz, Shannon M.
Rush Bilateral Single-stage Middle Facet Talocalcaneal Coalition Resection Combined with Flatfoot
Reconstruction: A Report of 3 Cases and Review of the Literature. Investigations Involving Middle Facet
Coalitions—Part 1; Journal of Foot and Ankle Surgery May 2008 (Vol. 47, Issue 3, Pages 180-190)
A 19 year-old female long distance runner experiences lateral foot and ankle pain secondary to a dislocating
peroneal tendon. Shoe modification and in-shoe orthotic therapy has not alleviated her condition. Her MRI and
a clinical photo are shown.
Which of the following is the most appropriate course of treatment?
A. Cast immobilization
B. Surgical repair
C. Steroid injection
D. AFO
Correct Answer: B
Suggested Readings:
M Ferroudji, F Spaas, M Martens Rerouting operation for recurrent dislocationof the peroneal tendons by the
Pöll and Duijfjes procedure. Foot and Ankle Surgery. 2003 (Vol. 9, Issue 2, Pages 103-108); Nicholas Antonio
Ferran, Nicola Maffulli, Francesco Oliva Maleagement of Recurrent Subluxation of the Peroneal Tendons.;
Foot and Ankle Clinics. September 2006 (Vol. 11, Issue 3, Pages 465-474)
A 52 year-old homeless male is evaluated for the condition shown. Two days ago he fell asleep over a heating
grate in sub-zero weather. Vascular examination reveals palpable DP and PT pulses, and an ABI of 0.55.
Which of the following is the most appropriate treatment?
A. Immediate debridement/amputation of necrotic areas

B. Angiogram for possible revascularization
C. Apply moist heat to affected areas
D. Allow area to demarcate and re-evaluate after several days
Correct Answer: D
Suggested Readings:
K Subramaleian, A.I Zubairy, N.P.J Geary. Frost bite in both feet—conservative approach. Foot and Ankle
Surgery. 2003 (Vol. 9, Issue 3, Pages 183-186); Nilesh N. Patel, Devesh N. Patel. Frostbite. The American
Journal of Medicine. September 2008 (Vol. 121, Issue 9, Pages 765-766)
A 37 year-old male is evaluated 4 hours after sustaining direct trauma to his left foot. Examination reveals
dorsal midfoot pain, swelling and ecchymosis. The toes are warm and the patient can demonstrate active but
painful dorsiflexion at the ankle and MTPJs. Radiograph is shown.
Based on the information given which of the following is the most appropriate course of action?
A. Immediate fasciotomy for compartment syndrome

B. ORIF of intraarticular navicular fracture
C. Compression dressing and non-weight bearing
D. Excision of fracture fragment
Correct Answer: C
Suggested Readings:
Christopher W DiGiovanni. Fractures of the navicular. Foot and Ankle Clinics March 2004 (Vol. 9, Issue 1,
Pages 25-63); Nilesh K. Makwana, Marck R. M.R. van Liefland. Injuries of the midfoot. Current
Orthopaedics. June 2005 (Vol. 19, Issue 3, Pages 231-242

Module 5 Surgical Criteria

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November 2010 ABPOPPM In-training Exam Page 1 of 50

Module 2: Surgical Criteria

Which of the following is the most appropriate course of action?

A. Defer treatment until apophyses are fully closed

Module 2: Surgical Criteria

Which of the following constitutes the most appropriate intraoperative sequencing?

A. Bunionectomy; then arthroplasty fifth; then arthroplasty second

Module 2: Surgical Criteria

Module 2: Surgical Criteria

A. McBride with closing base wedge osteotomy

Module 2: Surgical Criteria

Module 2: Surgical Criteria

Surgical syndactyly is most useful in which of the following conditions?

Module 2: Surgical Criteria

A. Apply a short leg, weight bearing cast

Module 2: Surgical Criteria

Which of the following is an appropriate indication for surgery?

A. Spontaneous reduction is occurring too slowly

Module 2: Surgical Criteria

A. Order appropriate systemic antibiotic therapy

Module 2: Surgical Criteria

Which of the following is the most likely mechanism of the injury?

Module 2: Surgical Criteria

Module 2: Surgical Criteria

Module 2: Surgical Criteria

A. Aligns and stabilizes the osteotomy

Module 2: Surgical Criteria

A. Arthritic joint changes

Module 2: Surgical Criteria

Which of the following is the most likely diagnosis?

A. Avulsion of the extensor tendon at the distal phalanx

Module 2: Surgical Criteria

Module 2: Surgical Criteria

Which of the following is the function of this plate?

A. Static compression plate

Module 2: Surgical Criteria

Module 2: Surgical Criteria

Which of the following must be considered in performing a "Z-plasty"?

A. The central limb of the Z should be perpendicular to the line of contracture

Module 2: Surgical Criteria

Which of the following is the primary indication for this procedure?

A. Restores digital function

Module 2: Surgical Criteria

A. Insert a drain to prevent hemarthrosis

Module 2: Surgical Criteria

Which of the following is most appropriate at this time?

A. Distal amputation of digit

Module 2: Surgical Criteria

Which of the following is most appropriate concerning her corticosteroid regimen?

A. Discontinue the medication pre-operatively

Module 2: Surgical Criteria

Which of the following surgical principles will aid in the determination?

A. Harris Benedict equation

Module 2: Surgical Criteria

Which of the following is an advantage of an allograft over an autograft?

A. More effective incorporation

Module 2: Surgical Criteria

A. Tophus interferes with tendon function

Module 2: Surgical Criteria

What is the most appropriate course of action at this time?

A. Encourage non-weight bearing

Module 2: Surgical Criteria

A. Advise only non-restrictive shoes, such as sandals