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ABPOPPM In-Training Exam

Module: Surgical Criteria

A 42 year-old athletic female presents with the mass shown on the photograph. The mass
developed six months ago, is painful with activity and has been getting larger. An attempt at
aspiration failed to withdraw fluid.

Based on the clinical findings and MRI shown which of the


following is the best course of action?

A. Immediate oncologic referral


B. Surgical excision, pathology evaluation
C. Re-aspirate, inject soluble steroid
D. Midtarsal amputation pending frozen section results
E. Monitor over the next few months

Correct Answer: B

Suggested Reading:

Blume PA, Moore JC, Novicki DC. Digital mucoid cyst excision by using the bilobed flap
technique and arthroplastic resection. J Foot Ankle Surg. Jan-Feb 2005;44(1):44-8

Kivanc-Altunay I, Kumbasar E, Gokdemir G, Koslu A, Tekkesin M, Basak T. Unusual


localization of multiple myxoid (mucous) cysts of toes. Dermatol Online J. Jul 15 2004;10(1):23

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ABPOPPM In-Training Exam

Module: Surgical Criteria

Radiographs of a 45 year-old male who is status-post motor vehicle accident, with multiple
fractures of the lower extremity, are shown.

What fixation technique was used on the patella?

A. Tension band
B. Lag screw
C. Crossed Kirschner wire
D. Dynamic compression plate
E. Neutralization plate

Correct Answer: A

Suggested Reading:

Fortis AP, Milis Z, Kostopoulos V, Tsantzalis S, Kormas P, Tzinieris N, et al. Experimental


investigation of the tension band in fractures of the patella. Injury. Jul 2002;33(6):489-93

Separate vertical wiring for the fixation of comminuted fractures of the inferior pole of the
patella. J Bone Joint Surg Br. Nov 2003;85(8):1155-60

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ABPOPPM In-Training Exam

Module: Surgical Criteria

A 44 year-old male who underwent fasciotomy of the forearm for compartment syndrome
following a motor vehicle accident is returned to the OR 48 hours later for repair of the
fasciotomy, as shown in the photograph.

Which of the following is indicated for closure of the wound shown?

A. Full thickness skin graft


B. Split thickness skin graft
C. Primary closure
D. Porcine xenograft
E. Apligraf

Correct Answer: B

Suggested Reading:

Feliciano DV, Cruse PA, Spjut-Patrinely V, et al. Fasciotomy after trauma to the extremities. Am
J Surg. Dec 1988;156(6):533-6

Sheridan GW, Matsen FA 3rd. Fasciotomy in the treatment of the acute compartment
syndrome. J Bone Joint Surg Am. Jan 1976;58(1):112-5

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ABPOPPM In-Training Exam

Module: Surgical Criteria

While performing surgical correction of brachymetatarsia with iliac bone autograft, the bone graft
is dropped on the operating room floor.

Which of the following is the most appropriate treatment of the graft prior to insertion into the
surgical site?

A. Autoclave sterilization
B. Rinsing in copious sterile saline solution for 15 minutes
C. Flash freezing
D. Soaking in iodine solution for 15 minutes
E. Rinsing in sequential dilutions of antimicrobial solution

Correct Answer: E

Suggested Reading:

Joseph WS, Kosinski MA. Prophylaxis in lower-extremity infectious diseases. Clin Podiatr Med
Surg. Oct 1996;13(4):647-60

Clemens MW, Parikh P, Hall MM, Attinger CE. External fixators as an adjunct to wound
healing. Foot Ankle Clin. Mar 2008;13(1):145-56

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ABPOPPM In-Training Exam

Module: Surgical Criteria

A 63 year-old patient with DM1 has undergone transmetatarsal amputation for ischemic
ulcerations of the digits.

Which of the following types of postoperative contractures must be planned for peri-operatively?

A. Forefoot/midfoot varus
B. Ankle equinus
C. Forefoot/midfoot valgus
D. Knee flexion
E. Dropfoot

Correct Answer: B

Suggested Reading:

Bevilacqua NJ, Rogers LC, DellaCorte MP, Armstrong DG. The narrowed forefoot at 1 year: an
advanced approach for wound closure after central ray amputations. Clin Podiatr Med
Surg. Jan 2008;25(1):127-33

Murdoch G, Wilson AB Jr, eds. Amputation: Surgical Practice and Patient Management. St
Louis, Mo: Butterworth-Heinemann Medical; 1996

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ABPOPPM In-Training Exam

Module: Surgical Criteria

This is a three month post-operative radiograph of a 29 year-old male who sustained a Weber
type B ankle fracture that was treated with ORIF using two cortical screws as shown.

Which of the following best describes the findings?

A. Normal healing
B. Delayed union
C. Syndesmostic widening
D. Soft tissue calcification
E. Screw loosening

Correct Answer: C

Suggested Reading:

Tandeter HB, Shvartzman P. Acute ankle injuries: clinical decision rules for radiographs. Am
Fam Physician. Jun 1997;55(8):2721-8

Clanton TO, Porter DA. Primary care of foot and ankle injuries in the athlete. Clin Sports
Med. Jul 1997;16(3):435-66

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ABPOPPM In-Training Exam

Module: Surgical Criteria

A 45 year-old female presents with an iatrogenic hallux varus, as shown on the radiograph.

Which of the following is the most probable cause?

A. Overcorrection of the intermetatarsal angle


B. Failure of fixation
C. Inappropriate placement of the osteotomy
D. Overcorrection of the hallux interphalangeus angle
E. Inappropriate screw fixation

Correct Answer: A

Suggested Reading:

Vanore JV, Christensen JC, Kravitz SR, et al. Diagnosis and treatment of first
metatarsophalangeal joint disorders. Section 3: hallux varus. J Foot Ankle Surg. May-
Jun 2003;42(3):137-42

Lagaay PM, Hamilton GA, Ford LA, Williams ME, Rush SM, Schuberth JM. Rates of revision
surgery using Chevron-Austin osteotomy, Lapidus arthrodesis, and closing base wedge osteotomy
for correction of hallux valgus deformity. J Foot Ankle Surg. Jul-Aug 2008;47(4):267-72

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ABPOPPM In-Training Exam

Module: Surgical Criteria

An 82 year-old female with rheumatoid arthritis is scheduled to undergo pan metatarsal head
resection with first MTP joint arthrodesis. DEXA scan densitometry testing is obtained which
confirms severe osteoporosis. Radiograph is shown.

Which of the following complications is most likely as a result of the osteoporosis?

A. Infection
B. Delayed bone healing
C. Hematoma
D. Hallux varus
E. Failure of fixation

Correct Answer: E

Suggested Reading:

Brunner CF, Weber BG. Special Techniques in Internal Fixation. Berlin: Springer-Verlag;. 1982

Muller ME, Allgower JM, Schneider R, Willenegger H. Manual of Internal Fixation, 3rd
ed. Berlin: Springer-Verlag;. 1992

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ABPOPPM In-Training Exam

Module: Surgical Criteria

While performing a lateral release during hallux valgus surgery the tendon of the first dorsal
interosseous muscle is severed.

Which of the following will most likely occur?

A. Lateral deviation of the second toe


B. Hammertoe deformity of the second toe
C. Medial deviation of the second toe
D. Decreased rate of recurrence of hallux valgus
E. Lateral deviation of the hallux

Correct Answer: A

Suggested Reading:

Bouché RT, Heit EJ. Combined plantar plate and hammertoe repair with flexor digitorum longus
tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal
joints: preliminary observations. J Foot Ankle Surg. Mar-Apr 2008;47(2):125-37

Trnka HJ, Gebhard C, Muhlbauer M, et al. The Weil osteotomy for treatment of dislocated lesser
metatarsophalangeal joints: good outcome in 21 patients with 42 osteotomies. Acta Orthop
Scand. Apr 2002;73(2):190-4

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ABPOPPM In-Training Exam

Module: Surgical Criteria

This is a radiograph of a 65 year-old, mentally retarded, non-compliant female complaining of


continued pain and swelling four months post first MTP joint arthrodesis.

Based on the suspected diagnosis, which of the following is indicated at this time?

A. Cast immobilization, non-weight bearing for six weeks


B. Continue to monitor healing
C. Repeat arthrodesis with external fixator
D. Arthroplastic procedure of the first MTP joint
E. Apply external bone stimulator

Correct Answer: D

Suggested Reading:

Banks AS, Downey MS, Martin DE, Miller S, eds. McGlamry's Comprehensive Textbook of
Foot and Ankle Surgery. 3rd ed. New York: Lippincott, Williams & Wilkins; 2001

Gerbert J, ed. Textbook of Bunion Surgery. 2nd ed. Mt Kisco, NY: Futura Publishing
Company;. 1991

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ABPOPPM In-Training Exam

Module: Surgical Criteria

A 32 year-old male with DM2 returns to the ED 72 hours following I&D of a deep space
infection. The wound had been packed open to enable daily local wound care. The patient has
noticed significant bleeding from the surgical site after bearing full weight on the foot.
Examination reveals arterial pulsatile bleeding. Pre-operative total Hgb was 11g/dl. After
surgical repair of the acute arterial bleed Hgb is noted to be 7.8 g/dl.

Which of the following is indicated?

A. Dextran
B. 0.9 percent sodium chloride solution (normal saline: NS)
C. Fresh frozen plasma
D. Packed red blood cells
E. Observation for 48 hours

Correct Answer: D

Suggested Reading:

Dutton RP, Carson JL. Indications for early red blood cell transfusion. J
Trauma. Jun 2006;60:S35-S40

Isbister JP. Blood Component Therapy. In: Fink MP, Abraham E, Vincent JL, Kochanek
PM. Textbook of Critical Care. Philadelphia: Elsevier Saunders; 2005:1427-1435

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ABPOPPM In-Training Exam

Module: Surgical Criteria

These are the radiographs of a 26 year-old male, in good health, who presented to the ED 30
minutes after a gunshot wound to the right foot. A 2.0 cm. entrance wound is located on the
dorsum of the first MTP joint.

Initial care for the patient should include all the following EXCEPT:

A. Irrigation & debridement


B. Cast immobilization
C. Tetanus prophylaxis
D. Primary fracture fixation
E. Antibiotics

Correct Answer: B

Suggested Reading:

Pfaff JA, Moore GP. Reducing risk in emergency department wound management. Emerg Med
Clin North Am. Feb 2007;25(1):189-201

Resnick CD, Fallat LM. Puncture wounds: therapeutic considerations and a new classification. J
Foot Surg. Mar-Apr 1990;29(2):147-53

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ABPOPPM In-Training Exam

Module: Surgical Criteria

A three year-old female is presented with a parental complaint of wide feet that do not fit into any
shoes. Radiographs are obtained. The fourth intermetatarsal angle is measured at 23 degrees.

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

A. Distal trans-positional osteotomy (reverse Austin) of the fifth metatarsal (MT)


B. Tarso-adductor shoes for six months, then reevaluate
C. Base wedge osteotomy of the fifth metatarsal
D. Soft tissue release of all metatarsal base articulations (e.g HHS procedure)
E. Abductory osteotomies of all metatarsal bases

Correct Answer: C

Suggested Reading:

Ajis A, Koti M, Maffulli N. Tailor's bunion: a review. J Foot Ankle Surg. May-
Jun 2005;44(3):236-45

Cohen BE, Nicholson CW. Bunionette deformity. J Am Acad Orthop Surg. May 2007;15(5):300-
7

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ABPOPPM In-Training Exam

Module: Surgical Criteria

A 52 year-old female presents with a three month history of pain and swelling about the medial
aspect of the ankle. She denies any history of trauma.

Examination reveals:
• the patient is able to perform single limb raises on the painful extremity
• full subtalar and ankle joint ranges of motion of the are available without pain or
crepitation
• tenderness upon palpation along the course of the tibialis posterior tendon, both posterior
and inferior to the medial malleolus
• plain radiographs are normal
• MRI identifies longitudinal tearing with tendinosis as shown

Based on these findings, which of the following procedures is most indicated?

A. Triple arthrodesis
B. Subtalar joint arthrodesis
C. Cast immobilization for 8-12 weeks
D. Flexor digitorum longus tendon transfer
E. Synovectomy and primary repair of the tibialis posterior tendon

Correct Answer: C

Suggested Reading:

Anzilotti K Jr, Schweitzer ME, Hecht P, Wapner K, Kahn M, Ross M. Effect of foot and ankle
MR imaging on clinical decision making. Radiology. Nov 1996;201(2):515-7

Erickson SJ, Johnson JE. MR imaging of the ankle and foot. Radiol Clin North
Am. Jan 1997;35(1):163-92

Feighan J, Towers J, Conti S. The use of magnetic resonance imaging in posterior tibial tendon
dysfunction. Clin Orthop Relat Res. Aug 1999;(365):23-38

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ABPOPPM In-Training Exam

Module: Surgical Criteria

A 62 year-old male with rheumatoid arthritis suffered the ulceration shown secondary to an
episode of acute vasculitis. After treatment of the vasculitis with steroids, surgical debridement is
planned, with application of a Vacuum Assisted Closure (VAC) device.

His pre-operative medications include:


• Aspirin 325mg qd.
• Prednisone 15mg qd.
• Celebrex® (celecoxib) 100 mg qd.
• Flomax® (tamsulosin) 0.4mg qd.

Which of the following additional medications is required on the morning of surgery?

A. Solu-Cortef (hydrocortisone sodium succinate) 200mg IV


B. Prednisone 5 mg po
C. Toradol (ketorolac) 30mg IM
D. Stadol (butorphanol tartrate) 2mg IM
E. MS Contin (morphine sulfate) 50mg po

Correct Answer: A

Suggested Reading:

Singh N, Armstrong DG, Lipsky BA. Preventing Foot Ulcers in Patients With Diabetes. JAMA
2005;293:217-28

Armstrong DG, Lavery LA; Diabetic Foot Study Consortium. Negative pressure wound therapy
after partial diabetic foot amputation: a multicentre, randomised controlled trial. Lancet
2005;366: 1704-10

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ABPOPPM In-Training Exam

Module: Surgical Criteria

The patient whose radiographs are shown is scheduled for ORIF of the fracture. Past medical
history is significant for a prior anaphylactic reaction to penicillin, requiring resuscitation.

Which of the following is the most appropriate


prophylactic antibiotic to use in this patient?

A. Cephalexin (Keflex) 2g IV
B. Clindamycin (Cleocin) 600mg IV
C. Metronidazole (Flagyl) 500mg IV
D. Ticarcillin/clavulanate (Timentin) 3.1g IV
E. Ciprofloxacin (Cipro) 500mg IV

Correct Answer: B

Suggested Reading:

Nichols RL. Surgical wound infection. Am J Med 1991;91 Suppl 3B:54S-64


Centers for Disease Control and Prevention. National Nosocomial Infections Surveillance (NNIS)
report, data summary from October 1986-April 1996, issued May 1996

A report from the National Nosocomial Infections Surveillance (NNIS) System. Am J Infect
Control 1996;24:380-8

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ABPOPPM In-Training Exam

Module: Surgical Criteria

A 27 year-old male presents three months after "twisting his foot in a hole". Initial radiographs
were read as unremarkable. He is still symptomatic at the base of the first metatarsal. Repeat
radiographs are as shown.

Which of the following is most likely?

A. Dislocated second metatarsal


B. Arthritis of metatarsal-cuneiform joint
C. Lisfrancs fracture dislocation
D. Fracture of base of first metatarsal
E. Stress fracture of first metatarsal

Correct Answer: C

Suggested Reading:

Bennell, K. L., S. A. Malcolm, S. A. Thomas, et al. Risk factors for stress fractures in track and
field athletes. A twelve-month prospective study. Am. J. Sports Med. 24:810-818, 1996

Mulier T, Reynders P, Sioen W, van den Bergh J, de Reymaeker G, Reynaert P, Broos P The
Treatment of Lisfranc Injuries Acta Orthopaedica Belgica 63(2):82-90, 1997 Jun

17
ABPOPPM In-Training Exam

Module: Surgical Criteria

The photomicrograph depicted shows "papillomatous proliferation of the epidermis with


hyperkeratosis" from a lesion excised from the dorsum of the foot.

Which of the following is most likely?

A. Squamous cell carcinoma


B. Bowen's disease
C. Verrucae plantaris
D. Superficial spreading malignant melanoma
E. Actinic keratosis

Correct Answer: C

Suggested Reading: Kuykendall-Ivy TD, Johnson SM. Evidence-based review of management of


nongenital cutaneous warts. Cutis. 2003;71:213-222

Bellew SG, Quartarolo N, Janniger CK. Childhood warts: an update. Cutis. 2004;73:379-384

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ABPOPPM In-Training Exam

Module: Surgical Criteria

Which of the following intravenous solutions is recommended for the peri-operative care of an
otherwise healthy surgical patient undergoing elective appendectomy?

A. 0.9 percent NaCl in water


B. 10 percent dextrose in water
C. 5 percent NaCl in water
D. Dextran
E. 2.14 percent ammonium chloride in water

Correct Answer: A

Suggested Reading:

Rahbari NN, Zimmerman JB, Schmidt T, et al: Meta-analysis of standard, restrictive, and
supplemental fluid administration in colorectal surgery. Br J Surg 96:331, 2009

Kehlet H, Wilmore DW: Evidence-based surgical care and the evolution of fast track surgery.
Ann Surg 248:189, 2008

19
ABPOPPM In-Training Exam

Module: Surgical Criteria

Which of the following radiographic angles is decreased in the fracture shown?

A. Critical angle of Geller


B. Bodman's crucial angle
C. Bohler's angle
D. Philip Fowler angle
E. Meary's angle

Correct Answer: C

Suggested Reading:

Miller WE, Lichtblau PO: The smashed heel. South Med J 58:1229-1237, 1965

Miller WE: Pain and impairment considerations following treatment of disruptive os calcis
fractures. Clin Orthop 177:82-86, 1983

20
ABPOPPM In-Training Exam

Module: Surgical Criteria

While on general surgery rotation, orders are being written for post-operative care of a patient
who underwent exploratory laparotomy.

Which of the following should be included in postoperative orders to prevent constipation?

A. Tylenol with Codeine


B. Milk of Magnesia
C. Dulcolax suppository
D. Colace
E. Citrucel

Correct Answer: D

Suggested Reading:

Brandt LJ, Prather CM, Quigley EMM, et al. Systematic review on the management of
constipation in North America. Am J Gastroenterol 2005;100(Suppl 1):S5-22

Hamilton JW, Wagner J, Burdick BB, et al. Clinical evaluation of methylcellulose as a bulk
laxative. Dig Dis Sci 1988;33:993-8

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ABPOPPM In-Training Exam

Module: Surgical Criteria

A 42 year-old male sustained burns from a gasoline fire while at work.

Which of the following characterizes the full thickness (third degree) burn on his leg?

A. Hyperesthesia, erythema, and blistering


B. Anesthesia, erythema, and blistering
C. Hyperesthesia and charred discoloration
D. Anesthesia and charred discoloration

Correct Answer: D

Suggested Reading:

Feller I, Tholen D, Cornell RG. Improvements in burn care, 1965 to 1979. JAMA
1980;244:2074-78

Greenbaum AR, Horton JB, Williams CJ, et al. Burn injuries inflicted on children or the elderly: a
framework for clinical and forensic assessment. Plast Reconstr Surg 2006;118:46-58

22
ABPOPPM In-Training Exam

Module: Surgical Criteria

This is a lateral radiograph of a 14 year-old female being worked up for surgical correction of a
flexible flat foot deformity.

Which of the following represents the radiographic apex of the deformity?

A. Talonavicular joint
B. Naviculocuneiform joint
C. Cuneiform first metatarsophalangeal joint (MTPJ)
D. Calcaneocuboid joint
E. Ankle joint

Correct Answer: A

Suggested Reading:

Evans AM. The flat-footed child -- to treat or not to treat: what is the clinician to do?. J Am
Podiatr Med Assoc. Sep-Oct 2008;98(5):386-93

Cohen BE, Ogden F. Medial column procedures in the acquired flatfoot deformity. Foot Ankle
Clin. Jun 2007;12(2):287-99, vi.

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ABPOPPM In-Training Exam

Module: Surgical Criteria

This is the radiograph of a 53 year-old female complaining of a painful, stiff, first MTP joint that
has been developing over the past three to five years. Ten years previously she underwent "some
type of surgery for arthritis" in her great toe.

Which of the following best describes the cause of silicone hemi-implant failure in this patient?

A. Silicone leakage into subcutaneous tissue


B. Joint alignment abnormality
C. Implant failure
D. Infection
E. Surgical technique

Correct Answer: C

Suggested Reading:

Vanore, J.V., O'Keefe, R.G., and Pikscher, I.: Silastic Implant Arthroplasty: Complications and
Their Classification. J. Amer. Podiatry Assoc. Vol. 74, No. 9, 423-433, 1984

Vanore, J.V and Montross, W..: Chapter --: First MTP joint implants, In McGlamry’s
Comprehensive Textbook of Foot and Ankle Surgery, 4th Edition, Lippincott Williams &
Wilkins., New York, expected publication 2009

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ABPOPPM In-Training Exam

Module: Surgical Criteria

These are the radiographs of a 32 year-old long distance runner who sustained an intra-articular
fracture of the first proximal phalanx as shown.

Which of the following is most appropriate for this patient?

A. Fluoroscopy-guided closed reduction and 12 weeks of BK non-weight bearing cast


B. Fluoroscopy-guided closed reduction and slipper cast immobilization
C. ORIF with a 4.5 mm. screw in each fragment
D. ORIF with crossed .045 K wires
E. Immediate interphalangeal fusion

Correct Answer: D

Suggested Reading:

Muller ME, Allgower JM, Schneider R, Willenegger H. Manual of Internal Fixation, 3rd
ed. Berlin: Springer-Verlag;. 1992

First Ray Injuries ;John D. Maskill, Donald R. Bohay, John G. Anderson;Foot and Ankle Clinics
March 2006 (Vol. 11, Issue 1, Pages 143-163)

25
ABPOPPM In-Training Exam

Module: Surgical Criteria

A 44 year-old farmer presents to the ED four hours after sustaining a degloving injury while
working on his tractor. He is diaphoretic with a pulse rate of 84 BPM. His oral temperature is
37.4 degrees C. No osseous damage is present.

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

A. Admit for observation


B. Send home with oral antibiotics after debridement and tetanus prophylaxis
C. Admit for immediate debridement in the operating room
D. Debridement and primary closure if possible
E. Debride in the operating room within 48 hours and cover with Apligraft

Correct Answer: C

Suggested Reading:

Prakash Chandran, Ravindra Puttaswamaiah, Mandeep Singh Dhillon, Shivender Singh Gill;
Management of Complex Open Fracture Injuries of the Midfoot With External FixationJournal of
Foot and Ankle Surgery September 2006 (Vol. 45, Issue 5, Pages 308-315)

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 5. Trauma Clinical Practice Guideline Forefoot Disorders Panel ;Journal of
Foot and Ankle Surgery March 2009 (Vol. 48, Issue 2, Pages 264-272)

26
ABPOPPM In-Training Exam

Module: Surgical Criteria

A metatarsal-cuneiform exostectomy is planned for the 41 year-old female shown.

Which of the following complications would you discuss with her preoperatively specific to the
anatomy in the surgical area?

A. Numbness to the second and third digits


B. Loss of dorsiflexion of the hallux
C. Loss of motion of the hallux
D. Damage to the dorsalis pedis artery

Correct Answer: A

Suggested Reading:

Salasche SJ, Bernstein G, Senkarik M, eds. Surgical Anatomy of the Skin. Norwalk,
Conn: Appleton & Lange; 1988

Levitsky KA, Alman BA, Jevsevar DS, Morehead J. Digital nerves of the foot: anatomic
variations and implications regarding the pathogenesis of interdigital neuroma. Foot
Ankle. May 1993;14(4):208-14

27
ABPOPPM In-Training Exam

Module: Surgical Criteria

An 82 year-old male is unable to walk comfortably due to the recurrent lesion shown. Orthotics
have not been sufficient in restoring him to his normal activity level. Medical history is positive
for hypertension and osteoporosis. The remainder of his medical history is unremarkable and
non-contributory.

Which of the following is the most appropriate surgical choice for this patient?

A. Primary excision of the lesion


B. Dorsiflexory osteotomy of the first metatarsal
C. Metatarsal head resection
D. Sesamoidectomy
E. Metatarsal-cuneiform fusion

Correct Answer: D

Suggested Reading:

Amol Saxena, Tom Krisdakumtorn Return to activity after sesamoidectomy in athletically active
individuals
Foot Ankle Int May 2003 (Vol. 24, Issue 5, Pages 415-9)

R E Van Enoo, E M Cane Tibial sesamoid planing for intractable plantar keratoses; Clin Podiatr
Med Surg Jan 1991 (Vol. 8, Issue 1, Pages 41-7)

28
ABPOPPM In-Training Exam

Module: Surgical Criteria

A neuropathic diabetic presents for care of the condition shown. Ascending cellulitis is present
and the head of the proximal phalanx of the digit is clearly visible protruding through the wound.
MRI findings are negative for osteomyelitis. The patient has an ABI of 0.75.

Following resolution of the ascending cellulitis with the use of IV antibiotics, which of the
following should be scheduled for this patient?

A. Primary closure
B. Interphalangeal fusion
C. Transmetatarsal amputation
D. Digital amputation
E. Open reduction and repair

Correct Answer: D

Suggested Reading:

Bamberger DM. Diagnosis and treatment of osteomyelitis. Compr Ther. Summer 2000;26(2):89-
95.

Perron AD, Brady WJ, Miller MD. Orthopedic pitfalls in the ED: osteomyelitis. Am J Emerg
Med. Jan 2003;21(1):61-7

29
ABPOPPM In-Training Exam

Module: Surgical Criteria

A 71 year-old female presents with the lesion shown, which she first noticed three months ago.
The lesion is painless and has continually enlarged but never ulcerated. No other such lesions are
noted on her body.

Based on the suspected diagnosis, which of the following is the most appropriate course of
action?

A. Measure carefully and reevaluate in two months


B. Schedule primary excision immediately
C. Perform outpatient punch biopsy from the center of lesion
D. Refer for oncologic workup
E. Debride to healthy tissue

Correct Answer: D

Suggested Reading:

Michael S. Downey, Bradley M. Lamm Metastatic Malignant Melanoma to the foot and ankle: A
review of the literature and case report Journal of Foot and Ankle Surgery November 2000 (Vol.
39, Issue 6, Pages 392-401)

Bradley Lemon, Robert Burns; Malignant Melanoma: A literature review and case presentation
Journal of Foot and Ankle Surgery January 1998 (Vol. 37, Issue 1, Pages 48-54)

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ABPOPPM In-Training Exam

Module: Surgical Criteria

A patient who is 29 days post-operative complains about the inability to bathe normally and
would like the pin (shown in the radiograph) removed.

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

A. Delay pin removal for a minimum of 13 additional days


B. Remove pin as clinical healing is noted
C. Rule out suspected delayed union
D. Re-evaluate patient's condition in one week
E. Delay pin removal until eight weeks post-op

Correct Answer: C

Suggested Reading:

Christopher F. Hyer, Jason P. Glover, Gregory C. Berlet, Thomas H. Lee Cost Comparison of
Crossed Screws versus Dorsal Plate Construct for First Metatarsophalangeal Joint Arthrodesis ,
12 November 2007 Journal of Foot and Ankle Surgery January 2008 (Vol. 47, Issue 1, Pages 13-
18)

Clifford D. Mah, Alan S. Banks Immediate Weight Bearing Following First Metatarsophalangeal
Joint Fusion with Kirschner Wire Fixation , Journal of Foot and Ankle Surgery November 2008

31
ABPOPPM In-Training Exam

Module: Surgical Criteria

This 76 year-old female complains of pain across the entire forefoot. IPKs are noted sub
metatarsal heads one, two, and four, associated with dislocated MTP joints. Shoe alterations have
not been successful.

Assuming no medical contraindication to surgery, which of the following is most indicated?

A. Panmetatarsal head resection


B. Transmetatarsal amputation
C. Focused repair of first second and fourth rays
D. Keller bunionectomy and arthroplasty of two and four
E. Joint replacements of MTP one, two and four

Correct Answer: A

Suggested Reading:

Narayan Hulse, Andrew M.C. Thomas Metatarsal Head Resection in the Rheumatoid Foot: 5year
Follow-Up With and Without Resection of the First Metatarsal HeadJournal of Foot and Ankle
Surgery March 2006 (Vol. 45, Issue 2, Pages 107-112)

Abatacept for the treatment of rheumatoid arthritis. National Institute for Health and Clinical
Excellence (NICE) - National Government Agency [Non-U.S.]. 2008 Apr. 29 pages.
NGC:006483

32
ABPOPPM In-Training Exam

Module: Surgical Criteria

A Brodie’s abscess is identified in a 17 year-old soccer player, as shown.

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

A. Curettage and pack with autologous bone


B. I &D and order IV antibiotics
C. Closed suction drainage
D. Needle biopsy for confirmation
E. No treatment is necessary

Correct Answer: B

Suggested Reading:

Scott A. Alter, Roy W. Sprinkle Brodie's abscess: A case report Journal of Foot and Ankle
Surgery March 1995 (Vol. 34, Issue 2, Pages 208-214)

Robert Kelsey, Alex Kor, Flavio Cordano Hematogenous osteomyelitis of the calcaneus in
children: Surgical treatment and use of implanted antibiotic beads Journal of Foot and Ankle
Surgery November 1995 (Vol. 34, Issue 6, Pages 547-555)

33
ABPOPPM In-Training Exam

Module: Surgical Criteria

A 27 year-old male presents with first MTP joint pain recalcitrant to conservative care.

Based on the radiograph shown, which of the following procedures is the most appropriate to
alleviate the patient’s condition?

A. Cheilectomy
B. Joint resection
C. First MTP joint arthrodesis
D. Joint replacement
E. First metatarsal osteotomy

Correct Answer: E

Suggested Reading:

Shannon M. Rush, Jeffrey C. Christensen, Cherie H. Johnson Biomechanics of the first ray. Part
II: Metatarsus primus varus as a cause of hypermobility. A three-dimensional kinematic analysis
in a cadaver model Journal of Foot and Ankle Surgery March 2000 (Vol. 39, Issue 2, Pages 68-
77)

Thomas S Roukis, Adam S Landsman Hypermobility of the first ray: a critical review of the
literature Journal of Foot and Ankle Surgery November 2003 (Vol. 42, Issue 6, Pages 377-390)

34
ABPOPPM In-Training Exam

Module: Surgical Criteria

The interdigital lesion shown is determined to be caused by abutment of the head of the fifth
proximal phalanx against the base of the fourth proximal phalanx.

Resection of the base of the fourth proximal phalanx as an isolated procedure is NOT indicated
because it:

A. Will not resolve the problem


B. Is technically more difficult to accomplish
C. Affects the toe’s intrinsic musculature
D. Will result in long term post operative stiffness
E. Is associated with a high recurrence rate

Correct Answer: C

Suggested Readging:

Banks AS, Downey MS, Martin DE, Miller S, eds. McGlamry's Comprehensive Textbook of
Foot and Ankle Surgery. 3rd ed. New York: Lippincott, Williams & Wilkins; 2001.

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)

35
ABPOPPM In-Training Exam

Module: Surgical Criteria

The 42 year-old female shown experiences recurrent infections of the hallux. For the current
episode she has failed to respond to six days of oral dicloxacillin, 1.5 gms/day.

Which of the following is the most likely explanation?

A. The wrong antibiotic is being used


B. The medication dosage is inappropriate
C. Concomitant hallux abductus interphalangeus is present
D. The offending nail border was not removed
E. Additional time is required for the antibiotic therapy

Correct Answer: D

Suggested Reading:

Daniel CR 3rd, Daniel MP, Daniel CM, et al. Chronic paronychia and onycholysis: a thirteenyear
experience. Cutis. Dec 1996;58(6):397-401

Hochman LG. Paronychia: more than just an abscess. Int J Dermatol. Jun 1995;34(6):385-6

36
ABPOPPM In-Training Exam

Module: Surgical Criteria

Pre-operative assessment of the tibial sesamoid position shown in the radiograph is made

Which of the following best explains the purpose of this assessment?

A. Aids in determining the location of an osteotomy


B. Identifies the extent of crista erosion
C. Predicts the effect of the adductor tendon on the deformity
D. Determines the need for excision of the tibial sesamoid
E. Verifies the need for osteotomy to avoid a post operative varus

Correct Answer: C

Suggested Reading:

Banks AS, Downey MS, Martin DE, Miller S, eds. McGlamry's Comprehensive Textbook of
Foot and Ankle Surgery. 3rd ed. New York: Lippincott, Williams & Wilkins; 2001

Gerbert J, ed. Textbook of Bunion Surgery. 2nd ed. Mt Kisco, NY: Futura Publishing
Company;. 1991

37
ABPOPPM In-Training Exam

Module: Surgical Criteria

Set 1 of 2
Questions 38 and 39 relate to the following clinical scenario:

A 35 year-old male sustained the tarso-metatarsal fracture/dislocation shown on the radiograph in


a motor vehicle accident. He was an unbelted front seat passenger with his feet on the dashboard.

allergies: Eggs, codeine, and sulfa


medications: Flovent inhaler and Zyrtec
social history: tobacco, 20 pack-year, regular use of marijuana, at least
a six-pack of beer daily
employment: self-employed carpenter
recent hospitalization for an appendectomy
past medical history is remarkable for alcoholism, seasonal allergies, and asthma

Based on this history and radiographic findings, which of the following best describes the
mechanism of injury?

A. Pronation abduction
B. Supination external rotation
C. Direct bending
D. Axial loading
E. Crush forces

Correct Answer: D

Suggested Reading:

Scurran BL. Foot and Ankle Trauma. 2nd ed. New York, NY: Churchill Livingstone; 1996

Hesp WL, van der Werken C, Goris RJ. Lisfranc dislocations: fractures and/or dislocations
through the tarso-metatarsal joints. Injury. Jan 1984;15(4):261-6

38
ABPOPPM In-Training Exam

Module: Surgical Criteria

Set 2 of 2

Which of the following elements in the medical/social history would have the greatest impact on
bone healing?

A. Long-term tobacco use


B. Presence of alcoholism
C. History of asthma
D. Current medications
E. Recent appendectomy

Correct Answer: A

Suggested Reading:

Brent D. Haverstock, Vincent J. Mandracchia Cigarette smoking and bone healing: Implications
in foot and ankle surgery Journal of Foot and Ankle Surgery January 1998 (Vol. 37, Issue 1,
Pages 69-74)

Kristopher W. Krannitz, Hon W. Fong, Lawrence M. Fallat, John Kish The Effect of Cigarette
Smoking on Radiographic Bone Healing After Elective Foot Surgery Journal of Foot and Ankle
Surgery September 2009 (Vol. 48, Issue 5, Pages 525-527)

39
ABPOPPM In-Training Exam

Module: Surgical Criteria

A distal arthroplasty is planned to correct the rigid deformity shown.

Which of the following is the most appropriate incision?

A. Dorsal linear at the distal interphalangeal joint


B. Dorsal linear at the proximal interphalangeal joint
C. Transverse linear at the distal interphalangeal joint
D. Llazy "S" at the distal interphalangeal joint
E. Transverse elliptical at the distal interphalangeal joint

Correct Answer: E

Suggested Reading:

Richard T. Bouché, Eric J. Heit ;Combined Plantar Plate and Hammertoe Repair with Flexor
Digitorum Longus Tendon Transfer for Chronic, Severe Sagittal Plane Instability of the Lesser
Metatarsophalangeal Joints: Preliminary Observations Journal of Foot and Ankle Surgery
March 2008 (Vol. 47, Issue 2, Pages 125-137)

Salasche SJ, Bernstein G, Senkarik M, eds. Surgical Anatomy of the Skin. Norwalk,
Conn: Appleton & Lange; 1988

40
ABPOPPM In-Training Exam

Module: Surgical Criteria

Surgery is planned for a 52 year-old male whose significant clinical, biomechanical and
radiographic findings reveal the following:

- generalized ligamentous laxity with


splayfoot
- hammertoes 2-5
- HAV
- flexible anterior equinus (global, i.e. 1-5
rays)
- excessive transverse plane motion at the
mid tarsal joint
- relaxed calcaneal stance position of 2
degrees everted
- ankle joint dorsiflexion (knees extended)
15 degrees
- propulsive gait

First MTP joint assessment:


No crepitus in corrected or adapted position
ROM 65 degrees dorsiflexion 12 degrees plantarflexion
Hallux abductus angle: 42 degrees
Metatarsus primus adductus angle: 26 degrees
PASA: 8 degrees
DASA: 6 degrees
Metatarsus adductus angle: 12 degrees

Based on the information provided, which of the following is the most appropriate combination
of procedures?

A. Reverdin-Laird, opening Evans, fifth metatarsal osteotomy


B. Lapidus, EDL tendon transfer to metatarsal necks 2-5, hammertoe correction 2-5
C. Closing base wedge of first metatarsal, Reverdin, calcaneocuboid arthrodesis
D. First MTP joint arthrodesis, Cotton procedure, peroneus longus reefing

Correct Answer: B

Suggested Reading:

Banks AS, Downey MS, Martin DE, Miller S, eds. McGlamry's Comprehensive Textbook of
Foot and Ankle Surgery. 3rd ed. New York: Lippincott, Williams & Wilkins; 2001

Gerbert J, ed. Textbook of Bunion Surgery. 2nd ed. Mt Kisco, NY: Futura Publishing
Company;. 1991

41
ABPOPPM In-Training Exam

Module: Surgical Criteria

A 59 year-old female complaining of "bump pain" presents with the following clinical and
radiographic findings:

- first MTP joint range of motion is adequate and pain free


- radiographic values are as follows:
Hallux abductus angle: 22 degrees
Intermetatrsal angle: 13 degrees
PASA: 6 degrees
DASA: 2 degrees
Metatarsus adductus angle: 9 degrees

Based upon the information provided, which of the following procedures is most indicated?

A. Silver
B. McBride
C. Austin
D. Keller
E. Reverdin-Laird

Correct Answer: C

Suggested Reading:

Banks AS, Downey MS, Martin DE, Miller S, eds. McGlamry's Comprehensive Textbook of
Foot and Ankle Surgery. 3rd ed. New York: Lippincott, Williams & Wilkins; 2001

Gerbert J, ed. Textbook of Bunion Surgery. 2nd ed. Mt Kisco, NY: Futura Publishing
Company;. 1991

42
ABPOPPM In-Training Exam

Module: Surgical Criteria

The patient shown sustained a burn, resulting in a scar as well as limited active dorsiflexion of the
toes. Passive range of motion, however, is unrestricted and pain free.

After excision of the scar which of the following would best restore active dorsiflexion of the
toes?

A. Tendon transfer
B. Split thickness skin graft
C. Full thickness skin graft
D. Free flap
E. Transpositional graft

Correct Answer: D

Suggested Reading:

Gang Zhao, Xue-Cheng Cao, Cheng-Lin Sang, Jin-long Zheng, Jin-Fang Cai Application of a
Fasciocutaneous Free Flap for Treatment of a Severe Soft Tissue Injury of the Foot and Ankle: A
Case Report Corrected Proof, Journal of Foot and Ankle Surgery11 September 2009

Hakan Agir, Cenk Sen, Murat Onyedi Extended Lateral Supramalleolar Flap for Very Distal Foot
Coverage: A Case With Arteriovenous Malformation Journal of Foot and Ankle Surgery July
2007 (Vol. 46, Issue 4, Pages 310-313)

43
ABPOPPM In-Training Exam

Module: Surgical Criteria

A 60 year-old female underwent a bunionectomy at the age of 55 and now presents with the
clinical and radiographic findings shown. She states that only the great toe is symptomatic, and
only when wearing shoe gear. Examination reveals the hallux and lesser digital contractures to be
completely reducible.

Which of the following is most appropriate for this patient?

A. Extensor tendon lengthening


B. Hallux amputation
C. MTP joint fusion with bone graft
D. Total first MTP joint replacement
E. Transmetatarsal amputation

Correct Answer: C

Suggested Reading:

Christopher F. Hyer, Jason P. Glover, Gregory C. Berlet, Thomas H. Lee Cost Comparison of
Crossed Screws versus Dorsal Plate Construct for First Metatarsophalangeal Joint Arthrodesis ,
12 November 2007 Journal of Foot and Ankle Surgery January 2008 (Vol. 47, Issue 1, Pages 13-
18)

Clifford D. Mah, Alan S. Banks Immediate Weight Bearing Following First Metatarsophalangeal
Joint Fusion with Kirschner Wire Fixation , Journal of Foot and Ankle Surgery November 2008

44
ABPOPPM In-Training Exam

Module: Surgical Criteria

A 29 year-old active male presents with a rigid hammertoe as shown, determined to have been
caused by a history of flexor substitution.

Which of the following is the most appropriate procedure for correcting the deformity?

A. Extensor tenotomy only


B. Proximal interphalangeal (PIP) joint fusion
C. Middle phalanx resection
D. PIP joint arthroplasty
E. Flexor tendon transfer

Correct Answer: B

Suggested Reading:

Richard T. Bouché, Eric J. Heit ;Combined Plantar Plate and Hammertoe Repair with Flexor
Digitorum Longus Tendon Transfer for Chronic, Severe Sagittal Plane Instability of the Lesser
Metatarsophalangeal Joints: Preliminary Observations Journal of Foot and Ankle Surgery
March 2008 (Vol. 47, Issue 2, Pages 125-137)

AS, Downey MS, Martin DE, Miller S, eds. McGlamry's Comprehensive Textbook of Foot and
Ankle Surgery. 3rd ed. New York: Lippincott, Williams & Wilkins; 2001

45
ABPOPPM In-Training Exam

Module: Surgical Criteria

A closing base wedge osteotomy is scheduled for this patient as part of a hallux valgus repair.

Which of the following is the most important criterion in performing the osteotomy?

A. Perpendicular to the weight-bearing surface


B. Perpendicular to the long axis of the bone
C. In the middle 1/3 of the metatarsal shaft
D. Avoiding the sesamoid apparatus
E. Ensuring dorsiflexion of the distal segment

Correct Answer: A

Suggested Reading:

JM Schuberth, CH Reilly, and CJ Gudas The closing wedge osteotomy. A critical analysis of
first metatarsal elevation J Am Podiatr Med Assoc 1984 74: 13-24

SA Kempe, D Grapel, and P Hovanec A mathematical approach to closing base wedge osteotomy
J Am Podiatr Med Assoc 1984 74: 601-a-604-a

46
ABPOPPM In-Training Exam

Module: Surgical Criteria

This 82 year-old insulin dependent diabetic has recurrent ulcerations as seen. There is no
evidence of osteomyelitis. The ABI is 1.3. Excision of bone from the third metatarsal region is
suggested.

Which of the following would be the most appropriate method of treatment?

A. Excision of the bone from the third metatarsal through a dorsal excision
B. Panmetarsal head resection
C. Amputation at level of Lisfrancs joint
D. Complete bed rest and wound-vac therapy for 6 weeks
E. Debride ulcer to bleeding tissue and pack open for drainage

Correct Answer: A

Suggested Reading:.

Page Jeffrey C, Critiquing clinical research of new technologies for diabetic foot wound
management Journal of Foot and Ankle Surgery July 2002 (Vol. 41, Issue 4, Pages 251-259)

Javier La Fontaine, Damieon Brown, Moffatt Adams, Michael VanPelt New and Recurrent
Ulcerations after Percutaneous Achilles Tendon Lengthening in Transmetatarsal Amputation
Journal of Foot and Ankle Surgery May 2008 (Vol. 47, Issue 3, Pages 225-229)

47
ABPOPPM In-Training Exam

Module: Surgical Criteria

The post-operative radiograph shown was obtained immediately following skin closure and
dressing application. The patient is still under anesthesia.

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

A. Replace current screw with a shorter one


B. Apply below knee non-weight bearing cast in lieu of slipper cast
C. Continue as originally planned as the desired result has been achieved
D. Add percutaneous pin(s) for added stability
E. Reposition and re-fixate the osteotomy

Correct Answer: E

Suggested Reading:

Banks AS, Downey MS, Martin DE, Miller S, eds. McGlamry's Comprehensive Textbook of
Foot and Ankle Surgery. 3rd ed. New York: Lippincott, Williams & Wilkins; 2001

Gerbert J, ed. Textbook of Bunion Surgery. 2nd ed. Mt Kisco, NY: Futura Publishing
Company;. 1991

48
ABPOPPM In-Training Exam

Module: Surgical Criteria

A 52 year-old male has had unilateral subtalar joint pain since childhood but no ankle pain or
pain in the other pedal joints. Standard radiographs identified sclerotic changes along the subtalar
joint as well as mild osteophytic lipping along the dorsal talonavicular and navicular-cuneiform
joints on the affected side. A CT scan revealed the findings shown.

Which of the following procedures is most indicated?

A. Resection of calcaneo-navicular bar


B. Resection of tarsal coalition
C. Calcaneal osteotomy
D. Subtalar fusion
E. Triple arthrodesis

Correct Answer: D

Suggested Reading:

Joby Jacob George Malal, Gopal Hegde, Rupert D. Ferdinand Tarsal Joint Fusion Using Memory
Compression Staples—A Study of 10 Cases Journal of Foot and Ankle Surgery March 2006 (Vol.
45, Issue 2, Pages 113-117)

Christopher R. Payette, Ronald A. Sage, Joseph V. Gonzalez, Mark Sartori, Avinash Patwardhan,
Lori Vrbos Triple Arthrodesis Stabilization: A quantitative analysis of screw versus staple
fixation in fresh cadaveric matched-pair specimens Journal of Foot and Ankle Surgery November
1998 (Vol. 37, Issue 6, Pages 472-480)

49
ABPOPPM In-Training Exam

Module: Surgical Criteria

A 47 year-old female sustained an infection following a bunionectomy performed twelve weeks


ago. Her medical history is unremarkable. The last C&S taken of this wound identified "few
staph epidermitis".

Which of the following is the most appropriate treatment at this time?

A. Continue oral antibiotics and daily dressing changes of Betadine soaked gauze
B. Apply a full thickness skin graft
C. Develop an advancement flap
D. Apply a split thickness skin graft
E. Take a free flap from the groin

Correct Answer: D

Suggested Reading:

MacFarlane DF. Current techniques in skin grafting. Adv Dermatol. 2006;22:125-38

Ratner D. Skin grafting. From here to there. Dermatol Clin. Jan 1998;16(1):75-90

50