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Gavin Heyes and Lyndon Mason
Gray J, Welck M, Cullen NP, Singh D.
Functional dystonia in the foot and ankle. Bone
Joint J. 2021; 103-B:1127–1132.
56. Answer E. Tibialis posterior reconstruction,
medialising calcaneal osteotomy, gastrocnemius slide, spring ligament reconstruction
The clinical history and examination illustrate a
progressive flat foot deformity, or what is sometimes described as a Johnson and Strom type 2B
deformity (flexible flat foot with forefoot abduction). As such, correcting the tibialis posterior
tendon alone, or with combined triceps surae contracture correction (additional gastrocnemius slide
or medialising calcaneal osteotomy) will not correct
the forefoot abduction. Therefore, either a medial
column ligamentous repair (spring ligament reconstruction) or lateral column lengthening is needed
to correct the forefoot.
Only the spring ligament option is given in
this case. A Cotton osteotomy is used to correct
metatarsal elevation if a flat foot reconstruction
has resulted in a compensatory supination of the
first ray on correction. A medial double fusion
(talanavicular and subtalar joint fusion) is often
preserved for fixed/arthritic deformities or in
older patients. The corrected case can be seen in
Figure 9.7.
Heyes G, Swanton E, Vosoughi AR, Mason
LW, Molloy AP. Comparative study of spring
ligament reconstructions using either hamstring
allograft or synthetic ligament augmentation.
Foot Ankle Int. 2020;41:803–810.
Myerson MS et al. Classification and nomen-
clature: progressive collapsing foot deformity.
Foot Ankle Int. 2020;41:1271–1276.
Figure 9.7 Anteroposterior (AP) and lateral radiographs of correction flat foot deformity
204
Section 2
Chapter
10
Adult Elective Orthopaedics and Spine
Foot and Ankle II Structured SBA
Andrea Nicolas and Simon Chambers
FOOT AND ANKLE II STRUCTURED SBA
QUESTIONS
Anatomy and Biomechanics
1. During the gate cycle?
A. At toe-off, the gastrocnemius and soleus com-
plex is eccentric contracting
B. During heel strike iliopsoas is concentrically
contracted
C. Gastrocnemius and soleus complex concen-
trically contract during midstance
D. Hamstrings are concentrically contracted
during pre-swing phase
E. Tibialis anterior eccentrically contracts after
heel strike
2. Regarding the anatomy of the medial longitudinal arch?
A. During mid-stance, the medial longitudinal
arch contracts due to pronation of the forefoot
B. The deltoid and spring ligaments are the primary
restraints against pronation and valgus deformity of the foot and preserve the medial arch
C. The medial arch reaches its maximal length
during the toe off phase
D. The medial longitudinal arch is formed by two
pillars. The medial two metatarsal heads comprise the anterior pillar, and the posterior
pillar is made up of the medial third of the
navicular bone
E. The posterior tibial tendon has a primary role
in plantar ar ch maintenance
3. Which of the following statements regarding the
nerve supply to the foot is correct?
A. The lateral plantar nerve innervates the
abductor and flexor digiti minimi, the
abductor hallucis and the interossei muscles
B. The medial and lateral plantar nerves are sens-
ory branches that provide sensation to the sole
of the foot
C. The sural nerve is formed from branches of
both the tibial and common peroneal nerves,
and supplies sensation to the medial foot
D. The tibial nerve divides into the two calcaneal
branches and medial and lateral plantar nerve
at the level of the tarsal tunnel
E. The tibial nerve innervates the gastrocnemius
plantaris, sole us, popliteus, posterior tibialis,
extensor digitorum longus and extensor hallucis longus muscles
4. What structure attaches to the medial
cuneiform?
A. Extensor hallucis longus
B. Flexor digitorum
C. Peroneus brevis
D. Tibialis anterior
E. Tibialis posterior
5. What is the antagonist muscle of tibialis
anterior?
A. Extensor hallucis longus
B. Flexor hallucis longus
C. Peroneus brevis
D. Peroneus longus
E. Tibialis posterior
6. What best describes the contents of the tarsal
tunnel from anteromedial to posterolateral?
A. The flexor digitorum longus tendon, posterior
tibial tendon, the posterior tibial artery and
veins, the posterior tibial nerve and the flexor
hallucis tendon
B. The flexor hallucis tendon, the posterior tibial
tendon, the flexor digitorum longus tendon,
the posterior tibial nerve and the posterior
tibial artery and veins
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Andrea Nicolas and Simon Chambers
C. The posterior tibial nerve, the posterior tibial
artery, the posterior tibial veins, the posterior
tibial tendon, the flexor digitorum longus
tendon and the flexor hallucis tendon
D. The posterior tibial tendon, the flexor digi-
torum longus tendon, the posterior tibial
artery and veins, the posterior tibial nerve
and the flexor hallucis tendon
E. The posterio r tibial tendon, the flexor digi-
torum longus tendon, the flexor hallucis
tendon, the posterio r tibial nerve and the posterior tibial artery and veins
7. What nerve supplies the flexor hallucis brevis?
A. Deep peroneal nerve
B. Lateral calcaneal nerve
C. Lateral plantar nerve
D. Medial plantar nerve
E. Superficial peroneal nerve
8. Which statemen t is not true in regard to the
Lisfranc joint complex?
A. Lisfranc joint complex is inherently stable with
little motion due to stable osseous architecture
(keystone configuration and strong ligamentous restrain)
B. Lisfranc ligament tightens with pronation and
abduction of forefoot
C. The dorsal tarsometatarsal ligaments are
weaker and therefore bony displacement with
injury is often dorsal
D. The intermetatarsal ligaments are located
between first and fifth metatarsal bases
E. The Lisfranc ligament. It is an interosseous
ligament that originates from medial cuneiform
to base of 2nd metatarsal on plantar surface
Trauma
9. A 45-year-old male sustained a right talus fracture
following a RTA. He was tr eated conservatively in
a below knee non-weight bearing cast. Radiograph
at 8 weeks demonstrated subchondral radiolucent
band in the talar dome.
What is the most appropriate next step?
A. Arrange CT scan
B. Arrange MRI
C. Continue non-weight bearing cast for a further
6 weeks
D. Plan for core decompression
E. To commence mobilisation in a moonboot
10. A 34-year-old man fell off a ladder and sustained
a closed, intra-articular fracture of right calcaneus. He is otherwise fit and well, he is a nonsmoker.
What is the most appropriate management?
A. Close reduction and external fixation
B. Conservative management in a below knee
cast
C. Open reduction and internal fixation using a
minimally invasive approach
D. Open reduction and internal fixation using
an extended lateral approach
E. Percutaneous fixation
11. An 88-year-old woman tripped and fell in the
garden. Her radiographs are shown in Figure 10.1.
What would be the most appropriate definitive
management for this patient?
A. Application of circular frame
B. Close contact cast
206
Figure 10.1 Anteroposterior (AP) and
lateral radiographs ankle
Foot and Ankle II Structured SBA
C. Open reduction and internal fixation of lateral
malleolus through a direct lateral approach
D. Open reduction and internal fixation of lat-
eral, medial and posterior malleolus through
a posterolateral and direct medial approach
E. Open reduction and internal fixation of lat-
eral, medial and posterior malleolus through
a posteromedial and direct lateral approach
12. A 25-year-old male sustained a fracture dislocation of the talus with subtalar and tibiotalar
dislocation.
According to Hawkins classification this is?
A. Hawkins I
B. Hawkins II
C. Hawkins III
D. Hawkins IV
E. Hawkins V
13. A 24-year-old female fell 3 steps and sustained an
injury to her left foot. At presentation she has a
grossly swollen foot with plantar ecchymosis.
Initial X-rays in ED do not demonstrate any
obvious injury.
What is the next step in managing this patient?
A. Moonboot and review in fracture clinic in 4
weeks
B. Moonboot, advice and discharge to
physiotherapy
C. MRI
D. Stress view X-rays
E. Weight-bearing X-rays
Ankle
14. A 25-year-old fit and well woman presents 3
months following inversion injury while walking
up a steep hill. She describes instability symptoms.
What is most likely ligament injured?
A. Anterior inferior tibiofibular ligament
B. Anterior talar fibular ligament
C. Calcaneofibular ligament
D. Posterior inferior tibiofibular ligament
E. Posterior talar fibular ligament
15. A 47-year-old male pr esents to the ED with difficulty
walking. He describes an injury while playing tennis
2 months ago with pain and difficulty walking on the
right side. On examination he mobilises with a limp,
he has a wasted right calf and squeeze calf test elicits
minimal ankle plantarflexion.
What would be the most appropriate next step?
A. MRI scan
B. Physiotherapy
C. Plain radiographs
D. Referral to foot and ankle surgeon for surgi-
cal repair
E. Ultrasound scan
16. A 34-year-old male presents to the clinic with a
chronic (3 months) history of an Achilles tendon
rupture. Ultrasound scan has confirmed an 8cm
gap between the edges. He is keen to resume
sporting activities.
The most appropriate management would be?
A. Direct surgical repair
B. Functional orthotic treatment
C. Reconstruction with ipsilateral flexor hallucis
longus
D. Reconstruction with ipsilateral hamstring
autograft
E. Reconstruction with V to Y advancement
17. A 68-year-old male presents to clinic complain-
ing of severe left ankle pain. It is limiting his
ability to walk more than 200 yards. He is a
retired policeman who enjoys gardening and
walks. He suffers from mild asthma, hypertension and hypercholesterolaemia. Radiographs are
shown in Figure 10.2.
What is the most appropriate treatment?
A. Analgesia and physiotherapy
B. Ankle arthrodesis
C. Ankle arthroscopy
D. Fixed bearing total ankle arthroplasty
E. Mobile bearing total ankle arthroplasty
18. A 22-year-old man sustained an inversion injury
to his right ankle in dorsiflexion with axial
loading while playing football. He complains of
ankle pain and swelling but is able to weight bear.
X-rays show no obvious fracture.
The most likely pathology would be?
A. Osteochondral lesion of the lateral distal tibia
B. Osteochondral lesion of the lateral talus
C. Osteochondral lesion of the medial distal tibia
D. Osteochondral lesion of the medial talus
E. Osteochondral lesion of the posterior talus
207
Andrea Nicolas and Simon Chambers
Figure 10.2
Anteroposterior
(AP) radiograph
ankle
19. During the ant erior approach to the ankle
A. Careful dissection must be taken to avoid
damage of the deep peroneal nerve at the
distal end of the incision
B. Careful dissection must be taken to avoid
damage of the superficial peroneal nerve at
the distal end of the incision
C. Deep dissection is between tibialis anterior
and FHL to avoid damage to the neurovascular bundle
D. Deep dissection is taken through the sheath
of FHL to avoid damage to the neurovascular
bundle
E. The incision is made lateral to EDL tendon
D. Silfverskiöld test
E. Single heel raise
21. A 45-year-old female presents for the first time
to an elective foot and ankle clinic complaining
of pain over the medial aspect of the right foot.
On clinical examination she has a valgus deformity of the hindfoot, medial longitudinal arch collapse and abduction of the midfoot.
According to Johnson and Strom classification
this patient is?
A. Stage I
B. Stage IIA
C. Stage IIB
D. Stage IVA
E. Stage IVB
22. A 67-year-old female presents to your clinic. You
observe she is wearing insoles (Figure 10.3).
Figure 10.3
Insoles
Hindfoot and Forefoot
20. A 45-year-old female presents with pain on both
feet when walking, left worse than right. She
states she has to change shoes regularly as she
wears off the lateral side of the shoe. Her mother
had similar problems.
What would be the most appropriate clinical test
to be performed in clinic to aid management?
A. Anterior drawer test
B. Coleman block test
C. Nerve conductive studies
208
What is the most likely diagnosis?
A. Flexible cavovarus foot
B. Hallux rigidus
C. Hallux valgus
D. Plantar fasciitis
E. Stage 1 posterior tibial tendon insufficiency
23. From the options listed below please choose the
one that best describes a claw toe.
A. Lesser toe deformity characterised by MTP
flexion with PIP hyperextension and DIP flexion
Foot and Ankle II Structured SBA
B. Lesser toe deformity characterised by PIP
flexion, DIP flexion and MTP flexion
C. Lesser toe deformity characterised by hyper-
flexion of the DIP joint with a normal MTPJ
and PIP
D. Lesser toe deformity characterised by MTP
hyperextension with PIP and DIP flexion
E. Lesser toe deformity characterised by PIP
flexion, DIP extensionand MTP slight extension
24. A 32-year-old female presents complaining of
pain and burning sensation over the third and
fourth toes.
What is the most appropriate management?
A. Corticosteroid injection in clinic
B. Metatarsal bar
C. Physiotherapy
D. Surgical excision
E. Ultrasound guided injection
25. What is the optimal position for first MTPJ
arthrodesis?
A. 0° of valgus and 15° of dorsiflexion with
neutral rotation
B. 0° of valgus and dorsiflexion
C. 10–15° of valgus and neutral dorsiflexion and
rotation
D. 10 –15° of valgus, 15° of dorsiflexion and neu-
tral rotation
E. 10–15° of varus and 15° of dorsiflexion and
neutral rotation
26. A 46-year-old female presents with pain at the
first MTPJ. She has difficulty finding appropriate
shoe wear and the pain is affecting her mobility.
Weight bearing X-rays reveal a distal articular
metatarsal angle of 8°, an intermetatarsal angle
of 14° and a hallux valgus angle of 36°.
What is the most appropriate management?
A. Chevron osteotomy +/ Akin osteotomy
B. Lapidus procedure
C. Modified McBride and medial eminence
resection
D. Scarf osteotomy +/ Akin osteotomy
E. Shoe modification and orthoses
27. The Hallux valgus angle is:
A. The angle created between the lines that lon-
gitudinally bisect the proximal phalanx of the
first metatarsal and the proximal phalanx of
the second metatarsal
B. The angle created between the lines that lon-
gitudinally bisect the proximal phalanx and
the first metatarsal
C. The angle drawn between the first and second
metatarsal shaft on an axial view of the foot
D. The angle drawn be tween the long axis of the
distal phalanx and proximal phalanx
E. The angle drawn between the longitudinal
axis and the articular surface of the first
metatarsophalangeal joint
Diabetes
28. A 46-year-old male presents to diabetic clinic
with a 4-month history of a plantar foot ulcer.
He has a good palpable pulse but no sensation to
the sole of the foot. He is systemically well, denies
fevers. Bloods taken on admission showed a CRP
of 4 and WCC of 11.
What is the most appropriate management?
A. Charcot restrain orthotic walker
B. Close contact cast
C. Six weeks of broad-spectrum antibiotics and
close contact cast
D. Surgical debridement, regular dressings and
prolonged course of antibiotics
E. Surgical debridement, tissue samples and
targeted antibiotics
29. A 56-year-old diabetic male presents to clinic
with a warm, swollen and erythematous left
foot.
X-rays demonstrated multiple joint dislocations on the midfoot.
A. Stage 1 Fragmentation
B. Stage 2 Coalescence
C. Stage 2 Fragmentation
D. Stage 3 Coalescence
E. Stage 3 Reconstruction
30. A 62-year-old male has been referred for vascular
assessment.
Regarding the ankle brachial index:
A. It consists of the ratio between the diastolic
blood pressure of the lower extremity, specifically the ankle, and the upper extremity.
Normal value is between 0.9–1.4
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Andrea Nicolas and Simon Chambers
B. It consists of the ratio between the diastolic
blood pressure of the lower extremity, specifically the ankle, and the upper extremity.
Normal value is <0.9
C. It consists of the ratio between the systolic
blood pressure of the lower extremity, specifically the ankle, and the upper extremity.
Normal value is <0.9
D. It consists of the ratio between the systolic
blood pressure of the lower extremity, specifically the ankle, and the upper extremity.
Normal value is >1.4
E. It consists of the ratio between the systolic
blood pressure of the lower extremity, specifically the ankle, and the upper extremity.
Normal value is between 0.9–1.4
31. A 29-year-old female presents to ED with a painful swollen right foot. She is a type 1 diabetic.
Bloods reveal a CRP 211, WCC 16. She has a
large ulcer on the dorsum of her foot with significant cellulitis up to the mid calf. She is very
tender. Radiographs confirmed ost eomyelitis on
the cuboid and 5th metatarsal. She has a temperature of 38.7°.
What is the most appropriate next step?
A. Below knee amputation
B. IV antibiotics
C. Oral antibiotics and urgent referral to the
diabetic foot clinic
D. Radical debridement
E. Urgent podiatry review
32. A 48-year-old female presents to an elective foot
and ankle clinic complaining of pain over the
medial aspect of the right foot. On clinical examination she has a valgus def ormity of the hindfoot, medial longitudinal arch collapse and
abduction of the midfoot.
What would be the most appropriate management for the patient?
A. Conservative management with orthoses
B. Medial calcaneal osteotomy, FDL tendon
transfer and spring ligament reconstruction
C. Medial calcaneal osteotomy, gastrocnemius
recession, FDL tendon transfer, spring ligament
reconstruction and opening wedge medial
cuneiform osteotomy (Cotton osteotomy)
D. Medial calcaneal osteotomy, tibialis posterior
tendon transfer and spring ligament
reconstruction
E. Triple arthrodesis
210
FOOT AND ANKLE II STRUCTURED SBA
ANSWERS
Anatomy and Biomechanics
1. Answer E. Tibialis anterior eccentrically con-
tracts after heel strike
In midstance the amount of forward movement is
restrained by eccentric contraction of the gastrocnemius soleus complex
During heel strike iliopsoas is inactive, hamstrings are inactive during pre-swing phase.
Immediately after heel-strike, the dorsiflexors
‘pay out’ eccentrically to lower the rest of the foot
to the ground.
At toe-off, the gastrocnemius and soleus complex is concentrically contracting.
With the third rocker the heel begins to lift
under the powerful concentric contraction of the
gastrocnemius soleus complex.
When a muscle contracts concentrically, the
muscle–tendon unit shortens and kinetic energy
is released. When contracting eccentrically the
overall unit lengthens and energy is stored.
Foot and Ankle II Structured SBA
compartment of the leg and innervates gastrocnemius plantaris, soleus, popliteus, posterior tibialis,
flexor digitorum longus, and flexor hallucis longus
muscles. It travels along the medial aspect of the
Achilles tendon and passes under the flexor retinaculum into the tarsal tunnel, where it divides into
its terminal branches: the calcaneal nerve branches
that provide sensory innervation to the heel, and
the medial and lateral plantar nerves. The medial
plantar nerve innervates the abductor hallucis,
flexor digitorum brevis, and flexor hallucis brevis
muscles. The lateral plantar nerve innervates the
abductor and flexor digiti minimi, the adductor
hallucis, and the interossei muscles. Both branches
also provide sensory innervation to the sole of the
foot. The sural nerve is formed from branches of
both the tibial and common peroneal nerves, and
supplies sensation to the lateral foot.
2. Answer B. The deltoid and spring ligaments are
the primary restraints against pronation and
valgus deformity of the foot and preserve the
medial arch
The medial longitudinal arch is formed by two
pillars (anterior and posterior pillars). The anterior pillar is formed by the medial three metatarsal
heads, and the posterior pillar comprises the calcaneal tuberosity. The deltoid and spring ligaments are the primary restraints against
pronation and valgus deformity of the foot and
preserve the medial arch. The posterior tibial
tendon has a secondary role .
Babu D, Bordoni B. Anatomy, Bony Pelvis
and Lower Limb, Medial Longitudinal Arch of the
Foot. Treasure Island (FL): StatPearls Publishing;
2022.
3. Answer D. The tibial nerve divides into the two
calcaneal branches and medial and lateral plantar nerve at the level of the tarsal tunnel
The tibial nerve is one of the two main terminal
branches of the sciatic nerve. It originates from the
lumbo-sacral plexus. It travels in the posterior
Figure 10.4 Anatomy of the tibial nerve
4. Answer D. Tibialis anterior
The tibialis anterior attaches to the medial cuneiform. Tibialis anterior muscle is the primary ankle
dorsiflexor. It originates on the proximal twothirds of the lateral surface of the tibia and
attaches to the medial cuneiform and base of the
first metatarsal. It is the most medial tendon of the
foot and ankle. It plays a critical role during the
211
Andrea Nicolas and Simon Chambers
swing phase on the gate cycle, as dorsiflexion is
essential to safely clear the foot during this phase.
Olewnik Ł, Podgórski M, Polguj M, Topol M.
A cadaveric and sonographic study of the morphology of the tibialis anterior tendon – a proposal
for a new classification. J Foot Ankle Res. 2019;12.
doi: 10.1186/s13047-019-0319-0.
Thielen M, Waible D, Krautwurst BK, Wolf
SI, Dreher T. Effects of artificially induced bilat-
eral internal rotation gait on gait kinematics and
kinetics. Gait Posture 2022;95:204–209.
5. Answer C. Peroneus brevis
The tibialis posterior muscle, originates from the
posterior aspect of the proximal tibia and fibula
and the interosseous membrane. It is the deepest
muscle of the deep posterior compartment of the
lower leg. It inserts on the navicular tuberosity,
cuneiforms, cuboid, 2–4 metatarsals, and sustentaculum tali of calcaneus. Its main function is
inversion of the foot and adduction of the forefoot. Its principal antagonist is the peroneus brevis, which no rmally everts the subtalar joint and
abducts the forefoot.
6. Answer D. The posterior tibial tendon, the flexor
digitorum longus tendon, the posterior tibial
artery and veins, the posterior tibial nerve and
the flexor hallucis tendon
The boundaries of the tarsal tunnel: the superior
border is formed by the medial malleolus, the
anterior border is the tibia, the posterior process
of the talus forms the posterior border, the calcaneus forms the lateral border, the inferior border
is formed by the abductor hallucis and the flexor
retinaculum which extends from the medial malleolus to the medial calcaneus and prevents medial
displacement of its contents.
Yang Y et al. Fine dissection of the tarsal
tunnel in 60 cases. Sci Rep. 2017;7:46351.
doi:10.1038/srep46351. Erratum in: Sci Rep.
2021;11.
Porter DA, Schon LC. Functional nerve dis-
orders and plantar heel pain. In Baxter’s The Foot
and Ankle in Sport, 3rd Ed., 224–229. Elsevier;
2020.
7. Answer D. Medial plantar nerve
The medial plantar nerve innervates the flexor
hallucis brevis, the flexor digitorum brevis, the
abductor hallucis and the second and third lumbrical. It also supplies the sensation of the three
and a half digits of the sole of the foot and the
medial part of the sole, excluding the heel pad
(innervated by medial calcaneal nerve, a branch
of the tibial nerve).
8. Answer C. The dorsal tarsometatarsal ligaments
are weaker and therefore bony displacement
with injury is often dorsal
The statement ‘the intermetatarsal ligaments are
located between first and fifth metatarsal bases’ is
not true. The intermetatarsal ligaments run
between the first and fifth metatarsal base. There
is no intermetatarsal ligamentous attachment
between the first and second metatarsal. The dorsal
ligament is the smallest with the plantar ligament
being twice as large. Being the smallest, it is also the
most common ligament damaged during injury
with subsequent dorsal bony displacement. The
intermetatarsal ligament is the largest, with the
greatest height, width and cross-sectional area.
Johnson A, Hill K, Ward J, Ficke J. Anatomy
of the lisfranc ligament. Foot Ankle Spec.
2008;1:19–23.
Mason L et al. Anatomy of the lateral plantar
ligaments of the transverse metatarsal arch. Foot
Ankle Int. 2020;41
1071100719873971.
Moracia-Ochagavía I, Rodríguez-Merchán
EC. Lisfranc fracture-dislocations: current man-
agement. EFORT Open Rev. 2019 ;4:430–444.
de Pa lma L, Santucci A, Sabetta SP, Rapali S.
Anatomy of the Lisfranc joint complex. Foot Ankle
Int. 1997;18:356–364.
:109–114. doi:10.1177/
Trauma
9. Answer E. To commence mobilisation in a
moonboot
This SBA deals with Hawkins sign and AVN.
When the Hawkins sign (subchondral radiolucent
band in the talar dome) is present on AP radiographs at 6–8 weeks, this suggests that the blood
supply to the talus had been preserved and avascular necrosis is unlikely to develop (Donelly 1999).
The radiolucent band resulted from increased bone
resorption relative to bone formation and it manifests with active hyperaemia of the bone.
212
Foot and Ankle II Structured SBA
Tezval et al. (2007) reported that the Hawkins
sign was a good indicator of talus vascularity
following fracture. If a full or partial positive
Hawkins sign was detected, it was unlikely that
AVN would develop at a later stage after injury.
Chen et al. (2014) found the Hawkins sign to
be a reliable predictor of AVN development and
suggested that MRI at 12 weeks might be valuable
to identify early AVN in patients who have a
negative Hawkins sign.
The Hawkins classification of talar neck fractures is based on the amount of displacement and
the associated dislocations or subluxations.
Type 1: Undisplaced fracture with no
associated joint dislocation is associated with
less than 15% risk of AVN.
Type 2: Talar neck fracture with associated
dislocation or subluxation of the subtalar joint.
Risk of AVN is 42%.
Type 3: Talar neck fracture with dislocation of
the talar body from both the ankle and
subtalar joints. Risk of AVN is 91%.
Type 4: The classification was later modified
by Canale and Kelly (1978) (not included in
Hawkin’s original paper). Type 4 implies
associated dislocation not only of the tibiotalar
and subtalar joints but also dislocation of the
talar head from the talonavicular joint. The
rate of AVN is quoted at 100%.
Canale ST, Kelly FB Jr. Fractures of the neck of
the talus: long-term evaluation of seventy-one
cases. J Bone Joint Surg Am. 1978;60:143–156.
Chen H, Liu W, Deng L, Song W. The prog-
nostic value of the Hawkins sign and diagnostic
value of MRI after talar neck fractures. Foot Ankle
Int. 2014;35:1255–1261.
Donnelly EF. The Hawkins sign. Radiology
1999;210:195–196.
Tezval M, Dumont C, Stürmer KM.
Prognostic reliability of the Hawkins sign in fractures of the talus. J Orthop Trauma.
2007;21:538–543.
10. Answer B. Conservative management in a
below knee cast
A multicentre randomised controlled trial of 151
patients comparing surgical and non-surgical
management of displaced, closed intraarticular
fractures of calcaneus demonstrated a similar
functional and symptomatic outcome between
both groups but a higher risk of complication
following operative fixation. Therefore, surgical
fixation it is not recommended for such
fractures.
Griffin D et al.; UK Heel Fracture Trial
Investigators. Operative versus non-operative
treatment for closed, displaced, intra-articular
fractures of the calcaneus: randomised controlled
trial. Br Med J 2014;349:g4483.
Lack of Hawkins sign with sclerosis is indicative of
AVN. In clinical practice, the Hawkins sign is
strongly predictive of the absence of AVN.
However, the sign has high sensitivity and low
specificity, so that its absence does not universally
predict AVN.
Five major vessel sources enter the talus in the
area of the talar neck. The extraosseous blood
supply comes from three arteries: the posterior
tibial artery, the anterior tibial artery and the
perforating peroneal artery. The main artery supplying blood to the body of the talus is the artery
of the tarsal canal. An anastomotic ring around
the inferior neck of the talus is formed by the
artery of the tarsal canal and the artery of the
tarsal sinus, but the body of the talus tends to have
limited intraosseous anastomosis so that interruption of any vessel may lead to areas of bone necrosis in the distribution of that vessel.
11. Answer B. Close contact cast
The AIM trial, a multicentre randomised controlled trial comparing close contact cast vs
open reduction and internal fixation in the
management of unstable ankle fracture in adults
over 60 years of age, demonstrated clinical
equivalent outcomes of close contact cast and
ORIFbutatareductionincost.TheORIF
group had a higher incidence of infection and
return to theatre while the CCC group had a
higher incidence of malunion and non-union of
the medial malleolus.
12. Answer C. Hawkins III
The Hawkins classification is still one of the most
widely used and accepted classifications for talar
neck fractures (Hawkins 1970). It is based on
displacement and dislocation, and therefore, presumed damage to the blood supply of the talus.
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