PC Treatment Planning & Management 3 — Questions and Answers
Question 1: A patient with Type 2 diabetes has an ABI of 0.55 and a non-healing plantar ulcer. What is the next most critical step in treatment planning?
- Start systemic antibiotics and observe for 4 weeks
- Refer for vascular evaluation and possible revascularization (Correct answer)
- Apply total contact cast immediately
- Perform bedside surgical debridement and discharge
Correct answer: Refer for vascular evaluation and possible revascularization
An ABI of 0.55 indicates moderate-to-severe peripheral arterial disease; revascularization assessment is critical before other wound care strategies can succeed.
Question 2: In planning surgical correction of a flexible hammertoe at the proximal interphalangeal joint (PIPJ), which procedure is most appropriate?
- DuVries arthroplasty (condylectomy)
- Jones tenosuspension
- PIPJ arthrodesis with K-wire fixation (Correct answer)
- Girdlestone-Taylor flexor-to-extensor tendon transfer only
Correct answer: PIPJ arthrodesis with K-wire fixation
For a flexible hammertoe with an acceptable long-term outcome goal, PIPJ arthrodesis with K-wire fixation corrects the deformity rigidly and has lower recurrence than arthroplasty.
Question 3: Which total contact cast (TCC) application principle is most important to prevent iatrogenic ulceration in a neuropathic patient?
- Applying the cast with maximum pressure to limit edema
- Using stockinette and felt padding to protect bony prominences before casting (Correct answer)
- Applying fiberglass directly over the foot without padding
- Leaving the heel exposed for wound monitoring
Correct answer: Using stockinette and felt padding to protect bony prominences before casting
Stockinette and felt padding over malleoli, metatarsal heads, and other bony prominences redistribute pressure and prevent cast-induced skin breakdown in insensate patients.
Question 4: A patient with gout has a first MPJ with acute swelling, erythema, and crystals confirmed on aspiration. Initial treatment should be:
- Corticosteroid injection into the joint, oral colchicine or NSAIDs, and activity rest (Correct answer)
- Urate-lowering therapy (allopurinol) started immediately during the acute attack
- Surgical excision of the tophus within 48 hours
- Ice only with no pharmacologic treatment
Correct answer: Corticosteroid injection into the joint, oral colchicine or NSAIDs, and activity rest
Acute gout is managed with anti-inflammatory therapy (colchicine, NSAIDs, or corticosteroids) and joint rest; urate-lowering agents should not be initiated during an acute attack as they can prolong inflammation.
Question 5: When planning a calcaneal osteotomy for symptomatic adult-acquired flatfoot, a medializing calcaneal osteotomy (Koutsogiannis) achieves correction by:
- Lengthening the lateral column of the foot
- Shifting the calcaneal tuberosity medially to realign the Achilles pull under the tibia (Correct answer)
- Fusing the subtalar joint
- Transferring the flexor digitorum longus to the navicular
Correct answer: Shifting the calcaneal tuberosity medially to realign the Achilles pull under the tibia
The medializing calcaneal osteotomy shifts the weight-bearing axis of the Achilles tendon medially, reducing valgus stress on the PTT and correcting hindfoot valgus.
Question 6: For a patient with plantar fasciitis failing 6 months of conservative treatment, what is the most appropriate next intervention?
- Immediate surgical plantar fascia release
- Extracorporeal shockwave therapy (ESWT) (Correct answer)
- Repeat corticosteroid injection series (5 injections)
- Casting in plantar flexion
Correct answer: Extracorporeal shockwave therapy (ESWT)
ESWT is recommended after failure of 6 months of conservative care as a minimally invasive option with strong evidence before surgical intervention is considered.
Question 7: In managing a Charcot neuroarthropathy foot (Eichenholtz Stage I), the primary treatment goal is:
- Surgical reconstruction of the arch immediately
- Immobilization to prevent further fragmentation and deformity progression (Correct answer)
- Weight bearing as tolerated with supportive shoes
- Amputation to prevent septic arthritis
Correct answer: Immobilization to prevent further fragmentation and deformity progression
Eichenholtz Stage I (development/fragmentation) requires strict offloading — typically with a total contact cast — to halt the destructive process before consolidation can occur.
PC Treatment Planning & Management 3
A patient with Type 2 diabetes has an ABI of 0.55 and a non-healing plantar ulcer.
What is the next most critical step in treatment planning?