Practice Perfect 678
Teachable Moments Session 1- Results from the 2019 Residency Rumble

One of the most important parts of residency training is receiving feedback on one’s performance. Without feedback, we never know our deficiencies and what we need to do to improve. Knowledge is also an incredibly important part of being a podiatrist. Acting on our patients’ behalf using well-honed technical skills and a deep knowledge of medicine is what makes a doctor a physician and not just a technician.

Imagine my excitement, then, when the folks from PRESENT e-Learning Systems suggested an excellent opportunity to provide feedback to our nation’s residents. This year’s 2019 Residency Rumble competitions took place at the Residency Education Summits East and Midwest that took place in August and September, as they have for the last eight years. During the competitions, those of us in attendance noticed there were some questions that resulted in a lower correct number of answers from the majority of teams. Like any good exam, it showed us what these residents didn’t know. Let’s use this opportunity to create a new ongoing series of the Practice Perfect editorial called “Teachable Moments.” In this series, we’ll take a look at some of the questions that were more commonly answered incorrectly and how one might derive the correct answers. We’ll review no more than 3-4 questions each session to keep the cognitive load relatively low, and I’ll chose to review well-written questions that resulted in less than 50% correct answers.

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Without further adieu here are the first three Teachable Moments questions.

Question 1

A 9-year-old male is presented for evaluation of right foot in-toeing.

 Examination findings on the right demonstrate:

  • Hip rotation (extended) 42 degrees internal 28 degrees external
  • Hip rotation (flexed) 42 degrees internal 40 degrees external
  • Malleolar position 19 degrees external
  • Metatarsus adductus angle 10 degrees

Which of the following is the most likely etiology of the in-toeing?

Possible answers:

  1. Femoral antetorsion
  2. Tight hip capsular ligaments
  3. Insufficient tibial torsion
  4. Metatarsus adductus

Correct answer: B - Tight hip capsular ligaments

Explanation: It’s a little concerning that only 7% of residents got this one correct considering it’s a biomechanics question. Let’s talk about in-toeing. Recognition of in-toeing is generally obvious, but the important part is determining the etiology of the internally rotated foot position (ie from where the in-toeing is derived), which is the skill this question is examining. It’s most convenient to break the etiologies down into anatomic sections, understanding that the internal rotation can come from the hip, femur, tibia, or foot. It’s our job to figure out which location is the cause (remembering that it’s possible to have more than one contributing etiology).

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When I’m confronted with a patient with this complaint, I start my examination with the patient standing, looking first at the patellar position. If the patella is in a rectus position (in the sagittal plane), but the foot is rotated inward, then the in-toeing comes from distal to the femur/hip (tibia or foot). If the patella is internally rotated, then the femur, hip, or both are the cause (the patella moves with the femur). In the case of the quiz question, we don’t know where the patella sits. What we do know is that the malleolar position and metatarsus adductus measurements are normal, so the in-toeing can’t come from these locations. This eliminates two of the possible answer choices.

If we think the internal position of the foot is due to the hip or femur, then examination of hip rotation is imperative. The information provided describes a hip joint that is internally rotated when the hip is extended and normalizes when the hip is flexed. Flexing the hip and then checking internal and external rotation relaxes the soft tissue structures around the anterior aspect of the hip. This situation is only possible if the capsular structures are tight, which is why this is the correct answer.

Let’s finish this one off with a couple of quick comments about femoral antetorsion. Recall first that torsion refers to the twist of the femur and version is the position of the femoral head and neck in the acetabulum of the pelvis. If the clinician measured normal internal and external hip rotation (measuring version), and malleolar position and metatarsus adductus measurements were also normal, then one must assume femoral torsion is abnormal, making the diagnosis of femoral antetorsion. Without using special radiographic views, femoral antetorsion is a diagnosis of exclusion. By the way, for those of you interested in treating this pathology, gait plates have been found to be effective in improving the “appearance” of the lower extremity (ie normalizing the angle of gait)1.

Question 2

A 51-year-old male presents with a painful, hot, swollen right great toe joint. Medications include hydochlorothiazide (Microzide) and losartan (Cozaar) for HTN. Radiograph is shown. Which of the following is the most likely etiology?

Possible answers:

  1. Renal insufficiency
  2. Hepatic dysfunction
  3. Adverse effect of diuretic
  4. Septic arthritis

Correct answer: C - Adverse effect of diuretic.

Explanation: This question seems straightforward, which is why I was surprised to see only 28% of residents getting this correct. What’s the primary diagnosis of a “red, hot, swollen” first MTP joint? Gout, septic joint, and cellulitis are possible. Charcot would be very rare (and this patient doesn’t have diabetes). Infections don’t commonly occur in the foot without an opening in the skin, and hematogenous spread is vanishingly rare. This patient has no history of ulcer so sepsis is highly unlikely. Additionally, the radiographs show joint erosions and not periostitis – the classic Martel’s sign. The history and radiograph make the diagnosis of gout. Hepatic dysfunction is unlikely to cause gout. That leaves us two possible answers.

Renal insufficiency is absolutely possible as a cause of gout (a major cause of gout due to underexcretion of uric acid), but the question stem gives us no information that would lead us to a diagnosis of renal insufficiency. The stem does tell us the patient is on two antihypertensive medications, and we know these medications, especially thiazide diuretics commonly cause gout – and there’s the answer! Here’s an ACFAS consensus statement2 for further study.

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Question 3

A 60-year-old female with RA presents with the painful right foot, shown. History is significant for long-term high-dose corticosteroid use. Which of the following is the most appropriate perioperative management?

Possible answers:

  1. Discontinue corticosteroids preoperatively
  2. Maintain the same dosage and regimen of corticosteroids
  3. Reduce corticosteroid dosage 1 week preoperatively and 1 week postoperatively
  4. Increase corticosteroid dosage on the day of surgery

Correct answer: D - Increase corticosteroid dosage on the day of surgery

Explanation: I can’t help but disagree with the stated correct answer, due to new evidence that I am aware of.  In the past, increasing the steroid dose perioperatively to prevent cardiovascular collapse resulting from hypothalamic pituitary axis depression would have been correct, making D the proper answer. However, new research has found this to be false. Current evidence suggests answer B – maintaining the same dose and regimen of corticosteroids – to be the best choice3,4,5,6,7. Answers A and C are clearly wrong; removing the steroid entirely or reducing the dose has never been an appropriate method. It is also now reasonably well established that stress dosing of corticosteroids perioperatively is not necessary. For those who want more detail, read the five references below on this topic.

And lest I be accused of bashing ABPM that does generously provide these questions for the Rumble each year, I realize that though they seek to keep all questions clinically relevant based on the most current evidence, it is a moving target and providing so many exam questions each year that are current and up to date is a huge task, which they largely do a great job with. PRESENT has told me that the Rumble questions are from past ABPM in-training exams that are most likely never used again. Based on these findings, they now have new evidence for one more question to re-consider for future use.

Desert Foot 2019

As in all things academic, I hope this discussion prods all of our residents to read more into these interesting and important topics.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
jarrod@podiatry.com
References
  1. Ganjehie S, Saeed H, Farahmand B, and Curran S. The efficiency of gait plate insole for children with in-toeing gait due to femoral antetorsion. Prosthet Orthot Int. 2017;41(1):51-57.
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  2. Mirmiran, R, Bush T, Cerra MM, Grambart S, Kauschinger E, Younger M, Zychowicz M. Joint Clinical Consensus Statement of the American College of Foot and Ankle Surgeons® and the American Association of Nurse Practitioners: Etiology, Diagnosis, and Treatment Consensus for Gouty Arthritis of the Foot and Ankle. J Foot Ankle Surg. 2018 Nov – Dec:57(6):1207-1217.
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  3. Garcia JEL, Hill GE, Joshi GP. Perioperative Stress Dose Steroids: Is It Really Necessary? ASA Newsletter. 2013;77(11):32-35.
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  4. Marik PE, Varon J. Requirement of perioperative stress doses of corticosteroids: a systematic review of the literature. ArchSurg. 2008 Dec;143(12):1222-1226.
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  5. Kelly KN, Domajnko B. Perioperative Stress-dose steroids. Clin Colon Rectal Surg. 2013 Sep;26(03):163-167.
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  6. MacKenzie CR, Goodman SM. Stress dose steroids: myths and perioperative medicine. Curr Rheumatol Rep. 2016;18(7):47.
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  7. Chilkoti GT, Singh A, Mohta M, Saxena AK Perioperative “stress dose” of corticosteroid: Pharmacological and clinical perspective. J Anaesthesiol Clin Pharmacol. 2019 Apr-Jun;35(2):147-152.
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