Practice Perfect 681
Teachable Moments Series Part 2: Results from the 2019 Residency Rumble

Welcome all! Class is in session. You might recall we recently began a new ongoing Practice Perfect series called Teachable Moments, where we look at questions from this year’s Residency Rumble competitions, focusing on the ones that a majority of residents answered incorrectly. Let’s fill in some education gaps and all get a little smarter as a result by examining a few more questions. Whether you are studying in anticipation of taking a board exam or are an active lifelong learner just like most physicians, this blog should help you in those pursuits.

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Question 1: A 29-year-old female s/p second metatarsal fracture has been immobilized in a below the knee cast for two months. Initial pain relief was noted, but for the last six weeks, increasing pain has developed. All the following are appropriate treatment options EXCEPT?

  1. Antidepressants
  2. Local nerve blocks
  3. Immobilization
  4. Steroids

Correct answer: C

Explanation: The stem question here is a little vague, and I believe the reason almost half of responds indicated “steroids” rather than the correct answer “C”, immobilization, is because they were thinking the diagnosis was a nonunion of the metatarsal fracture, rather than complex regional pain syndrome (CRPS). Looking back in hindsight, the question’s authors appear to be thinking the diagnosis is CRPS, and immobilization would be the last treatment we’d want for someone with this diagnosis. Here are two good review articles on CRPS.1,2

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Question 2: A 62-year-old male presents five hours s/p falling with right foot pain. Examination reveals tented and blanched skin at the first TMTJ; tibialis anterior strength is 4/5; protective sensation is intact, and DP pulse is palpable. Post-reduction radiograph is shown.

Which of the following conditions justifies emergent ORIF in this case?

  1. Deep peroneal nerve injury
  2. Partial rupture of the anterior tibialis tendon
  3. Soft tissue devitalization
  4. Compartment syndrome

Correct answer: C

Explanation: I was surprised that exactly zero percent of resident competitors got the correct answer here. Examining the radiograph, one can see the dorsally dislocated 1st tarsometatarsal joint. The palpable pulses and intact sensation eliminate compartment syndrome, while the 4/5 tibialis anterior strength wouldn’t be surprising in a trauma case, especially when the insertion of the tendon is so near the dislocated joint. There’s nothing in the stem that would hint at a deep peroneal nerve injury, but the stem gives us the answer. “Tented and blanched skin” will lead to tissue devitalization, which is why this case needs operative intervention immediately. Here’s an interesting, current review on complex injury management of the foot.3

Question 3:  A 17-year-old male presents for the inability to dorsiflex and invert his foot after motor vehicle accident where his left foot was crushed between the car seats. Which of the following is the antagonist of the tendon ruptured?

  1. Tibialis anterior
  2. Extensor hallucis longus
  3. Peroneus longus
  4. Tibialis posterior

Correct answer: C

Explanation: Answering this question correctly requires understanding of two concepts: functional anatomy of the foot to realize the ruptured tendon was the tibialis anterior (which inverts and dorsiflexes the foot in open kinetic chain movement) and knowledge of muscle antagonists. Peroneus longus is the antagonist to tibialis anterior, which is why it is the correct answer.

Question 4:  A 55-year-old male is seen s/p I&D, as shown. Gram stain reveals gram positive cocci in chains.

Which of the following is the most likely infecting organism?

  1. Staphylococcus
  2. Diptherioids
  3. Streptococcus
  4. Bacteroides

Correct answer: C

Explanation: This is a basic science question of first order that requires us to recall that staphylococcus species are gram positive cocci in clusters (not chains), Diptherioids are gram positive bacilli (rods), and Bacteroides are gram negative bacilli. That leaves Streptococcus as the correct answer since they form gram positive cocci in chains.

For the interested, the Gram stain, was invented by the bacteriologist doctor Hans Christian Gram in 1884. No one is certain how Dr Gram invented the stain, but legend has it that he was working one night on lung tissue that had been stained with methyl violet when he accidentally spilled potassium iodide on the tissue. He was unable to remove the stain with alcohol from the coccus bacteria in the lung (causing a purple color to these organisms), while the bacillus bacteria were pink (from the methyl violet washing back out).

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Question 5:  A 67-year-old male with Type 1 DM presents with recent onset of hammertoes and pain in the plantar forefoot. Which of the following is the most likely etiology of the deformity?

  1. Motor neuropathy
  2. Flexor stabilization
  3. Charcot-Marie-Tooth
  4. Sensory polyneuropathy

Correct answer: A

When the results of a test question show a broad distribution across distractors – which is what occurred here - it makes one think there was a problem with the question. It may be that residents chose answer B thinking this patient has hammertoes and flexor stabilization is a highly common cause. Charcot-Marie-Tooth would be unlikely given that the stem mentioning the diabetes diagnosis and giving no descriptors for a CMT diagnosis. Sensory polyneuropathy would cause loss of sensation or paresthesias (not described in the stem), while motor neuropathy, the other part of diabetic neuropathy, directly causes intrinsic muscle atrophy and resultant hammertoes due to an imbalance between the intrinsic and extrinsic muscles. A good general review of diabetic neuropathy is included in the references.4

Desert Foot 2019

A Few Wrap-Up Comments

For those of you still in training, consider that the common thread through all these questions is “basic stuff I should have known.” While in training, residents spend so much time focused on procedures and “doing stuff” but forget that being a podiatrist requires knowing a lot of information. This translates to keeping your basic science and principles of pathology in mind and taking the time to review those principles. “Doing” is important, but “knowing” is the foundation of everything you do. Take the time to know more, and you’ll be that much better for it.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
jarrod@podiatry.com
References
  1. Shim H, Rose J, Halle S, Shekane P. Complex regional pain syndrome: a narrative review for the practicing clinician. Br J Anaesth. 2019 Aug;123(2):e424-e433.
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  2. Bussa M, Guttilla D, Lucia M, Mascaro A, Rinaldi S. Complex regional pain syndrome type I: a comprehensive review. Acta Anaesthesiol Scand, 2015 Jul;59(6):685-697.
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  3. Schepers T, Rammelt S. Complex Foot Injury: Early and Definite Management. Foot Ankle Clin. 2017 Mar;22(1):193-213.
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  4. Vinik AI. CLINICAL PRACTICE. Diabetic Sensory and Motor Neuropathy. N Engl J Med. 2016 Apr 14;374(15):1455-1464.
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