Medical Licensing (MD/DO) · Independent exam preparation
ABFAS Board Certification Examinations: Foot Surgery and Reconstructive Rearfoot/Ankle (RRA) Surgery Study Guide
Practise imaging choices, fixation mechanics, operative anatomy, deformity correction, postoperative protection, infection care, and systemic perioperative decisions.
By CertMedbry · Updated 19 October 2026
Practise deciding when imaging changes management, how fixation supports healing, which operation matches the pathology, and when complications require urgent intervention. These 60 concepts selectively cover clinical knowledge relevant to ABFAS Foot Surgery. The [official outline](https://www.abfas.org/become-board-qualified/part-i-qualification-exam-overview/part-i-qualification-exam-subject-areas) defines the full scope, including additional congenital, neurovascular, metabolic, inflammatory, tendon, and reconstructive subjects. Connect each finding to its anatomical or physiological mechanism, then explain how that mechanism changes diagnosis, treatment, or recovery.
Try 20 free practice questionsWhat is the exam format?
Check the question types, timing and outline before planning your revision.
Which certification pathway does this guide follow?
This guide follows ABFAS Board Certification in Foot Surgery. Part I Board Qualification includes separate didactic and computer-based patient simulation examinations; Part II certification includes Case Review. The September 2026 handbook requires a DPM, appropriate residency training, active unrestricted podiatric licensure in the United States or Canada, and surgical privileges consistent with the certification sought.
Information and Requirements for Board Certification — September 2026, for 2027 Case Review
How does Reconstructive Rearfoot/Ankle Surgery differ?
RRA Surgery is a separate certification extending to conditions affecting the foot, ankle, and leg. It has separate Part I didactic and CBPS examinations and a separate Case Review pathway. Foot Surgery certification is required before RRA certification can be awarded. Foot didactic domains can include RRA diagnostic and management subjects, but the Foot outline excludes specified rearfoot and ankle subjects from Surgical Procedures/Techniques.
Become Board Certified | ABFAS · Part I Board Qualification Exam Content | ABFAS
How many questions are on each didactic examination?
The official Part I overview identifies each Foot Surgery or RRA didactic examination as computer adaptive, with 80 questions and 120 minutes. The supplied overview does not specify a scored versus pretest question split or a detailed inventory of didactic item styles.
What is the current CBPS format?
Each current Foot Surgery or RRA CBPS examination contains 12 cases, with 15 minutes per case. It assesses examination, information gathering, clinical analysis, diagnosis, and treatment. Foot CBPS management-area ranges are Physical Examination 15–35%, Diagnostic Procedures/Labs/Imaging 15–35%, Diagnosis 10–30%, and Treatment 20–40%. These differ from didactic topic weights. This guide's single-best-answer questions are educational drills rather than CBPS simulations.
Part I Qualification Exam Overview | ABFAS · Part I Board Qualification Exam Content | ABFAS
What does Part II Case Review assess?
ABFAS reviews actual post-residency surgical care, including preoperative assessment, diagnosis, indications, technical performance, postoperative management, complications, and outcomes. It selects eight Foot Surgery and/or eight RRA Surgery cases, as applicable. Candidates submit complete electronic documentation for all procedures on each selected patient case. Case Review is document-based; candidates do not attend the reviewers' meeting.
Part II Case Review Overview | ABFAS · Information and Requirements for Board Certification — September 2026, for 2027 Case Review
Which blueprint weights organize this guide?
The live Foot Surgery Part I didactic targets are Diagnostic Studies/Medical Imaging 17%, Surgical Principles 20%, Surgical Procedures/Techniques 22%, Procedural Perioperative Management 15%, Complications 13%, and General Medicine 13%. Their acceptable ranges are respectively 12–22%, 15–25%, 17–27%, 10–20%, 8–18%, and 8–18%. This guide allocates 10, 12, 13, 9, 8, and 8 concepts accordingly. Each 20-item question and flashcard set uses 3, 4, 4, 3, 3, and 3 items. These are educational approximations of Foot didactic emphasis, not Case Review weights or official subtopic quotas.
Which dated documents apply?
The September 2026 certification handbook applies only to the 2027 Case Review cycle. The live Part I content page displays no publication or effective date. The linked Fall 2025 Part I handbook is historical and should not be presented as a Fall 2026 handbook.
Information and Requirements for Board Certification — September 2026, for 2027 Case Review · Part I Board Qualification Exam Content | ABFAS · Information and Requirements for Part I Board Qualification — Fall 2025 Examinations
How do historical CBPS requirements affect certification?
The current handbook states that candidates who passed the former eight-case CBPS must also pass the current twelve-case CBPS, unless they previously passed Part II CBPS. Candidates who passed the current CBPS during Board Qualification proceed to Case Review for the remaining examination component of certification. Individual requirements depend on examination history.
Information and Requirements for Board Certification — September 2026, for 2027 Case Review · Become Board Certified | ABFAS
Does this practice test reproduce the examination or predict passing?
No. The 20 original questions are four-option educational MCQs with explanations. They sample the six Foot didactic domains but do not reproduce adaptive delivery, establish a passing score, simulate CBPS interactions, or assess the documentation and outcomes evaluated in Case Review. Use the official outline to identify additional study needs beyond this selective guide.
Part I Qualification Exam Overview | ABFAS · Part II Case Review Overview | ABFAS
ABFAS awards podiatric surgical board certification for DPMs. Foot Surgery and Reconstructive Rearfoot/Ankle Surgery are distinct certifications. This independent educational guide selects the Foot Surgery pathway and its six didactic domains. Its original exercises support clinical reasoning and carry no implication of ABFAS authorship or endorsement.
Outline used: Verified on 2026-10-10. The workbook label is an umbrella for ABFAS certification in Foot Surgery and in Reconstructive Rearfoot/Ankle (RRA) Surgery, rather than one examination with that generic name. The assigned slug is preserved. The current certification handbook is dated September 2026 and applies only to the 2027 Case Review cycle. Clinical learning domains use the live Part I Board Qualification Exam Content page, which displays no publication or effective date. Part I didactic and CBPS examinations are components of the evidenced certification pathway; Part II certification uses Case Review. The linked Fall 2025 Part I handbook is historical and is not represented as a 2026 handbook.
60 key concepts: understand, apply and avoid the traps
Work through the questions by exam domain. Explain the answer in your own words, try the example, then check the common pitfall.
Diagnostic Studies/Medical ImagingFoot Surgery: 17%; RRA Surgery: 15%
1.When do weightbearing radiographs reveal a Lisfranc injury?
Lisfranc ligament disruption can permit tarsometatarsal separation under load while alignment appears normal on nonweightbearing images. Plantar midfoot bruising, focal tenderness, and pain with standing should sustain suspicion despite initially reassuring films. Weightbearing radiographs, when tolerable and appropriate, can demonstrate instability; comparison with the opposite foot may help. CT defines associated fractures, while MRI can clarify ligament injury when radiographs do not explain persistent clinical concern.
Apply it
A patient twists a planted foot and develops plantar bruising. Initial nonweightbearing films show no displacement. Persistent tarsometatarsal tenderness prompts protected activity and further assessment, including weightbearing imaging when tolerated, rather than clearance for running.
Common pitfall: A normal unloaded radiograph does not establish ligament competence. Forcing painful weightbearing or dismissing characteristic plantar bruising can both undermine appropriate evaluation.
2.When should MRI evaluate possible diabetic foot osteomyelitis?
MRI is recommended when diabetes-related foot osteomyelitis remains uncertain after clinical assessment, plain radiographs, and laboratory findings. It can define marrow involvement and associated soft-tissue collections, helping establish the extent of disease relevant to treatment. Its specificity decreases when reactive marrow edema arises from trauma, previous surgery, or Charcot neuroarthropathy. Interpretation therefore requires the ulcer location, examination, and clinical course rather than an isolated abnormal marrow signal.
Apply it
A chronic plantar ulcer overlies a metatarsal head. Radiographs are inconclusive, and examination leaves bone infection uncertain. MRI assesses bone involvement and looks for a collection that would change surgical planning.
Common pitfall: Marrow edema alone is not synonymous with osteomyelitis. Recent surgery and neuropathic change can create similar appearances and lower specificity.
IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-Related Foot Infections
3.How should initial tests for diabetic foot osteomyelitis be combined?
An initial assessment can combine probe-to-bone testing, plain radiographs, and an inflammatory marker such as ESR, CRP, or procalcitonin. Each contributes different information: probing assesses contact with a hard structure through the ulcer, radiographs show structural changes, and markers reflect inflammation. No component independently settles every case. The value of a positive probe-to-bone result depends on the patient's underlying likelihood of osteomyelitis and the examiner's technique.
Apply it
A deep recurrent ulcer contacts hard bone on probing, and radiographs show adjacent cortical erosion. These concordant findings strengthen suspicion compared with a superficial ulcer and a negative probe in a low-risk presentation.
Common pitfall: One negative test cannot reliably exclude bone infection in a high-risk ulcer. A positive probe also requires interpretation alongside anatomy, examination, and other studies.
IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-Related Foot Infections
4.Which findings suggest a lesser metatarsophalangeal plantar plate tear?
The plantar plate supports MTP stability. A tear commonly affects the second toe, producing plantar joint pain followed by elevation, drift toward the hallux, or reduced ability to grip the ground. Examine toe alignment and stability; radiographs assess alignment, while MRI can evaluate the suspected tear. The [AOFAS clinical overview](https://www.footcaremd.org/foot-and-ankle-conditions/toes/plantar-plate-tear) describes this progression.
Apply it
Plantar second-MTP tenderness with a progressively elevated crossover toe supports a joint-restraint problem and directs examination toward instability.
Common pitfall: Walking-on-a-marble discomfort is nonspecific. Interdigital neuropathy can produce a similar description; distinguish plantar joint pain and deformity from web-space burning or tingling.
5.How is interdigital nerve compression distinguished from other forefoot pain?
Burning web-space pain radiating into adjacent toes, tingling, and reproduction with web-space compression favor interdigital neuropathy. Ultrasound can assess the nerve; radiographs investigate competing osseous or joint abnormalities. The [AAOS clinical overview](https://www.orthoinfo.org/diseases--conditions/mortons-neuroma/) emphasizes symptom location and focused examination.
Apply it
Third-web-space burning provoked by narrow shoes, with radiating toe symptoms on compression, supports a nerve source. Compare this distribution with focal plantar MTP tenderness and abnormal toe alignment before choosing additional imaging.
Common pitfall: A pebble sensation alone does not identify the involved structure. Investigating a nerve without examining adjacent joints can overlook a competing or coexisting pain generator.
6.Which pattern should raise concern for rheumatoid foot disease?
Bilateral corresponding small-joint pain, swelling, and stiffness suggest inflammatory polyarthritis. Radiographs assess joint-space loss and alignment, while examination identifies symptomatic joints and remaining flexibility. These findings support evaluation for rheumatoid disease but do not establish a specific systemic diagnosis by themselves. The [AAOS clinical overview](https://www.orthoinfo.org/diseases--conditions/rheumatoid-arthritis-of-the-foot-and-ankle/) explains the combined assessment.
Apply it
Painful swelling in corresponding forefoot joints on both sides warrants systemic inflammatory assessment. Compare the tender joints with radiographic abnormalities before attributing symptoms to the most conspicuous deformity.
Common pitfall: An abnormal image does not identify the pain generator automatically. Bilateral deformity also should not be attributed solely to footwear without examining the inflammatory pattern.
7.What does CT add after a talus fracture is identified?
CT provides detailed assessment of talar fracture configuration, displacement, comminution, and joint involvement when plain radiographs do not adequately define the injury. These details influence treatment planning because the talus participates in several loadbearing articulations. CT is primarily a structural study; it does not establish that talar blood supply is intact or eliminate future avascular necrosis risk. Integrate imaging with dislocation, soft-tissue condition, and neurovascular assessment.
Apply it
Radiographs show a talar fracture but poorly define a suspected articular fragment. CT maps the fracture and joint surfaces so management addresses the actual geometry rather than a limited projectional appearance.
Common pitfall: A well-characterized fracture can still have compromised blood supply. Structural definition and prediction of avascular necrosis are different diagnostic tasks.
8.How do CT and MRI complement evaluation of tarsal coalition?
A tarsal coalition is an abnormal connection between tarsal bones that may be osseous, cartilaginous, or fibrous. Radiographs reveal some coalitions, but CT better defines bony connections and their anatomy. MRI can demonstrate nonosseous connections and associated soft-tissue or marrow abnormalities. Restricted hindfoot motion and recurrent activity-related symptoms provide important clinical context. Select the study according to whether the unresolved question concerns a bony bridge, nonosseous connection, or associated joint changes.
Apply it
An adolescent has recurrent ankle symptoms and a rigid hindfoot. Plain films do not explain the restriction. Further imaging evaluates coalition anatomy, with MRI particularly useful when a nonosseous connection remains suspected.
Common pitfall: A coalition need not be a complete bony bridge. Negative plain films do not exclude a cartilaginous or fibrous connection causing restricted motion.
9.Which findings distinguish dorsal impingement from advanced hallux arthritis?
Hallux rigidus assessment combines the pain pattern, available first-MTP motion, and radiographic degeneration. A dorsal osteophyte with pain concentrated near terminal dorsiflexion suggests impingement that may respond to joint-preserving treatment. Diffuse joint-space loss, substantial stiffness, and pain across the motion arc suggest more advanced articular disease. The spur is only part of the assessment; its size alone cannot establish whether the remaining joint can provide useful painless motion.
Apply it
Two patients have dorsal first-MTP spurs. One retains comfortable midrange motion; the other has marked narrowing and pain throughout movement. Interpret their radiographs with these contrasting examinations before selecting treatment.
Common pitfall: Treating every dorsal spur identically overlooks the condition of the underlying articulation. Spur prominence does not measure remaining cartilage function.
10.Why should imaging precede a planned sarcoma biopsy?
A suspicious soft-tissue mass requires evaluation that defines its anatomical extent before a biopsy route is selected. Imaging identifies relationships to compartments, neurovascular structures, and a potential definitive resection. Coordinate biopsy planning with the team that would treat a sarcoma so the sampling route can be incorporated into later surgery. Histological diagnosis and specialist pathological review remain essential because imaging alone cannot reliably establish the precise tumor type.
Apply it
A deep enlarging foot mass undergoes imaging and coordinated biopsy planning. The team selects a route that provides representative tissue while preserving options for definitive resection if the lesion proves malignant.
Common pitfall: An unplanned office excision can contaminate additional tissue planes and complicate subsequent treatment. Apparent accessibility does not make an undiagnosed mass suitable for casual removal.
Soft Tissue Sarcoma Treatment (PDQ®) — Health Professional Version | National Cancer Institute
Surgical PrinciplesFoot Surgery: 20%; RRA Surgery: 20%
11.How do absolute and relative stability support different healing patterns?
Absolute stability minimizes interfragmentary motion and supports direct bone healing when a simple fracture can be accurately reduced and compressed. Relative stability permits controlled motion and callus formation, as in bridge fixation across a comminuted zone. Match the mechanical environment to the fracture pattern and biological condition. Compressing every small fragment of a multifragmentary injury may require harmful stripping without improving restoration of overall length, alignment, and rotation.
Apply it
A simple oblique metatarsal fracture accepts interfragmentary compression. Another fracture has extensive comminution. Different stability strategies respect the geometry and biological needs of each injury.
Common pitfall: Callus is not inherently evidence of poor fixation. Its significance depends on whether the construct was intended to provide relative or absolute stability.
Cortical lag screw insertion | AO Surgery Reference · Bridge plating | AO Surgery Reference
12.Why preserve soft-tissue attachments around comminuted fragments?
Small fracture fragments often depend on their remaining soft-tissue attachments for blood supply. Indirect reduction and bridge fixation can restore the major bone segments while leaving the comminuted zone relatively undisturbed. This preserves the biological environment needed for callus formation. The principle applies across fracture surgery, although a technique described for one anatomical site does not prescribe an identical implant elsewhere. Articular surfaces may still require direct anatomical reduction when joint congruity is threatened.
Apply it
Planning prioritizes overall alignment and preservation of attached fragments. An articular component is assessed separately because acceptable shaft alignment cannot compensate for a displaced joint surface.
Common pitfall: Preserving biology does not justify leaving an incongruent joint untreated. Extra-articular comminution and displaced articular fragments create different reduction requirements.
13.How can mechanical instability prevent union despite viable bone?
Bone healing requires a mechanical environment that permits the intended repair process. Excessive motion, inadequate fixation, persistent distraction, or poor construct alignment can prevent bridging even when tissues retain biological activity. A revision plan should assess stability, apposition, alignment, and loading rather than treating every nonunion as a shortage of graft. Graft can address a biological deficit but cannot independently correct instability, infection, inadequate perfusion, or deformity.
Apply it
An osteotomy remains painful with progressive hardware loosening and persistent motion. Revision addresses fixation and alignment instead of assuming that additional graft around the loose construct will restore union.
Common pitfall: Visible callus does not guarantee adequate stability. Biological activity can coexist with motion sufficient to prevent consolidation, so graft alone may miss the dominant problem.
14.How does rheumatoid inflammation produce a combined forefoot deformity?
Inflamed synovium damages cartilage and supporting ligaments. Joint instability and dislocation can then coexist with hallux valgus, digital deformities, and altered plantar pressure. The [AAOS clinical overview](https://www.orthoinfo.org/diseases--conditions/rheumatoid-arthritis-of-the-foot-and-ankle/) describes these interacting abnormalities. An AO clinical example illustrates combined first-MTP fusion and lesser-metatarsal head procedures in a severely affected forefoot.
Apply it
A bunion with multiple dislocated lesser MTP joints requires assessment of the whole forefoot, including pain location, flexibility, joint destruction, and pressure lesions.
Common pitfall: Correcting one prominence can leave adjacent deformity and overload untreated. A published combined reconstruction illustrates an individual case; it does not establish one operation for every rheumatoid foot.
15.Why does smoking increase wound and bone-healing risk?
Smoking impairs the conditions required for orthopaedic healing. Nicotine reduces blood flow, and tobacco exposure adversely affects bone-forming activity and tissue oxygen delivery. These effects increase concern for delayed bone healing, nonunion, infection, and wound problems. Smoking is therefore a modifiable surgical risk factor to address before elective reconstruction and throughout recovery. A technically sound operation still depends on adequate perfusion and cellular repair afterward.
Apply it
A patient seeking elective first-ray fusion continues smoking. Counseling connects cessation to wound healing and fusion, alongside discussion of fixation, nutrition, and postoperative protection.
Common pitfall: Smoking risk is not solely pulmonary. Local wound perfusion and bone repair remain relevant even when respiratory symptoms are absent.
16.Why are prompt antibiotics important in an open fracture?
An open fracture exposes injured tissues and bone to contamination through a communicating wound. Prompt systemic antibiotics reduce infectious risk while definitive care addresses the wound and fracture. Antibiotics complement debridement, stabilization, and soft-tissue management; they do not remove devitalized tissue or foreign material. Initial assessment also considers contamination, neurovascular status, and the overall injury. The apparent size of the skin wound may underestimate deeper damage.
Apply it
A small puncture overlies a displaced foot fracture after a contaminated injury. The team treats it as a potential open fracture, begins prompt antibiotic management, protects the wound, and arranges operative assessment.
Common pitfall: Waiting for a large wound, positive culture, or established infection misses the preventive role of antibiotics. A tiny opening can communicate with substantial deep injury.
Principles of management of open fractures | AO Surgery Reference
17.What makes debridement essential in contaminated fracture care?
Debridement removes devitalized tissue and contaminants that compromise healing and provide a substrate for infection. Irrigation assists cleaning but does not substitute for evaluating viability and excising nonviable material. Adequate exposure allows assessment of the full injury zone, including structures more damaged than the skin suggests. Repeat assessment may be necessary when viability is uncertain. Stabilization should maintain alignment while allowing necessary wound access and further treatment.
Apply it
An open fracture contains embedded debris and damaged tissue. Operative care includes systematic assessment and removal of nonviable material rather than relying on irrigation or antibiotics to compensate for retained contamination.
Common pitfall: A superficially clean wound does not establish that deeper tissue is viable. Cosmetic appearance cannot replace systematic exploration of the injury zone.
Principles of management of open fractures | AO Surgery Reference
18.Why must neurovascular anatomy be mapped before dissection?
Safe exposure requires anticipating structures at risk, then identifying and protecting them during dissection. In the distal leg, superficial peroneal branches can cross an anterolateral exposure; medially, the saphenous nerve and vein are vulnerable. The posterior tibial neurovascular bundle is a separate deep structure and becomes relatively superficial near the medial ankle. These relationships help distinguish a safe tissue plane from blind extension through a vulnerable region.
Apply it
Before extending an exposure, identify the expected nerve course and protect visible branches rather than assuming a single textbook branching pattern. Plan retraction around the structures actually encountered.
Common pitfall: Preserving a major nerve trunk does not protect unrecognized distal branches from traction or division. Anatomical variation makes direct identification important.
19.Why does a colonized ulcer not automatically require antibiotics?
Open ulcers commonly contain microorganisms, but infection is diagnosed clinically from tissue invasion and inflammation rather than culture positivity alone. In a clinically uninfected diabetes-related foot ulcer, systemic or local antibiotics should not be used simply to promote healing or prevent infection. Management addresses wound care, pressure relief, perfusion, and other healing barriers. Neuropathy, ischemia, or immune dysfunction can reduce the usual inflammatory response, so classification requires a careful examination.
Apply it
A plantar ulcer has no purulence or surrounding inflammatory signs, but a surface swab grows bacteria. Address pressure and wound care instead of prescribing antibiotics solely for the culture result.
Common pitfall: Culture positivity is not equivalent to infection. Conversely, subtle findings in a high-risk patient require assessment rather than automatic classification as uninfected.
IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-Related Foot Infections
20.How are moderate and severe diabetic foot infections classified?
Moderate infection has erythema extending at least 2 cm from the wound margin and/or involvement deeper than skin and subcutaneous tissue, without systemic manifestations. Severe infection has at least two SIRS findings: temperature above 38°C or below 36°C; heart rate above 90/min; respiratory rate above 20/min or PaCO2 below 32 mmHg; leukocytes above 12,000/mm³, below 4,000/mm³, or more than 10% immature bands. Consider hospitalization for severe infection and moderate infection with important comorbidities, especially peripheral arterial disease.
Apply it
An infected ulcer with 3-cm erythema and tendon involvement but no SIRS findings is moderate. Associated arterial disease strengthens the case for admission.
Common pitfall: Fever is not required for severe infection. Deep infection can be moderate without systemic illness, and osteomyelitis alone does not mandate admission.
21.When does a diabetic foot infection need urgent surgical consultation?
Urgent surgical consultation is indicated for severe infection or moderate infection complicated by extensive gangrene, necrotizing infection, signs of a deep abscess, compartment syndrome, or severe lower-limb ischemia. These findings suggest problems that antibiotics cannot adequately resolve alone, including undrained pus, nonviable tissue, or critically impaired perfusion. When infection coexists with peripheral arterial disease, surgical and vascular specialists should coordinate drainage and revascularization decisions.
Apply it
An infected ulcer has a deep collection and ischemic tissue changes. Request urgent surgical and vascular assessment so source control and perfusion are addressed together instead of extending antibiotics alone.
Common pitfall: Clinical stability does not make a deep abscess safe to observe indefinitely. Local anatomical threats can require urgent intervention before systemic deterioration develops.
IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-Related Foot Infections
22.How does coordinated biopsy planning protect future tumor treatment?
A biopsy is part of the treatment pathway for possible sarcoma. Its location and route should be planned with definitive resection in mind because contaminated tissue may need removal later. Representative tissue and expert pathological interpretation support accurate classification and treatment selection. A poorly placed incision, unnecessary dissection, or unplanned excision can enlarge the field that subsequently requires treatment and compromise reconstructive options.
Apply it
An enlarging deep mass lies near important tendons. Instead of choosing a convenient transverse incision, coordinate biopsy with a specialist team that can plan tissue diagnosis and any eventual definitive operation.
Common pitfall: A biopsy can obtain diagnostic tissue yet remain poorly planned oncologically. Diagnostic yield and preservation of later treatment options must both inform the approach.
Soft Tissue Sarcoma Treatment (PDQ®) — Health Professional Version | National Cancer Institute
Surgical Procedures/TechniquesFoot Surgery: 22%; RRA Surgery: 25%
23.How does a cortical screw create a lag effect?
A fully threaded cortical screw creates a lag effect when its threads purchase the far fragment while freely gliding through the near fragment. Prepare a near-fragment gliding hole matching the screw's outer thread diameter and a far-fragment pilot hole matching the screw's core diameter. The smaller pilot hole leaves bone for the threads to engage. As the screw head seats against the near cortex, tightening draws the far fragment toward the near fragment and compresses the reduced fracture.
Apply it
For a reduced oblique metatarsal fracture, maintain reduction while preparing the thread-diameter gliding hole in the near fragment and the core-diameter pilot hole in the far fragment. Confirm that thread purchase is confined to the far fragment before applying compression.
Common pitfall: Enlarging the far-fragment hole to the outer thread diameter compromises the purchase required for compression. Conversely, core-diameter pilot holes in both fragments allow threads to engage both fragments, preventing the intended lag effect. A fully threaded screw creates compression through correct hole preparation and engagement, not merely through tightening.
24.Why orient a lag screw perpendicular to the fracture plane?
A lag screw placed approximately perpendicular to the fracture plane directs compression across that plane and limits translation during tightening. A poorly oriented screw can introduce shear and disturb reduction. The trajectory must also respect available bone, nearby joints, and safe anatomy. Perpendicularity is a mechanical objective within those constraints, not permission to violate a joint or accept inadequate far-fragment purchase.
Apply it
A reduced oblique fracture has two possible screw paths. Select the safe trajectory closest to perpendicular to the fracture plane and monitor reduction during tightening instead of choosing a convenient but strongly oblique path.
Common pitfall: Perpendicular to the bone's long axis is not necessarily perpendicular to its fracture. Judge screw direction against actual fracture geometry and safe anatomy.
25.What correction does rigid hammertoe arthrodesis require?
Hammertoe involves PIP flexion. In a rigid deformity, limited joint bone resection permits straightening, and fixation maintains apposition during fusion. Tendon lengthening may accompany correction. The [AAOS clinical overview](https://www.orthoinfo.org/diseases--conditions/hammer-toe/) describes these operative components.
Apply it
A fixed PIP contracture that cannot be passively corrected requires attention to the rigid joint component. After preparation, assess alignment and opposing surfaces before accepting fixation. The implant maintains the correction while bone healing occurs.
Common pitfall: Tendon lengthening alone may leave a fixed joint deformity unchanged. A straighter immediate appearance also does not establish fusion; stability and biological healing remain necessary.
Part I Board Qualification Exam Content | ABFAS · Nonunions | AAOS OrthoInfo
26.How are impacted metatarsal articular fragments reduced?
An impacted articular fragment may remain depressed even after the main fracture segments are aligned. Direct visualization and careful elevation can restore the joint surface, using intact articular anatomy as a reference. Temporary fixation maintains the reconstruction while definitive fixation is applied. Assess both joint congruity and overall metatarsal alignment. Compressing the main fragments before correcting the depression can lock an unreduced articular defect into place.
Apply it
A distal metatarsal fracture has an impacted joint fragment despite acceptable shaft alignment. Elevate and reconstruct that segment before completing fixation rather than assuming the plate will restore the depression automatically.
Common pitfall: A straight metatarsal can still have an incongruent joint. Shaft alignment and articular reduction each require assessment before definitive fixation is accepted.
27.How can plantar plate repair address instability and overload?
Repair addresses the disrupted MTP restraint. A selected metatarsal osteotomy can correct alignment or shorten the ray to reduce overload; a chronic irreparable tear may require tendon transfer. The [AOFAS clinical overview](https://www.footcaremd.org/foot-and-ankle-conditions/toes/plantar-plate-tear) describes these options.
Apply it
Repairable tissue and ray alignment guide the reconstruction. When an osteotomy accompanies repair, assess metatarsal length, rotation, and sagittal position before fixation. Correcting instability while creating unfavorable osseous alignment can leave an abnormal loading pattern.
Common pitfall: Straightening the toe alone may leave its unstable MTP joint untreated. Conversely, repairing soft tissue does not automatically correct a separate metatarsal malalignment.
Part I Board Qualification Exam Content | ABFAS · Nonlocking plate with/without lag screws for distal articular metatarsal fractures | AO Surgery Reference
28.Which anatomical relationship matters during interdigital nerve decompression?
The common digital plantar nerve passes plantar to the transverse metatarsal ligament. Decompression releases constraining tissue while preserving the nerve; neurectomy removes diseased nerve. The [AAOS clinical overview](https://www.orthoinfo.org/diseases--conditions/mortons-neuroma/) distinguishes these procedures.
Apply it
Identify the nerve and surrounding tissue before release. State the operative target explicitly: relieving compression while retaining continuity differs from removing a nerve segment. This distinction also determines how expected postoperative sensation is discussed.
Common pitfall: Decompression and neurectomy are not interchangeable descriptions. Blind release risks injury, while nerve preservation alone does not establish that the intended constraining tissue has been adequately released.
29.Which alignment checks matter before final metatarsal fixation?
Metatarsal reconstruction must restore length, rotation, and sagittal alignment as well as the articular surface. Malposition can alter how the metatarsal head shares plantar load with neighboring rays. Assess fixation in multiple projections, including the reconstructed head's relationship to the shaft and adjacent metatarsals. A locally reduced fracture line can still produce an abnormal overall ray if rotation or head elevation is overlooked.
Apply it
One fluoroscopic view looks satisfactory, but another reveals an elevated metatarsal head. Correct the sagittal malalignment before final tightening rather than accepting union in a mechanically unfavorable position.
Common pitfall: One attractive image can conceal rotational or sagittal error. Articular congruity alone does not establish appropriate restoration of the entire metatarsal.
30.What does cheilectomy change mechanically?
Cheilectomy removes dorsal osteophytes and a limited amount of adjacent bone at the first MTP joint to reduce impingement and improve available motion. Benefit depends on enough remaining joint function to use the gained motion. It does not replace diffusely damaged cartilage or eliminate the underlying arthritis. Understanding this anatomical target prevents treating spur removal as a universal solution for every painful, stiff great-toe joint.
Apply it
During treatment of dorsal impingement, remove obstructing osteophytes and reassess movement. The objective is relief of the mechanical block, with expectations based on the remaining articular condition.
Common pitfall: More bone removal does not restore more cartilage. Successful relief of impingement can leave pain caused by advanced diffuse arthritis unresolved.
31.How does first-MTP arthrodesis relieve arthritic pain?
Arthrodesis removes painful motion from a damaged first-MTP joint by preparing opposing surfaces and stabilizing them until they unite. Fixation holds the intended position during healing. The tradeoff is deliberate loss of movement at that joint, making functional positioning and patient expectations important. Unlike cheilectomy, fusion does not depend on preserving an arthritic articulation's remaining motion; it converts the articulation into a stable united segment.
Apply it
For advanced painful arthritis, prepare the surfaces and establish stable fixation. Explain that expected pain relief follows successful union and elimination of movement through the damaged joint.
Common pitfall: Fusion does not increase first-MTP motion. Pain relief depends on appropriate positioning and healing, with permanent loss of movement at the fused articulation.
32.Why does a bunion osteotomy address more than the prominence?
A bunion includes abnormal bone and joint alignment rather than simply excess bone at the medial first-metatarsal head. An osteotomy permits controlled repositioning, with fixation maintaining correction during healing. The location and extent of the cut depend on the deformity and selected operation. Removing only the prominence leaves the underlying relationship unchanged and can permit persistence or recurrence.
Apply it
A patient has a painful medial prominence with first-ray malalignment. The operation includes corrective bone work because the target includes the abnormal alignment producing the prominence. Assess the intended correction before fixing the fragments.
Common pitfall: Exostectomy can change the bump's outline without correcting the deformity. Cosmetic flattening should not be mistaken for restoration of first-ray alignment.
33.How can tendon procedures correct a flexible hammertoe?
Lengthening a tight tendon reduces deforming tension. A selected transfer redirects a plantar tendon dorsally to help straighten the toe. These procedures act on soft-tissue imbalance and depend on the joint remaining correctable. The [AAOS clinical overview](https://www.orthoinfo.org/diseases--conditions/hammer-toe/) distinguishes these options from fusion for rigid deformity.
Apply it
Passive correction demonstrates that soft-tissue rebalancing may address the deformity. Identify which tendon force is being reduced or redirected and reassess toe position after correction.
Common pitfall: A fixed joint contracture can require an additional joint procedure. Similar standing appearances do not establish that two toes have the same reducibility or operative target.
34.How do first-TMT and first-MTP fusions address different problems?
A first-TMT corrective fusion can realign and stabilize an abnormal medial column while preserving first-MTP motion if that joint is healthy. An AO example describes hallux valgus with a hypermobile medial column treated through TMT/intertarsal reconstruction; it illustrates a selected case rather than a universal indication. First-MTP fusion instead unites a severely arthritic MTP joint and eliminates its motion. Compression and stable fixation maintain prepared surfaces until union.
Apply it
Hallux valgus with medial-column instability and a mobile nonarthritic MTP joint presents a different target from hallux valgus with painful advanced MTP arthritis.
Common pitfall: Neither fusion automatically treats pathology at the other joint. A precontoured implant also does not guarantee appropriate correction; verify alignment before final fixation.
VA-LCP Forefoot/Midfoot set · Bunion Surgery | AAOS OrthoInfo
35.How should operative infection specimens preserve diagnostic value?
Operative sampling should match the tissue whose infection is being investigated and minimize collection contamination. A tissue specimen can guide soft-tissue infection treatment, whereas suspected osteomyelitis calls for a bone specimen. Aseptic collection and identification of anatomical origin improve interpretation. Surface drainage or a specimen indiscriminately mixed with adjacent tissue may yield organisms that do not accurately represent the deeper process requiring treatment.
Apply it
During debridement, separately identify deep soft tissue and suspected infected bone for appropriate sampling. Preserve the distinction between these sources for subsequent microbiological interpretation.
Common pitfall: Labeling every specimen as wound culture loses useful information. A technically obtained sample still requires a clear anatomical source and appropriate collection technique.
IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-Related Foot Infections
Procedural Perioperative ManagementFoot Surgery: 15%; RRA Surgery: 20%
36.When is cheilectomy a reasonable joint-preserving choice?
Cheilectomy is most useful when hallux rigidus symptoms are driven by dorsal impingement and the joint retains useful function. Terminal dorsiflexion pain, a dorsal prominence, and less advanced arthritis support consideration after appropriate nonsurgical treatment. Include activity goals and expectations about progression. Diffuse pain across the motion arc and extensive articular loss reduce the likelihood that removing the dorsal obstruction alone will adequately address symptoms.
Apply it
A patient has shoe irritation from a dorsal spur and pain near terminal dorsiflexion but comfortable midrange movement. Discuss cheilectomy after nonsurgical care proves insufficient.
Common pitfall: Selection based only on the spur ignores remaining joint function. Extensive arthritis can persist as the main pain generator after technically successful spur removal.
37.When does hallux rigidus favor arthrodesis?
Advanced first-MTP arthritis with marked stiffness and pain throughout movement can favor arthrodesis after nonsurgical care fails. Fusion provides a stable alternative to preserving a broadly painful articulation. Discuss permanent loss of joint motion, footwear implications, and the need for union. The key discriminator is whether useful painless movement remains, rather than age alone or the presence of any dorsal osteophyte.
Apply it
Severe joint-space loss, minimal movement, and pain throughout the available arc persist despite shoe modification. Discuss fusion because preservation of the damaged articulation is less likely to provide useful painless function.
Common pitfall: A preference for motion preservation does not establish that the joint can provide useful motion. Articular condition and symptoms must inform procedure selection.
38.Why does rehabilitation differ after cheilectomy and first-MTP fusion?
After isolated cheilectomy, early prescribed toe motion helps prevent scar-related recurrent stiffness. First-MTP fusion requires protection of prepared surfaces until union; attempting to restore motion across that articulation contradicts the operation's purpose. Additional procedures can change loading and motion restrictions. Rehabilitation must therefore reflect whether the joint was preserved or deliberately eliminated.
Apply it
Before prescribing exercises, verify the operation. A patient after cheilectomy may need a motion program, whereas a patient after arthrodesis needs protection of the fusion and appropriate assessment before loading advances.
Common pitfall: Do not copy a cheilectomy exercise plan into arthrodesis recovery. Less pain does not establish osseous union or justify stressing the fusion site.
Hallux Rigidus (Stiff Big Toe) | AAOS OrthoInfo · Nonunions | AAOS OrthoInfo
39.What must be protected after plantar plate repair?
Dressings, protective footwear, loading restrictions, and sometimes temporary pins protect the repaired restraint. Recovery depends on the combined operation. The [AOFAS clinical overview](https://www.footcaremd.org/foot-and-ankle-conditions/toes/plantar-plate-tear) describes this protection.
Apply it
Review whether repair included metatarsal osteotomy before advancing activity. The soft-tissue restraint must recover, and any osteotomy also needs sufficient stability and bone healing. Assess maintained correction and the relevant healing findings rather than using comfort alone as clearance.
Common pitfall: Reduced pain does not establish unrestricted loading tolerance. A temporary pin maintains position but does not prove that soft tissue or an associated osteotomy has completed healing.
Part I Board Qualification Exam Content | ABFAS · Nonunions | AAOS OrthoInfo
40.When can a Lisfranc injury be treated without surgery?
Nonsurgical treatment can be appropriate when a Lisfranc injury has no displacement or instability requiring operative stabilization. Protection and follow-up remain necessary because an initially aligned injury can later displace. Selection depends on a reliable stability assessment rather than pain intensity alone. Persistent symptoms or uncertainty require further evaluation. The central distinction is a stable tarsometatarsal relationship versus one that separates or loses alignment under physiological loading.
Apply it
A carefully evaluated injury remains stable. Prescribe immobilization, loading restrictions, and follow-up imaging, explaining that displacement or continuing concern may change treatment.
Common pitfall: A stable-looking unloaded film alone does not establish suitability for nonsurgical care. Stability assessment and interval follow-up are essential parts of selection.
41.What determines weightbearing progression after Lisfranc surgery?
Operative Lisfranc care usually begins with nonweightbearing protection. AAOS describes approximately 6–8 weeks of nonweightbearing, with progression in a boot when follow-up radiographs are appropriate, often within a 6–12-week assessment window. The injury, procedure, healing, and construct determine progression. These intervals describe typical recovery rather than automatic clearance dates.
Apply it
A comfortable patient at six weeks still needs assessment of maintained alignment and healing before loading advances. Establish whether treatment involved fixation or fusion because the structures being protected differ.
Common pitfall: Pain improvement does not establish ligament healing or fusion. Successful reduction also cannot eliminate later arthritis caused by cartilage injury sustained during the original trauma.
42.How do flexibility and arthritis change treatment of collapsing foot deformity?
A flexible deformity with preserved joints may suit motion-preserving reconstruction using selected tendon, ligament, and alignment procedures after nonsurgical care fails. An isolated tendon transfer may remain overloaded if the underlying shape is uncorrected. A painful rigid deformity with arthritic joints may require fusion because tendon transfer or osteotomy alone cannot restore useful movement through fixed diseased articulations. Fusion sacrifices selected joint motion while addressing deformity and arthritic pain.
Apply it
A passively correctable foot without significant degeneration prompts discussion of reconstruction. Fixed painful hindfoot arthritis prompts consideration of fusion-based treatment.
Common pitfall: Flexibility does not make an isolated tendon procedure sufficient. Rigid appearance alone also does not identify which joints require treatment; localize pain and degeneration.
43.When does a symptomatic coalition require operative consideration?
Coalition treatment begins with symptoms and functional limitation rather than the image alone. Nonsurgical measures can include activity modification, orthoses, medication, or temporary immobilization. Persistent symptoms despite appropriate care can lead to operative consideration. Resection and fusion address different circumstances; anatomy, remaining motion, alignment, and associated arthritis influence selection. An asymptomatic connection does not automatically require surgery.
Apply it
An adolescent remains symptomatic despite a structured nonsurgical course. Review coalition anatomy, motion, and degeneration before discussing resection or another operation. A rigid arthritic foot presents a different problem from an isolated connection with preserved surrounding joints.
Common pitfall: Finding a coalition does not establish a need for removal. Symptoms, response to conservative care, and surrounding joint condition determine its management relevance.
44.When can forefoot osteomyelitis be treated without bone surgery?
The IWGDF/IDSA guideline allows consideration of antibiotics without surgery for selected forefoot osteomyelitis when there is no immediate incision-and-drainage need, no peripheral arterial disease, and no exposed bone. These criteria identify a narrower group than all diabetic foot osteomyelitis. A collection, ischemia, or another source-control problem changes the decision. Follow-up must be capable of identifying failure or progression.
Apply it
A stable patient has forefoot osteomyelitis without exposed bone, arterial disease, or a collection requiring drainage. Medical treatment is an option; the same approach does not automatically suit an ischemic abscess.
Common pitfall: An antibiotic-only option does not establish that surgery is unnecessary in every case. Drainage needs, perfusion, and exposed bone define important selection boundaries.
IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-Related Foot Infections
ComplicationsFoot Surgery: 13%; RRA Surgery: 20%
45.Which findings suggest acute compartment syndrome?
Acute compartment syndrome occurs when rising pressure within a closed fascial space compromises tissue perfusion. Pain out of proportion to the apparent injury and pain with passive muscle stretch are important early clues; sensory changes can follow. A palpable pulse does not exclude the condition because microvascular perfusion can fail before major arterial flow disappears. Suspected acute compartment syndrome requires urgent assessment and timely decompression.
Apply it
After a crush injury, escalating pain despite analgesia and marked pain with passive toe movement prompt urgent assessment despite preserved pedal pulses.
Common pitfall: Pulselessness is a late and unreliable diagnostic requirement. Waiting for it can allow irreversible muscle and nerve damage while distal arterial flow remains detectable.
46.How does acute compartment syndrome differ from exertional symptoms?
Acute compartment syndrome is a limb-threatening process requiring emergency evaluation and decompression when established. Chronic exertional compartment syndrome produces activity-related symptoms that commonly improve after stopping exercise. The temporal pattern matters: persistent escalating posttraumatic pain differs from reproducible exercise discomfort relieved by rest. Pressure testing can assist uncertain evaluations, but a convincing acute presentation should not wait for elective testing.
Apply it
A runner has recurrent exercise pain that resolves after stopping. Another patient develops progressive unrelenting pain after a fracture. The latter requires emergency assessment while the former permits structured evaluation of exertional symptoms.
Common pitfall: The shared term does not imply identical urgency. A prior chronic exercise pattern cannot safely explain away new persistent pain after acute injury.
Compartment Syndrome | AAOS OrthoInfo · Compartment syndrome in the leg
47.Why can avascular necrosis follow a talus fracture?
A talus fracture can disrupt its vulnerable blood supply, allowing bone tissue to die and potentially collapse. Greater injury severity and displacement increase concern, but satisfactory reduction does not guarantee avoidance of vascular injury. Follow-up must distinguish fracture healing from viability of the talar body. New or persistent pain after a major talar injury warrants assessment for avascular necrosis and other causes.
Apply it
A displaced talus fracture heals in acceptable alignment, but renewed pain develops. Evaluate talar viability and possible collapse instead of assuming union excludes a significant posttraumatic complication.
Common pitfall: Union and maintained alignment do not prove intact blood supply. Avascular necrosis can emerge despite technically appropriate treatment because the original injury damaged vascular connections.
48.Why can arthritis develop after a healed talus fracture?
Talar fractures can damage cartilage at the ankle, subtalar, or related articulations. Even after union, injured joint surfaces may become painful and stiff from posttraumatic arthritis. Residual incongruity adds abnormal loading, but cartilage injury itself also matters. Localize persistent symptoms to the involved articulation and assess them separately from nonunion or avascular necrosis. A healed bone does not necessarily restore a normal joint surface.
Apply it
A patient has a united talus fracture with activity-related hindfoot pain and restricted joint motion. Evaluate the symptomatic articulation and degeneration instead of presuming failed union.
Common pitfall: Avascular necrosis and arthritis can coexist but are distinct mechanisms. Vascular bone injury and articular degeneration require separate assessment when explaining late pain.
49.How should a painful suspected nonunion be evaluated?
Nonunion assessment combines symptoms, serial imaging, and investigation of why healing failed. Persistent local pain, a continuing gap, and lack of progression support concern; hardware failure can indicate inadequate mechanical support. Consider infection, blood supply, smoking, nutrition, and systemic contributors. Revision follows the identified causes. Neither one radiograph nor elapsed time alone explains whether the principal deficit is mechanical, biological, or combined.
Apply it
A painful fusion shows no meaningful progression on serial images. Assess stability, infection risk, and patient healing factors before selecting revision treatment rather than prescribing graft solely for a visible gap.
Common pitfall: Nonunion is the start of causal assessment. Identical treatment for every case can leave infection, instability, or impaired biology unresolved.
50.How can metatarsal malunion produce load-related symptoms?
A metatarsal that heals with abnormal length, rotation, or sagittal position can redistribute plantar loading. An elevated head may unload its ray and increase stress beneath neighboring metatarsals; other malpositions can create focal overload. Assess whether bone united in a functional relationship, not merely whether union occurred. Connect pain and callus location with reconstructed alignment rather than attributing every postoperative symptom to hardware.
Apply it
Pain beneath an adjacent ray develops after metatarsal fracture union. Imaging reveals elevation of the previously fractured head, supporting a mechanical loading explanation that a union-only assessment would miss.
Common pitfall: Radiographic union is not synonymous with successful reconstruction. Implant removal without assessing load distribution can leave the actual mechanical source of pain unchanged.
51.Which sensory outcomes should be distinguished after interdigital neurectomy?
Neurectomy can leave permanent numbness in the supplied toes. Recurrent focal nerve pain can reflect a stump neuroma. The [AAOS clinical overview](https://www.orthoinfo.org/diseases--conditions/mortons-neuroma/) distinguishes these outcomes.
Apply it
Compare current symptoms with the preoperative pattern and the sensory consequences discussed before surgery. Painless reduced sensation after nerve removal is a different finding from renewed burning pain localized to the operative web space.
Common pitfall: Numbness alone does not establish recurrent neuroma. Pain recurrence also requires localization rather than an automatic diagnosis; document whether symptoms are sensory loss, focal neural pain, or pain arising from an adjacent joint.
52.Why does ischemia change management of an infected wound?
Peripheral arterial disease impairs delivery of oxygen and resources needed for repair, while infection increases tissue demands. Together they raise concern for poor healing and limb loss. An infected diabetes-related foot wound with arterial disease requires coordinated surgical and vascular assessment to determine drainage and revascularization needs. Antibiotic selection cannot restore perfusion. Ischemia also limits applicability of selected antibiotic-only approaches to forefoot osteomyelitis.
Apply it
An infected ulcer remains poorly healing with evidence of arterial insufficiency. Expand management to vascular and surgical assessment rather than repeatedly changing antibiotics while leaving perfusion unaddressed.
Common pitfall: A susceptible organism does not establish that antimicrobial treatment alone will succeed. Tissue perfusion remains a separate determinant of recovery and limb preservation.
IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-Related Foot Infections
General MedicineFoot Surgery: 13%; RRA Surgery: no separate target listed
53.When should perioperative cardiac stress testing be considered?
Consider stress testing only in selected patients with poor or unknown functional capacity and elevated perioperative cardiovascular risk estimated by a validated tool, such as RCRI or an NSQIP calculator, when results would change management. Elevated risk alone does not make testing automatic. Patients at low risk, with good functional capacity, or undergoing low-risk procedures should not receive routine stress testing without another indication.
Apply it
An asymptomatic patient with good functional capacity undergoing low-risk foot surgery needs no routine stress test. Unknown capacity plus elevated calculated risk may justify consideration if the result changes treatment or operative planning.
Common pitfall: Foot pain can make functional capacity unknown. It does not independently establish myocardial ischemia or justify automatic testing.
2024 AHA/ACC Perioperative CV Management Guideline: Key Points - American College of Cardiology
54.When does perioperative anticoagulant interruption warrant bridging?
Routine heparin bridging during anticoagulant interruption increases bleeding risk and is inappropriate for most patients. Selected patients at high thrombotic risk who must interrupt warfarin, a vitamin K antagonist, may warrant bridging with heparin or low-molecular-weight heparin. Examples include patients receiving warfarin for a mechanical mitral valve, recent left ventricular thrombus, or atrial fibrillation with recent stroke. Direct oral anticoagulant interruption generally uses a schedule based on the specific drug, renal function, and procedural bleeding risk without heparin bridging.
Apply it
A patient interrupting warfarin for a mechanical mitral valve requires assessment for possible bridging. A patient interrupting a direct oral anticoagulant for atrial fibrillation generally requires appropriately timed interruption and resumption without bridging. Identify the anticoagulant before applying a thrombotic-risk exception.
Common pitfall: The selected high-risk bridging recommendation concerns vitamin K antagonist interruption; it should not automatically be extended to direct oral anticoagulants. Atrial fibrillation alone does not establish a bridging indication. Weigh recent embolic events, the anticoagulation indication, and surgical bleeding risk when planning warfarin interruption.
2024 AHA/ACC Perioperative CV Management Guideline: Key Points - American College of Cardiology
55.Why interrupt an SGLT2 inhibitor before planned surgery?
SGLT2 inhibitors increase perioperative ketoacidosis concern during fasting, reduced intake, illness, and metabolic stress. The 2024 cardiovascular guideline recommends stopping them three to four days before planned surgery. The empagliflozin label specifies withholding it for at least three days, if possible, before surgery or procedures associated with prolonged fasting. This interruption addresses metabolic safety. Resumption requires clinical stability and return of oral intake.
Apply it
A patient taking empagliflozin is preparing for elective surgery with fasting. Plan the appropriate interruption and reassess postoperative stability and intake before resumption.
Common pitfall: Skipping only the operative morning dose does not match the recommended interval. Do not assume hypoglycemia is the principal perioperative hazard of every diabetes medicine.
ACC, AHA Release New Perioperative Guideline for Patients Undergoing Noncardiac Surgery · JARDIANCE (empagliflozin) Prescribing Information — revised January 2026 | DailyMed
56.How can SGLT2-associated ketoacidosis occur without marked hyperglycemia?
SGLT2 inhibition promotes urinary glucose loss, so ketoacidosis can occur at glucose concentrations lower than typically expected in diabetic ketoacidosis. In an exposed perioperative patient, nausea, vomiting, abdominal pain, malaise, or abnormal breathing should prompt consideration regardless of a reassuring glucose value. Ketone and acid-base assessment address the metabolic disturbance directly. Absence of pronounced hyperglycemia must not end evaluation when symptoms and context are compatible.
Apply it
After surgery and poor intake, an empagliflozin-treated patient develops nausea and tachypnea with modest glucose elevation. Evaluate ketones and acid-base status rather than dismissing ketoacidosis.
Common pitfall: Glucose alone is an inadequate screen here. A less striking glucose value can coexist with dangerous ketotic metabolic acidosis requiring urgent treatment.
JARDIANCE (empagliflozin) Prescribing Information — revised January 2026 | DailyMed
57.Which medicines increase hypoglycemia risk when combined with empagliflozin?
Insulin and insulin secretagogues, including sulfonylureas, can cause hypoglycemia. The empagliflozin label warns of increased hypoglycemia risk with these combinations in adults. Medication review therefore includes every glucose-lowering agent, with consideration of reducing the accompanying insulin or secretagogue dose when appropriate. This risk differs from SGLT2-associated ketoacidosis, which can occur without marked hyperglycemia.
Apply it
An adult taking empagliflozin and a sulfonylurea needs assessment of combination-related hypoglycemia rather than evaluation of empagliflozin alone. Reduced perioperative intake makes the complete medication plan particularly relevant.
Common pitfall: A ketoacidosis prevention plan is not a complete glucose-management plan. Withholding an SGLT2 inhibitor does not automatically address risks created by accompanying therapies.
JARDIANCE (empagliflozin) Prescribing Information — revised January 2026 | DailyMed
58.Which findings suggest local anesthetic systemic toxicity?
Local anesthetic systemic toxicity can cause neurological and cardiovascular deterioration after administration, including seizures, arrhythmias, or cardiovascular collapse. Exposure and timing support suspicion, but a complete textbook sequence is unnecessary. Immediately stop administration, call for help, support oxygenation and ventilation, and activate a LAST-specific response with early consideration of 20% lipid emulsion. Assessment and treatment proceed together when deterioration is rapid.
Apply it
A patient develops a seizure and unstable rhythm shortly after regional injection. Stop local anesthetic delivery and mobilize airway, circulatory, and LAST rescue resources instead of continuing the procedure.
Common pitfall: Absence of reported early sensory symptoms does not exclude LAST. Sedation or rapid deterioration can prevent observation of the classic warning sequence.
Checklist for Treatment of Local Anesthetic Systemic Toxicity | ASRA Pain Medicine · Local Anesthetic Systemic Toxicity Checklist — 2020, version 1.1
59.Which treatments distinguish LAST resuscitation?
Consider 20% intravenous lipid emulsion early while supporting airway, ventilation, and circulation. Benzodiazepines are preferred for seizures. If epinephrine is needed, the ASRA checklist favors smaller initial doses, starting below 1 microgram/kg. Avoid vasopressin, beta-blockers, calcium-channel blockers, and additional local anesthetics. Large propofol doses are unsuitable in cardiovascular instability, and propofol is not an equivalent lipid-rescue substitute.
Apply it
For suspected LAST with hypotension and convulsions, coordinate benzodiazepine seizure treatment, ventilatory support, lipid rescue, and the modified circulatory medication strategy. Assign tasks so these actions proceed together.
Common pitfall: Applying routine arrest drug choices automatically can conflict with LAST treatment. Obtaining lipid must not delay airway support or active seizure management.
Local Anesthetic Systemic Toxicity Checklist — 2020, version 1.1
60.What should newly diagnosed perioperative atrial fibrillation trigger?
Evaluate and address medical triggers for rapid atrial fibrillation, including anemia and sepsis, while managing the rhythm according to clinical stability. Newly diagnosed perioperative AF also warrants follow-up for surveillance and anticoagulation management. Postoperative anticoagulation decisions weigh stroke prevention against bleeding risk. Resolution of a provoking illness does not establish that future AF or thromboembolic risk has disappeared.
Apply it
Rapid AF develops during systemic infection. Treat the trigger and arrhythmia, assess competing bleeding and stroke concerns, and arrange follow-up even if sinus rhythm returns before discharge.
Common pitfall: Automatic anticoagulation without bleeding assessment and dismissal as a purely transient rhythm both overlook part of the decision. Acute improvement does not replace longitudinal risk assessment.
2024 AHA/ACC Perioperative CV Management Guideline: Key Points - American College of Cardiology
What to focus on during revision
The following are CertMedbry study suggestions. Use the official outline to check the full scope of your examination.
- Use the official outline as the full scope; these concepts selectively sample all six Foot didactic domains.
- Connect imaging to instability, fracture geometry, infection extent, coalition anatomy, inflammatory joint damage, nerve pathology, or tumor extent.
- Explain fixation through fragment purchase, compression direction, stability, and preservation of blood supply.
- Distinguish digital contracture, plantar plate insufficiency, interdigital neuropathy, and inflammatory forefoot deformity by their anatomical targets.
- Match postoperative motion and loading to the operation and the structures that must heal.
- Practise infection classification, source-control decisions, nonunion assessment, cardiac testing selection, anticoagulant management, metabolic emergencies, and LAST.
- Extend study to additional congenital, vascular, neuropathic, metabolic, inflammatory, tendon, and reconstructive subjects in the official outline.
A practical preparation plan
1. Map the complete clinical scope
Build a study map using the official domains and listed subtopics. Identify subjects sampled here and schedule additional study for the remaining areas.
2. Turn findings into decisions
For each concept, state the decisive finding, its mechanism, and its management implication. Compare stable with unstable Lisfranc injury, flexible with rigid deformity, focal impingement with diffuse arthritis, and moderate with severe infection.
3. Draw the anatomical explanation
Sketch screw purchase, articular depression, metatarsal head position, the plantar MTP restraint, and the interdigital nerve's relationship to the transverse ligament. Explain which abnormality each operation changes.
4. Plan recovery from the procedure
Identify which structures must heal, whether motion is preserved or eliminated, and which findings permit loading progression. Explain why symptom improvement alone does not establish structural healing.
5. Review competing answers
Complete the questions before reading explanations. For each uncertain answer, identify the decisive cue and describe which different findings would make a competing option appropriate.
6. Rehearse complete case reasoning
Connect preoperative findings, indications, technical choices, postoperative care, complications, and outcomes. Explain both the intended benefit and the mechanism of a plausible treatment failure.
Use your sample score as a starting point
The free set contains 20 original practice questions. It is a small learning sample, not an official examination or a validated pass prediction. Review each explanation and its source before moving to another topic.
Start the free sampleOfficial sources and updates
- Become Board Certified | ABFAS
- Information and Requirements for Board Certification — September 2026, for 2027 Case Review
- Part I Board Qualification Exam Content | ABFAS
- Part I Qualification Exam Overview | ABFAS
- Part II Case Review Overview | ABFAS
- Information and Requirements for Part I Board Qualification — Fall 2025 Examinations
- IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-Related Foot Infections
- Lisfranc (Midfoot) Injury | AAOS OrthoInfo
- Talus Fractures | AAOS OrthoInfo
- Cortical lag screw insertion | AO Surgery Reference
- Bridge plating | AO Surgery Reference
- Nonlocking plate with/without lag screws for distal articular metatarsal fractures | AO Surgery Reference
- ORIF — Navicular plate | AO Surgery Reference
- Lateral approach to the malleoli | AO Surgery Reference
- Extended lateral approach to the calcaneus | AO Surgery Reference
- Principles of management of open fractures | AO Surgery Reference
- Orthopaedic Surgery and Smoking | AAOS OrthoInfo
- Nonunions | AAOS OrthoInfo
- Compartment Syndrome | AAOS OrthoInfo
- Hallux Rigidus (Stiff Big Toe) | AAOS OrthoInfo
- Bunion Surgery | AAOS OrthoInfo
- Tarsal Coalition | AAOS OrthoInfo
- Progressive Collapsing Foot Deformity | AAOS OrthoInfo
- Soft Tissue Sarcoma Treatment (PDQ®) — Health Professional Version | National Cancer Institute
- ACC, AHA Release New Perioperative Guideline for Patients Undergoing Noncardiac Surgery
- Checklist for Treatment of Local Anesthetic Systemic Toxicity | ASRA Pain Medicine
- Local Anesthetic Systemic Toxicity Checklist — 2020, version 1.1
- JARDIANCE (empagliflozin) Prescribing Information — revised January 2026 | DailyMed
- IWGDF-2023-04-Infection-Guideline.pdf
- Compartment syndrome in the leg
- VA-LCP Forefoot/Midfoot set
- 2024 AHA/ACC Perioperative CV Management Guideline: Key Points - American College of Cardiology
- Hammer Toe: Comprehensive Guide - OrthoInfo - AAOS
- Morton's Neuroma - OrthoInfo - AAOS
- Rheumatoid Arthritis of the Foot and Ankle - OrthoInfo - AAOS
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