Rearfoot and ankle problems rarely present as a single isolated finding. A valgus heel may coexist with forefoot abduction, a tight calf, tendon failure, and arthritis; each changes which correction will work. This guide follows the clinical sequence from interpreting weight-bearing studies through choosing a mechanical goal, performing the reconstruction, protecting it afterward, and recognizing failure early. Use each case to ask what tissue or joint is driving the problem, whether the deformity remains correctable, and which risks change the plan. Trauma, infection, vascular disease, pediatric growth, tumors, and systemic illness appear alongside degenerative deformity because they can alter both diagnosis and operative choices. The emphasis is on decisions a reconstructive foot and ankle surgeon makes, using descriptive findings that stand on their own.
Diagnostic Studies/Medical Imaging
1. Measure loaded hindfoot alignment
A weight-bearing hindfoot alignment view shows where the heel contacts the ground relative to the tibial axis. Draw the tibial reference line and locate the center of the calcaneal contact area; their horizontal separation is the hindfoot moment arm. State both its distance in millimeters and its direction, because the same magnitude can describe valgus or varus. Compare measurements made with similar positioning and loading. The change between two measurements describes how far the heel shifted, while the final measurement describes where it ended. Also inspect the standing foot and ankle views: a heel brought closer to the tibial axis can coexist with forefoot abduction or ankle tilt. The ABFAS RRA content outline includes imaging interpretation, and this measurement is most useful when tied to the deformity being corrected.
Worked example: Assume comparable standing views show a hindfoot moment arm of 12 mm valgus before reconstruction and 3 mm valgus afterward. The medial shift is 12 minus 3, or 9 mm. The operation reduced the valgus moment arm by 9 mm, but the final heel position remains 3 mm valgus. Calling the result neutral would confuse the amount of correction with its endpoint.
Watch the distinction: Subtracting the measurements gives the correction, not the final alignment. Report the postoperative direction and distance separately, and check that positioning is comparable before interpreting a small change.
Reference: [1]
2. Map a collapsing foot on radiographs
Progressive collapsing foot deformity has components that appear on different standing views. On the anteroposterior foot view, reduced talar head coverage by the navicular reflects forefoot abduction through the talonavicular region. On the lateral view, loss of medial arch height and plantar sag reveal collapse in the sagittal plane; identify the joint where the sag occurs rather than calling every low arch identical. A hindfoot alignment view shows whether the calcaneus sits in valgus beneath the leg. Examine ankle alignment as well, because ankle valgus can add a separate source of malalignment. These findings guide correction by component: a heel procedure redirects the hindfoot, while persistent abduction or medial column collapse may require additional correction. Read the images under load, then test flexibility to determine whether the joints can be realigned without fusion.
Worked example: A patient has standing talonavicular uncoverage, plantar sag centered at the talonavicular joint, and a valgus heel. Those findings identify forefoot abduction, arch collapse, and hindfoot valgus, respectively. If a medializing heel osteotomy brings the calcaneus beneath the leg but uncoverage remains, the forefoot is still abducted. Planning must address that component rather than treating improved heel position as complete correction.
Watch the distinction: A valgus heel does not account for every part of a collapsing foot. Track the forefoot and medial arch independently, or a technically successful heel correction may leave substantial deformity.
Reference: [1]
3. Image a suspected tarsal coalition
A tarsal coalition links two bones by bone, cartilage, or fibrous tissue and may restrict subtalar motion. Recurrent hindfoot pain, a rigid valgus posture, and limited inversion should prompt examination of the subtalar joint and standing radiographs. Plain films may show a calcaneonavicular bridge or indirect signs of a talocalcaneal coalition, but they may not define a nonosseous connection or its full extent. CT maps osseous anatomy and helps assess the neighboring joint surfaces before a procedure is chosen. MRI can clarify a suspected fibrous or cartilaginous coalition and show marrow reaction or associated soft-tissue findings. The decision is broader than proving that a bridge exists: document hindfoot flexibility and adjacent arthritis, since these affect whether motion-preserving resection is reasonable. The broader ABFAS certification guide places this RRA topic within the certification pathway.
Worked example: An adolescent has recurrent lateral hindfoot pain, a rigid valgus heel, and little subtalar motion. Radiographs suggest a calcaneonavicular bridge. CT can define how much bone joins the two structures and whether adjacent joints are damaged. If CT leaves a suspected nonosseous portion uncertain, MRI can characterize it and look for surrounding marrow reaction. Imaging therefore answers both what the coalition is and what else may be painful.
Watch the distinction: A suggestive radiograph does not fully establish coalition composition or joint condition. Choosing resection from that image alone can overlook extensive coalition or adjacent arthritis that changes the operative plan.
Reference: [1]
4. Read ankle arthritis with alignment
Ankle arthritis should be read as a loading pattern, not merely as a narrow space on one view. Standing mortise and lateral views show where joint space has been lost, whether the talus tilts beneath the tibial plafond, and whether deformity originates above or below the ankle. Varus tilt concentrates load medially; valgus tilt shifts it laterally. Note osteophytes, talar translation, and any remaining congruent cartilage surface. CT adds detail about cysts, bone loss, and the three-dimensional shape of the tibia and talus, which can affect fixation or implant support. A standing image and a non-weight-bearing CT answer different questions, so reconcile them rather than letting one replace the other. Finally, assess flexibility and ligament stability: apparent correction on imaging does not prove that the joint will remain balanced after reconstruction.
Worked example: A standing mortise view shows medial joint-space loss and varus talar tilt. CT also shows a large medial tibial cyst. The narrowed medial side identifies asymmetric loading, the tilt identifies malalignment, and the cyst identifies deficient supporting bone. An operative plan based only on the remaining lateral joint space would miss both the imbalance and the structural defect.
Watch the distinction: Visible joint space on one side does not mean the ankle is mechanically balanced. Talar tilt and bone defects may determine whether realignment, fusion, or replacement can be supported.
Reference: [1]
5. Classify posterior facet fractures on CT
For a displaced intra-articular calcaneal fracture, coronal CT through the widest part of the posterior facet helps describe how the weight-bearing joint surface is divided. In the Sanders system, count the major fracture lines crossing that facet and the resulting articular pieces. Two lines creating three pieces indicate type III; the line positions further describe fragment location. This classification concerns the posterior facet, not the whole shape of the heel. Inspect axial and sagittal images for tuberosity position, calcaneal height and width, lateral wall displacement, and extension into other joints. Those features explain impingement and influence reduction and fixation. Soft-tissue findings can be more urgent than the articular classification, especially if a posterior fragment threatens heel skin. Use CT to construct a three-dimensional injury map rather than assigning a type from an isolated slice.
Worked example: Coronal CT at the widest posterior facet shows two distinct fracture lines dividing the articular surface into three pieces. That is a Sanders type III pattern. The classification establishes substantial facet fragmentation, but it does not state whether the heel is widened or shortened. Axial and sagittal views are still needed to assess tuberosity displacement, height loss, and possible lateral wall impingement.
Watch the distinction: Counting every visible calcaneal fragment will misclassify the posterior facet. Count the major articular pieces at the appropriate coronal level, then describe the rest of the fracture separately.
Reference: [1]
6. Identify growth-plate injury
A pediatric ankle fracture must be traced in relation to the open physis. The growth plate is weaker than surrounding ligaments in some injuries, so a pattern that resembles an adult sprain or malleolar fracture may cross the physis instead. In the Salter-Harris system, type II passes through the physis and exits through metaphysis, leaving a metaphyseal fragment. Type III extends from the physis through the epiphysis into the joint, while type IV traverses metaphysis, physis, and epiphysis. Imaging should establish displacement, articular involvement, and remaining growth potential. Reduction seeks joint and limb alignment without adding avoidable physeal damage. Even a fracture that unites promptly can later develop partial growth arrest, producing progressive ankle tilt. Follow-up therefore asks whether growth remains symmetric, not simply whether the fracture line has disappeared.
Worked example: A child has a distal tibial fracture line running through the open physis and into the metaphysis, with a triangular metaphyseal fragment. It does not enter the epiphysis or joint surface. The pattern is Salter-Harris II. Reduction should restore alignment while limiting further physeal injury; subsequent standing alignment checks matter because union alone cannot exclude later asymmetric growth.
Watch the distinction: Calling the injury an adult-type ankle fracture overlooks the physis. Identify where the line enters and exits, then consider both immediate alignment and delayed growth disturbance.
Reference: [1]
7. Integrate studies for deep infection
Suspected calcaneal osteomyelitis is a synthesis of the wound, examination, imaging, and laboratory pattern. Ask whether an ulcer or sinus approaches bone, whether there is exposed bone or deep tenderness, and whether systemic illness suggests spreading infection. Elevated inflammatory markers increase concern but are nonspecific; a normal or modest result may not settle a chronic case. On MRI, contiguous low T1 marrow signal, fluid-sensitive edema, and cortical disruption strengthen the case for infection when they connect to the wound. Recent surgery, fracture, and neuropathic change can also alter marrow signal, so distribution and chronology matter. Plain radiographs may reveal destruction or another explanation, though early infection can be occult. When definitive treatment is planned, properly obtained deep tissue or bone samples can identify organisms more reliably than a superficial swab.
Worked example: A chronic heel ulcer probes toward the calcaneus. MRI shows low T1 marrow signal immediately beneath the wound, adjacent edema, and cortical disruption; inflammatory markers are elevated. The wound-to-bone continuity and destructive change make osteomyelitis more likely than an isolated laboratory abnormality would. Deep tissue or bone sampling during definitive evaluation can guide treatment, while a surface swab may reflect colonizing organisms.
Watch the distinction: Neither an elevated inflammatory marker nor MRI edema alone proves osteomyelitis. Match the abnormality to the wound, account for competing causes, and seek an appropriate deep sample when needed.
Reference: [1]
8. Characterize a rearfoot mass
A rearfoot mass should be described by its behavior and anatomical relationships before anyone plans a biopsy. Establish its size, depth, growth history, pain, and effect on nerves, vessels, tendons, or bone. MRI shows whether a lesion is confined to a familiar fluid-filled space or has solid enhancement, heterogeneous tissue, cortical invasion, or extension across fascial planes. Plain films may reveal bone destruction or mineralization. None of these features alone provides histology, but aggressive features change the route to diagnosis. A biopsy tract may need removal during definitive surgery, so its entry point and path should be planned with a tumor specialist. Casual excision through multiple compartments can make later margin control harder. A convincingly benign, stable lesion may follow a different pathway, provided clinical and imaging features agree.
Worked example: An ankle mass has enlarged over several months and lies deep to the fascia. MRI shows heterogeneous enhancement and extension across tissue planes rather than a simple fluid-filled cyst. Those findings warrant specialist review and a planned biopsy route before excision. Removing the mass through a convenient transverse incision could contaminate tissue that a later definitive operation would otherwise preserve.
Watch the distinction: A palpable lump near the ankle is not automatically a routine cyst. Growth, deep location, and tissue-plane invasion should change biopsy planning before a specimen is removed.
Reference: [1]
9. Assess perfusion when arteries calcify
An ankle pressure can overstate distal perfusion when arterial walls are calcified and resist cuff compression. The ankle-brachial index compares ankle systolic pressure with arm systolic pressure, but an incompressible ankle artery can produce an artificially high numerator. That result cannot establish that a wound has enough blood flow to heal. Interpret the pressure alongside pulse examination, skin temperature, capillary refill, Doppler waveforms, and wound behavior. Toe pressures and toe waveforms may be more informative because digital vessels are often less affected by the same calcification, although no single test replaces the full vascular assessment. If perfusion remains uncertain before reconstruction or wound coverage, define the arterial problem further with the vascular team. The key reasoning step is to identify measurement failure before treating a reassuring number as proof of adequate flow.
Worked example: A patient with diabetes has a nonhealing ankle wound, delayed capillary refill, and weak toe waveforms. Ankle arteries remain incompressible under the cuff, so the reported ankle pressure cannot be used as evidence of good healing potential. The clinical findings and toe-based study point toward impaired distal perfusion. Further vascular assessment is needed before relying on the wound to heal after reconstruction.
Watch the distinction: An unusually high ankle reading in calcified arteries is not reassuring. Recognize that the cuff may measure arterial stiffness instead of usable tissue perfusion, then use complementary findings.
Reference: [1]
Surgical Principles
10. Separate flexible from fixed deformity
A standing deformity describes what the limb does under load; manual correction shows what can still move. Examine the hindfoot, midfoot, ankle, and forefoot separately while the patient is weight-bearing and unloaded. A heel that can be brought toward a plantigrade position with preserved subtalar cartilage may be corrected through motion-preserving procedures that redirect forces and support failing tissues. If the heel remains fixed and the subtalar joint is painful and arthritic, moving the calcaneal tuberosity alone cannot restore a damaged joint surface or free a rigid joint. Pain localization matters because radiographic deformity may coexist with a different symptomatic joint. Also check whether apparent flexibility comes from a neighboring joint compensating for a fixed segment. The surgical choice follows the combination of correctability, joint condition, and pain generator rather than the standing angle alone.
Worked example: Two patients have similarly valgus heels on standing views. In one, the heel corrects manually, subtalar motion remains, and joint surfaces are preserved; osteotomy-based correction is mechanically plausible. In the other, the heel stays fixed and subtalar motion is painful with arthritic narrowing. A heel shift alone would leave the painful joint intact, so the second plan must address subtalar arthritis and fixed alignment.
Watch the distinction: Similar standing images do not imply the same operation. Test where motion remains and identify the painful joint before choosing a motion-preserving reconstruction or an arthritis-directed procedure.
Reference: [1]
11. Find the driver of a cavus foot
The Coleman block test asks whether a plantarflexed first ray drives hindfoot varus. Place a block beneath the lateral foot and heel while letting the first ray hang free. If the heel moves from varus toward neutral, it was able to evert when the first ray stopped forcing the forefoot against the floor. That points to a flexible hindfoot with a forefoot driver. If heel varus persists, assess for a fixed hindfoot component that may need its own correction. The test does not identify every tendon imbalance or replace examination of ankle stability, subtalar motion, and plantar pressure. In reconstruction, correct the driver and rebalance forces, then reassess the residual heel position before adding a calcaneal osteotomy. Related RRA Didactic practice questions can help apply that sequence to different presentations.
Worked example: A patient has a high arch, a plantarflexed first ray, and heel varus while standing. With the lateral foot and heel on a Coleman block and the first ray unsupported, the heel moves toward neutral. The change shows that the hindfoot can correct when the forefoot driver is removed. First-ray correction and tendon balancing are considered first; heel osteotomy depends on residual varus.
Watch the distinction: Persistent standing heel varus does not prove a fixed heel. Letting the first ray drop off the block tests whether the hindfoot can correct when that forefoot force is removed.
Reference: [1]
12. Localize equinus
Compare ankle dorsiflexion with the knee extended and flexed while keeping the subtalar joint controlled. The gastrocnemius crosses both knee and ankle; knee flexion relaxes it. If dorsiflexion improves substantially with flexion, gastrocnemius tightness is a likely contributor. If restriction persists in both positions, consider tightness in the combined triceps surae, ankle capsular restriction, bony impingement, or another mechanical block. Avoid letting midfoot collapse masquerade as ankle dorsiflexion: stabilize the foot and observe motion at the tibiotalar joint. Equinus can increase forefoot load and encourage compensatory midfoot collapse, so identifying its source helps select an appropriate procedure within a broader reconstruction. The test is a localization tool, not a complete indication by itself; examine symptoms, deformity, and joint imaging before deciding what to lengthen or release.
Worked example: With the subtalar joint held steady, a patient's ankle barely dorsiflexes when the knee is extended, then dorsiflexes clearly when the knee is flexed. Flexion relaxes the gastrocnemius, so the change favors isolated gastrocnemius tightness. If motion had remained restricted in both positions, the evaluation would extend to the Achilles complex and ankle joint rather than assigning the limit to gastrocnemius alone.
Watch the distinction: Extra midfoot bending can look like improved ankle dorsiflexion. Control the foot during the test and compare the two knee positions before attributing equinus to a specific structure.
Reference: [1]
13. Match fixation to mechanical demand
A fracture or fusion construct must resist the forces the patient will place across it. Compression brings prepared surfaces into contact and can reduce an interfragmentary gap, but stability also requires control of rotation, shear, bending, and axial load. A single fixation axis may compress well while allowing motion around that axis. Divergent or supplemental fixation can address the missing direction of control, provided it fits the bone stock and anatomy. Load sharing differs by construct: bone contact can carry some force, while an unsupported gap shifts more demand onto implants and graft. Evaluate the quality of reduction before adding hardware, because strong fixation cannot make malaligned surfaces plantigrade. Healing also depends on blood supply and the biological environment. When studying a fixation choice, name the dominant force, the interface at risk, and how each device counters movement there.
Worked example: An ankle fusion has broad, well-prepared contact and visible compression, but one fixation axis offers limited resistance to rotation. As the patient moves, torsion could disturb the fusion interface despite good initial contact. A construct that adds rotational control while preserving compression better matches the mechanical demand. Its value comes from controlling another direction of motion, not merely from adding more metal.
Watch the distinction: Compression is one property of stability, not the entire construct. Check torsion, shear, bending, bone contact, and alignment before assuming a well-compressed fusion will remain still.
Reference: [1]
14. Choose graft by the missing function
Choose graft according to the deficit it must solve. Cancellous graft offers a porous environment and surface area for bone formation, making it useful in a contained defect where surrounding bone and fixation already preserve shape. A structural graft must maintain length, height, or alignment while healing across a gap. Its geometry, contact area, and fixation matter because a graft that crushes or shifts can recreate deformity even if bone eventually bridges. Bone substitutes may fill space or contribute a scaffold, but their load-bearing properties vary and cannot be inferred from the word graft. Before choosing material, determine whether the defect is contained, whether viable host bone contacts it, and what forces cross the site. Infection, poor perfusion, and instability can defeat either graft strategy; they require their own management as part of revision.
Worked example: After a collapsed hindfoot nonunion is corrected, a gap remains where height must be restored under load. Loose cancellous chips can fill the space but offer little immediate resistance to compression. A structural graft or another load-bearing reconstruction is needed to hold the restored geometry, with stable fixation and viable host contact to support eventual union.
Watch the distinction: Filling a defect is not equivalent to supporting it. If the space determines hindfoot height or length, graft choice must meet that mechanical demand as well as support bone healing.
Reference: [1]
15. Protect the wound's blood supply
An ankle incision must reach the target while preserving perfused tissue for closure. Prior scars, local swelling, vascular disease, and thin skin affect where a new cut can safely run. Two nearby parallel incisions can leave a narrow skin bridge with limited blood supply. Excessive retraction, broad undermining, and closure under tension further reduce tissue perfusion, even when the original incision was well placed. Plan the dissection with the relevant nerves and vessels in mind, and preserve soft-tissue attachments where possible. Before closing, assess whether the skin edges meet without blanching or undue force and whether a dead space or exposed structure needs another coverage strategy. This reasoning is especially important around the anterior ankle and lateral heel, where soft-tissue envelopes can be unforgiving. Good bone alignment cannot compensate for a wound that lacks viable coverage.
Worked example: A patient has thin anterior ankle skin and a prior longitudinal scar near the proposed exposure. A second parallel incision would create a narrow intervening bridge that may have poor perfusion. The exposure should be planned around the existing scar, required access, and available viable skin. If closure would blanch or pull tightly, the coverage plan must change rather than forcing the edges together.
Watch the distinction: A neat-looking incision does not guarantee a viable wound. Consider the blood supply between scars, retraction injury, dead space, and closure tension before judging an exposure safe.
Reference: [1]
16. Control infection at its source
Deep ankle infection requires control of the infected focus as well as systemic treatment. Purulence inside a joint or abscess cavity persists where antibiotics may not adequately clear it without drainage. Obtain clinically appropriate blood, joint, or deep tissue samples to identify organisms; superficial drainage swabs may be misleading. Drain the infected space, remove devitalized tissue, and assess whether exposed bone or implants are involved. If fixation is present, determine whether it remains stable and whether removal would destabilize the limb. Antimicrobial treatment addresses organisms in tissue and bloodstream, with selection refined by reliable cultures and clinical response. In a systemically ill patient, sampling should not create a harmful delay in treatment. Later reconstruction is a separate decision after infection control, viable tissue, and mechanical stability have been established.
Worked example: A patient is febrile with a swollen, painful ankle, and aspiration yields purulent fluid. The fluid supports septic arthritis and provides a specimen for culture. Prompt joint drainage addresses the enclosed infectious focus; antimicrobials address systemic and residual infection. If cartilage is damaged, definitive arthritis reconstruction is considered later, after the acute infection is controlled and the joint's condition is reassessed.
Watch the distinction: An oral antibiotic prescription cannot drain an infected joint. Purulence calls for source control, appropriate sampling, and systemic treatment while stability and surrounding tissue involvement are assessed.
Reference: [1]
17. Recognize compartment syndrome
Compartment syndrome develops when pressure within a closed muscle compartment impairs capillary flow, threatening muscle and nerve viability. The early clinical pattern is escalating pain that seems disproportionate to the injury, pain with passive stretch of involved muscles, and increasing analgesic need. Sensory change or weakness can follow. A palpable pulse does not exclude the condition because major arterial flow may persist while microvascular perfusion fails. Inspect casts and dressings and perform repeated examinations when findings evolve. In a patient who cannot communicate reliably or whose examination is uncertain, pressure measurement may help the surgical team, but it should not delay action when the clinical pattern is compelling. The decision is time-sensitive: urgent surgical assessment determines whether decompression is required. The injury mechanism, trend in symptoms, and neurologic findings matter more than a single reassuring observation.
Worked example: After a crush injury, a patient's leg pain worsens despite immobilization and analgesia. Passive toe stretch increases pain, and new sensory change appears. Distal pulses are still palpable. The evolving pain and neurologic findings raise strong concern for compartment syndrome despite the pulses. The limb needs immediate surgical assessment and relief of external constriction while the team evaluates urgent decompression.
Watch the distinction: Waiting for a pulse to disappear is unsafe reasoning. Compartment pressure can injure muscle and nerves before major arterial flow is lost, so follow the evolving clinical pattern.
Reference: [1]
18. Preserve pediatric growth potential
In a child, fracture care must protect present alignment and future growth. Open physes can be injured by the fracture, forceful manipulation, or a fixation path that unnecessarily crosses healthy growth plate. Define the fracture line and residual displacement on appropriate images, then choose reduction and fixation that restore alignment with minimal additional physeal injury. Assess joint congruity when the fracture enters the epiphysis. After union, surveillance remains important because a partial physeal bar can slow one side of the distal tibia while the other side keeps growing, producing angular deformity. Complete arrest may cause a length difference. The amount of growth remaining changes how much deformity can develop and which corrective options remain. Thus, a healed fracture and a well-aligned ankle immediately after treatment answer only the short-term question.
Worked example: A child with substantial growth remaining has a displaced distal tibial physeal fracture. Reduction restores the ankle relationship, and fixation is planned to avoid unnecessary additional injury to the physis. At later standing follow-up, alignment is checked as growth continues. Progressive ankle tilt would suggest asymmetric growth arrest even if the original fracture had united in good position.
Watch the distinction: Union is not the final outcome measure for a physeal fracture. Later asymmetric closure can change ankle alignment, so follow growth and compare serial standing images when indicated.
Reference: [1]
19. Plan the biopsy tract
A biopsy is part of the definitive surgical map for a suspicious rearfoot tumor. The tract and any contaminated tissue may have to be removed with the lesion, so the route should be short, direct, and compatible with a future excision. Avoid crossing uninvolved compartments, joint spaces, and major neurovascular structures when another planned route is available. Imaging first defines the lesion's full extent, viable target, cortical breach, and relationship to vessels and tendons. The biopsy must sample diagnostic tissue without making later margin control harder. A specialist team should coordinate the route and technique, especially for destructive bone lesions or deep soft-tissue masses. Histology then guides treatment; imaging behavior alone cannot establish tumor type. The operative question is therefore not only where a needle can reach, but which path can safely be incorporated into definitive treatment.
Worked example: Imaging shows a destructive talar lesion extending into adjacent soft tissue. A convenient biopsy path through an unrelated compartment could contaminate tissue that might otherwise remain outside the resection. A specialist-planned tract approaches a representative part of the lesion along a route compatible with possible definitive excision. Sampling is performed after the extent and tissue planes have been mapped.
Watch the distinction: The shortest path on a scan is not automatically the best biopsy path. A tract crossing clean compartments can enlarge the eventual treatment field and complicate margin control.
Reference: [1]
20. Prioritize limb viability after vascular injury
After ankle trauma, determine whether the foot is perfused before pursuing routine fracture planning. A cool, pale foot, absent distal Doppler signals, an expanding hematoma, or active bleeding raises concern for major vascular injury. Recheck limb alignment and remove external constriction while coordinating urgent trauma and vascular assessment. A displaced joint or fracture can compromise flow, and reduction may change the vascular examination; document findings before and after any necessary maneuver. If perfusion remains threatened, further imaging must be weighed against delay to definitive vascular care. A stable foot with preserved signals and no expanding hematoma permits a different sequence in which vascular imaging can define an uncertain injury. The decision turns on current limb viability, repeated examination, and the trajectory of the findings, not merely on whether a pulse was recorded earlier.
Worked example: Following ankle trauma, the foot becomes cool and pale. A hematoma expands near the injury, and distal Doppler signals are absent. These findings indicate threatened perfusion and demand immediate trauma and vascular coordination. Limb alignment and any constricting dressing are assessed at once; routine imaging must not delay treatment if ischemia persists. A previously documented pulse does not override the new examination.
Watch the distinction: An earlier normal vascular check cannot clear a changing limb. New pallor, cooling, expanding hematoma, or lost signals requires urgent reassessment because perfusion may deteriorate after the initial examination.
Reference: [1]
21. Integrate medical and anesthesia risk
Major reconstruction depends on the patient's capacity to heal and tolerate anesthesia as well as on the deformity. The ABFAS RRA Surgery Didactic subject outline includes medicine and anesthesia within this scope. Start with the proposed operation's blood loss, duration, wound demands, and expected period of limited mobility. Then connect each illness to a practical consequence: diabetes may impair wound healing and increase infection risk; renal disease may change fluid balance and drug handling; anticoagulation raises bleeding concerns if interrupted or continued. Assess cardiopulmonary status, prior anesthetic problems, medication indications, and the consequences of delaying surgery. Coordinate a medication and anesthesia plan before committing to the procedure. Optimization is specific to the patient and operation, not a universal laboratory cutoff or a promise that complications will be avoided.
Worked example: A patient scheduled for ankle fusion has variable glucose control, chronic kidney disease, and anticoagulation for a prior clot. The team evaluates current metabolic and renal status, establishes why anticoagulation is needed, and plans anesthesia, bleeding management, and postoperative mobility together. If a correctable problem makes the elective operation unusually hazardous, they address it before surgery. A glucose result alone cannot settle all three risks.
Watch the distinction: A tempting shortcut is to label the patient fit because one laboratory result improved. Healing, medication interruption, anesthetic tolerance, and postoperative immobility pose separate questions.
Reference: [1]
Surgical Procedures/Techniques
22. Shift the heel under the leg
A medializing calcaneal osteotomy changes where the heel contacts the ground relative to the leg's load axis. In flexible planovalgus, the heel lies lateral to that axis, creating a valgus moment. Translating the posterior calcaneal tuberosity medially reduces that moment while retaining subtalar motion. Plan the cut through suitable calcaneal bone and judge correction with the foot loaded or with appropriate intraoperative alignment checks; the amount moved is distinct from the heel's final position. Protect the nearby sural nerve laterally and medial neurovascular structures, and avoid a cut that leaves inadequate purchase for fixation. Screws or another stable construct must resist displacement while bone heals. This maneuver chiefly addresses hindfoot valgus. Residual forefoot abduction, medial column collapse, or equinus requires its own assessment.
Worked example: A patient has a flexible valgus heel after forefoot factors have been assessed. The surgeon translates the posterior calcaneal fragment medially and fixes it in the corrected position. A hypothetical loaded alignment reading changes from 11 mm valgus to 2 mm valgus: the heel moved 9 mm medially, yet remains slightly valgus. Persistent talonavicular uncoverage would still need separate correction.
Watch the distinction: Moving the tuberosity medially does not automatically center every part of a collapsing foot. The osteotomy changes the heel's lever arm, while abduction may persist elsewhere.
Reference: [1]
23. Lengthen for forefoot abduction
Lateral column lengthening addresses transverse plane forefoot abduction in a flexible collapsing foot. Lengthening the lateral side changes the relationship between the anterior calcaneus and forefoot, helping bring the navicular back over the talar head. Standing talonavicular coverage and forefoot position help reveal whether abduction remains after hindfoot valgus correction. The surgeon must choose a cut, graft or implant, and fixation that maintain the intended length while preserving joint surfaces and viable bone. Correction is judged across the entire foot: an apparent gain in coverage is harmful if it shifts excessive pressure to the calcaneocuboid region or lateral forefoot. Check for residual hindfoot valgus and medial column instability as independent components. A longer lateral column cannot replace every other element of reconstruction.
Worked example: Following correction of a flexible valgus heel, standing assessment still shows forefoot abduction and substantial talonavicular uncoverage. Lateral column lengthening is considered for that residual component. The surgeon checks coverage and lateral joint loading as length is restored. If the forefoot swings into excessive adduction or the lateral border bears disproportionate pressure, further lengthening would trade one deformity for another.
Watch the distinction: An uncovered talar head does not prescribe unlimited lengthening. Excess correction can overload the lateral column even when the radiograph appears more covered.
Reference: [1]
24. Restore dynamic medial support
Posterior tibial tendon failure removes an important dynamic inverter and supporter of the medial arch. A flexor tendon transfer can supply an active line of pull when the native tendon is ineffective, but its force is limited by the bony position beneath it. The spring ligament helps restrain plantar and medial displacement of the talar head; repair or reconstruction strengthens that passive support when it is deficient. Before transferring or fixing tissue, correct substantial heel valgus and forefoot abduction so the soft tissues are not asked to hold an uncorrected deformity. Assess the medial column for residual instability and distinguish flexible collapse from established painful arthritis. Place and tension the transfer in a corrected, functional position, preserving its excursion and secure fixation. Follow-up evaluates both alignment and tendon function.
Worked example: A patient has flexible planovalgus, a dysfunctional posterior tibial tendon, spring-ligament attenuation, and marked heel valgus. The surgeon corrects the bony alignment, then secures a flexor tendon transfer and reinforces the medial ligament restraint. The tendon supplies dynamic support, while the ligament resists talar head displacement. Neither soft-tissue step would reliably counter the original valgus lever arm by itself.
Watch the distinction: Treating a transferred tendon as a substitute for realignment asks it to resist persistent deforming forces. It supports a corrected foot; it does not erase substantial bony malalignment.
Reference: [1]
25. Prepare a subtalar fusion
Subtalar fusion removes painful motion at the talocalcaneal joint and fixes the hindfoot in a useful position. Confirm that symptoms, examination, and imaging point to this joint; pain from adjacent joints needs separate evaluation. Preparation removes remaining cartilage and nonviable surface tissue to expose viable bone across the posterior facet and any other joint surfaces selected for fusion. The surgeon corrects varus or valgus before compression, because a solid fusion in poor alignment remains a mechanical problem. Broad contact, compression, and fixation that resist rotation and shear support union. Bone defects may need graft selected for their structural or biological role. Check that the corrected heel allows a plantigrade foot without impingement. Postoperative loading follows construct stability and evidence of healing rather than a calendar date alone.
Worked example: A healed calcaneal fracture leaves painful subtalar arthritis and a fixed, mild valgus heel. At fusion, the arthritic surfaces are prepared to viable bone, the heel is brought to functional alignment, and fixation compresses the apposed surfaces while controlling rotation. The operation addresses joint pain and position together. Compressing surfaces while retaining the valgus position would leave abnormal loading despite eventual union.
Watch the distinction: Removing cartilage is only one part of fusion. Inadequate alignment or fixation can leave a painful foot even if the surgeon thoroughly prepares the joint.
Reference: [1]
26. Align a triple arthrodesis
Triple arthrodesis joins the subtalar, talonavicular, and calcaneocuboid joints when their combined disease or deformity warrants it. Each joint influences a different portion of hindfoot and midfoot position, so the sequence of preparation, reduction, and temporary fixation matters. First define the desired plantigrade result from standing examination and imaging. After exposing and preparing the involved surfaces, reduce the hindfoot and forefoot together, checking heel position, talonavicular coverage, lateral column contact, and the ability of the sole to meet the floor. Fixation should maintain corrected relationships and compress suitable bone surfaces. Avoid forcing the heel into varus or excessively shortening or compressing the lateral side merely to make one joint look congruent. A preserved joint should be evaluated for symptoms and stability before it is included in a fusion plan.
Worked example: A rigid planovalgus foot has pain and degenerative changes at all three hindfoot joints. During correction, the surgeon brings the heel beneath the leg and restores a plantigrade forefoot before final fixation. Temporary alignment is checked across the three joints. If each joint were fixed where it initially rested, the foot could unite yet retain valgus and poor ground contact.
Watch the distinction: Three well-compressed joints do not guarantee a useful foot. Whole-foot alignment and pressure distribution must be checked before the position is locked in.
Reference: [1]
27. Build an ankle fusion
Tibiotalar fusion replaces painful ankle motion with a stable, aligned connection between tibia and talus. The operative problem has two parts: create viable opposing bone surfaces and place the foot beneath the leg in a functional position. Joint preparation removes damaged cartilage and addresses irregular bone while conserving enough support for broad contact. Correct coronal tilt, rotation, and sagittal position before fixation; otherwise compression can preserve the deformity. A stable construct must maintain apposition and control bending and rotation during healing. Account for hindfoot alignment and adjacent-joint motion, since these determine how the foot meets the ground after ankle motion is lost. Assess bone loss and infection when choosing graft or staging. Union on imaging is meaningful, but a plantigrade, comfortable foot is the mechanical goal.
Worked example: A patient with end-stage ankle arthritis has a varus talus beneath the tibia. The surgeon prepares both surfaces, corrects the talar position until the foot sits beneath the leg, and applies fixation that holds compression and alignment. Simply drawing the original tilted surfaces together could produce union in varus, leaving the lateral foot overloaded during walking.
Watch the distinction: Compression is not a correction method by itself. The tibia and talus must be positioned properly before the fixation construct preserves their relationship.
Reference: [1]
28. Balance an ankle replacement
Total ankle arthroplasty aims to retain ankle motion while replacing damaged bearing surfaces. It needs reliable bone support, accurately positioned components, a congruent talus beneath the tibia, and balanced soft tissues. If coronal deformity or ligament laxity persists, the joint can load one edge of the implant repeatedly, promoting pain, instability, or component failure. Evaluate deformity in the ankle and neighboring foot rather than treating the implant as an isolated part. Bone defects may limit support, while prior wounds and poor soft tissue can complicate exposure and closure. Trial reduction allows assessment of motion, tracking, and ligament tension before final components are secured. Additional alignment or ligament procedures may be needed to create a stable construct; their need follows the demonstrated deformity rather than a fixed recipe.
Worked example: A candidate has end-stage ankle arthritis, a correctable coronal tilt, and unequal medial and lateral ligament tension. After preparing the bone, a trial implant appears centered, but the talus still tilts under stress. The surgeon must address the remaining imbalance before relying on final component placement. A centered implant on a static image would not prove balanced loading during movement.
Watch the distinction: Component centering alone does not establish stability. A malaligned hindfoot or unequal ligament tension can repeatedly shift load to one side of an otherwise well-positioned implant.
Reference: [1]
29. Redirect load above the ankle
Supramalleolar osteotomy changes the orientation of the distal tibial joint surface and redirects the line of force through the ankle. It is most relevant when deformity originates above the joint and usable cartilage remains in a portion of the ankle. Standing leg and ankle views help locate the deformity and identify where load is concentrated. Plan the osteotomy in the plane of the deformity, preserving or restoring appropriate sagittal alignment and rotation as well as correcting coronal tilt. An opening wedge, closing wedge, or other configuration changes bone contact and may require graft or different fixation. Reassess the talus, fibula, and hindfoot after correction; a distal tibial cut cannot solve independent ligament instability or advanced damage throughout the joint. The intended result is improved load distribution, not regenerated cartilage.
Worked example: Standing images show distal tibial varus with medial ankle wear and usable lateral cartilage. The planned correction changes the tibial plafond's coronal orientation so more load passes through the preserved surface. If the cut corrected rotation but left the coronal tilt unchanged, the medial concentration would remain. Post-correction imaging must also confirm that the talus stays centered.
Watch the distinction: Any osteotomy near the ankle does not necessarily unload the diseased surface. Its plane and location must address the actual deformity and resulting force direction.
Reference: [1]
30. Correct a cavus reconstruction in sequence
Cavus reconstruction works best when the primary driver is identified before the heel is cut. A plantarflexed first ray can push the forefoot against the ground and make the hindfoot appear fixed in varus. During Coleman block testing, the first ray hangs free while the lateral forefoot and heel remain supported; heel correction indicates that much of the varus is flexible and forefoot driven. Correct the first-ray position and address muscle imbalance, such as excessive peroneus longus pull, then reassess the heel under load. A persistent fixed varus component may need calcaneal osteotomy, while arthritic rigidity may call for a joint-directed operation. Tendon transfers redistribute force only when joints and bone are positioned so that the new force is useful. Assess ankle instability and equinus because either can maintain symptoms after an apparently straight reconstruction.
Worked example: A patient has a plantarflexed first ray, cavus arch, and varus heel that corrects on a Coleman block. The peroneus longus also overpowers the first ray. The operative sequence addresses first-ray position and tendon balance, then tests whether heel varus remains. A heel osteotomy is considered only for the residual hindfoot component; doing it first risks correcting a compensatory position.
Watch the distinction: A varus heel on a standing photograph is not proof of a fixed heel deformity. Block testing can reveal a flexible response to the first ray.
Reference: [1]
31. Resect a suitable coalition
Coalition resection aims to separate an abnormal bridge while preserving useful hindfoot motion. Its prospects depend on coalition anatomy, the amount of adjacent joint cartilage retained, heel alignment, and whether deformity is correctable. Radiographs identify the pattern, and cross-sectional imaging can define the bridge and surrounding joint surfaces when needed. The surgeon removes enough coalition tissue to create a durable interval without damaging important normal joint areas. Interposition tissue can help keep the resected surfaces apart and reduce rebridging. After resection, reassess subtalar movement and heel position; persistent substantial valgus may require a separate corrective procedure. A large coalition with painful established arthritis poses a different problem because restoring a gap cannot restore the damaged joint surface. The procedure is chosen for a motion-preserving opportunity, not for every radiographic bridge.
Worked example: An adolescent has a symptomatic calcaneonavicular coalition, preserved neighboring joint surfaces, and a valgus heel that corrects manually. Resection removes the bridge and creates a clear interval, with interposition selected to discourage rebridging. The surgeon then checks motion and alignment. Leaving only a slit between raw bony surfaces would make recurrence more likely, while overlooking fixed arthritis would leave another pain source.
Watch the distinction: Seeing a coalition on imaging does not make resection sufficient. The adjacent cartilage and flexibility determine whether separation can relieve the patient's mechanical problem.
Reference: [1]
32. Restore pediatric talonavicular alignment
Congenital vertical talus is a rigid rocker-bottom deformity in which the talonavicular relationship remains dislocated, commonly with the navicular positioned dorsally relative to the talar head. Stress views help distinguish a fixed dislocation from a flexible appearance. Correction must restore the talonavicular relationship and then address remaining contractures, including equinus. Serial manipulation and casting can progressively improve alignment before limited operative stabilization or soft-tissue work, depending on the case. The Achilles tendon can be tight, but lengthening it changes ankle dorsiflexion rather than directly reducing the navicular onto the talus. Throughout treatment, inspect the foot's skin, neurovascular status, and position, and verify that correction is maintained rather than merely appearing improved on one view. Growth and recurrence risk make follow-up part of the treatment sequence.
Worked example: An infant has a rigid convex sole. Stress imaging shows that the talonavicular joint remains dislocated when the foot is manipulated. Treatment focuses on bringing the navicular into alignment with the talus and maintaining that relationship; persistent equinus is addressed as another component. Achilles lengthening alone might improve dorsiflexion, but the rocker-bottom deformity would remain if the joint stayed dislocated.
Watch the distinction: The visible rocker-bottom shape is not simply an Achilles contracture. Its defining fixed talonavicular malalignment requires direct correction and verification.
Reference: [1]
33. Reduce the ankle mortise
Ankle fracture fixation aims to restore a congruent mortise, not merely attach hardware to each broken bone. Fibular shortening or malrotation can leave the talus displaced even when a plate holds the fracture. Assess fibular length and rotation, medial and posterior articular fragments, and the tibiofibular relationship. After bony reduction, reassess syndesmotic alignment and stability; fixation of the syndesmosis cannot compensate for a fibula positioned incorrectly in the incisura. Intraoperative mortise views and appropriate direct assessment help reveal residual talar shift or widening. Verify reduction after final fixation because clamps and implants can themselves change relationships. Postoperative RRA Didactic practice questions can help rehearse this sequence, but the clinical decision rests on the whole injury pattern and demonstrated mortise stability.
Worked example: After a displaced fibular fracture is plated, an intraoperative mortise view still shows lateral talar shift and syndesmotic widening. The surgeon checks fibular length and rotation, articular fragments, and fibular position within the incisura before deciding on syndesmotic fixation. Adding a screw without correcting a malrotated fibula could hold an incongruent mortise in place.
Watch the distinction: A plated fibula is not proof of anatomic ankle reduction. Persistent talar shift or syndesmotic widening demands reassessment of the bone and joint relationships.
Reference: [1]
34. Protect the heel's threatened skin
A displaced calcaneal tuberosity fragment can press directly against the thin posterior heel skin. In a tongue-type fracture, the Achilles tendon may pull the fragment upward, increasing pressure over a small skin area. Blanching, tenting, or evolving discoloration signals threatened tissue viability even though the fracture is closed. The immediate priority is to relieve that pressure through prompt reduction and stabilization while assessing the skin and neurovascular status. The precise fixation method depends on fragment size, bone quality, fracture pattern, and available soft tissue. This timing differs from many swollen intra-articular calcaneal fractures, where definitive reconstruction may wait for the soft-tissue envelope to recover. The key distinction is a specific threatened skin site: delay can convert a closed injury into skin necrosis and a much harder reconstruction.
Worked example: A patient arrives after a fall with a tongue-type calcaneal fracture. The posterior fragment is elevated and the heel skin over it is taut and pale. The team prioritizes reducing and stabilizing the fragment to remove pressure, while monitoring skin viability. Waiting for generalized swelling to subside would expose that already threatened patch of skin to continuing pressure.
Watch the distinction: The usual caution about operating through swollen heel skin does not justify leaving a tuberosity fragment pressing on blanching skin. That focal threat changes the sequence.
Reference: [1]
35. Restore tendon tracking
Peroneal tendon pain may arise from tendon substance damage, failure of its retaining structures, or both. Behind the fibula, the superior peroneal retinaculum holds the tendons in the groove. A longitudinal peroneus brevis split can cause mechanical symptoms, but repairing the split alone does not restrain tendons if the retinaculum has stripped away. During surgery, inspect the tendon quality, both peroneal tendons, the groove, and the retinacular attachment. Debride or repair the damaged tendon according to viable tissue, then restore the restraint and confirm that the tendons track without subluxation through ankle motion. Groove shape and crowding may matter in selected cases. A tight reconstruction can also impair gliding, so stability must be balanced with free movement. Persistent symptoms warrant checking for associated ankle instability or hindfoot malalignment.
Worked example: An athlete has snapping behind the lateral malleolus and a peroneus brevis split tear. Exploration also finds a stripped superior peroneal retinaculum. Repairing viable tendon addresses the split, while restoring the retinacular attachment prevents it from jumping out of the groove. Motion testing confirms both stable tracking and acceptable glide before closure.
Watch the distinction: A tendon tear visible on imaging can distract from the cause of snapping. Without restoring the retinacular restraint, a repaired tendon may still sublux.
Reference: [1]
36. Close a complex ankle wound
Closing an ankle wound requires a durable barrier over tendon, bone, joint, or implant. After debridement, determine which tissue is viable, how much dead space remains, whether infection is controlled, and whether skin edges meet without tension. Exposed tendon without its nourishing covering may not accept a simple skin graft well; exposed hardware or joint structures often require more substantial vascularized tissue. A flap can supply living coverage where local skin cannot. The choice of local or more distant coverage depends on defect size, location, perfusion, and available donor tissue. Drains or specialized dressings may manage fluid and dead space, but they do not create viable coverage by themselves. Stabilize the underlying skeletal problem and coordinate infection treatment, because a technically closed wound can fail if deep disease or unstable hardware remains.
Worked example: Following debridement of an anterior ankle wound, viable skin edges cannot meet without tension and a tendon is exposed. The team plans vascularized coverage and evaluates residual dead space, infection, and skeletal stability. Pulling the skin tightly across the tendon might close the wound on the table, but poor perfusion and tension would make breakdown likely.
Watch the distinction: A wound is not solved merely because its edges touch. Exposed structures, tissue viability, deep infection, and tension determine whether closure will survive.
Reference: [1]
Procedural Perioperative Management
37. Select surgery for flexible collapse
Flexible progressive collapse is a collection of deformity components that can occur together: heel valgus, forefoot abduction, medial arch or ligament failure, and equinus. Examine the loaded shape, then test which portions correct manually. Weight-bearing images show where joints uncover or sag, while knee-flexed and knee-extended dorsiflexion helps identify gastrocnemius contribution. Choose procedures by the remaining mechanical problems. A medializing heel osteotomy addresses hindfoot valgus; lateral column lengthening may address abduction; tendon transfer and spring-ligament work can restore medial support; a gastrocnemius procedure may address isolated tightness when clinically relevant. The combination is adjusted to the individual foot, with attention to overcorrection and lateral overload. Arthritis or rigidity changes the decision because motion-preserving correction may no longer treat the painful joint. The ABFAS didactic exam guide describes questions that test application of clinical findings.
Worked example: A patient has a manually correctable valgus heel, standing talonavicular uncoverage, deficient medial support, and dorsiflexion that improves when the knee bends. The plan addresses heel position, forefoot abduction, ligament and tendon support, and the gastrocnemius contribution. Repairing the painful posterior tibial tendon alone would leave several forces causing collapse.
Watch the distinction: The label flatfoot does not identify one operation. The selected procedures must correspond to the correctable deformity components and the joints that actually hurt.
38. Select joints for rigid deformity
In a rigid painful deformity, determine which joints are diseased and which joints must be included to achieve a stable plantigrade correction. History and targeted palpation locate pain; standing imaging shows alignment and arthritic changes; motion testing identifies joints that no longer correct. Subtalar and talonavicular arthritis can require fusion of both joints if they generate pain and prevent correction. The calcaneocuboid joint should be assessed separately for cartilage loss, tenderness, and whether leaving it mobile would compromise stability. Fusing an uninvolved joint sacrifices motion, but excluding a joint essential to alignment may leave deformity or abnormal loading. Plan correction across the whole hindfoot, not as three independent radiographic decisions. The operative goal is to eliminate painful motion where necessary while retaining useful motion where feasible.
Worked example: A patient has rigid valgus with marked subtalar and talonavicular degeneration, yet the calcaneocuboid joint is preserved and painless. The proposed fusion addresses the two diseased joints and brings the foot plantigrade. Before sparing the calcaneocuboid joint, the surgeon checks whether corrected alignment remains stable without including it. A routine triple fusion would surrender a potentially useful joint without first answering that question.
Watch the distinction: Rigid valgus does not automatically mean all three hindfoot joints require fusion. Pain, cartilage, correctability, and the stability of the planned correction guide inclusion.
Reference: [1]
39. Choose fusion or ankle replacement
Both fusion and total ankle replacement can treat end-stage tibiotalar arthritis, but they place different demands on the surrounding limb. Fusion trades ankle motion for a stable, aligned bone connection; remaining joints then accommodate more movement. Replacement preserves some ankle motion but depends on adequate bone support, stable ligaments, useful alignment, viable soft tissue, and the patient's ability to manage an implant over time. Evaluate neuropathy, infection history, vascular status, deformity, adjacent-joint disease, and patient goals together. Correctability matters more than the presence of deformity alone: an unstable foot that cannot support balanced loading is a poor platform for an implant. Fusion also needs healing capacity and sound fixation, so it is not a risk-free fallback. The related RRA NEW CBPS guide covers a different assessment format; here, focus on the clinical treatment comparison.
Worked example: Two patients have painful end-stage ankle arthritis. One has severe neuropathy and an unstable deformity that threatens balanced implant loading; fusion may offer a more supportable reconstruction after individual risk assessment. The other has correctable alignment, adequate bone, stable soft tissues, and a strong preference to retain motion; replacement can be considered. The diagnosis alone does not select the operation.
Watch the distinction: Motion preservation is not an automatic reason to choose replacement. An implant must remain supported and balanced, while fusion requires its own healing and alignment assessment.
Reference: [1]
40. Choose coalition resection or fusion
Coalition treatment depends on whether the painful problem is chiefly a restrictive bridge or an already damaged joint. Define coalition size and location with imaging, inspect adjacent cartilage, and test hindfoot flexibility and alignment. In a young patient with a limited coalition, preserved joint surfaces, and correctable deformity, resection can create a separation and retain subtalar motion. Persistent valgus may need correction alongside resection. When the subtalar joint is arthritic and the hindfoot rigid, removing the bridge can restore neither cartilage nor comfortable movement. Fusion of the painful joint, with alignment correction, then addresses the structural source of symptoms. The decision also accounts for other involved joints, patient activity, and prior treatment. A technically successful resection is a poor outcome if it leaves an arthritic joint as the main pain generator.
Worked example: One adolescent has a small symptomatic calcaneonavicular coalition, preserved adjacent joints, and a flexible heel. Resection with attention to the residual gap is a motion-preserving option. Another patient has a broad coalition, rigid valgus, and painful subtalar arthritis. Removing the bridge alone would leave damaged cartilage and deformity; fusion planning addresses the arthritic joint and heel position.
Watch the distinction: Age or the mere presence of a coalition does not decide between resection and fusion. Flexibility, coalition anatomy, and adjacent arthritis determine what each operation can accomplish.
Reference: [1]
41. Plan for recurrent clubfoot
Recurrent clubfoot needs a fresh assessment of what moves and what drives the walking pattern. Observe the child barefoot for dynamic forefoot supination, then test whether the forefoot, heel, and ankle can each be corrected by hand. A foot that rests plantigrade when positioned but supinates during swing or initial contact suggests a muscle imbalance. Tendon transfer can redirect that pull, provided the foot has first regained enough passive correction. Persistent equinus, heel varus, or forefoot adductus represents a structural problem that requires its own correction; transfer into a rigid deformity cannot make the foot plantigrade. Examine skin, pain, prior treatment, and standing alignment before choosing an intervention. Clubfoot is among the deformities in the ABFAS RRA subject areas.
Worked example: A child treated for clubfoot lands on the lateral border because the forefoot supinates during gait. On examination, the foot can be placed flat, the heel corrects, and ankle dorsiflexion is available. This supports a dynamic relapse, so tendon balancing is plausible. If the ankle instead remains in equinus when the child relaxes, that fixed component needs correction before transfer can maintain a plantigrade result.
Watch the distinction: Visible supination during walking does not automatically mean a fixed recurrence. Passive correction distinguishes a dynamic pull from a structural deformity and determines whether tendon balancing can help.
Reference: [1]
42. Time fracture reconstruction around soft tissue
Soft tissues govern the sequence after a calcaneal fracture. Displacement of the posterior facet may justify reconstruction, but marked swelling and fragile skin increase the risk of wound breakdown after a large exposure. Examine the entire heel for blisters, threatened skin, open wounds, and neurovascular changes; CT defines the fracture once immediate threats have been addressed. For a closed fracture without skin or vascular compromise, protect the limb, control swelling, and reassess the soft tissue before definitive fixation. A displaced posterior tuberosity fragment is different: it can press directly against the thin posterior heel skin, causing blanching and impending necrosis. That pressure calls for prompt reduction and stabilization, even when other parts of the heel remain swollen. Urgency follows the threatened tissue, not the fracture label alone.
Worked example: A patient has a displaced intra-articular calcaneal fracture with substantial lateral swelling. The posterior heel skin is perfused, and distal examination is stable. Definitive articular reconstruction can be planned after swelling improves. In a second patient, a lifted tuberosity fragment tents a blanched patch of posterior skin. That skin threat makes prompt reduction the priority, with later reconstruction planned around the remaining soft-tissue condition.
Watch the distinction: Delaying every calcaneal fracture until swelling resolves can sacrifice posterior heel skin under a displaced tuberosity fragment. Check for focal skin pressure before applying a routine delayed-fixation plan.
Reference: [1]
43. Decide whether ankle instability needs fixation
Ankle stability depends on the entire ring of bony and ligamentous restraints that keeps the talus centered in the mortise. A high fibular fracture raises concern for injury extending through the interosseous and syndesmotic structures; medial tenderness, deltoid injury, or a medial fracture may complete the unstable pattern. Review full-length leg and ankle imaging when the mechanism and examination warrant it, then assess mortise congruity and syndesmotic alignment under appropriate conditions. Persistent widening or talar shift signals loss of restraint and calls for an anatomic reduction plan, often including stabilization of the injured syndesmosis. A ligament name or an isolated view cannot settle the decision. The diagnostic overlap with Foot Surgery is outlined in the Foot Didactic guide; RRA management still centers on the complete ankle injury.
Worked example: A patient twists the ankle and has a proximal fibular fracture, medial ankle tenderness, and mortise widening on appropriate assessment. The high fracture and medial findings suggest force passed through the syndesmosis, while the widened mortise shows that the talus is not securely contained. This is an unstable ankle injury. Management must restore mortise alignment and assess syndesmotic fixation rather than treating a presumed isolated sprain.
Watch the distinction: A high fibular fracture is not judged by its distance from the ankle alone. Medial injury and mortise widening reveal whether the ankle has lost stability.
44. Manage a septic ankle joint
Septic arthritis is an infected joint-space emergency because inflammatory enzymes and organisms can damage cartilage rapidly. A hot, painful ankle with restricted motion, fever, or bacteremia prompts aspiration when feasible; purulent fluid supports the diagnosis, while cultures help identify the organism. Draw appropriate blood cultures when systemic infection is suspected and begin antimicrobial treatment without allowing sampling to cause a harmful delay. An established infected joint needs prompt drainage and removal of infected material, with repeat assessment if symptoms or inflammatory findings fail to improve. Review nearby wounds, bone, and implants for a source or extension of infection. Once infection is controlled, residual cartilage damage and alignment determine whether later reconstruction is needed. The acute drainage decision and the later arthritis decision occur at different stages.
Worked example: A febrile patient has an acutely swollen ankle that is exquisitely painful with passive motion. Aspiration produces purulent fluid, and a nearby ulcer may be the source. Obtain cultures, arrange urgent joint drainage, and start appropriate antimicrobial treatment that can be refined after results return. If the joint later remains painful because cartilage has been destroyed, reconstruction is considered after the infection has been controlled.
Watch the distinction: Antibiotics alone may not clear purulence enclosed within the ankle joint. Drainage, diagnostic sampling, and assessment for adjacent bone or implant infection are part of source control.
Reference: [1]
45. Stage reconstruction after osteomyelitis
Chronic osteomyelitis can defeat a technically sound fusion if infected, nonviable bone or unstable fixation remains. Start by defining the extent of infection, wound tracks, vascular supply, bone loss, and mechanical instability. Debridement removes necrotic bone and infected tissue; deep specimens obtained during that work are more useful than a superficial swab for directing treatment. Loose hardware may be an infection reservoir and cannot provide reliable stability. After debridement, the limb still needs a stable alignment and viable soft-tissue cover, sometimes through an interim fixation and wound strategy. Definitive grafting or fusion follows when the bed is suitable and infection control is credible. The sequence may require more than one operation because clearing infection, preserving length, and obtaining coverage solve different problems.
Worked example: A patient has a draining subtalar nonunion. Imaging shows a lucent area around loose screws, and surgery reveals devitalized bone. Remove infected material, collect deep samples, debride to viable tissue, and maintain a stable interim hindfoot position with a coverage plan. Only after the wound and infection are controlled should the surgeon fill the remaining defect and rebuild a stable fusion construct.
Watch the distinction: Replacing loose screws and adding graft to a draining nonunion addresses neither infected bone nor the wound. Clear the source and establish viable coverage before definitive reconstruction.
Reference: [1]
46. Choose a path for a suspicious tumor
A rearfoot lesion is judged by its behavior and anatomy, not by a familiar sounding label. A small, unchanged lesion with a narrow zone of transition, intact cortex, and no aggressive symptoms may be observed with a reasoned follow-up plan. Growth, cortical destruction, a soft-tissue component, or extension across tissue planes changes the pathway. Cross-sectional imaging maps the lesion before tissue sampling, and biopsy should be coordinated with a team able to perform definitive treatment. The biopsy tract can seed tissue outside the lesion and may need removal during later excision, so its route matters. Do not use a casual excision as the first diagnostic step for an aggressive mass. Distinguish an incidental benign finding from a lesion whose progression demands diagnosis.
Worked example: A small talar lesion has remained unchanged on serial studies, has a defined border, and causes no focal pain. Observation is reasonable. A different lesion enlarges, breaks through cortex, and forms a deep soft-tissue mass. Its progression calls for specialist-directed imaging and a planned biopsy tract before excision, because the biopsy route could affect the extent of a later operation.
Watch the distinction: A mass near the ankle is not automatically a routine cyst. Destructive imaging features and documented growth require planned tissue diagnosis before an excision that could compromise margins.
Reference: [1]
47. Match talar necrosis treatment to collapse
Talar avascular necrosis spans different mechanical stages. MRI may detect loss of viable bone before the articular dome changes shape. At that stage, assess symptoms, lesion extent, remaining blood supply, and joint surfaces while considering measures that protect the intact structure. Once subchondral bone fails and the dome collapses, altered contact pressure can damage the ankle and subtalar joints. A joint-preserving plan that assumes an intact dome may no longer address pain or deformity. Compare serial standing radiographs and cross-sectional studies for collapse, talar height, alignment, and adjacent arthritis. The salvage choice then depends on the lost bone support, involved joints, and overall hindfoot position. Separate the diagnosis of necrotic bone from the consequential finding of structural collapse.
Worked example: One patient has talar body signal changes on MRI, but standing radiographs show an intact dome and preserved joint spaces. The plan can focus on protecting and assessing a still-shaped talus. Another has dome flattening, loss of talar height, and painful ankle and subtalar arthritis. Structural reconstruction or fusion of involved joints becomes more relevant because bone shape and joint surfaces have failed.
Watch the distinction: An MRI diagnosis of talar necrosis does not by itself dictate fusion. The presence of collapse and arthritis changes which mechanical problem treatment must solve.
Reference: [1]
48. Protect recovery after ankle fusion
After ankle fusion, postoperative care protects both the healing interface and the patient during reduced mobility. Loading depends on bone contact, fixation stability, graft use, bone quality, wound condition, and signs of union on follow-up examination and imaging. Advancing solely because a calendar interval has passed can overload a weak construct; prolonged restriction also has costs, including deconditioning and clot risk. Venous thromboembolism planning therefore uses individual factors such as prior thrombosis, mobility, bleeding risk, and concurrent medication. Mechanical measures, mobilization within the allowed limits, and medication decisions should fit that combined assessment. Evaluate new calf symptoms or breathing complaints promptly rather than attributing them to normal recovery. The RRA Didactic practice questions provide a way to rehearse decisions that combine fixation, healing, and systemic risk.
Worked example: Two patients have ankle fusions with similar fixation. One has a previous venous thromboembolism and expects prolonged limited mobility; the other has no clot history and mobilizes readily within restrictions. Their clot-prevention plans merit different risk assessments. At follow-up, neither should advance loading solely because the same number of weeks has passed; tenderness, alignment, and imaging evidence of healing also matter.
Watch the distinction: A fixed postoperative timetable cannot account for a weak fusion interface or an individual clot history. Judge loading and thrombosis prevention from the construct and patient together.
Reference: [1]
Complications
49. Diagnose a painful fusion gap
A painful gap after subtalar fusion becomes more concerning when symptoms, imaging, and fixation changes point in the same direction. Persistent focal pain under loading suggests motion at the intended fusion site; CT can clarify whether trabecular bridging is present when radiographs are equivocal. Progressive screw loosening or loss of alignment adds mechanical evidence of failure. Search for causes before revision: inadequate compression, residual deformity, poor contact, smoking exposure, impaired bone biology, and occult infection can coexist. History, wound findings, laboratory tests when indicated, and deep cultures during revision help distinguish aseptic failure from infection. Revision must correct the cause as well as replace fixation, restoring viable bone contact, alignment, and stability. A radiographic line alone, without symptoms or progression, deserves a more measured interpretation.
Worked example: Several months after subtalar fusion, a patient reports pain centered below the ankle with every step. CT shows little bridging across the joint, and screws have developed surrounding lucency. These findings support symptomatic nonunion rather than routine slow recovery. Revision assessment checks heel position, contact and compression, biological risks, and infection before selecting new fixation and any graft.
Watch the distinction: A visible fusion line alone does not prove clinically important nonunion. Correlate it with focal symptoms, bridging, alignment, and fixation behavior before planning revision.
Reference: [1]
50. Interpret calcaneal malunion
Calcaneal malunion changes several dimensions at once. Loss of height can alter the talar position and ankle mechanics; increased heel width can impinge on the fibula or peroneal tendons; varus or valgus shifts the load path; and posterior facet damage can leave painful subtalar arthritis. Ask where pain occurs, examine hindfoot alignment and subtalar motion, and use standing radiographs and CT to identify the responsible anatomy. A lateral prominence with tendon irritation calls for a different correction from an arthritic, malaligned subtalar joint, although both can occur together. Revision can combine decompression, realignment, and fusion when each addresses a demonstrated pain generator. Hardware removal alone helps only if hardware itself is the problem. Match the operation to the altered shape and diseased joint.
Worked example: A patient has lateral heel pain after a healed calcaneal fracture. Standing films show a widened, valgus heel; CT shows lateral wall contact with the fibula and an irregular posterior facet. Examination also reproduces pain with subtalar motion. The findings identify both impingement and arthritis. Removing a prominent screw might reduce local irritation but would leave the widened heel and painful joint untreated.
Watch the distinction: Post-fracture heel pain should not be assigned to hardware just because screws are present. Heel width, height, alignment, tendon impingement, and subtalar cartilage can each be the source.
Reference: [1]
51. Find a malreduced syndesmosis
A syndesmosis can remain malreduced even when the fibular fracture has healed and the fixation looks intact on plain films. The fibula must sit at the correct depth and rotation within the tibial incisura to maintain a congruent ankle mortise. Persistent deep pain, limited motion, or an uneven mortise after fixation should prompt review of the original injury, reduction, and current alignment. CT can show rotational or translational mismatch that overlapping radiographic shadows conceal; joint surface injury and retained instability also need assessment. If the fibula is fixed in the wrong position, rehabilitation cannot restore that bony relationship. Revision planning addresses the malposition, any obstructing tissue or fixation, syndesmotic stability, and associated articular damage. Distinguish structural incongruity from ordinary postoperative stiffness before prescribing more therapy.
Worked example: Months after ankle fracture fixation, a patient has deep pain despite fracture union. The mortise appears subtly asymmetric on standing radiographs, and CT shows the fibula externally rotated within the incisura compared with its expected position. This is a structural syndesmotic malreduction. Revision assessment should determine how to restore fibular position and stability while checking for cartilage injury; stretching alone cannot rotate the fixed fibula.
Watch the distinction: A healed fibular fracture does not guarantee a reduced syndesmosis. Persistent mortise symptoms warrant scrutiny of fibular rotation and position, even when implants have not failed.
Reference: [1]
52. Explain recurrent flatfoot after reconstruction
Recurrent flatfoot after reconstruction may reflect a missed deformity component, loss of a correction, failed soft-tissue support, or new joint degeneration. First compare current weight-bearing alignment with the early postoperative result to decide whether the foot never fully corrected or later lost correction. Examine heel valgus, forefoot abduction, medial column position, flexibility, tendon function, and painful joints separately. A transferred tendon can remain intact while residual abduction or a collapsing lateral column continues to pull the foot outward. Conversely, a new fixed painful joint may require an arthritis-directed plan rather than another flexible-foot procedure. Imaging of the standing foot and hindfoot helps localize the change; MRI or other studies answer targeted tendon or joint questions. Revision should correct the proven mechanical driver, not simply repeat the original operation.
Worked example: A patient initially improves after flexible flatfoot reconstruction, then develops renewed valgus and forefoot abduction. The transferred tendon is intact on examination and targeted imaging. Standing views show persistent talonavicular uncoverage and loss of lateral column support. The recurrence is primarily a remaining or failed bony correction, so revising only the tendon would leave the abduction force and alignment problem in place.
Watch the distinction: An intact tendon transfer does not rule out recurrent deformity. Check whether alignment was fully corrected and whether bone support or adjacent joints have changed.
Reference: [1]
53. Separate superficial from deep postoperative infection
Postoperative erythema spans superficial irritation, limited skin infection, and deep infection involving bone or an implant. Assess the timing and progression of redness, drainage, fever, deep tenderness, wound opening, and whether a tract reaches hardware. Inspect fixation stability and bone changes on imaging; inflammatory tests can add context but do not localize infection by themselves. A minor superficial finding with an intact wound requires close reassessment because progression changes its meaning. Persistent drainage, exposed fixation, deep pain, or destructive changes raise concern for implant-associated infection and call for a source-control plan with appropriate deep sampling. Stability matters: infected loose fixation threatens the fusion, while removing a stable construct prematurely may create a separate mechanical problem. Classify the depth before choosing treatment.
Worked example: One patient has a small red area at the edge of a closed hindfoot incision, no drainage, no fever, and no deep pain. Another has a draining opening that reaches exposed fusion hardware, with bone lucency and increasing pain. The second pattern warrants evaluation of deep infection and fixation stability. Treating both as the same superficial skin problem would miss a threatened fusion.
Watch the distinction: Redness alone does not establish a deep infection, but drainage to hardware is not simple surface inflammation. Use wound depth, symptoms, imaging, and construct stability together.
Reference: [1]
54. Respond to wound breakdown
An open ankle wound threatens the deeper structure it exposes. Determine whether skin is viable, whether tendon, bone, or implant is uncovered, and whether infection or dead space lies beneath the defect. A tight closure across poorly perfused tissue can fail again, while a dressing cannot provide durable protection for an exposed implant. Debridement removes nonviable tissue and reveals the true size of the defect; cultures are useful when deep infection is suspected. Coverage may require local or free vascularized tissue, chosen in coordination with the reconstructive team and the needs of the implant or tendon. At the same time, evaluate implant stability and whether retention is feasible. The decision joins infection control, tissue coverage, and preservation of mechanical reconstruction.
Worked example: After ankle replacement, an anterior incision separates and the prosthesis is visible. The surgeon examines surrounding skin viability, drainage, implant stability, and signs of deeper infection. Nonviable tissue needs debridement, and the exposed prosthesis needs a durable coverage strategy if retention is appropriate. Simply tightening the skin edges would place tension on compromised tissue and would not resolve possible deep contamination.
Watch the distinction: An exposed tendon or implant is not protected by repeated surface dressings alone. Assess viability, infection, stability, and the need for vascularized coverage promptly.
Reference: [1]
55. Evaluate a failing ankle implant
Pain and component migration after total ankle replacement require a cause-specific workup. Aseptic loosening can follow poor bone support, uneven loading, or progressive bone loss; infection can produce similar radiographic lucency and migration. Instability may arise from ligament imbalance, malalignment, or component position and can accelerate wear or loosening. Compare serial weight-bearing images for subsidence and tilt, assess bone stock and alignment, and examine the wound and systemic symptoms. Laboratory testing and joint sampling, when indicated, help investigate infection before labeling failure aseptic. Revision replacement needs adequate bone support and a stable, balanced ankle; major loss of support or uncontrolled infection may instead require staged treatment or fusion. A new component alone cannot correct an unrecognized cause of failure.
Worked example: A patient with an ankle replacement develops progressive pain. Serial films show tibial component migration, but inflammatory tests are abnormal and the incision has intermittently drained. Migration establishes mechanical failure, yet its cause remains unresolved. The infection evaluation must precede a decision for implant revision. If deep infection is confirmed, management and timing differ from an aseptic revision built on viable bone.
Watch the distinction: Component migration does not prove aseptic loosening. Infection and instability can produce or accelerate the same mechanical failure, so identify the cause before choosing revision hardware.
Reference: [1]
56. Recognize adjacent-joint overload
A solid ankle fusion removes tibiotalar motion and can shift movement and load to the subtalar and midfoot joints. Over years, an adjacent joint may become painful, especially if the fused ankle is malaligned or the joint already had cartilage injury. Confirm that the original fusion is solid and well positioned, then localize pain through examination of adjacent joints and standing imaging. Subtalar joint-space loss with pain on hindfoot motion points toward that joint; a painful fusion gap would point elsewhere. Consider footwear, alignment, injections used diagnostically when appropriate, and the patient's functional demands before deciding on further surgery. If an adjacent joint needs fusion, understand the additional loss of motion and the effect on remaining joints. A successful ankle union does not make every later hindfoot symptom an ankle problem.
Worked example: Years after ankle fusion, a patient develops new pain beneath the ankle on uneven ground. Imaging shows a solid tibiotalar union but progressive subtalar joint-space narrowing, and hindfoot motion reproduces the pain. The likely pain source is adjacent subtalar degeneration. Evaluation should also check fusion alignment; revision of the solid ankle fusion is not the first response to isolated subtalar findings.
Watch the distinction: New pain near an old ankle fusion does not automatically mean the fusion failed. Confirm union, then examine the subtalar and midfoot joints that now carry altered motion.
Reference: [1]
57. Localize postoperative nerve injury
A postoperative nerve complaint becomes more informative when mapped anatomically. The sural nerve supplies sensation along much of the posterolateral ankle and lateral foot, so a lateral hindfoot approach can place it at risk. Burning, numbness, or electric pain confined to that territory suggests a local sensory nerve problem; a focal tender point with radiating symptoms may suggest a neuroma or entrapment. Check motor function and other sensory territories to look for a broader nerve injury, and compare symptoms with the incision, swelling, and hardware position. Diffuse pain with joint tenderness or vascular changes needs a different workup. Document the distribution over time and consider targeted testing if localization remains uncertain. The pattern guides treatment and prevents a sensory complaint from being misread as recurrent arthritis.
Worked example: After a lateral hindfoot incision, a patient reports burning over the lateral foot. Light touch is reduced in that strip, toe and ankle motor function is intact, and subtalar motion does not reproduce the symptom. This distribution points toward sural nerve irritation or injury. Examination should trace tenderness along the incision and nerve course rather than assuming the fused joint has become painful again.
Watch the distinction: All pain after hindfoot surgery is not joint pain. A reproducible sensory territory, especially without motor loss, can localize a cutaneous nerve injury.
Reference: [1]
58. Detect threatened perfusion after surgery
New coolness, pallor, severe pain, or lost distal Doppler signals after ankle surgery suggests threatened perfusion until proved otherwise. Compare the foot with its immediate postoperative baseline and the other side, and check capillary refill, temperature, motor function, sensation, and arterial signals. A tight dressing, hematoma, displaced reconstruction, thrombosis, or arterial injury can each reduce flow. Release external constriction while arranging immediate surgical and vascular assessment; further imaging is useful only if it does not delay action in a threatened limb. Expected postoperative swelling usually occurs in a warm, perfused foot. An isolated sensory nerve deficit follows a nerve territory and does not explain absent arterial signals. Reassessment must be rapid because muscle and nerve damage worsen as ischemia persists.
Worked example: After ankle reconstruction, a previously warm foot becomes pale and cool, pain intensifies, and distal Doppler signals disappear. The surgeon promptly checks and relieves any constrictive dressing while assessing alignment, hematoma, and arterial flow with vascular support. These serial changes indicate threatened perfusion. A warm swollen foot with preserved signals would require assessment too, but it would not justify dismissing the ischemic pattern here.
Watch the distinction: Pulses and Doppler signals lost after surgery are not explained by ordinary swelling or a sural nerve injury. Treat the new perfusion deficit as urgent.
Reference: [1]
59. Follow talar fracture for necrosis
The talus relies on a vulnerable blood supply after a neck fracture. Union of the fracture does not establish that the body remains viable, so follow symptoms and serial images for changing density and shape. Increasing talar body sclerosis can reflect impaired revascularization, while subchondral collapse or dome flattening shows that the bone has lost structural support. Weight-bearing pain and new ankle or subtalar joint narrowing help establish clinical consequence. Interpret each image against earlier studies rather than treating one dense radiograph as a complete diagnosis. If the dome stays intact, the aim is to assess and preserve its shape where feasible; collapse shifts planning toward reconstruction of lost height, alignment, and diseased joints. The key distinction is viable union of the fracture versus durable support of the talar articular surface.
Worked example: A talar neck fracture unites in acceptable alignment. Later films show progressively denser talar body bone, then early flattening of the dome, while the patient develops pain with loading. The sequence raises concern for avascular necrosis progressing to collapse. Follow-up assessment must map the amount of shape loss and ankle or subtalar arthritis; calling the fracture healed does not resolve the new mechanical problem.
Watch the distinction: Fracture union and talar viability are separate outcomes. A united neck fracture can still develop body necrosis, dome collapse, and secondary joint damage.
Reference: [1]
60. Recognize growth arrest after physeal injury
A pediatric distal tibial fracture can heal in good initial alignment yet damage part of the growth plate. If one segment closes while the rest continues growing, the ankle gradually tilts toward the arrested side; complete arrest can cause a length difference. Compare serial standing images and both limbs rather than judging only the immediate post-reduction film. Increasing angular change during growth suggests a physeal bar, while a stable deformity present immediately after healing suggests malunion. Cross-sectional imaging can locate and estimate the bar when treatment planning requires it. The remaining growth, bar position, joint orientation, and symptoms determine whether growth modulation, bar treatment, or corrective osteotomy is appropriate. Continued surveillance matters because union ends the fracture-healing phase, while growth-related deformity may emerge later.
Worked example: A child's distal tibial physeal fracture heals with a level ankle joint. At later visits, standing images show progressively increasing ankle tilt without a new injury. The changing alignment during growth favors partial physeal arrest over a fracture that healed crooked from the start. The surgeon evaluates remaining growth and maps the arrested portion of the physis before selecting a correction that addresses both current tilt and future growth.
Watch the distinction: A well-aligned healed pediatric fracture does not exclude later growth arrest. Progressive tilt after union points to asymmetric physeal closure and warrants serial comparison.
Reference: [1]
Official references and further reading
- Part I Board Qualification Exam Content | ABFAS
- How to Navigate the Didactic Exam | ABFAS
- New Certification Process, Effective September 2020 | ABFAS