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Ankle Trauma & Sports MCQs

Practice Set 2 of 9

This practice set contains high-yield board review questions covering key concepts in Ankle Trauma & Sports. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 21

Topic: Ankle Trauma & Sports

When placing a trans-syndesmotic positioning screw for a syndesmosis rupture, what is the optimal trajectory of the screw to ensure accurate engagement of the tibia?

. Parallel to the joint line and directed strictly from lateral to medial
. Directed 20 to 30 degrees anteriorly from the posterolateral fibula to the anteromedial tibia
. Directed 20 to 30 degrees posteriorly from the anterolateral fibula to the posteromedial tibia
. Angled 15 degrees distal to proximal
. Angled 15 degrees proximal to distal

Correct Answer & Explanation

. Directed 20 to 30 degrees anteriorly from the posterolateral fibula to the anteromedial tibia

Explanation

Due to the posterior position of the fibula relative to the tibia, a trans-syndesmotic screw must be directed 20 to 30 degrees anteriorly (from posterolateral to anteromedial) to properly capture the center of the tibial metaphysis.

Question 22

Topic: Ankle Trauma & Sports
A 35-year-old skier presents with an ankle fracture resulting from a pronation-abduction (PA) mechanism. What is the characteristic morphology of the fibular fracture in a Lauge-Hansen PA stage III injury?
. Transverse fracture at or below the syndesmosis
. Short oblique fracture extending from anterior-inferior to posterior-superior
. High spiral fracture of the proximal fibula
. Comminuted or short oblique fibular fracture with a lateral butterfly fragment at the level of the joint
. Avulsion fracture of the fibular tip

Correct Answer & Explanation

. Comminuted or short oblique fibular fracture with a lateral butterfly fragment at the level of the joint

Explanation

A pronation-abduction injury classically results in a transverse or comminuted fibular fracture at the level of the syndesmosis, often presenting with a lateral butterfly fragment due to bending forces.

Question 23

Topic: Ankle Trauma & Sports

A 20-year-old gymnast complains of medial ankle pain and proximal lateral calf pain after landing awkwardly. Radiographs reveal a widened medial clear space and a proximal third fibula fracture. What is the appropriate surgical management for this Maisonneuve injury?

. Non-operative management in a short leg cast
. Open reduction and internal fixation of the proximal fibula only
. Syndesmotic reduction and stabilization with screws or suture buttons
. Medial malleolus pinning only
. Primary arthrodesis of the distal tibiofibular joint

Correct Answer & Explanation

. Syndesmotic reduction and stabilization with screws or suture buttons

Explanation

A Maisonneuve fracture involves disruption of the medial structures, interosseous membrane, and proximal fibula, leading to an unstable syndesmosis. The primary treatment relies on anatomical reduction and fixation of the syndesmosis.

Question 24

Topic: Ankle Trauma & Sports

In a Pronation-External Rotation (PER) type ankle fracture according to the Lauge-Hansen classification, what is the most characteristic finding of the fibular fracture?

. Transverse fracture below the syndesmosis
. Spiral fracture starting at the joint line and extending posterosuperiorly
. Short oblique or spiral fracture above the level of the syndesmosis
. Transverse fracture at the level of the syndesmosis
. Comminuted fracture of the fibular head

Correct Answer & Explanation

. Short oblique or spiral fracture above the level of the syndesmosis

Explanation

The PER mechanism typically results in a high fibular fracture (Weber C type), which is a short oblique or spiral fracture located above the level of the syndesmosis.

Question 25

Topic: Ankle Trauma & Sports

According to the Lauge-Hansen classification, what is the exact sequence of structures injured in a Pronation-External Rotation (PER) stage IV ankle fracture?

. Deltoid ligament, AITFL, PITFL, High fibula
. AITFL, High fibula, PITFL, Deltoid ligament
. Deltoid ligament (or medial malleolus), AITFL, High fibula, PITFL (or posterior malleolus)
. High fibula, AITFL, PITFL, Deltoid ligament
. Deltoid ligament, PITFL, High fibula, AITFL

Correct Answer & Explanation

. Deltoid ligament (or medial malleolus), AITFL, High fibula, PITFL (or posterior malleolus)

Explanation

In the Pronation-External Rotation mechanism, the sequence of injury is: 1) Medial structures (Deltoid or medial malleolus), 2) Anterior syndesmosis (AITFL), 3) High fibular fracture above the syndesmosis, and 4) Posterior syndesmosis (PITFL or posterior malleolus).

Question 26

Topic: Ankle Trauma & Sports
According to the Lauge-Hansen classification, what is the precise sequential order of ligamentous and osseous injury in a Supination-External Rotation (SER) stage IV ankle fracture?
. AITFL, short oblique fibula fracture, PITFL/posterior malleolus, deltoid ligament/medial malleolus
. Deltoid ligament/medial malleolus, AITFL, short oblique fibula fracture, PITFL/posterior malleolus
. AITFL, high fibula fracture above syndesmosis, PITFL, medial malleolus
. PITFL, short oblique fibula fracture, AITFL, deltoid ligament/medial malleolus
. Transverse fibula fracture below plafond, vertical medial malleolus fracture

Correct Answer & Explanation

. AITFL, short oblique fibula fracture, PITFL/posterior malleolus, deltoid ligament/medial malleolus

Explanation

The SER sequence begins anterolaterally with the Anterior Inferior Tibiofibular Ligament (Stage I), progresses to a short oblique fibula fracture (Stage II), then the Posterior Inferior Tibiofibular Ligament or posterior malleolus (Stage III), and finishes medially with the deltoid/medial malleolus (Stage IV).

Question 27

Topic: Ankle Trauma & Sports

A 40-year-old female twists her ankle. Radiographs show a short oblique fracture of the distal fibula at the level of the syndesmosis and a transverse medial malleolus fracture. Based on the Lauge-Hansen classification (Supination-External Rotation), what is the first structure injured in this sequence?

. Medial malleolus
. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Deltoid ligament
. Interosseous membrane

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

In the Lauge-Hansen Supination-External Rotation (SER) sequence, the injury progresses from anterior to posterior. Stage 1 is the rupture of the anterior inferior tibiofibular ligament (AITFL).

Question 28

Topic: Ankle Trauma & Sports

During a Weber C ankle fracture, the distal tibiofibular syndesmosis is disrupted. Which of the following ligaments provides the greatest percentage of resistance against lateral displacement of the fibula?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Interosseous ligament
. Anterior talofibular ligament
. Calcaneofibular ligament

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

The posterior inferior tibiofibular ligament (PITFL) is the strongest component of the syndesmotic complex, providing approximately 42% of the resistance to lateral fibular displacement. The AITFL is the most commonly torn but provides less overall strength (approx. 35%).

Question 29

Topic: Ankle Trauma & Sports

In the context of chronic lateral ankle instability, what is the most common surgical procedure employed for primary repair?

. Chrisman-Snook reconstruction
. Watson-Jones tenodesis
. Modified Brostrom procedure (Brostrom-Gould)
. Anatomical reconstruction with allograft
. Peroneal tendon transfer

Correct Answer & Explanation

. Modified Brostrom procedure (Brostrom-Gould)

Explanation

Correct Answer: CThe Modified Brostrom procedure, often referred to as Brostrom-Gould, is the most common and gold standard surgical procedure for primary repair of chronic lateral ankle instability. It involves direct repair of the attenuated ATFL and CFL, often augmented with the inferior extensor retinaculum. Chrisman-Snook and Watson-Jones are older tenodesis procedures using peroneal tendons, which are non-anatomical reconstructions. Anatomical reconstruction with allograft is typically reserved for revision cases or patients with poor tissue quality/generalized laxity. Peroneal tendon transfer isn't a primary repair technique for instability.

Question 30

Topic: Ankle Trauma & Sports

A patient presents with recurrent ankle sprains and complaints of the ankle 'giving way'. Clinically, you suspect chronic mechanical instability. Which of the following imaging modalities is most sensitive for evaluating the integrity of the ATFL and CFL?

. Plain radiographs (AP, lateral, mortise views)
. Stress radiographs (anterior drawer and talar tilt views)
. Computed Tomography (CT) scan
. Magnetic Resonance Imaging (MRI)
. Bone scintigraphy

Correct Answer & Explanation

. Magnetic Resonance Imaging (MRI)

Explanation

Correct Answer: DMagnetic Resonance Imaging (MRI) is the most sensitive imaging modality for evaluating the integrity of soft tissue structures like the ATFL and CFL. It can show attenuation, scarring, or complete tears of these ligaments. While stress radiographs are excellent for demonstrating functional mechanical instability by measuring talar tilt and anterior translation, they don't directly visualize the ligaments' integrity as well as MRI. Plain radiographs are for bony anatomy, and CT scans are superior for bony detail but less so for soft tissues.

Question 31

Topic: Ankle Trauma & Sports

A 35-year-old male with chronic lateral ankle instability undergoes a modified Brostrom-Gould procedure. Which structure is commonly imbricated with the repaired ATFL and CFL to augment the repair?

. Peroneus brevis tendon
. Inferior extensor retinaculum
. Peroneus longus tendon
. Spring ligament
. Superior peroneal retinaculum

Correct Answer & Explanation

. Inferior extensor retinaculum

Explanation

Correct Answer: BIn the modified Brostrom-Gould procedure, the attenuated ATFL and CFL are directly repaired and imbricated. The repair is then augmented by incorporating a flap of the inferior extensor retinaculum over the repaired ligaments. This provides additional strength and stability to the lateral ankle complex. The peroneal tendons are used in tenodesis procedures (e.g., Chrisman-Snook), not typically in a Brostrom-Gould repair. The spring ligament is on the medial side, and the superior peroneal retinaculum stabilizes the peroneal tendons.

Question 32

Topic: Ankle Trauma & Sports

A 22-year-old dancer presents with chronic lateral ankle instability. Her Beighton score is 7/9, indicating generalized ligamentous laxity. Which surgical approach would be most appropriate given her hypermobility?

. Primary repair using a modified Brostrom-Gould technique.
. Non-anatomical reconstruction using the Watson-Jones technique.
. Anatomical reconstruction using an autograft or allograft.
. Arthroscopic debridement of the anterolateral gutter.
. An isolated posterior talofibular ligament repair.

Correct Answer & Explanation

. Anatomical reconstruction using an autograft or allograft.

Explanation

Correct Answer: CFor patients with generalized ligamentous laxity (like a high Beighton score) or poor tissue quality, a primary repair (like a modified Brostrom-Gould) may not provide sufficient long-term stability due to the inherent laxity. In such cases, an anatomical reconstruction using an autograft (e.g., gracilis, semitendinosus) or allograft is often preferred to provide a stronger and more durable repair. Non-anatomical reconstructions are generally less favored due to altered biomechanics. Arthroscopic debridement addresses impingement but not instability, and isolated PTFL repair is rare.

Question 33

Topic: Ankle Trauma & Sports

During the operative fixation of a supination-external rotation (Weber B) ankle fracture, the surgeon performs a 'Cotton test' (lateral pull on the fibula) using a bone hook. Which of the following fluoroscopic findings definitively indicates syndesmotic instability necessitating screw or button fixation?

. Widening of the syndesmotic clear space by greater than 2 mm under stress
. An absolute medial clear space measurement of 3 mm on the unstressed AP view
. Talocrural angle of 83 degrees on the mortise view
. Tibiofibular overlap of 5 mm on the AP view
. Posterior subluxation of the fibula by 1 mm on the lateral view

Correct Answer & Explanation

. Widening of the syndesmotic clear space by greater than 2 mm under stress

Explanation

During intraoperative stress testing of the syndesmosis (the Cotton or Hook test), widening of the medial clear space or the tibiofibular clear space by greater than 2 mm compared to the unstressed state indicates syndesmotic instability requiring operative stabilization.

Question 34

Topic: Ankle Trauma & Sports

A surgeon is performing a proximal tibial osteotomy for a 15-degree varus correction using a circular fixator. A concomitant fibular osteotomy is required to allow unhindered correction.

To minimize the risk of peroneal nerve injury, what is the most appropriate location and technique for the fibular osteotomy?

. Proximal third of the fibula using a Gigli saw
. Middle third of the fibula using a multiple drill-hole and osteotome technique
. Distal third of the fibula at the level of the syndesmosis
. Fibular neck excision to decompress the nerve directly
. Mid-diaphyseal fibula using a high-speed burr without coolant

Correct Answer & Explanation

. Middle third of the fibula using a multiple drill-hole and osteotome technique

Explanation

The middle third of the fibula is the safest zone for osteotomy to avoid the common peroneal nerve proximally and the syndesmosis distally. A low-energy technique using drill holes and an osteotome minimizes thermal necrosis and iatrogenic nerve injury.

Question 35

Topic: Ankle Trauma & Sports

When planning a proximal tibial osteotomy for a severe angular deformity, a fibular osteotomy is often required. At which level is the fibular osteotomy most safely and commonly performed to avoid peroneal nerve injury and distal tibiofibular syndesmotic disruption?

. Fibular neck
. Proximal third of the diaphysis
. Middle third of the diaphysis
. Distal metaphysis
. Through the lateral malleolus

Correct Answer & Explanation

. Middle third of the diaphysis

Explanation

A fibular osteotomy is safely performed in the middle third of the diaphysis. Proximal osteotomies risk injury to the common peroneal nerve, while distal osteotomies can disrupt the lateral collateral ligament complex or the distal tibiofibular syndesmosis.

Question 36

Topic: Ankle Trauma & Sports

When performing a high tibial osteotomy (HTO) with gradual correction using a circular external fixator, a concomitant fibular osteotomy is generally required. To minimize the risk of iatrogenic injury to the common peroneal nerve, which location is preferred for the fibular osteotomy?

. Directly through the fibular head
. At the fibular neck
. At the middle third of the fibular diaphysis
. At the distal tibiofibular syndesmosis
. Through the lateral malleolus

Correct Answer & Explanation

. At the middle third of the fibular diaphysis

Explanation

A fibular osteotomy at the middle third of the diaphysis avoids the common peroneal nerve (which wraps around the fibular neck) while providing enough segment mobility to allow unhindered tibial deformity correction.

Question 37

Topic: Ankle Trauma & Sports

When performing a proximal tibial osteotomy for gradual deformity correction with a circular frame, a fibular osteotomy is required. At which level is the fibula typically osteotomized to minimize the risk of common peroneal nerve injury?

. Proximal fibular neck
. Proximal third of the fibular diaphysis
. Middle to distal third junction of the fibula
. Exactly at the level of the tibial osteotomy
. Through the distal tibiofibular syndesmosis

Correct Answer & Explanation

. Middle to distal third junction of the fibula

Explanation

A fibular osteotomy in the middle to distal third junction minimizes the risk of injury to the common peroneal nerve, which courses around the fibular neck proximally.

Question 38

Topic: Ankle Trauma & Sports

When performing a tibial deformity correction that requires a fibular osteotomy, at what anatomical level should the fibular osteotomy ideally be performed to minimize complications?

. The proximal metaphyseal-diaphyseal junction
. The mid-diaphysis
. The junction of the middle and distal thirds
. Distal to the syndesmosis
. Directly through the fibular head

Correct Answer & Explanation

. The junction of the middle and distal thirds

Explanation

Fibular osteotomies are generally performed at the junction of the middle and distal thirds of the diaphysis. This level is safely distal to the common peroneal nerve and proximal enough to preserve the distal tibiofibular syndesmosis.

Question 39

Topic: Ankle Trauma & Sports

During a significant correction of a proximal tibial angular deformity, a fibular osteotomy is planned to prevent tethering. Where is the most appropriate anatomical level for the fibular osteotomy to minimize the risk of peroneal nerve injury while effectively releasing the tether?

. Fibular neck
. Proximal metaphyseal-diaphyseal junction
. Middle and distal third junction
. Distal tibiofibular syndesmosis
. Lateral malleolus

Correct Answer & Explanation

. Middle and distal third junction

Explanation

Fibular osteotomies are typically performed at the junction of the middle and distal thirds of the fibula to minimize risk to the common peroneal nerve proximally and preserve the distal syndesmotic stability.

Question 40

Topic: Ankle Trauma & Sports

A 21-year-old professional football player suffers an acute syndesmotic injury (high ankle sprain) with dynamic widening of the distal tibiofibular joint visualized on stress fluoroscopy. He is treated with a flexible suture-button construct. Compared to traditional rigid syndesmotic screw fixation, what is the primary biomechanical advantage of the suture-button construct?

. It provides absolute rigid fixation, eliminating all syndesmotic motion
. It maintains physiologic micromotion at the distal tibiofibular joint during the gait cycle
. It inherently decreases the risk of superficial peroneal nerve entrapment
. It allows for immediate, unrestricted full weight-bearing on post-operative day one
. It completely prevents any external rotation of the fibula relative to the tibia

Correct Answer & Explanation

. It provides absolute rigid fixation, eliminating all syndesmotic motion

Explanation

Suture-button constructs provide dynamic stabilization of the syndesmosis. The primary biomechanical advantage over rigid screw fixation is that they allow for the maintenance of physiologic micromotion and normal kinematics of the distal tibiofibular joint during the normal gait cycle, while preventing pathologic widening.

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