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Ankle Trauma & Sports MCQs

Practice Set 4 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 61

Topic: Ankle Trauma & Sports

A 26-year-old male sustains an external rotation injury to his ankle. Radiographs show a widened medial clear space and a proximal fibular shaft fracture (Maisonneuve). What is the most appropriate intraoperative test to assess the integrity of the distal tibiofibular syndesmosis after fibular fixation?

. Anterior drawer test
. Cotton test (lateral hook test)
. Squeeze test
. Talar tilt test
. Thompson test

Correct Answer & Explanation

. Cotton test (lateral hook test)

Explanation

The Cotton test, or lateral hook test, is performed intraoperatively by grasping the fibula with a bone hook and applying a lateral force under fluoroscopy. Widening of the syndesmosis under stress confirms instability requiring syndesmotic fixation.

Question 62

Topic: Ankle Trauma & Sports

A 28-year-old female twists her ankle. Radiographs show a short oblique fracture of the lateral malleolus at the level of the syndesmosis and a transverse fracture of the medial malleolus. According to the Lauge-Hansen classification, what is the mechanism of injury?

. Supination-Adduction
. Supination-External Rotation
. Pronation-Abduction
. Pronation-External Rotation
. Axial Loading

Correct Answer & Explanation

. Supination-External Rotation

Explanation

The injury described is a Supination-External Rotation (SER) type fracture, which is the most common ankle fracture pattern. It progresses in stages: (1) Anterior inferior tibiofibular ligament rupture, (2) Short oblique/spiral fracture of the distal fibula at the syndesmosis, (3) Posterior inferior tibiofibular ligament rupture or posterior malleolus fracture, (4) Medial malleolus transverse fracture or deltoid ligament rupture.

Question 63

Topic: Ankle Trauma & Sports
In the Lauge-Hansen classification of ankle fractures, a Supination-External Rotation (SER) injury follows a specific, sequential pattern of structural failure. Which of the following accurately represents Stage III of an SER injury?
. Rupture of the anterior inferior tibiofibular ligament
. Spiral fracture of the distal fibula at the level of the syndesmosis
. Rupture of the posterior inferior tibiofibular ligament or fracture of the posterior malleolus
. Transverse fracture of the medial malleolus
. Rupture of the deltoid ligament only

Correct Answer & Explanation

. Rupture of the posterior inferior tibiofibular ligament or fracture of the posterior malleolus

Explanation

The Lauge-Hansen SER sequence is: Stage I - Anterior inferior tibiofibular ligament (AITFL) rupture; Stage II - Spiral/oblique fracture of the lateral malleolus; Stage III - Posterior inferior tibiofibular ligament (PITFL) rupture or posterior malleolus fracture; Stage IV - Medial malleolus transverse fracture or deltoid ligament rupture.

Question 64

Topic: Ankle Trauma & Sports

According to the Lauge-Hansen classification, what is the sequence of injury in a Supination-External Rotation (SER) ankle fracture?

. Anterior inferior tibiofibular ligament -> short oblique fibula fracture -> posterior inferior tibiofibular ligament -> medial malleolus/deltoid ligament
. Medial malleolus -> anterior inferior tibiofibular ligament -> high fibula fracture -> posterior inferior tibiofibular ligament
. Medial malleolus -> transverse fibula fracture
. Anterior inferior tibiofibular ligament -> posterior inferior tibiofibular ligament -> high fibula fracture
. Deltoid ligament -> short oblique fibula fracture -> syndesmosis rupture

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament -> short oblique fibula fracture -> posterior inferior tibiofibular ligament -> medial malleolus/deltoid ligament

Explanation

The Lauge-Hansen SER sequence is: Stage 1) Anterior inferior tibiofibular ligament (AITFL) rupture; Stage 2) Spiral/short oblique fracture of the lateral malleolus; Stage 3) Posterior inferior tibiofibular ligament (PITFL) tear or posterior malleolus fracture; Stage 4) Medial malleolus fracture or deltoid ligament tear.

Question 65

Topic: Ankle Trauma & Sports

A 30-year-old athlete sustains a supination-external rotation (Weber B) ankle fracture. Intraoperatively, after anatomic fixation of the lateral malleolus, the surgeon utilizes a 'hook test' to assess the integrity of the syndesmosis under fluoroscopy. Which of the following radiographic parameters during the stress maneuver most reliably indicates syndesmotic instability necessitating fixation?

. Tibiofibular clear space > 5 mm on the AP view
. Tibiofibular overlap < 10 mm on the AP view
. Medial clear space > 4 mm on the mortise view
. Talar tilt > 5 degrees on the mortise view
. Tibiofibular clear space > 2 mm on the lateral view

Correct Answer & Explanation

. Medial clear space > 4 mm on the mortise view

Explanation

Intraoperative assessment of the syndesmosis is performed using the hook test (lateral pull on the fibula) or external rotation stress. The most reliable and clinically relevant indicator of syndesmotic incompetence (and deep deltoid ligament rupture) during these maneuvers is the asymmetric widening of the medial clear space, typically greater than 4-5 mm on the mortise view.

Question 66

Topic: Ankle Trauma & Sports

A 45-year-old man sustains an ankle injury. Radiographs show a spiral fracture of the distal fibula above the level of the syndesmosis (Weber C). The medial clear space is widened to 6 mm. Which of the following structures is unequivocally torn in this injury pattern?

. Anterior talofibular ligament (ATFL)
. Calcaneofibular ligament (CFL)
. Interosseous membrane up to the level of the fracture
. Spring ligament
. Plantar fascia

Correct Answer & Explanation

. Interosseous membrane up to the level of the fracture

Explanation

A Weber C fracture with widening of the medial clear space indicates a completely unstable syndesmotic injury. The interosseous membrane is torn from the ankle joint up to the level of the fibula fracture.

Question 67

Topic: Ankle Trauma & Sports

An ankle fracture characterized by a vertical fracture of the medial malleolus and a transverse fracture of the fibula below the level of the syndesmosis most likely corresponds to which Lauge-Hansen classification pattern?

. Supination-Adduction (SAD)
. Supination-External Rotation (SER)
. Pronation-Abduction (PAB)
. Pronation-External Rotation (PER)
. Pronation-Adduction (PAD)

Correct Answer & Explanation

. Supination-Adduction (SAD)

Explanation

The Supination-Adduction (SAD) mechanism causes tension on the lateral side (transverse fibular fracture or lateral ligament tear) and compression on the medial side, resulting in a vertical shear fracture of the medial malleolus.

Question 68

Topic: Ankle Trauma & Sports

A 35-year-old female sustains a twisting injury to her leg. Radiographs reveal an isolated, displaced fracture of the proximal third of the fibula. To prevent a missed diagnosis of a Maisonneuve injury, which structure must be thoroughly evaluated clinically and radiographically?

. Distal tibiofibular syndesmosis
. Spring ligament complex
. Bifurcate ligament
. Anterior talofibular ligament (ATFL)
. Calcaneofibular ligament (CFL)

Correct Answer & Explanation

. Distal tibiofibular syndesmosis

Explanation

A Maisonneuve fracture results from a pronation-external rotation force that tears the medial structures (or medial malleolus), disrupts the syndesmosis, and propagates proximally to fracture the proximal fibula.

Question 69

Topic: Ankle Trauma & Sports
An ankle fracture characterized by a transverse fracture of the medial malleolus, rupture of the syndesmosis, and a short oblique or comminuted fracture of the fibula at or above the level of the syndesmosis represents which Lauge-Hansen mechanism?
. Supination-External Rotation III
. Supination-Adduction II
. Pronation-Abduction III
. Pronation-External Rotation IV
. Supination-External Rotation IV

Correct Answer & Explanation

. Pronation-Abduction III

Explanation

A transverse medial malleolar fracture indicates a pronation injury (tension medially). A bending force laterally causes a short oblique or comminuted fibular fracture at the syndesmosis, classic for the Pronation-Abduction mechanism.

Question 70

Topic: Ankle Trauma & Sports

A 28-year-old man sustains a twisting injury to his ankle. Non-weight-bearing radiographs show a spiral fracture of the distal fibula at the level of the syndesmosis, with an intact medial malleolus and normal medial clear space. A subsequent external rotation stress radiograph reveals a medial clear space of 6 mm. What is the appropriate management?

. Short leg cast for 6 weeks
. CAM boot with immediate weight-bearing
. Open reduction and internal fixation of the fibula only
. Open reduction and internal fixation of the fibula and stabilization of the syndesmosis
. Deltoid ligament repair only

Correct Answer & Explanation

. Open reduction and internal fixation of the fibula and stabilization of the syndesmosis

Explanation

A positive external rotation stress test with widening of the medial clear space indicates a syndesmotic or deep deltoid injury (bimalleolar equivalent fracture). This requires ORIF of the lateral malleolus and evaluation with potential stabilization of the syndesmosis.

Question 71

Topic: Ankle Trauma & Sports

A 25-year-old soccer player is diagnosed with a high ankle sprain. Which of the following ligaments is the strongest and provides the most stability to the distal tibiofibular syndesmosis?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Interosseous ligament
. Transverse tibiofibular ligament
. Deltoid ligament

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

The posterior inferior tibiofibular ligament (PITFL) is the strongest component of the syndesmotic ligament complex. It contributes approximately 42% of the overall strength of the syndesmosis.

Question 72

Topic: Ankle Trauma & Sports

A 24-year-old athlete sustains a severe high ankle sprain. Anatomically, which ligament provides the strongest restraint to diastasis of the distal tibiofibular syndesmosis?

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

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

The PITFL provides the greatest resistance (approx. 40%) to lateral displacement of the fibula. While the AITFL is the most commonly injured in syndesmotic sprains, it is weaker than the PITFL.

Question 73

Topic: Ankle Trauma & Sports
Which of the following physical examination tests is the most sensitive and specific for diagnosing an acute high ankle (syndesmotic) sprain?
. Anterior drawer test
. Talar tilt test
. External rotation stress test
. Thompson test
. Silfverskiöld test

Correct Answer & Explanation

. External rotation stress test

Explanation

The external rotation stress test is considered the most reliable clinical test for a syndesmotic injury. It reproduces pain over the anterior tibiofibular ligament and interosseous membrane by gapping the syndesmosis.

Question 74

Topic: Ankle Trauma & Sports

During internal fixation of a bimalleolar ankle fracture, the surgeon performs a 'Cotton test' pulling the fibula laterally. Which specific anatomic structure is this test primarily designed to evaluate?

. Deltoid ligament integrity
. Anterior talofibular ligament (ATFL) integrity
. Calcaneofibular ligament (CFL) integrity
. Syndesmotic (distal tibiofibular) integrity
. Spring ligament integrity

Correct Answer & Explanation

. Syndesmotic (distal tibiofibular) integrity

Explanation

The Cotton test (or hook test) involves applying lateral traction to the fibula using a bone hook. It is performed intraoperatively to assess the stability of the distal tibiofibular syndesmosis after medial and lateral bony fixation.

Question 75

Topic: Ankle Trauma & Sports

During open reduction and internal fixation of a Weber C ankle fracture, the surgeon needs to evaluate the syndesmosis. Which intraoperative method is considered the most reliable indicator of syndesmotic instability requiring fixation?

. Direct visualization of an intact anterior inferior tibiofibular ligament
. Positive intraoperative fluoroscopic Cotton test
. Measurement of the medial clear space as exactly 3mm
. Observation of tibiofibular overlap greater than 15mm
. Preoperative MRI showing isolated deltoid sprain

Correct Answer & Explanation

. Positive intraoperative fluoroscopic Cotton test

Explanation

The intraoperative fluoroscopic Cotton test (lateral pull on the fibula using a bone hook) is the most reliable clinical test to assess dynamic syndesmotic instability. Widening of the tibiofibular clear space under stress dictates the need for syndesmotic fixation.

Question 76

Topic: Ankle Trauma & Sports

A 40-year-old patient presents with a severe ankle injury. Radiographs show a transverse fracture of the medial malleolus and a comminuted, bending-type fracture of the fibula located above the level of the syndesmosis. Which Lauge-Hansen classification does this pattern most accurately fit?

. Supination-Adduction
. Supination-External Rotation
. Pronation-External Rotation
. Pronation-Abduction
. Supination-Plantarflexion

Correct Answer & Explanation

. Pronation-Abduction

Explanation

The Pronation-Abduction injury pattern begins with tension medially (transverse medial malleolus fracture or deltoid rupture), followed by syndesmotic rupture, and concludes with a comminuted bending fracture of the fibula above the joint level.

Question 77

Topic: Ankle Trauma & Sports

During open reduction and internal fixation of a Weber C ankle fracture, the surgeon suspects a syndesmotic injury. Which of the following intraoperative tests is considered the most reliable for evaluating syndesmotic instability?

. Cotton test
. Silfverskiold test
. Anterior drawer test
. Talar tilt test
. Coleman block test

Correct Answer & Explanation

. Cotton test

Explanation

The Cotton test involves placing a bone hook around the fibula and applying a lateral force to assess for diastasis of the syndesmosis. It is highly reliable for intraoperative evaluation of syndesmotic integrity.

Question 78

Topic: Ankle Trauma & Sports

A 35-year-old patient undergoes open reduction and internal fixation of a Weber C fibula fracture. Following anatomic fixation of the fibula, an intraoperative intra-articular hook test is performed, demonstrating 4 mm of lateral shift of the fibula. What is the most appropriate next step in management?

. No further fixation is needed as the fibula is stable
. Fixation of the syndesmosis with trans-syndesmotic screws or dynamic suture buttons
. Open repair of the deep deltoid ligament alone
. Primary temporary external fixation of the ankle
. Tibiotalar transarticular pinning

Correct Answer & Explanation

. Fixation of the syndesmosis with trans-syndesmotic screws or dynamic suture buttons

Explanation

A positive intraoperative hook test after fibular fixation confirms an unstable syndesmotic disruption. Operative stabilization utilizing either syndesmotic screws or dynamic suture button devices is imperative to maintain the anatomic relationship of the distal tibiofibular joint.

Question 79

Topic: Ankle Trauma & Sports

On an AP radiograph of an ankle fracture, you note a transverse fracture of the medial malleolus and a short oblique fracture of the fibula originating at the joint line and extending posterosuperiorly. According to Lauge-Hansen, what was the mechanism of injury?

. Supination-External Rotation
. Supination-Adduction
. Pronation-External Rotation
. Pronation-Abduction
. Plantarflexion-Inversion

Correct Answer & Explanation

. Supination-External Rotation

Explanation

A Supination-External Rotation (SER) injury typically presents with an oblique or spiral fibular fracture starting at the level of the syndesmosis (anterior-inferior to posterior-superior). A transverse medial malleolus fracture represents the stage 4 avulsion injury in this sequence.

Question 80

Topic: Ankle Trauma & Sports
A 13-year-old boy presents with ankle pain after an external rotation injury. Radiographs show a Salter-Harris III fracture of the anterolateral distal tibia. Which ligament's avulsion force is responsible for this specific fracture pattern?
. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Anterior talofibular ligament (ATFL)
. Calcaneofibular ligament (CFL)
. Deltoid ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

This describes a juvenile Tillaux fracture, caused by the pull of the anterior inferior tibiofibular ligament (AITFL) on the anterolateral epiphysis, which is the last portion of the distal tibial physis to close.

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