Menu

Ankle Trauma & Sports MCQs

Practice Set 5 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 81

Topic: Ankle Trauma & Sports
A 13-year-old girl sustains an inversion and external rotation injury to her ankle. Radiographs show a Salter-Harris III fracture of the anterolateral distal tibial epiphysis. Avulsion of which ligament is responsible for this specific fracture pattern?
. Anterior talofibular ligament (ATFL)
. Calcaneofibular ligament (CFL)
. Deltoid ligament
. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

This is a Tillaux fracture, caused by external rotation forces. The anterior inferior tibiofibular ligament (AITFL) is stronger than the anterolateral distal tibial physis in adolescents, resulting in an avulsion fracture as the central and medial physis has already closed.

Question 82

Topic: Ankle Trauma & Sports

In an unstable syndesmotic injury of the ankle, multiple ligamentous structures are disrupted. Which structure provides the greatest resistance to lateral displacement (diastasis) of the distal fibula relative to the tibia?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Interosseous membrane
. Deltoid ligament
. Anterior talofibular ligament (ATFL)

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

Biomechanical studies have shown that the posterior inferior tibiofibular ligament (PITFL) provides the strongest restraint to diastasis of the distal tibiofibular syndesmosis, accounting for approximately 42% of the resistance.

Question 83

Topic: Ankle Trauma & Sports

During a lateral approach to the fibula, the superficial peroneal nerve is at risk of iatrogenic injury. At what approximate location does this nerve typically pierce the crural fascia to become subcutaneous?

. 5 cm proximal to the tip of the lateral malleolus
. 10 to 12 cm proximal to the tip of the lateral malleolus
. 20 cm proximal to the tip of the lateral malleolus
. Posterior to the fibular head
. At the level of the distal tibiofibular syndesmosis

Correct Answer & Explanation

. 5 cm proximal to the tip of the lateral malleolus

Explanation

The superficial peroneal nerve typically pierces the crural fascia to become subcutaneous in the anterolateral leg approximately 10 to 12 cm proximal to the lateral malleolus. It is highly susceptible to injury here during lateral approaches or fasciotomies.

Question 84

Topic: Ankle Trauma & Sports

A 21-year-old wide receiver sustains a forceful external rotation injury to his ankle. Examination reveals tenderness over the anterior inferior tibiofibular ligament (AITFL) and a positive squeeze test. Radiographs show a tibiofibular clear space of 7 mm. What is the most appropriate treatment?

. Immediate return to play with taping
. Functional rehabilitation and return to play in 2-4 weeks
. Short-leg cast immobilization for 6 weeks
. Surgical stabilization of the syndesmosis
. Anterior talofibular ligament (ATFL) repair

Correct Answer & Explanation

. Immediate return to play with taping

Explanation

A tibiofibular clear space >5 mm on AP or mortise radiographs indicates a syndesmotic injury with frank diastasis. Operative stabilization (using screws or suture-button constructs) is required to restore the mortise and prevent post-traumatic arthritis.

Question 85

Topic: Ankle Trauma & Sports

A 19-year-old collegiate soccer player sustains a high ankle sprain. On evaluation 3 weeks post-injury, he is pain-free with walking but unable to run. Weight-bearing CT is utilized to assess the syndesmosis. Which finding would most strongly indicate the need for surgical stabilization?

. Subchondral sclerosis of the tibial plafond
. Asymmetry of the syndesmotic area compared to the contralateral side > 2 mm
. Thickening of the AITFL
. Anterior talofibular ligament (ATFL) discontinuity
. Calcification of the interosseous membrane

Correct Answer & Explanation

. Subchondral sclerosis of the tibial plafond

Explanation

Weight-bearing CT is highly sensitive for detecting subtle syndesmotic instability. Asymmetry in the syndesmotic clear space, volume, or area (e.g., >2 mm side-to-side difference) under weight-bearing loads indicates a dynamic instability that warrants surgical fixation.

Question 86

Topic: Ankle Trauma & Sports

A 19-year-old female gymnast with chronic lateral ankle instability fails non-operative management and is indicated for a modified Broström procedure. The Gould modification of this procedure involves advancing which structure to reinforce the repair?

. Peroneus brevis tendon
. Inferior extensor retinaculum
. Superior peroneal retinaculum
. Plantaris tendon
. Calcaneofibular ligament

Correct Answer & Explanation

. Peroneus brevis tendon

Explanation

The standard Broström procedure involves anatomic repair of the ATFL and CFL. The Gould modification reinforces this repair by advancing the extensor retinaculum (specifically the inferior portion) over the repaired ligaments.

Question 87

Topic: Ankle Trauma & Sports

A 21-year-old athlete sustains an external rotation injury to his ankle. Radiographs show a widened medial clear space and tibiofibular clear space. He is tender along the proximal fibula. What is the standard operative management?

. Isolated repair of the deltoid ligament
. Isolated repair of the anterior talofibular ligament
. Syndesmotic fixation (screws or suture button)
. Conservative management in a walking boot
. Proximal fibulectomy

Correct Answer & Explanation

. Isolated repair of the deltoid ligament

Explanation

An external rotation force causing syndesmotic injury with medial clear space widening indicates an unstable syndesmosis (often a Maisonneuve variant). This requires operative reduction and syndesmotic fixation.

Question 88

Topic: Ankle Trauma & Sports

A 45-year-old man sustains a pronation-external rotation (PER) ankle fracture. Intraoperatively, after rigid internal fixation of the medial and lateral malleoli, an intraoperative Hook test demonstrates 3 mm of lateral syndesmotic widening. Which of the following represents the most appropriate next step?

. Non-weight bearing in a short leg cast for 6 weeks without further fixation
. Placement of a syndesmotic screw or suture-button construct
. Primary arthrodesis of the tibiofibular joint
. Repair of the anterior talofibular ligament (ATFL)
. Removal of the lateral malleolar hardware to allow auto-reduction

Correct Answer & Explanation

. Non-weight bearing in a short leg cast for 6 weeks without further fixation

Explanation

Widening of the syndesmosis during a stress examination after bony fixation of the malleoli indicates persistent dynamic instability. It requires stabilization with trans-syndesmotic screws or a flexible suture-button construct.

Question 89

Topic: Ankle Trauma & Sports

A 45-year-old man sustains an ankle injury. Radiographs show an isolated lateral malleolus fracture at the level of the syndesmosis. A gravity stress view shows 6 mm of medial clear space widening. What Lauge-Hansen classification does this injury represent?

. Supination-adduction
. Supination-external rotation
. Pronation-abduction
. Pronation-external rotation
. Pronation-adduction

Correct Answer & Explanation

. Supination-adduction

Explanation

An SER-IV injury involves a fracture of the fibula at the syndesmosis with disruption of the deltoid ligament or medial malleolus. The disruption of the medial structures is indicated by medial clear space widening on a stress view.

Question 90

Topic: Ankle Trauma & Sports

A 40-year-old male sustains an ankle fracture. Radiographs reveal a transverse fracture of the medial malleolus and a high spiral fracture of the fibula above the syndesmosis (Weber C).

According to the Lauge-Hansen classification, what was the mechanism of injury?

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

Correct Answer & Explanation

. Supination-External Rotation

Explanation

A transverse medial malleolus fracture combined with a high or short oblique fibular fracture (Weber C) is the classic hallmark of a Pronation-External Rotation (PER) injury. The mechanism initiates medially with a tension failure (deltoid tear or transverse medial malleolus fracture) and progresses laterally through the syndesmosis.

Question 91

Topic: Ankle Trauma & Sports

A 28-year-old hockey player sustains a high ankle sprain. Intraoperative stress testing reveals gross syndesmotic instability, and the patient undergoes surgical stabilization. Which of the following factors is the most significant predictor of poor long-term clinical outcome and post-traumatic arthritis in this patient?

. Use of a suture-button construct instead of syndesmotic screws
. Malreduction of the distal tibiofibular syndesmosis
. Failure to primarily repair the medial deltoid ligament
. Retention of syndesmotic screws beyond 12 weeks
. Allowing partial weight-bearing at 4 weeks postoperatively

Correct Answer & Explanation

. Use of a suture-button construct instead of syndesmotic screws

Explanation

Anatomic reduction of the distal tibiofibular syndesmosis is the most critical prognostic factor in determining long-term functional outcomes and preventing post-traumatic arthritis. Suture-button constructs and screws have comparable clinical outcomes, and routine deltoid repair is generally not required if the syndesmosis is anatomically reduced.

Question 92

Topic: Ankle Trauma & Sports

A 28-year-old male sustains an unstable syndesmotic injury requiring screw fixation. Which of the following ligaments provides the greatest contribution to the stability of the distal tibiofibular syndesmosis?

. Anterior inferior tibiofibular ligament
. Posterior inferior tibiofibular ligament
. Interosseous ligament
. Deltoid ligament
. Transverse tibiofibular ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament

Explanation

The posterior inferior tibiofibular ligament (PITFL) is the strongest of the syndesmotic ligaments and provides roughly 42% of the resistance to diastasis. The AITFL provides approximately 35%, and the interosseous ligament provides 22%.

Question 93

Topic: Ankle Trauma & Sports

Current orthopedic literature suggests that direct open reduction and internal fixation of a posterior malleolus fracture fragment, as opposed to percutaneous AP screw fixation or nonoperative management, offers which of the following distinct biomechanical advantages?

. Eliminates the need for concomitant lateral malleolar fixation
. Decreases the rates of postoperative deep vein thrombosis
. Restores the posterior incisura and provides superior syndesmotic stability
. Prevents anterior talar translation in the mortise
. Allows for earlier weight-bearing at 2 weeks postoperatively

Correct Answer & Explanation

. Eliminates the need for concomitant lateral malleolar fixation

Explanation

Direct fixation of the posterior malleolus anatomically restores the posterior incisura fibularis. This restores the intact posterior inferior tibiofibular ligament (PITFL), providing superior biomechanical stability to the syndesmosis compared to trans-syndesmotic screws alone.

Question 94

Topic: Ankle Trauma & Sports

According to the Lauge-Hansen classification system, what is the sequence of injury in a Pronation-Abduction (PA) Stage III ankle fracture?

. Deltoid rupture -> AITFL rupture -> Transverse/short oblique fibula fracture -> Posterior malleolus fracture
. AITFL rupture -> Spiral fibula fracture -> Posterior malleolus fracture -> Deltoid rupture
. Transverse medial malleolus fracture -> PITFL rupture -> Low transverse fibula fracture
. Deltoid rupture -> Anterior syndesmosis rupture -> Oblique fracture of the fibula at the joint level
. Deltoid rupture -> Syndesmosis rupture -> Bending fracture of the fibula above the syndesmosis

Correct Answer & Explanation

. Deltoid rupture -> AITFL rupture -> Transverse/short oblique fibula fracture -> Posterior malleolus fracture

Explanation

In the Pronation-Abduction sequence: Stage 1 is deltoid ligament rupture or transverse medial malleolar fracture; Stage 2 is rupture of the AITFL/syndesmosis; Stage 3 is a bending (transverse or comminuted) fracture of the fibula above the level of the syndesmosis.

Question 95

Topic: Ankle Trauma & Sports

A 28-year-old football player sustains a high ankle sprain. A positive stress radiograph confirms a syndesmotic injury. During surgical repair, an understanding of the syndesmotic anatomy is critical. Which of the following ligaments provides the greatest structural strength and primary stabilization to the distal tibiofibular syndesmosis?

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

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

The posterior inferior tibiofibular ligament (PITFL) is the strongest component of the syndesmotic complex, contributing approximately 40% to 45% of the total syndesmotic resistance to fibular displacement.

Question 96

Topic: Ankle Trauma & Sports

A 13-year-old boy sustains a Salter-Harris III fracture of the anterolateral distal tibia. The avulsion of this fragment is caused by the pull of which of the following ligaments?

. Anterior talofibular ligament (ATFL)
. Calcaneofibular ligament (CFL)
. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Deltoid ligament

Correct Answer & Explanation

. Anterior talofibular ligament (ATFL)

Explanation

This describes a juvenile Tillaux fracture. It occurs because the anterolateral distal tibial physis is the last to close, and the fragment is avulsed by the anterior inferior tibiofibular ligament (AITFL).

Question 97

Topic: Ankle Trauma & Sports

A 26-year-old soccer player sustains a high ankle sprain with widening of the tibiofibular clear space on radiographs. Which of the following ligaments of the distal tibiofibular syndesmosis provides the greatest biomechanical strength and resistance to diastasis?

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

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

The posterior inferior tibiofibular ligament (PITFL) is the strongest and thickest of the syndesmotic ligaments, providing the greatest stabilizing force against diastasis. The AITFL is the most commonly injured but is biomechanically weaker.

Question 98

Topic: Ankle Trauma & Sports

During open reduction and internal fixation of a severe Pilon fracture, the Chaput fragment is identified. Which ligament attaches to this fragment?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Deltoid ligament
. Interosseous membrane
. Anterior talofibular ligament (ATFL)

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

The Chaput fragment is the anterolateral fragment of the distal tibia. The anterior inferior tibiofibular ligament (AITFL) attaches the Chaput fragment to the Wagstaffe fragment of the fibula.

Question 99

Topic: Ankle Trauma & Sports

A 30-year-old male has an unstable ankle syndesmosis after fixation of a Weber C fibula fracture. Which of the following is true regarding suture button fixation compared to rigid syndesmotic screws?

. Suture buttons require routine removal at 3 months
. Suture buttons provide rigid fixation preventing all physiologic fibular motion
. Suture buttons allow earlier weight-bearing and reduce the need for hardware removal
. Suture buttons have a significantly higher rate of syndesmotic malreduction
. Suture buttons are only indicated in purely ligamentous injuries without fracture

Correct Answer & Explanation

. Suture buttons require routine removal at 3 months

Explanation

Suture button constructs provide dynamic stabilization, allowing physiologic motion while maintaining reduction. They generally allow earlier weight-bearing and eliminate the need for routine hardware removal compared to syndesmotic screws.

Question 100

Topic: Ankle Trauma & Sports
A 26-year-old female presents with chronic lateral ankle instability despite 6 months of targeted physical therapy. She undergoes a Broström-Gould procedure. Which anatomical structures are anatomically repaired and advanced during this surgery?
. ATFL and CFL advanced with the inferior extensor retinaculum
. ATFL and PTFL advanced with the superior peroneal retinaculum
. CFL and PTFL advanced with the inferior extensor retinaculum
. Deltoid ligament complex advanced with the flexor retinaculum
. ATFL only, advanced with the superior extensor retinaculum

Correct Answer & Explanation

. ATFL and CFL advanced with the inferior extensor retinaculum

Explanation

The modified Broström-Gould procedure involves direct repair of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL), augmented by mobilizing and advancing the inferior extensor retinaculum over the repair.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page