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Ankle Trauma & Sports MCQs

Practice Set 8 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 141

Topic: Ankle Trauma & Sports

A 30-year-old male presents to the emergency department after a twisting injury to his ankle. Radiographs show a widened medial clear space and an isolated proximal third fibula fracture (Maisonneuve fracture). Given the location of the proximal fibula fracture, which nerve is at greatest risk of associated injury?

. Tibial nerve
. Deep peroneal nerve
. Superficial peroneal nerve
. Common peroneal nerve
. Sural nerve

Correct Answer & Explanation

. Tibial nerve

Explanation

A Maisonneuve fracture involves a pronation-external rotation injury that tears the syndesmosis and fractures the proximal fibula. The common peroneal nerve wraps around the fibular neck and is highly vulnerable to stretching or entrapment from injuries in this proximal region.

Question 142

Topic: Ankle Trauma & Sports

A 26-year-old soccer player has chronic lateral ankle instability despite aggressive physical therapy. You plan a modified Brostrom-Gould procedure. Which structures are repaired and advanced in this procedure?

. Anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the inferior extensor retinaculum.
. Posterior talofibular ligament (PTFL), ATFL, and the superior peroneal retinaculum.
. Deltoid ligament and spring ligament.
. ATFL only.
. CFL and peroneus brevis tendon.

Correct Answer & Explanation

. Anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the inferior extensor retinaculum.

Explanation

The Brostrom procedure involves direct repair of the torn ATFL and CFL. The Gould modification incorporates the mobilization and advancement of the extensor retinaculum (specifically the inferior extensor retinaculum) to reinforce the repair, limit inversion, and help address subtle subtalar instability.

Question 143

Topic: Ankle Trauma & Sports
The distinction between a Lauge-Hansen supination-external rotation III injury and a Lauge-Hansen supination-external rotation IV injury is:
. A spiral oblique fracture of the lateral malleolus
. Anteroinferior tibiofibular ligament (AITFL) disruption
. Posteroinferior tibiofibular ligament (PITFL) disruption or posterior malleolus fracture
. Deltoid ligament disruption or medial malleolus fracture
. Anterior talo-fibular ligament disruption

Correct Answer & Explanation

. Deltoid ligament disruption or medial malleolus fracture

Explanation

The sequence of injury according to the Lauge-Hansen classification system in supination-external rotation injuries is AITFL disruption, spiral oblique fracture of the lateral malleolus, PITFL disruption or posterior malleolus fracture, and finally stage IV, which is a deltoid ligament disruption or medial malleolus fracture.

Question 144

Topic: Ankle Trauma & Sports

An athlete suffers an inversion ankle sprain. The anterior drawer test is positive. A subsequent talar tilt test in inversion is also distinctly positive compared to the normal side. Which ligament is primarily assessed by this talar tilt maneuver?

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

Correct Answer & Explanation

. Anterior talofibular ligament (ATFL)

Explanation

The talar tilt test in inversion primarily evaluates the calcaneofibular ligament (CFL). The anterior drawer test primarily evaluates the anterior talofibular ligament (ATFL).

Question 145

Topic: Ankle Trauma & Sports

According to the Lauge-Hansen classification, what is the sequence of structural failure in a pronation-abduction (PA) ankle injury?

. Anterior inferior tibiofibular ligament -> Fibula fracture -> Posterior inferior tibiofibular ligament -> Deltoid ligament
. Deltoid ligament -> Anterior inferior tibiofibular ligament -> Fibula fracture above syndesmosis -> Posterior inferior tibiofibular ligament
. Deltoid ligament -> Anterior and posterior inferior tibiofibular ligaments -> Transverse or comminuted fibula fracture at or just above the joint line
. Lateral collateral ligaments -> Medial malleolus transverse fracture
. Anterior inferior tibiofibular ligament -> Short oblique fibula fracture -> Posterior inferior tibiofibular ligament -> Medial malleolus

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament -> Fibula fracture -> Posterior inferior tibiofibular ligament -> Deltoid ligament

Explanation

The Pronation-Abduction (PA) sequence begins with 1) Medial structure failure (Deltoid ligament rupture or medial malleolus transverse fracture), 2) Syndesmotic ligament failure (AITFL, PITFL), and 3) Fibula fracture (short oblique or transverse fracture at or just above the joint line, frequently featuring lateral comminution/butterfly fragment).

Question 146

Topic: Ankle Trauma & Sports

A 40-year-old male falls from a ladder and sustains a pilon fracture. Preoperative CT imaging shows a displaced anterolateral distal tibia fragment. This specific fragment remains attached to which of the following ligaments?

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

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

The anterolateral fragment of the distal tibia (the Tillaux-Chaput fragment) serves as the tibial attachment for the anterior inferior tibiofibular ligament (AITFL). Understanding these ligamento-osseous relationships dictates the reduction sequence.

Question 147

Topic: Ankle Trauma & Sports
A 27-year-old male sustains an isolated Lauge-Hansen Supination-External Rotation (SER) stage IV ankle fracture. According to this classification, what is the precise sequential order of structural failure?
. Medial malleolus -> ATFL -> Lateral malleolus -> PITFL
. AITFL -> Lateral malleolus -> PITFL -> Deltoid ligament/Medial malleolus
. Deltoid ligament -> AITFL -> Fibula fracture above syndesmosis -> PITFL
. Lateral malleolus -> AITFL -> Medial malleolus -> PITFL
. ATFL -> CFL -> PTFL -> Medial malleolus

Correct Answer & Explanation

. AITFL -> Lateral malleolus -> PITFL -> Deltoid ligament/Medial malleolus

Explanation

In the Lauge-Hansen SER sequence, failure begins anterolaterally with the AITFL (Stage I), followed by a spiral lateral malleolus fracture (Stage II), PITFL rupture or posterior malleolus fracture (Stage III), and finally deltoid rupture or medial malleolus fracture (Stage IV).

Question 148

Topic: Ankle Trauma & Sports

A 21-year-old soccer player sustains a high ankle sprain. Which of the following ligaments provides the greatest percentage of biomechanical restraint against diastasis of the distal tibiofibular syndesmosis?

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

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

The posterior inferior tibiofibular ligament (PITFL) is the strongest ligament of the syndesmotic complex. Biomechanical studies have shown that the PITFL contributes approximately 42% of the resistance to syndesmotic diastasis, whereas the AITFL contributes ~35%, and the interosseous ligament provides ~22%.

Question 149

Topic: Ankle Trauma & Sports

A 25-year-old skier presents after an acute injury feeling a 'snap' behind his lateral malleolus. On examination, the peroneal tendons dislocate anteriorly over the lateral malleolus with resisted dorsiflexion and eversion. Radiographs show a small bony avulsion flake lateral to the distal fibula.

What structure has been compromised?

. Anterior Talofibular Ligament (ATFL)
. Calcaneofibular Ligament (CFL)
. Inferior Extensor Retinaculum
. Superior Peroneal Retinaculum (SPR)
. Peroneus Longus tendon itself

Correct Answer & Explanation

. Superior Peroneal Retinaculum (SPR)

Explanation

The 'fleck sign' lateral to the distal fibula represents an avulsion of the Superior Peroneal Retinaculum (SPR) from its fibular attachment. Disruption of the SPR allows the peroneal tendons to subluxate or dislocate anteriorly over the lateral malleolus. Treatment often requires deepening of the fibular groove and repair of the SPR.

Question 150

Topic: Ankle Trauma & Sports

During surgical stabilization of an acute syndesmotic injury of the ankle, a thorough understanding of the native anatomy is required. Which of the following ligaments provides the greatest biomechanical strength and resistance to diastasis of the distal tibiofibular joint?

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

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

The syndesmotic complex consists of the AITFL, PITFL, transverse ligament, and interosseous ligament/membrane. Biomechanical studies demonstrate that the Posterior Inferior Tibiofibular Ligament (PITFL) provides the strongest restraint, accounting for approximately 42% of the total strength against syndesmotic widening, followed by the AITFL (35%) and the interosseous ligament (22%).

Question 151

Topic: Ankle Trauma & Sports

A 24-year-old soccer player sustains a high ankle sprain. On examination, he has a positive squeeze test and external rotation stress test. Which ligament is the primary restraint to anterior translation of the distal fibula relative to the tibia?

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

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

The anterior inferior tibiofibular ligament (AITFL) is the most commonly injured structure in a syndesmotic 'high ankle' sprain. It serves as the primary restraint to anterior translation and external rotation of the distal fibula.

Question 152

Topic: Ankle Trauma & Sports
A 25-year-old male sustains an ankle injury while playing basketball. Radiographs show a transverse fracture of the distal fibula at the level of the syndesmosis and widening of the syndesmosis. The medial clear space is also increased. This injury pattern most closely corresponds to which Weber classification type?
. Weber A
. Weber B
. Weber C
. Maisonneuve fracture
. Pilon fracture

Correct Answer & Explanation

. Weber C

Explanation

The Weber classification for ankle fractures describes the level of the fibular fracture relative to the syndesmosis. A Weber C fracture involves a fibular fracture proximal to the syndesmosis, often with syndesmotic disruption and medial injury (deltoid ligament tear or medial malleolus fracture). A transverse fibular fracture at the level of the syndesmosis combined with syndesmotic widening and increased medial clear space (indicating medial ligamentous injury or fracture) is the hallmark of a Weber C injury, specifically indicating syndesmotic instability. Weber A is distal to syndesmosis, Weber B is at the level. A Maisonneuve fracture is a specific type of Weber C where the fibular fracture is very high, near the fibular head.

Question 153

Topic: Ankle Trauma & Sports
A 60-year-old female sustains a distal fibula fracture with no medial tenderness or widening of the medial clear space on stress views. The fracture is located 4 cm above the ankle joint, but radiographs show no syndesmotic widening. Which Weber classification best describes this injury?
. Weber A.
. Weber B.
. Weber C.
. Maisonneuve fracture.
. Pilon fracture.

Correct Answer & Explanation

. Weber C.

Explanation

The Weber classification describes the fibular fracture location relative to the syndesmosis. A Weber C fracture involves a fibular fracture proximal to the syndesmosis. Even if the syndesmosis is not widened on static radiographs, a fracture 4 cm above the ankle joint clearly places it proximal to the syndesmosis, making it a Weber C equivalent. This type of fracture inherently suggests potential syndesmotic injury, even if not grossly apparent. Weber A is distal to the syndesmosis, Weber B is at the level of the syndesmosis. A Maisonneuve fracture is a very high Weber C fracture, typically at the fibular neck. Pilon fractures involve the distal tibia.

Question 154

Topic: Ankle Trauma & Sports

What is the most appropriate management for an undisplaced, stable fracture of the lateral malleolus (Weber A)?

. Immediate surgical fixation with a plate and screws.
. Open reduction and internal fixation with a tension band.
. Non-weight bearing in a short leg cast for 6 weeks.
. Functional bracing or a walking boot with early weight bearing as tolerated.
. Skeletal traction.

Correct Answer & Explanation

. Functional bracing or a walking boot with early weight bearing as tolerated.

Explanation

Weber A fractures (fracture of the fibula distal to the syndesmosis) are typically stable injuries because the syndesmosis and deltoid ligament are intact. For undisplaced and stable fractures, functional bracing or a walking boot with early weight-bearing as tolerated is the most appropriate management. This allows for earlier return to function and typically good outcomes. Surgical fixation is not indicated for stable, undisplaced fractures. Non-weight bearing in a cast is overly conservative for this stable pattern. Skeletal traction is not relevant.

Question 155

Topic: Ankle Trauma & Sports

What is the typical mechanism of injury for a lateral ankle sprain involving the ATFL?

. Dorsiflexion and eversion
. Plantarflexion and inversion
. Isolated dorsiflexion
. Isolated inversion
. Plantarflexion and eversion

Correct Answer & Explanation

. Plantarflexion and inversion

Explanation

The most common mechanism of injury for a lateral ankle sprain, specifically involving the ATFL, is plantarflexion and inversion. In this position, the ATFL is most taut and therefore most susceptible to injury. Dorsiflexion and eversion are more associated with syndesmotic or deltoid ligament injuries. Isolated dorsiflexion or inversion without a plantarflexion component is less common for ATFL injury.

Question 156

Topic: Ankle Trauma & Sports
In an acute Grade III lateral ankle sprain, which ligaments are typically involved?
. Only the ATFL
. ATFL and CFL
. ATFL, CFL, and PTFL
. ATFL and AITFL
. CFL and PTFL

Correct Answer & Explanation

. ATFL and CFL

Explanation

A Grade III lateral ankle sprain typically involves a complete rupture of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). The posterior talofibular ligament (PTFL) is rarely injured in isolation and usually only in severe dislocations or fracture-dislocations. The AITFL is part of the syndesmosis. Therefore, ATFL and CFL are the key ligaments in a Grade III lateral ankle sprain.

Question 157

Topic: Ankle Trauma & Sports

Which of the following ligaments is taut during ankle dorsiflexion and therefore best assessed for inversion instability in this position?

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

Correct Answer & Explanation

. Calcaneofibular ligament (CFL)

Explanation

The calcaneofibular ligament (CFL) is taut in dorsiflexion, which makes this the optimal position to assess its integrity using the talar tilt test. The ATFL is taut in plantarflexion and resists anterior translation. The PTFL resists posterior translation. The deltoid ligament is on the medial side, and the AITFL is part of the syndesmosis.

Question 158

Topic: Ankle Trauma & Sports

What is the typical timeframe for initiating protected weight-bearing after a modified Brostrom-Gould procedure?

. Immediately post-op with full weight-bearing.
. Non-weight-bearing for 6 weeks, then gradual progression.
. Partial weight-bearing in a boot or brace after 2 weeks.
. Full weight-bearing after 3 months.
. Non-weight-bearing for 3 months.

Correct Answer & Explanation

. Partial weight-bearing in a boot or brace after 2 weeks.

Explanation

After a modified Brostrom-Gould procedure, protected weight-bearing typically begins after 2 weeks in a walking boot or brace, often progressing to full weight-bearing by 4-6 weeks, depending on surgeon preference and patient progress. Immediate full weight-bearing is generally avoided to protect the repair. Non-weight-bearing for 6 weeks or 3 months is too conservative for most primary repairs, and full weight-bearing at 3 months is usually when more advanced activities are initiated.

Question 159

Topic: Ankle Trauma & Sports

Which of the following patient populations is generally NOT considered a good candidate for primary lateral ankle ligament repair (e.g., modified Brostrom procedure)?

. Young, high-demand athlete with recurrent instability.
. Patient with chronic instability, no significant generalized laxity, and good tissue quality.
. Patient with significant generalized ligamentous laxity and poor quality local tissues.
. Patient who has failed 6 months of comprehensive physiotherapy.
. Patient with isolated ATFL and CFL insufficiency.

Correct Answer & Explanation

. Patient with significant generalized ligamentous laxity and poor quality local tissues.

Explanation

Patients with significant generalized ligamentous laxity (e.g., high Beighton score) and poor quality local tissues are generally not good candidates for primary repair (like modified Brostrom). In these cases, the native tissues are often too attenuated or inherently weak to provide long-lasting stability, leading to a higher failure rate. For such patients, an anatomical reconstruction using an autograft or allograft is often a more appropriate choice. Other listed groups are generally good candidates for primary repair if indicated.

Question 160

Topic: Ankle Trauma & Sports

Which examination technique involves stabilizing the distal tibia with one hand and inverting the hindfoot with the other, primarily to assess the integrity of the CFL?

. Anterior drawer test
. Talar tilt test (inversion stress)
. External rotation stress test
. Squeeze test
. Kleiger test

Correct Answer & Explanation

. Talar tilt test (inversion stress)

Explanation

The talar tilt test, specifically applying an inversion stress with the ankle in neutral or slight dorsiflexion, primarily assesses the integrity of the calcaneofibular ligament (CFL). Increased talar tilt compared to the contralateral side suggests CFL insufficiency. The anterior drawer test assesses the ATFL. External rotation and squeeze tests are for syndesmotic injuries, and Kleiger test is also for syndesmotic and deltoid ligament integrity.

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