Menu

8. Foot and Ankle MCQs

Practice Set 102 of 353

This practice set contains high-yield board review questions covering key concepts in 8. Foot and Ankle. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 2021

Topic: 8. Foot and Ankle

When evaluating a severely traumatized lower extremity to determine the viability of limb salvage, the Mangled Extremity Severity Score (MESS) is often calculated. Which of the following variables is NOT a component of the MESS?

. Skeletal and soft-tissue injury severity
. Limb ischemia time
. Patient age
. Systemic hemodynamics (Shock)
. Distal neurological status (e.g., plantar sensation)

Correct Answer & Explanation

. Skeletal and soft-tissue injury severity

Explanation

The MESS scoring system includes Skeletal/Soft-tissue injury, Limb ischemia, Age, and Shock. Distal neurological status, such as an insensate foot, is an independent factor often debated but is formally excluded from the MESS calculation.

Question 2022

Topic: 8. Foot and Ankle
The histology of the lesion is shown in Figure 101d. What is the most likely complication after treatment of this lesion?
. Arthrofibrosis
. Local recurrence
. Chondrolysis
. Disseminated infection
. Metastasis

Correct Answer & Explanation

. Local recurrence

Explanation

The MRI scans show a well-circumscribed inhomogeneous mass at the anterior ankle joint consistent with a diagnosis of pigmented villonodular synovitis (PVNS). The histologic image shows multiple multinucleated giant cells, hemosiderin, and very few mitotic figures, which is consistent with PVNS. A common complication of PVNS treatment is local recurrence. Arthrofibrosis and chondrolysis are not seen with proper surgical care. Because this is not an infectious lesion, disseminated infection is highly unlikely. PVNS rarely metastasizes.

Question 2023

Topic: 8. Foot and Ankle
A 32-year-old laborer reports left ankle pain and deformity. History reveals that he sustained a left ankle fracture 2 years ago and was treated with closed reduction and casting. Radiographs are shown in Figures 25a through 25c. What is the most appropriate management?
. Bracing and physical therapy
. Intra-articular injection of steroids into the ankle joint, bracing, and physical therapy
. Intra-articular injection of hyaluronic acid product into the ankle joint, bracing, and physical therapy
. Ankle fusion
. Corrective osteotomy of the fibula and medial malleolus with reconstruction of the syndesmosis if unstable

Correct Answer & Explanation

. Corrective osteotomy of the fibula and medial malleolus with reconstruction of the syndesmosis if unstable

Explanation

Corrective osteotomy of fibular malunions, with appropriate lengthening, even in the presence of early arthritis, has been shown to decrease ankle pain and increase stability. Reduction and bone grafting of the medial malleolar nonunion is also needed. Lateral talar displacement of even 1 mm has been reproducibly shown to decrease tibiotalar contact by 40% to 42%, causing a predisposition to arthritis.

Question 2024

Topic: 8. Foot and Ankle
The modified Brostrom lateral ankle ligamentous reconstruction uses which of the following structures to provide supplementary stabilization?
. One half of the peroneus brevis tendon
. The entire peroneus brevis tendon
. Peroneus longus tendon
. Plantaris
. Extensor retinaculum

Correct Answer & Explanation

. Extensor retinaculum

Explanation

DISCUSSION: The modified Brostrom lateral ankle ligament stabilization procedure uses the remnants of the anterior talofibular and the calcaneofibular ligaments, supplemented by the inferior retinaculum and the transferred talocalcaneal ligament to stabilize the lateral ankle. Chrisman and associates described the use of one half of the peroneus brevis. Watson-Jones and Evans used the entire peroneus brevis. The peroneus longus has been taken by mistake. The plantaris has been used in triligamentous reconstruction.

Question 2025

Topic: 8. Foot and Ankle
A 45-year-old man who underwent an ankle arthrodesis reports that for the first 6 years he had significant pain relief after the fusion healed. However, he now has increasing pain in the sinus tarsi. AP and lateral radiographs are shown in Figures 8a and 8b. What is the most likely cause of the patient’s symptoms?
. Nonunion
. Tarsal tunnel syndrome
. Degenerative arthritis of the hindfoot joints
. Sinus tarsi syndrome
. Chronic osteomyelitis of the distal tibia

Correct Answer & Explanation

. Degenerative arthritis of the hindfoot joints

Explanation

DISCUSSION: The patient has a solid ankle fusion radiographically. With a tibiotalar arthrodesis, the adjacent joints (subtalar and transverse tarsal) take additional stress. Over time, progressive degenerative arthritis will occur in these adjacent joints, often necessitating further surgery.

Question 2026

Topic: 8. Foot and Ankle
A 66-year-old patient with type 1 diabetes mellitus has a deep, nonhealing ulcer under the first metatarsal head and a necrotic tip of the great toe. He has been under the direction of a wound care clinic for 4 months and has had orthotics and shoe wear changes. What objective findings are indicative of the patient’s ability to heal the wound postoperatively?
. Absolute toe pressures of 55 mm Hg
. Transcutaneous oxygen level of 20 mm Hg
. Arterial brachial indices (ABI) of 1.2 at the level of surgery
. ABI 0.3 at the level of surgery
. Albumin level of 2.5

Correct Answer & Explanation

. Absolute toe pressures of 55 mm Hg

Explanation

Absolute toe pressures greater than 40 to 50 mm Hg are a good sign of healing potential. An ABI of greater than 0.45 favors healing, but indices greater than 1 are falsely positive due to calcifications in the vessels. Normal albumin is an overall indication of nutritional status. A transcutaneous oxygen level should be greater than 40 mm Hg for healing.

Question 2027

Topic: 8. Foot and Ankle
A 48-year-old woman with a history of a spinal cord injury as a teenager has unilateral weakness in the left lower extremity. She has used an ankle-foot orthosis for many years without difficulty but recently has had a recurrent painful callus beneath the great toe that has been recalcitrant to nonsurgical management. Examination reveals intact sensation with an intractable plantar keratosis (IPK) beneath the first metatarsal head. Motor examination reveals no active ankle or great toe dorsiflexion, and 4/5 plantar flexion strength at the ankle and great toe. Passive ankle dorsiflexion is 10 degrees, whereas passive plantar flexion is 40 degrees. Passive great toe dorsiflexion is 30 degrees and plantar flexion is 10 degrees. Foot alignment on standing is normal. Radiographs are shown in Figures 47a and 47b with a marker beneath the IPK. Based on her request for surgical treatment, what is the most appropriate procedure?
. Gastrocnemius recession
. Keller bunionectomy
. Flexor hallucis longus tendon transfer
. Planing/excising the superficial half of the medial sesamoid
. Dorsiflexion osteotomy of the first metatarsal

Correct Answer & Explanation

. Planing/excising the superficial half of the medial sesamoid

Explanation

Passive dorsiflexion is adequate to accommodate standing erect without excessive pressure, and a gastrocnemius recession may lead to more instability. Complete excision of the medial sesamoid could lead to an iatrogenic hallux valgus deformity. She does not have a cock-up toe deformity; therefore, a flexor hallucis longus tendon transfer is not warranted. There is no significant foot deformity; therefore, a dorsiflexion osteotomy is not warranted. The appropriate procedure is planing of the plantar half of the medial sesamoid, thereby preserving its function while diminishing the excessive pressure.

Question 2028

Topic: 8. Foot and Ankle
A 21-year-old football player who sustained a direct blow to the posterior hindfoot while making a cut is unable to bear weight on the injured foot. Examination reveals tenderness and swelling of the great toe metatarsophalangeal (MTP) joint. Radiographs are shown in Figures 9a and 9b. What is the most likely diagnosis?
. Dislocation of the great toe MTP joint
. Rupture of the volar plate
. Fracture of the lateral sesamoid
. Fracture of the lateral sesamoid and rupture of the plantar plate
. Subluxation of the sesamoids

Correct Answer & Explanation

. Fracture of the lateral sesamoid and rupture of the plantar plate

Explanation

Turf toe occurs in collision and contact sports in which the athlete pushes off to accelerate or change direction and there is hyperextension of the great toe MTP joint. Typically, there is also axial loading of the posterior hindfoot, which increases the hyperextension of the MTP joint. The most common presentation is pain and swelling of the MTP joint and inability to hyperextend the joint without significant symptoms. With significant force, fractures of the sesamoids and plantar soft tissues can occur. The radiographs do not show a dislocation of the great toe MTP joint because it is concentrically located on both radiographs. However, the radiographs show a fracture of the lateral sesamoid or a diastasis of a bipartite lateral sesamoid. The medial sesamoid is also proximal indicating a rupture of the plantar (volar) plate. Therefore, the most likely diagnosis is a fracture of the lateral sesamoid with rupture of the plantar plate leading to proximal migration of the proximal fragment of the lateral sesamoid and the medial sesamoid.

Question 2029

Topic: 8. Foot and Ankle
Examination of a 7-year-old girl with myelomeningocele reveals calcaneal deformities of both feet. She ambulates on both extremities wearing ankle-foot orthoses and has no upper extremity aids. She has grade 5/5 motor strength to the tibialis anterior muscles and absent motor strength to the triceps surae. There is no varus or valgus deformity of the hindfoot, and the skin over the heels is intact; however, mild callosities are present. Management should consist of:
. bilateral calcaneal osteotomies.
. modification of the ankle-foot orthoses.
. extra-articular subtalar arthrodesis.
. transfer of the anterior tibial tendon to the calcaneus.
. Achilles tendon tenodesis to the fibula.

Correct Answer & Explanation

. transfer of the anterior tibial tendon to the calcaneus.

Explanation

A calcaneal deformity of the foot may occur in children who have low lumbar myelomeningocele. Strong dorsiflexors overcome a weak or absent gastrocnemius-soleus complex, leading to downward growth of the calcaneal apophysis. The deformity is usually progressive and does not respond to nonsurgical management. Most authorities recommend transfer of the tibialis anterior muscle through the interosseous membrane to the posterior aspect of the calcaneus. This procedure has been reported to be effective in limiting progression of the deformity.

Question 2030

Topic: 8. Foot and Ankle
What is the most appropriate orthosis for hallux rigidus?
. Morton’s extension
. Metatarsal arch pad
. Full-length semi-rigid longitudinal arch support
. Full-length semi-rigid longitudinal arch support with medial hindfoot posting
. Full-length semi-rigid longitudinal arch support with lateral forefoot posting

Correct Answer & Explanation

. Morton’s extension

Explanation

A Morton’s extension limits excursion of the first metatarsophalangeal joint. It also functions as a ground reaction stabilizer during the toe-off phase of gait and thus reduces torque and joint reaction force at the first metatarsophalangeal joint. The metatarsal arch pad and full-length semi-rigid longitudinal arch support may help by dorsiflexing the first metatarsal relative to the phalanx and thus decompress the first metatarsophalangeal joint. However, they are not as biomechanically effective as the Morton’s extension. Both medial hindfoot and lateral forefoot posting are contraindicated because they increase ground reaction at the first metatarsophalangeal joint.

Question 2031

Topic: Midfoot & Hindfoot
A 34-year-old male is involved in a high-speed motor vehicle collision and sustains a Hawkins Type III talar neck fracture. According to the Hawkins classification, a Type III injury is characterized by a fracture of the talar neck with dislocation of which of the following joints?
. Subtalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Talonavicular and calcaneocuboid joints
. Tibiotalar joint only

Correct Answer & Explanation

. Subtalar and tibiotalar joints

Explanation

The Hawkins classification describes talar neck fractures: Type I is non-displaced; Type II involves subtalar subluxation/dislocation; Type III involves both subtalar and tibiotalar (ankle) dislocation; Type IV involves subtalar, tibiotalar, and talonavicular dislocation. Type III carries a nearly 100% risk of avascular necrosis if not rapidly reduced.

Question 2032

Topic: 8. Foot and Ankle
A 40-year-old roofer falls 15 feet onto his feet, sustaining a severely comminuted, joint-depression type intra-articular calcaneus fracture with profound loss of height and varus deformity. On a lateral radiograph of the foot, which of the following angles is typically decreased (flattened) as a result of the posterior facet impaction?
. Gissane's angle
. Meary's angle
. Kite's angle
. Böhler's angle
. Fowler-Philip angle

Correct Answer & Explanation

. Böhler's angle

Explanation

Böhler's angle is normally between 20 and 40 degrees. It is formed by a line from the highest point of the anterior process to the highest point of the posterior facet, and a second line from the posterior facet to the superior edge of the calcaneal tuberosity. In intra-articular calcaneus fractures with depression of the posterior facet, Böhler's angle decreases or becomes negative.

Question 2033

Topic: Midfoot & Hindfoot
According to the Hawkins classification of talar neck fractures, a Type III fracture involves displacement of the talar neck with subluxation or dislocation of the talar body from which of the following articulations?
. Subtalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Tibiotalar joint only
. Talonavicular joint only

Correct Answer & Explanation

. Subtalar and tibiotalar joints

Explanation

The Hawkins classification for talar neck fractures is: Type I (nondisplaced), Type II (displaced with subtalar subluxation/dislocation), Type III (displaced with both subtalar and tibiotalar dislocation), and Type IV (displaced with subtalar, tibiotalar, and talonavicular dislocation). The risk of avascular necrosis increases progressively with the grade.

Question 2034

Topic: 8. Foot and Ankle
A 28-year-old male sustains a knee dislocation (KD-III) while stepping off a curb. Upon arrival in the emergency department, his knee is spontaneously reduced, and pedal pulses are palpable and symmetric to the contralateral leg. His Ankle-Brachial Index (ABI) is calculated at 0.85. What is the most appropriate next step in management regarding his vascular status?
. Immediate application of a spanning external fixator
. Discharge home in a knee immobilizer with outpatient follow-up
. Observation with serial neurovascular checks every 4 hours
. CT angiography of the affected lower extremity
. Immediate open exploration of the popliteal artery

Correct Answer & Explanation

. CT angiography of the affected lower extremity

Explanation

In the setting of a multiligament knee injury or knee dislocation, an ABI of less than 0.90 is highly sensitive for an occult arterial injury (popliteal artery). Even in the presence of palpable pulses, an ABI < 0.90 mandates advanced imaging, typically CT angiography (or traditional arteriography), to definitively rule out a flow-limiting intimal flap or other vascular injury.

Question 2035

Topic: 8. Foot and Ankle

During a classic posterolateral approach to the ankle to treat a trimalleolar ankle fracture with a large posterior malleolus fragment, the surgeon develops the primary internervous/intermuscular interval. Dissection is carried down to the posterior tibia between which two specific muscle bellies?

. Peroneus longus and Extensor digitorum longus
. Flexor hallucis longus and Peroneus brevis
. Tibialis posterior and Flexor digitorum longus
. Gastrocnemius and Soleus
. Tibialis anterior and Extensor hallucis longus

Correct Answer & Explanation

. Peroneus longus and Extensor digitorum longus

Explanation

The standard posterolateral approach to the ankle is highly effective for exposing the posterior malleolus and lateral malleolus simultaneously. The correct intermuscular interval is between the flexor hallucis longus (FHL, innervated by the tibial nerve) medially and the peroneus brevis (innervated by the superficial peroneal nerve) laterally. During this approach, care must be taken to identify and protect the sural nerve and short saphenous vein, which lie in the superficial subcutaneous tissue crossing from medial to lateral.

Question 2036

Topic: 8. Foot and Ankle
The talocrural angle of an ankle mortise X-ray is formed between a line perpendicular to the tibial plafond and a line drawn:
. perpendicular to the medial clear space
. parallel to the talar body
. between the tips of the malleoli
. perpendicular to the shaft of the fibula
. parallel to the subtalar joint

Correct Answer & Explanation

. between the tips of the malleoli

Explanation

DISCUSSION: The talocrural angle is formed by the intersection of a line perpendicular to the plafond with a line drawn between the malleoli (average = 83+/-4 degrees). When the lateral malleolus is shortened secondary to fracture, this can lead to an increased talocrural angle. This malunion leads to lateral tilt of the talus. Phillips et al looked at 138 patients with a closed grade-4 supination-external rotation or pronation-external rotation ankle fracture. Although the conclusions were limited due to poor follow-up, they found the difference in the talocrural angle between the injured and normal sides was a statistically significant radiographic indicator of a good prognosis. Pettrone et al looked at a series of 146 displaced ankle fractures, and the effect of open or closed treatment, and internal fixation of one or both malleoli. They found open reduction proved superior to closed reduction, and in bimalleolar fractures open reduction of both malleoli was better than fixing only the medial side.

Question 2037

Topic: 8. Foot and Ankle
Figures 33a and 33b show the radiographs of a 10-year-old girl who reports a 4-month history of medial foot pain after she was kicked while playing soccer. The pain is worse with activity and partially relieved by rest. Examination reveals tenderness directly over a prominent navicular tuberosity. Management should consist of:
. calcaneal lengthening osteotomy with reefing of the tibialis posterior tendon.
. excision of the ossicle in the navicular and tibialis posterior tendon advancement.
. talonavicular joint arthrodesis.
. open reduction and internal fixation of the navicular.
. activity and shoe modification and non-narcotic analgesics.

Correct Answer & Explanation

. activity and shoe modification and non-narcotic analgesics.

Explanation

DISCUSSION: An accessory tarsal navicular is located at the medial tuberosity of the navicular bone. Nearly all children and adolescents who have a symptomatic accessory tarsal navicular bone become asymptomatic when they reach skeletal maturity. Initial management should include activity restrictions, shoe modification to avoid pressure over the prominent navicular, and non-narcotic analgesics. Although anecdotal, the use of arch supports may be helpful. When pain is refractory to these methods, a short period of cast immobilization may be useful. Surgery should be reserved for patients who have disabling symptoms despite a prolonged period of nonsurgical management. When surgery is indicated, simple excision of the accessory navicular is recommended. REFERENCES: Sella EJ, Lawson JP, Ogden JA: The accessory navicular synchondrosis. Clin Orthop 1986;209:280-285. Bennett GL, Weiner DS, Leighley B: Surgical treatment of symptomatic accessory tarsal navicular. J Pediatr Orthop 1990;10:445-449.

Question 2038

Topic: 8. Foot and Ankle

A 19-year-old female field hockey player sustains a right ankle injury last night during a game. The patient is on crutches and reports that she has not been able to put any weight on her right ankle since the injury. She was running alongside with another player when her right ankle “gave out” and she twisted it, falling to the ground. Physical examination reveals discoloration similar to a hematoma and significant swelling around the lateral ankle area. Pain is elicited during palpation of the anterior talofibular ligament. What test should be performed to aid in this diagnosis?

. Thompson test
. External rotation stress test
. Anterior drawer test
. Squeeze test

Correct Answer & Explanation

. Thompson test

Explanation

The anterior drawer test is performed with the ankle in 10° of plantar flexion, which results in the greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed over the edge of a table or bench, the physician uses one hand to stabilize the distal leg and with the other hand applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the tibia. The anterior talofibular ligament and calcaneofibular ligament are both compromised based on the examination findings. The anterior drawer test result reflects injury to the anterior talofibular ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement >15° degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments. The diagnosis is a severe lateral ligament complex sprain. This is optimally managed with early mobilization and a guided rehabilitation program that emphasizes proprioceptive stability.

Question 2039

Topic: 8. Foot and Ankle
A 35-year-old female runner reports progressive vague aching pain involving her midfoot. Her pain is most notable when running. She denies specific injury. Examination reveals minimal swelling and localized tenderness over the dorsal medial midfoot and navicular. Radiographs and an MRI scan are shown in Figures 37a through 37c. What is the most appropriate management?
. Non-weight-bearing immobilization and CT
. Walking boot and weight bearing as tolerated
. Activity restrictions (avoidance of running) and repeat radiographs in 2 to 4 weeks
. Activity restrictions and a bone scan
. Surgical fixation

Correct Answer & Explanation

. Non-weight-bearing immobilization and CT

Explanation

DISCUSSION: A high index of suspicion is required to identify a possible navicular stress fracture, especially in runners. High pain tolerance in the competitive athlete and often minimal swelling contribute to frequent delays in diagnosis. Localized tenderness over the dorsal navicular (so-called “N spot”) in a running athlete should alert the treating physician. In this patient, the radiographs are negative and the MRI scan shows marrow edema within the navicular. This could represent a stress reaction, stress fracture, or osteonecrosis. Appropriate management should include non-weight-bearing immobilization and obtaining a CT scan to determine if a fracture is present. Early surgical treatment may be considered but only if a fracture is identified. REFERENCES: Lee A, Anderson R: Stress fractures of the tarsal navicular. Foot Ankle Clin 2004;9:85-104. Coughlin M: Tarsal navicular stress fractures. Tech Foot Ankle Surg 2002;1:112-122.

Question 2040

Topic: 8. Foot and Ankle

A 19-year-old female field hockey player sustains a right ankle injury last night during a game. The patient is on crutches and reports that she has not been able to put any weight on her right ankle since the injury. She was running alongside with another player when her right ankle “gave out” and she twisted it, falling to the ground. Physical examination reveals discoloration similar to a hematoma and significant swelling around the lateral ankle area. Pain is elicited during palpation of the anterior talofibular ligament. Radiographs of the player’s right ankle confirm there are no fractures. With a lateral talar tilt test result of 19°, which additional structure is most likely damaged?

. Deltoid ligament
. Calcaneofibular ligament
. Anterior tibiofibular ligament
. Posterior tibiofibular ligament

Correct Answer & Explanation

. Deltoid ligament

Explanation

The anterior drawer test is performed with the ankle in 10° of plantar flexion, which results in the greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed over the edge of a table or bench, the physician uses one hand to stabilize the distal leg and with the other hand applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the tibia. Theanterior talofibular ligament and calcaneofibular ligament are both compromised based on the examination findings. The anterior drawer test result reflects injury to the anterior talofibular ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement >15° degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments. The diagnosis is a severe lateral ligament complex sprain. This is optimally managed with early mobilizationand a guided rehabilitation program that emphasizes proprioceptive stability.

Test Yourself

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

On this Page