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8. Foot and Ankle MCQs

Practice Set 103 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 2041

Topic: 8. Foot and Ankle
When the great toe deviates into a valgus position, the action of the abductor hallucis muscle becomes one of
. increased abduction.
. pronation.
. flexion.
. flexion and pronation.
. extension.

Correct Answer & Explanation

. flexion and pronation.

Explanation

DISCUSSION: The abductor hallucis muscle inserts together with the medial tendon of the flexor hallucis brevis into the medial base of the proximal phalanx of the great toe. When the hallux assumes a valgus position, the action of the abductor becomes one of flexion and pronation of the first metatarsal. REFERENCES: Resch S: Functional anatomy and topography of the foot and ankle, in Myerson M (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, vol 1, pp 25-49. Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.

Question 2042

Topic: 8. Foot and Ankle
Arthrodesis of which of the following joints has the greatest cumulative effect on midfoot/hindfoot motion?
. Talonavicular
. Naviculocuneiform
. Subtalar
. Cuboid-fifth metatarsal
. Calcaneocuboid

Correct Answer & Explanation

. Talonavicular

Explanation

Arthrodesis of the talonavicular joint eliminates almost all hindfoot motion. Arthrodesis of the subtalar joint eliminates 74% of talonavicular motion and 44% of calcaneocuboid motion. Arthrodesis of the calcaneocuboid joint eliminates 33% of talonavicular motion and 8% of subtalar motion. Arthrodesis of the naviculocuneiform or cuboid-fifth metatarsal joint has limited effect on hindfoot motion.

Question 2043

Topic: Midfoot & Hindfoot

A 35-year-old male sustains a purely ligamentous Lisfranc injury. He undergoes primary arthrodesis of the first, second, and third tarsometatarsal joints. Compared to open reduction and internal fixation (ORIF), which of the following is true regarding primary arthrodesis in this scenario?

. Higher rate of hardware removal.
. Decreased rate of subsequent procedures.
. Lower functional outcome scores.
. Higher rate of nonunion.
. Faster return to sport.

Correct Answer & Explanation

. Higher rate of hardware removal.

Explanation

Primary arthrodesis for purely ligamentous Lisfranc injuries has been shown to result in decreased rates of subsequent procedures (e.g., hardware removal) and equivalent or superior functional outcomes compared to ORIF. ORIF is associated with a higher likelihood of hardware removal and potential progression to post-traumatic arthritis requiring salvage arthrodesis.

Question 2044

Topic: 8. Foot and Ankle
A 25-year-old involved in an MVC sustains a Hawkins III talar neck fracture. Which of the following structures provides the remaining blood supply to the talar body?
. Artery of the tarsal canal
. Artery of the tarsal sinus
. Deltoid branches from the posterior tibial artery
. Dorsalis pedis branches
. None of the above

Correct Answer & Explanation

. None of the above

Explanation

Hawkins III fractures involve a fracture of the talar neck with dislocation of both the subtalar and tibiotalar joints. This displacement disrupts the artery of the tarsal canal, the artery of the tarsal sinus, and the deltoid branches. Thus, all three primary sources of blood supply to the talar body are disrupted, resulting in an avascular necrosis (AVN) rate approaching 100%.

Question 2045

Topic: 8. Foot and Ankle

A 22-year-old snowboarder presents with severe lateral ankle pain after landing a jump. Radiographs show a fracture of the lateral process of the talus. This injury is most commonly caused by which of the following mechanisms?

. Dorsiflexion and inversion
. Dorsiflexion and eversion
. Plantarflexion and inversion
. Plantarflexion and eversion
. Direct axial loading on a neutral foot

Correct Answer & Explanation

. Dorsiflexion and inversion

Explanation

A fracture of the lateral process of the talus, commonly known as a 'snowboarder's fracture', classically occurs via dorsiflexion and axial loading with eversion. It can easily be misdiagnosed as a severe lateral ankle sprain if radiographs are not carefully scrutinized.

Question 2046

Topic: 8. Foot and Ankle

A collegiate football lineman presents with severe pain at the base of his great toe after being tackled from behind while his foot was planted. He is diagnosed with a turf toe injury. Which structure is primarily injured?

. Extensor hallucis longus tendon
. Plantar plate of the first metatarsophalangeal joint
. Dorsal capsule of the first metatarsophalangeal joint
. Flexor hallucis longus tendon
. Medial collateral ligament of the first MTP joint

Correct Answer & Explanation

. Extensor hallucis longus tendon

Explanation

Turf toe is a hyperextension injury to the first metatarsophalangeal (MTP) joint, resulting in a sprain or tear of the plantar plate and capsuloligamentous complex (including the sesamoid complex).

Question 2047

Topic: Midfoot & Hindfoot

A 30-year-old male presents with an isolated medial subtalar dislocation. Closed reduction is attempted in the emergency department but is completely blocked. Which of the following structures is the most common block to closed reduction in a medial subtalar dislocation?

. Extensor digitorum brevis
. Tibialis posterior tendon
. Flexor hallucis longus tendon
. Peroneus brevis tendon
. Extensor hallucis longus tendon

Correct Answer & Explanation

. Extensor digitorum brevis

Explanation

In a medial subtalar dislocation (the most common type), the foot is displaced medially, and lateral structures can become entrapped. The extensor digitorum brevis (EDB) muscle, along with the talonavicular joint capsule, is the most common block to reduction. In a lateral subtalar dislocation, the most common block is the tibialis posterior tendon.

Question 2048

Topic: 8. Foot and Ankle

A 35-year-old worker sustains a high-energy forced plantarflexion injury to the foot, resulting in a Chopart joint dislocation. This injury inherently involves dislocation between which of the following structures?

. Tarsometatarsal joints
. Talus and calcaneus
. Talonavicular and calcaneocuboid joints
. Navicular and cuneiforms
. Cuboid and 4th/5th metatarsals

Correct Answer & Explanation

. Tarsometatarsal joints

Explanation

The Chopart joint, also known as the transverse tarsal or midtarsal joint, consists of the talonavicular and calcaneocuboid articulations. A Chopart dislocation involves disruption of these joints, effectively separating the hindfoot from the midfoot.

Question 2049

Topic: 8. Foot and Ankle

A 35-year-old female sustains an inversion injury to her ankle and foot. Radiographs demonstrate a fracture of the tuberosity of the fifth metatarsal (Zone 1). Which of the following soft tissue structures is primarily responsible for the avulsion force in this injury?

. Peroneus longus
. Peroneus brevis
. Peroneus tertius
. Extensor digitorum longus
. Tibialis posterior

Correct Answer & Explanation

. Peroneus longus

Explanation

Avulsion fractures of the fifth metatarsal tuberosity (Zone 1) are primarily caused by the pull of the peroneus brevis tendon, as well as the lateral band of the plantar fascia, during forced inversion of a plantarflexed foot.

Question 2050

Topic: 8. Foot and Ankle

A 32-year-old male sustains a Hawkins II talar neck fracture and undergoes ORIF. At 1-year follow-up, he presents with painful, limited hindfoot motion. Radiographs demonstrate a malunion of the talar neck in varus. Which of the following physical examination findings is most likely to be present as a direct consequence of this specific malunion?

. Increased hindfoot valgus during the stance phase
. Decreased ability to evert the hindfoot and rigid forefoot
. Unrestricted motion of the transverse tarsal joint
. Increased dorsiflexion of the ankle joint
. Forefoot abduction with a flat medial longitudinal arch

Correct Answer & Explanation

. Increased hindfoot valgus during the stance phase

Explanation

Varus malunion of the talar neck decreases subtalar eversion. A varus hindfoot biomechanically locks the transverse tarsal joint (talonavicular and calcaneocuboid joints), leading to a rigid forefoot and a severely decreased ability to accommodate uneven terrain during ambulation.

Question 2051

Topic: 8. Foot and Ankle

A 25-year-old snowboarder presents with lateral ankle pain after a fall. Examination reveals tenderness just anterior and inferior to the lateral malleolus. Radiographs are initially read as normal, but a CT scan reveals a fracture. What is the most likely mechanism of injury for this specific fracture?

. Plantar flexion and inversion
. Dorsiflexion and inversion
. Plantar flexion and eversion
. Dorsiflexion and eversion
. Axial loading with the foot in neutral

Correct Answer & Explanation

. Plantar flexion and inversion

Explanation

The clinical scenario describes a 'snowboarder's fracture,' which is a fracture of the lateral process of the talus. The classic mechanism of injury involves axial loading with dorsiflexion and inversion of the ankle. It is frequently misdiagnosed as an anterior talofibular ligament (ATFL) sprain.

Question 2052

Topic: 8. Foot and Ankle

A 30-year-old male presents with midfoot pain after missing a step on the stairs. He has plantar ecchymosis. AP weight-bearing radiograph shows a 3 mm diastasis between the base of the 1st and 2nd metatarsals. What is the primary stabilizing structure of this interval that is likely injured?

. Plantar ligament connecting the 1st and 2nd metatarsal bases
. Dorsal ligament connecting the medial cuneiform and 2nd metatarsal base
. Interosseous ligament connecting the medial cuneiform and 2nd metatarsal base
. Interosseous ligament connecting the medial and intermediate cuneiforms
. Plantar fascia

Correct Answer & Explanation

. Plantar ligament connecting the 1st and 2nd metatarsal bases

Explanation

The Lisfranc ligament complex has three components (dorsal, interosseous, and plantar). The interosseous ligament, connecting the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal, is the largest, strongest, and most important stabilizer of the Lisfranc joint. Notably, there is no direct ligamentous connection between the bases of the 1st and 2nd metatarsals.

Question 2053

Topic: 8. Foot and Ankle

Recent randomized controlled trials comparing dynamic functional rehabilitation (non-operative) to surgical repair for acute Achilles tendon ruptures have consistently demonstrated which of the following regarding outcomes?

. Surgical repair significantly decreases the re-rupture rate even when functional rehabilitation is used.
. Functional rehabilitation is associated with a significantly higher rate of deep infection.
. There is no clinically significant difference in re-rupture rates when dynamic functional rehabilitation protocols are utilized.
. Surgical repair leads to a significant increase in plantar flexion strength at 2 years compared to functional rehabilitation.
. Non-operative treatment with rigid cast immobilization results in the lowest re-rupture rate.

Correct Answer & Explanation

. Surgical repair significantly decreases the re-rupture rate even when functional rehabilitation is used.

Explanation

Recent high-quality evidence (e.g., Willits et al.) demonstrates that when dynamic functional rehabilitation protocols (early weight-bearing and ROM in a functional brace/boot) are employed, the re-rupture rates for non-operatively treated acute Achilles tendon ruptures are equivalent to those treated operatively. Furthermore, surgical repair carries a significantly higher risk of soft tissue complications, wound breakdown, and sural nerve injury.

Question 2054

Topic: 8. Foot and Ankle

A 24-year-old skier presents with posterolateral ankle pain and a snapping sensation. Examination reveals subluxation of the peroneal tendons over the lateral malleolus with resisted dorsiflexion and eversion. The superior peroneal retinaculum (SPR) is compromised. Where is the most common site of SPR avulsion in this injury?

. From the posterior margin of the lateral malleolus
. From the calcaneal tuberosity
. From the Achilles tendon sheath
. From the base of the 5th metatarsal
. From the lateral talar process

Correct Answer & Explanation

. From the posterior margin of the lateral malleolus

Explanation

The superior peroneal retinaculum (SPR) acts as the primary restraint to prevent subluxation of the peroneal tendons. In cases of traumatic subluxation, the SPR most commonly avulses from its fibular insertion (the posterior and lateral margin of the lateral malleolus), creating a false pouch into which the tendons subluxate. This injury pattern is classified by the Eckert and Davis classification.

Question 2055

Topic: 8. Foot and Ankle
In a Lauge-Hansen Supination-External Rotation (SER) stage IV ankle fracture, what is the anatomical sequence of structural failure?
. Anterior inferior tibiofibular ligament -> Lateral malleolus -> Posterior inferior tibiofibular ligament -> Deltoid ligament/Medial malleolus
. Deltoid ligament -> Anterior inferior tibiofibular ligament -> Lateral malleolus -> Posterior inferior tibiofibular ligament
. Lateral malleolus -> Anterior inferior tibiofibular ligament -> Posterior inferior tibiofibular ligament -> Medial malleolus
. Medial malleolus -> Posterior inferior tibiofibular ligament -> Lateral malleolus -> Anterior inferior tibiofibular ligament
. Anterior inferior tibiofibular ligament -> Deltoid ligament -> Lateral malleolus -> Posterior inferior tibiofibular ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament -> Lateral malleolus -> Posterior inferior tibiofibular ligament -> Deltoid ligament/Medial malleolus

Explanation

According to the Lauge-Hansen classification, the sequence for a Supination-External Rotation (SER) injury begins anterolaterally and progresses circumferentially: 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 avulsion. Stage IV: Deltoid ligament rupture or transverse medial malleolus fracture.

Question 2056

Topic: 8. Foot and Ankle

A patient sustains a severe crush injury to the foot. The treating orthopedic surgeon suspects acute compartment syndrome of the foot and plans for emergency fasciotomies. How many distinct osseofascial compartments are generally recognized in the foot?

. 4
. 5
. 7
. 9
. 11

Correct Answer & Explanation

. 4

Explanation

The foot contains 9 distinct osseofascial compartments: the medial, lateral, superficial (central), and calcaneal compartments, as well as 4 interosseous compartments and the adductor compartment. They are typically released via dual dorsal incisions (over the 2nd and 4th metatarsals) or a combined medial approach with dorsal incisions depending on the extent of the crush.

Question 2057

Topic: 8. Foot and Ankle

During operative management of a pronation-external rotation (PER) ankle fracture, the surgeon evaluates the integrity of the syndesmosis. After rigidly fixing the medial and lateral malleoli, a bone hook is placed around the fibula and pulled laterally. Which fluoroscopic radiographic finding indicates syndesmotic instability (a positive Cotton test)?

. Tibiofibular clear space greater than 5 mm on the AP view
. Tibiofibular overlap greater than 10 mm on the mortise view
. Medial clear space greater than 4 mm on the mortise view
. Talar tilt of more than 5 degrees on the AP view
. Anterior displacement of the fibula greater than 2 mm on the lateral view

Correct Answer & Explanation

. Tibiofibular clear space greater than 5 mm on the AP view

Explanation

The Cotton test involves applying a lateral traction force to the fibula using a bone hook. Syndesmotic instability is defined by pathological widening of the tibiofibular clear space (abnormal is >5 mm) on the AP or mortise views, or asymmetric widening of the medial clear space. Normal tibiofibular overlap should be >10 mm on the AP and >1 mm on the mortise view.

Question 2058

Topic: 8. Foot and Ankle

Six weeks following open reduction and internal fixation of a displaced talar neck fracture, an AP radiograph of the ankle demonstrates a distinct subchondral radiolucent band in the dome of the talus. What is the clinical significance of this finding?

. It indicates impending osteonecrosis and collapse of the talar body.
. It is a highly specific sign of pyogenic infection within the ankle joint.
. It represents subchondral bone resorption and strongly implies intact vascularity to the talar body.
. It is a normal artifactual finding that has no predictive value for talar viability.
. It indicates an unrecognized intra-articular step-off in the talar dome.

Correct Answer & Explanation

. It indicates impending osteonecrosis and collapse of the talar body.

Explanation

A subchondral radiolucent line in the talar dome visible at 6 to 8 weeks post-injury is known as the Hawkins sign. It represents subchondral osteopenia secondary to hyperemia and disuse. Its presence is an excellent prognostic indicator that the talar body retains sufficient blood supply and will not undergo avascular necrosis. Conversely, its absence does not definitively confirm AVN, but warrants closer surveillance.

Question 2059

Topic: 8. Foot and Ankle

A 28-year-old male presents after a high-speed motor vehicle collision with massive midfoot swelling and deformity. Radiographs indicate a catastrophic dislocation of the transverse tarsal (Chopart) joint. Which two specific joints anatomically comprise the Chopart joint complex?

. Talonavicular and calcaneocuboid joints
. Naviculocuneiform and tarsometatarsal joints
. Subtalar and talonavicular joints
. Calcaneocuboid and cuboid-metatarsal joints
. Talonavicular and naviculocuneiform joints

Correct Answer & Explanation

. Talonavicular and calcaneocuboid joints

Explanation

The Chopart joint, also known as the transverse tarsal joint or midtarsal joint, is formed by the talonavicular articulation medially and the calcaneocuboid articulation laterally. It serves as the primary functional boundary separating the hindfoot from the midfoot. Dislocation represents a massive high-energy disruption of medial and lateral column stability.

Question 2060

Topic: 8. Foot and Ankle

A 65-year-old active male presents with a 'slapping gait' and an inability to clear his foot during the swing phase of ambulation. He reports feeling a sharp pop in his anterior ankle while hastily walking down a steep hill 3 weeks ago. On examination, he has weak ankle dorsiflexion against resistance and a palpable defect anterior to the ankle joint. Which of the following is the most appropriate definitive management for this patient?

. Ankle-foot orthosis (AFO) and long-term observation
. Corticosteroid injection into the anterior tendon sheath
. Primary end-to-end repair or reconstruction of the tendon
. Transfer of the flexor hallucis longus tendon to the calcaneus
. Gastrocnemius recession

Correct Answer & Explanation

. Ankle-foot orthosis (AFO) and long-term observation

Explanation

The patient has suffered an acute/subacute rupture of the tibialis anterior tendon, resulting in a foot drop and a characteristic slapping gait. In active, relatively healthy individuals, surgical repair (primary or with reconstruction/allografting depending on gap size and chronicity) is highly recommended to restore dorsiflexion power and normalize gait mechanics. AFOs are generally reserved for sedentary, low-demand, or medically unfit patients.

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