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8. Foot and Ankle MCQs

Practice Set 104 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 2061

Topic: 8. Foot and Ankle
A 32-year-old male sustains a Hawkins Type III talar neck fracture. Which of the following provides the predominant blood supply to the talar body that is disrupted in this specific injury pattern?
. Artery of the tarsal sinus
. Artery of the tarsal canal
. Deltoid branches
. Anterior tibial artery branches
. Posterior tibial artery branches

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, provides the majority of the blood supply to the talar body. In a Hawkins III talus fracture (talar neck fracture with subtalar and tibiotalar dislocation), the blood supply from the artery of the tarsal canal, artery of the tarsal sinus, and deltoid branches are all typically disrupted, leading to an avascular necrosis (AVN) risk approaching 100%.

Question 2062

Topic: 8. Foot and Ankle

When utilizing the extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, what structure is at greatest risk during the development of the full-thickness flap?

. Superficial peroneal nerve
. Deep peroneal nerve
. Sural nerve
. Saphenous nerve
. Medial plantar nerve

Correct Answer & Explanation

. Superficial peroneal nerve

Explanation

The sural nerve is at significant risk during the extensile lateral approach to the calcaneus. The incision must be planned carefully (an L-shaped incision avoiding the course of the nerve) and a full-thickness subperiosteal flap developed. Using a 'no-touch' technique with K-wires inserted into the talus and fibula to retract the flap helps protect the skin edges and the sural nerve.

Question 2063

Topic: 8. Foot and Ankle

According to biomechanical studies of ankle syndesmotic injuries, which ligament contributes the greatest resistance to lateral displacement of the distal fibula?

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

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament

Explanation

According to Ogilvie-Harris et al., the posterior inferior tibiofibular ligament (PITFL) provides the most strength to the syndesmosis, accounting for approximately 42% of its resistance to diastasis. The anterior inferior tibiofibular ligament (AITFL) provides roughly 35%, and the interosseous ligament provides about 22%.

Question 2064

Topic: Midfoot & Hindfoot

A 45-year-old male sustains a lateral subtalar dislocation after a high-energy motor vehicle collision. Closed reduction is attempted in the emergency department but is unsuccessful. What anatomic structure is most likely interposing and blocking the reduction?

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

Correct Answer & Explanation

. Tibialis posterior tendon

Explanation

In a lateral subtalar dislocation, the talar head displaces medially. The most common block to closed reduction is the tibialis posterior tendon, which can 'buttonhole' around the talar neck. In contrast, medial subtalar dislocations are more common, and their reduction is typically blocked by the extensor retinaculum, extensor digitorum brevis, or the capsule of the talonavicular joint.

Question 2065

Topic: 8. Foot and Ankle

When managing an acute Achilles tendon rupture non-operatively using an accelerated functional rehabilitation protocol, which of the following outcomes is most consistently supported by recent Level I evidence when compared to open surgical repair?

. Lower rate of soft tissue complications and equivalent re-rupture rate
. Higher rate of soft tissue complications and higher re-rupture rate
. Lower rate of soft tissue complications but significantly higher re-rupture rate
. Higher rate of deep infection but lower re-rupture rate
. Equivalent soft tissue complications and equivalent re-rupture rate

Correct Answer & Explanation

. Lower rate of soft tissue complications and equivalent re-rupture rate

Explanation

High-quality randomized controlled trials (e.g., Willits et al.) have demonstrated that when a functional rehabilitation protocol (early weight-bearing in a boot with heel wedges and early active range of motion) is utilized, non-operative management results in an equivalent re-rupture rate compared to operative repair, while entirely avoiding the risk of surgical soft-tissue complications such as infection and wound breakdown.

Question 2066

Topic: 8. Foot and Ankle

A 26-year-old male complains of persistent lateral ankle pain 6 weeks after a snowboarding accident. Initial radiographs in the emergency department were interpreted as a 'severe ankle sprain.' A subsequent CT scan reveals a delayed union of a 'snowboarder's fracture.' This injury is most commonly produced by which mechanism?

. Plantarflexion and inversion
. Dorsiflexion and eversion
. Plantarflexion and eversion
. Axial loading and internal rotation
. Direct crush

Correct Answer & Explanation

. Plantarflexion and inversion

Explanation

A 'snowboarder's fracture' is a fracture of the lateral process of the talus. It is classically caused by a mechanism of dorsiflexion and eversion with axial loading, an injury pattern frequently seen when a snowboarder lands a jump improperly. Because they are difficult to see on standard plain films, they are often misdiagnosed as lateral ankle sprains.

Question 2067

Topic: 8. Foot and Ankle

The Lisfranc ligament is a critical stabilizer of the midfoot arch and the tarsometatarsal articulation. Between which two osseous structures does the primary Lisfranc ligament traverse?

. Medial cuneiform and base of the first metatarsal
. Medial cuneiform and base of the second metatarsal
. Middle cuneiform and base of the second metatarsal
. Lateral cuneiform and base of the third metatarsal
. Cuboid and base of the fourth metatarsal

Correct Answer & Explanation

. Medial cuneiform and base of the first metatarsal

Explanation

The Lisfranc ligament is a stout interosseous ligament that runs from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the strongest and most important ligamentous stabilizer of the midfoot, compensating for the lack of an intermetatarsal ligament between the first and second metatarsal bases.

Question 2068

Topic: 8. Foot and Ankle

A 55-year-old patient with long-standing poorly controlled diabetes presents with a unilaterally warm, swollen, and erythematous foot. Radiographs demonstrate fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints, without frank ulceration or osteomyelitis. According to the Eichenholtz classification, what stage is this patient in, and what is the immediate treatment of choice?

. Stage 0; surgical arthrodesis
. Stage 1; total contact casting
. Stage 2; surgical arthrodesis
. Stage 2; customized orthotic shoe
. Stage 3; total contact casting

Correct Answer & Explanation

. Stage 0; surgical arthrodesis

Explanation

Eichenholtz Stage 1 (Developmental/Fragmentation phase) is characterized by clinical warmth, swelling, and erythema, with radiographic evidence of bony fragmentation, joint subluxation, and periarticular debris. The gold standard treatment during this active inflammatory phase is rigid immobilization and off-loading, typically with a Total Contact Cast (TCC), to prevent further mechanical destruction until the acute phase resolves.

Question 2069

Topic: 8. Foot and Ankle
An image of a lateral foot radiograph shows a depressed intra-articular calcaneus fracture. Which two lines are strictly used to measure Böhler's angle?
. A line from the highest point of the anterior process to the highest point of the posterior facet, and a line from the highest point of the posterior facet to the highest point of the calcaneal tuberosity.
. A line from the inferior margin of the calcaneocuboid joint to the inferior margin of the posterior facet, and a line from the posterior facet to the plantar tuberosity.
. A line from the anterior process to the posterior facet, and a line from the lateral process of the talus to the posterior tuberosity.
. A line from the talar neck to the first metatarsal, and a line from the talar neck to the calcaneal pitch.
. A line parallel to the ground and a line along the inferior border of the calcaneus.

Correct Answer & Explanation

. A line from the highest point of the anterior process to the highest point of the posterior facet, and a line from the highest point of the posterior facet to the highest point of the calcaneal tuberosity.

Explanation

Böhler's angle is formed by the intersection of two lines drawn on a lateral radiograph of the foot: one line drawn from the highest point of the anterior process to the highest point of the posterior articular facet, and a second line drawn from the highest point of the posterior articular facet to the highest point of the superior calcaneal tuberosity. The normal angle is 20 to 40 degrees, and it is typically decreased in intra-articular calcaneus fractures.

Question 2070

Topic: 8. Foot and Ankle

Osteochondral lesions (OCLs) of the talar dome have different morphological and historical characteristics depending on their anatomic location. Which of the following best describes the typical morphology and etiology of a medial OCL of the talar dome?

. Deep, cup-shaped, often atraumatic or insidious onset
. Shallow, wafer-shaped, often associated with a distinct traumatic event
. Deep, cup-shaped, exclusively caused by direct high-energy trauma
. Shallow, wafer-shaped, typically atraumatic
. Cystic, lateral-based, extending into the subtalar joint

Correct Answer & Explanation

. Deep, cup-shaped, often atraumatic or insidious onset

Explanation

Medial osteochondral lesions of the talus are typically located posteromedially, are deep and cup-shaped, and frequently present with an insidious onset or a vague, atraumatic history. In contrast, lateral lesions are typically located anterolaterally, are shallow and wafer-shaped, and are strongly associated with a specific traumatic inversion/dorsiflexion event. A helpful mnemonic is 'DIAL a PIMP' (Dorsiflexion Inversion Anterior Lateral; Plantarflexion Inversion Medial Posterior).

Question 2071

Topic: 8. Foot and Ankle

A 30-year-old equestrian sustains a severe forced plantarflexion and abduction injury to her foot. Radiographs demonstrate a comminuted fracture of the cuboid with lateral column shortening, classically known as a 'nutcracker' fracture. What is the primary functional goal of operative fixation in this specific injury?

. Arthrodesis of the calcaneocuboid joint
. Restoration of lateral column length
. Primary repair of the peroneal tendons
. Resection of the cuboid with allograft interposition
. Plating of the 4th and 5th metatarsals

Correct Answer & Explanation

. Arthrodesis of the calcaneocuboid joint

Explanation

The 'nutcracker' fracture of the cuboid occurs when the cuboid is crushed between the calcaneus and the base of the 4th/5th metatarsals during severe forced abduction of the forefoot. This results in comminution and shortening of the lateral column, leading to a severe abduction deformity of the midfoot and altered biomechanics. The primary surgical goal (whether via ORIF or external fixation) is the restoration of lateral column length.

Question 2072

Topic: 8. Foot and Ankle

A 42-year-old male undergoes open reduction and internal fixation of a displaced intra-articular calcaneus fracture via an extensile lateral approach. Which of the following describes the most appropriate plane of surgical dissection to minimize the risk of injury to the sural nerve and the vascular supply of the flap?

. Subcutaneous dissection, leaving the sural nerve superficial to the flap
. Subfascial dissection immediately superficial to the peroneal tendons
. Subperiosteal dissection off the lateral calcaneal wall, elevating the nerve and tendons within a full-thickness flap
. Trans-tendinous dissection splitting the peroneus brevis tendon longitudinally
. Subperiosteal dissection beginning at the medial calcaneal wall

Correct Answer & Explanation

. Subcutaneous dissection, leaving the sural nerve superficial to the flap

Explanation

The extensile lateral approach to the calcaneus requires the creation of a full-thickness fasciocutaneous flap via subperiosteal dissection. This technique retracts the sural nerve, peroneal tendons, and local vascular supply anteriorly and superiorly, minimizing soft tissue complications and nerve injury.

Question 2073

Topic: 8. Foot and Ankle

The Lisfranc ligament complex provides primary stability to the tarsometatarsal articulation. What are the correct anatomic attachments of the primary, stout interosseous Lisfranc ligament?

. Medial cuneiform to the base of the second metatarsal
. Medial cuneiform to the base of the first metatarsal
. Lateral cuneiform to the base of the third metatarsal
. Navicular to the medial cuneiform
. Cuboid to the base of the fourth metatarsal

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The primary interosseous Lisfranc ligament connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is the strongest of the tarsometatarsal ligaments and critical for stabilizing the midfoot arch.

Question 2074

Topic: 8. Foot and Ankle

A 24-year-old snowboarder presents with lateral ankle pain and swelling after a hard landing. Initial radiographs are negative, but an MRI demonstrates a displaced fracture of the lateral process of the talus. This bony fragment typically contains articular surfaces for which two joints?

. Tibiotalar and subtalar joints
. Talonavicular and calcaneocuboid joints
. Talofibular and posterior subtalar joints
. Anterior subtalar and talonavicular joints
. Tibiotalar and talonavicular joints

Correct Answer & Explanation

. Tibiotalar and subtalar joints

Explanation

The lateral process of the talus provides articular surfaces for the lateral malleolus (talofibular articulation) and the posterior facet of the subtalar joint. Fractures of this structure ('snowboarder\'s fracture') are frequently missed on plain radiographs.

Question 2075

Topic: 8. Foot and Ankle

During open reduction and internal fixation of a pronation-external rotation ankle fracture, a Cotton test demonstrates persistent syndesmotic instability. The surgeon opts for dynamic fixation using a suture-button construct rather than static syndesmotic screws. Which of the following is a recognized advantage of the suture-button construct?

. Superior biomechanical rigidity in internal rotation compared to quad-cortical screws
. Decreased rate of routine implant removal
. Increased incidence of beneficial tibiofibular synostosis
. Requirement for rigid postoperative casting
. Elimination of the need for intraoperative fluoroscopic reduction

Correct Answer & Explanation

. Superior biomechanical rigidity in internal rotation compared to quad-cortical screws

Explanation

Suture-button constructs provide dynamic stabilization of the syndesmosis, which mimics physiologic movement and generally does not require routine removal. In contrast, syndesmotic screws often break or require a secondary surgery for removal before weight-bearing.

Question 2076

Topic: 8. Foot and Ankle

A 40-year-old male sustains an acute Achilles tendon rupture. He is counseled on nonoperative versus operative management. Based on recent high-level evidence, which of the following best describes the expected outcomes comparing nonoperative to operative treatment?

. Nonoperative treatment has a significantly higher re-rupture rate.
. Operative treatment results in greater long-term plantarflexion strength.
. Nonoperative treatment has equivalent re-rupture rates when an early functional rehabilitation protocol is used.
. Operative treatment significantly reduces the time to return to work.
. Nonoperative treatment leads to higher rates of deep vein thrombosis.

Correct Answer & Explanation

. Nonoperative treatment has a significantly higher re-rupture rate.

Explanation

Recent randomized controlled trials demonstrate that nonoperative management of acute Achilles tendon ruptures yields equivalent re-rupture rates to operative treatment when an early functional weight-bearing rehabilitation protocol is utilized. Operative management does, however, carry a higher risk of superficial and deep soft-tissue infections.

Question 2077

Topic: 8. Foot and Ankle
A 42-year-old man reports a 12-month history of a painful fusiform swelling of the Achilles tendon. Physical therapy, heel lifts, and anti-inflammatory drugs have failed to provide relief. MRI scans are shown in Figures 44a and 44b. What is the treatment of choice?
. Steroid injection
. Debridement and side-to-side repair
. Debridement and flexor hallucis longus tendon transfer
. Brisement
. Continued nonsurgical management with use of a short leg walking cast

Correct Answer & Explanation

. Debridement and flexor hallucis longus tendon transfer

Explanation

The area of the tendon degeneration is greater than 50% of the width so a supplemental tendon transfer is needed. Debridement and repair alone do not provide adequate strength. Injection risks tendon rupture. Brisement is indicated for peritendinitis, not tendinosis. Nonsurgical management is unlikely to be of benefit after 12 months.

Question 2078

Topic: 8. Foot and Ankle
The hallucal sesamoids are held together by which of the following structures?
. Intersesamoid ligament
. Intermetatarsal ligament
. Spring ligament
. Plantar fascia
. Flexor hallucis longus tendon

Correct Answer & Explanation

. Intersesamoid ligament

Explanation

The two sesamoids of the metatarsophalangeal joint are embedded in the tendons of the short flexor of the great toe. They are held together by the intersesamoid ligament and the plantar plate, which inserts on the base of the proximal phalanx of the hallux.

Question 2079

Topic: 8. Foot and Ankle
A 50-year-old man reports the onset of back pain and incapacitating pain radiating down his left leg posterolaterally and into the first dorsal web space of his foot 1 day after doing some yard work. He denies any history of trauma. Examination reveals ipsilateral extensor hallucis longus weakness. MRI scans are shown in Figures 19a through 19c. What nerve root is affected?
. Left L4
. Right L4
. Left L5
. Right L5
. Left S1

Correct Answer & Explanation

. Left L5

Explanation

The MRI scans clearly show an extruded L4-5 disk that is affecting the L5 root on the left side. In addition, the L5 root has a cutaneous distribution in the first dorsal web space. S1 affects the lateral foot, and L4 affects the medial calf.

Question 2080

Topic: 8. Foot and Ankle

A 42-year-old male twists his ankle. Radiographs show a transverse fracture of the medial malleolus and a vertical fracture of the lateral malleolus extending proximally from the joint line. A representative radiograph is shown. According to the Lauge-Hansen classification, what was the position of the foot and the deforming force at the time of injury?

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

Correct Answer & Explanation

. Supination-External Rotation

Explanation

The injury pattern described is a Supination-Adduction (SAD) fracture. In the SAD mechanism, the talus inverts, first placing tension on the lateral side, resulting in a transverse avulsion fracture of the lateral malleolus below the joint line (or an LCL tear). As adduction continues, the talus impacts the medial malleolus, causing a vertical shear fracture of the medial malleolus. This aligns with a Danis-Weber Type A fracture.

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