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8. Foot and Ankle MCQs

Practice Set 107 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 2121

Topic: 8. Foot and Ankle

A 40-year-old male underwent open reduction and internal fixation of a severe rotational ankle fracture. The syndesmosis was stabilized utilizing a single 3.5 mm cortical screw placed across four cortices. At 3 months post-operatively, he is asymptomatic, but radiographs show the syndesmotic screw has fractured within the clear space. What is the current consensus regarding the management of this finding?

. Immediate re-operation is required to extract the broken hardware and place a flexible suture button.
. The broken screw mandates a return to strict non-weight-bearing to prevent syndesmotic diastasis.
. Routine removal prior to breakage is mandatory; since it broke, he will likely suffer significant loss of dorsiflexion.
. No intervention is required; broken, loose, or retained syndesmotic screws do not significantly worsen long-term clinical outcomes.
. The fibula must be explored to ensure the interosseous membrane has not ossified.

Correct Answer & Explanation

. Immediate re-operation is required to extract the broken hardware and place a flexible suture button.

Explanation

Current orthopedic evidence and randomized trials suggest that routine removal of syndesmotic screws is unnecessary. Screws that break, loosen, or are intentionally retained generally do not result in poorer clinical outcomes, increased pain, or clinically significant loss of range of motion compared to screws that are electively removed. Therefore, asymptomatic broken screws require no intervention.

Question 2122

Topic: 8. Foot and Ankle

The posterior process of the talus is anatomically divided into a medial tubercle and a lateral tubercle, separated by a distinct fibro-osseous groove. Which of the following tendons traverses this groove and may become symptomatic in cases of a lateral tubercle fracture (Shepherd's fracture) or a symptomatic os trigonum?

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

Correct Answer & Explanation

. Tibialis posterior tendon

Explanation

The flexor hallucis longus (FHL) tendon runs directly through the groove located between the medial and lateral tubercles of the posterior process of the talus. Pathologies in this posterior talar region, such as a fracture of the lateral tubercle (Shepherd's fracture) or impingement from an os trigonum, frequently cause FHL tenosynovitis or mechanical entrapment (triggering) of the tendon.

Question 2123

Topic: 8. Foot and Ankle

A 42-year-old female undergoes fixation of a posterior malleolus fracture via a posterolateral approach.

Which of the following describes the correct internervous/intermuscular interval for this approach?

. Between the Achilles tendon and the flexor hallucis longus
. Between the peroneus brevis and the flexor hallucis longus
. Between the flexor digitorum longus and the tibialis posterior
. Between the peroneus longus and the Achilles tendon
. Between the lateral gastrocnemius and soleus

Correct Answer & Explanation

. Between the Achilles tendon and the flexor hallucis longus

Explanation

The posterolateral approach to the ankle utilizes the interval between the peroneus brevis (superficial peroneal nerve) and the flexor hallucis longus (tibial nerve). This allows excellent access to the posterior malleolus while protecting the sural nerve laterally.

Question 2124

Topic: 8. Foot and Ankle

A 30-year-old male presents with a severely deformed ankle following a fall. Radiographs demonstrate a fracture of the fibula with the proximal fibular fragment displaced posterior to the posterior tubercle of the distal tibia. Closed reduction in the emergency department is unsuccessful. What is the most likely anatomic block to reduction?

. Interposition of the posterior tibial tendon
. Entrapment of the superficial peroneal nerve
. The intact posterior tibiofibular ligament locking the fibula behind the tibia
. Incarceration of the flexor hallucis longus
. Osteochondral defect of the talar dome

Correct Answer & Explanation

. Interposition of the posterior tibial tendon

Explanation

This describes a Bosworth fracture-dislocation. Closed reduction is typically prevented because the proximal fibular fragment becomes mechanically locked behind the posterolateral tibial ridge by the intact posterior syndesmotic ligaments.

Question 2125

Topic: 8. Foot and Ankle

A 45-year-old female sustains a Supination-External Rotation (SER) stage IV ankle injury. Radiographs show a trans-syndesmotic fibula fracture. A gravity stress view shows a medial clear space of 6 mm. Which specific component of the medial ligamentous complex must be disrupted to allow this lateral talar shift?

. Superficial deltoid ligament
. Deep deltoid ligament
. Spring ligament
. Talonavicular ligament
. Anterior tibiotalar ligament

Correct Answer & Explanation

. Superficial deltoid ligament

Explanation

The deep deltoid ligament is the primary medial stabilizer of the ankle against lateral talar translation. Its disruption is the hallmark of an SER IV injury when a medial malleolus fracture is absent.

Question 2126

Topic: Ankle Trauma & Sports
A 14-year-old boy presents with an ankle injury after a skateboarding accident. Radiographs reveal a Salter-Harris type III fracture of the anterolateral aspect of the distal tibia epiphysis. Which of the following ligaments is responsible for this avulsion injury?
. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Calcaneofibular ligament (CFL)
. Anterior talofibular ligament (ATFL)
. Deep deltoid ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

A juvenile Tillaux fracture is an avulsion of the anterolateral distal tibial epiphysis caused by tension from the anterior inferior tibiofibular ligament (AITFL). It occurs in adolescents because the lateral physis is the last to close.

Question 2127

Topic: 8. Foot and Ankle

According to the Lauge-Hansen classification, what is the correct sequential order of structural failure in a Supination-External Rotation (SER) ankle fracture?

. AITFL -> Distal fibula -> PITFL -> Deltoid ligament
. Deltoid ligament -> AITFL -> Distal fibula -> PITFL
. Lateral collateral ligaments -> Medial malleolus -> Posterior malleolus -> AITFL
. Distal fibula -> AITFL -> PITFL -> Deltoid ligament
. AITFL -> Deltoid ligament -> Distal fibula -> PITFL

Correct Answer & Explanation

. AITFL -> Distal fibula -> PITFL -> Deltoid ligament

Explanation

The SER sequence is: 1) Anterior inferior tibiofibular ligament (AITFL), 2) Short oblique fracture of the distal fibula, 3) Posterior inferior tibiofibular ligament (PITFL) or posterior malleolus, 4) Deltoid ligament or medial malleolus.

Question 2128

Topic: 8. Foot and Ankle

A 72-year-old male with severe peripheral neuropathy and a history of Charcot arthropathy presents with an acute, closed, highly unstable bimalleolar ankle fracture. The soft tissues are significantly compromised. To minimize catastrophic failure and soft tissue complications, what is the most appropriate definitive surgical intervention?

. Standard open reduction and internal fixation with early mobilization
. Application of a circular fine-wire external fixator
. Primary tibiotalocalcaneal (TTC) retrograde nailing
. Closed reduction and casting with immediate weight-bearing
. Minimalist percutaneous screw fixation

Correct Answer & Explanation

. Standard open reduction and internal fixation with early mobilization

Explanation

In elderly diabetic patients with severe neuropathy and unstable fractures, primary TTC nailing provides rigid, load-sharing fixation. This significantly reduces the risk of hardware failure and soft tissue breakdown compared to standard ORIF.

Question 2129

Topic: 8. Foot and Ankle

A 32-year-old male is involved in a motor vehicle collision and sustains a talar neck fracture. Radiographs show a displaced talar neck fracture with subluxation of the subtalar joint, but the ankle joint remains reduced. What is the expected rate of avascular necrosis (AVN) of the talar body for this specific injury pattern, and which blood supply is most commonly disrupted first?

. 0-15%, artery of the tarsal canal
. 20-50%, artery of the tarsal canal
. 20-50%, branches of the dorsalis pedis
. 75-100%, artery of the tarsal sinus
. 75-100%, deltoid branches

Correct Answer & Explanation

. 0-15%, artery of the tarsal canal

Explanation

This is a Hawkins Type II talar neck fracture (subluxation/dislocation of the subtalar joint with a normal ankle joint). The risk of AVN of the talar body for Type II fractures is classically reported as 20-50%. The artery of the tarsal canal (a branch of the posterior tibial artery) is the predominant blood supply to the talar body and is typically disrupted in displaced talar neck fractures.

Question 2130

Topic: 8. Foot and Ankle

A 24-year-old football player presents with midfoot pain after a plant-and-twist injury. Weight-bearing radiographs demonstrate widening of the space between the medial and middle cuneiforms. A pure ligamentous Lisfranc injury is suspected. Which of the following best describes the normal anatomy of the Lisfranc ligament?

. Connects the medial cuneiform to the base of the first metatarsal
. Connects the medial cuneiform to the base of the second metatarsal
. Connects the middle cuneiform to the base of the second metatarsal
. Connects the lateral cuneiform to the base of the third metatarsal
. Connects the cuboid to the base of the fourth metatarsal

Correct Answer & Explanation

. Connects the medial cuneiform to the base of the first metatarsal

Explanation

The Lisfranc ligament is an interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the largest and strongest of the ligaments supporting the first and second ray articulation. Notably, there is no direct transverse intermetatarsal ligament connecting the bases of the first and second metatarsals.

Question 2131

Topic: Forefoot

A 50-year-old woman complains of a painful bunion. Radiographs reveal a hallux valgus angle (HVA) of 35 degrees, an intermetatarsal angle (IMA) of 16 degrees, and a distal metatarsal articular angle (DMAA) of 20 degrees. Clinical examination demonstrates hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate to provide lasting correction?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. Lapidus procedure (First TMT arthrodesis)
. Akin osteotomy alone
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The patient has a moderate-to-severe hallux valgus deformity (IMA > 13 degrees, HVA > 30 degrees) with clinical first TMT hypermobility. The Lapidus procedure (arthrodesis of the first TMT joint) directly addresses the hypermobility and provides powerful correction of the high IMA, minimizing the risk of recurrence.

Question 2132

Topic: Midfoot & Hindfoot

A 55-year-old overweight woman complains of medial ankle pain and flattening of her arch over the past year. She is unable to perform a single-limb heel rise on the affected side. Weight-bearing radiographs show a flexible flatfoot deformity with normal joint spaces and no subtalar arthritis. What is the most appropriate surgical intervention if conservative management fails?

. Gastrocnemius recession, flexor digitorum longus (FDL) transfer, and medial displacement calcaneal osteotomy
. Subtalar arthrodesis alone
. Triple arthrodesis
. Tibiotalocalcaneal arthrodesis
. Spring ligament repair only

Correct Answer & Explanation

. Gastrocnemius recession, flexor digitorum longus (FDL) transfer, and medial displacement calcaneal osteotomy

Explanation

The patient has a Stage II adult acquired flatfoot deformity (posterior tibial tendon dysfunction) characterized by a flexible deformity and an inability to perform a single-leg heel rise. Joint-sparing procedures are indicated. The classic reconstruction includes a soft tissue transfer (FDL to navicular), a bony procedure to restore the mechanical axis (medial displacement calcaneal osteotomy), and often a gastrocnemius recession for equinus contracture.

Question 2133

Topic: 8. Foot and Ankle

A 16-year-old boy presents with progressive bilateral foot deformities and frequent ankle sprains. Examination reveals a cavovarus foot posture, depressed first ray, and a positive Coleman block test. Neurologic exam reveals decreased sensation in the distal lower extremities and diminished reflexes. Which muscle's relative preservation and overpowering of its weak antagonist primarily drives the plantarflexion of the first ray?

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

Correct Answer & Explanation

. Tibialis anterior

Explanation

In Charcot-Marie-Tooth (CMT) disease, muscle weakness occurs in a typical pattern: intrinsic foot muscles first, followed by the tibialis anterior and peroneus brevis. The relative preservation and strong pull of the peroneus longus overpowers the weak tibialis anterior, driving the first metatarsal into severe plantarflexion and creating the forefoot-driven cavovarus deformity.

Question 2134

Topic: 8. Foot and Ankle

A 42-year-old weekend warrior feels a 'pop' in his posterior ankle while playing tennis. He has a positive Thompson test. Non-operative management is chosen. Which of the following rehabilitation protocols has been shown in high-quality randomized controlled trials to yield re-rupture rates comparable to surgical management?

. 8 weeks of strict non-weight-bearing in a short leg cast
. Early functional rehabilitation with early weight-bearing in a functional brace
. 4 weeks of non-weight-bearing followed by aggressive passive dorsiflexion stretching
. Prolonged immobilization in neutral dorsiflexion
. Non-operative treatment always has significantly higher re-rupture rates regardless of protocol

Correct Answer & Explanation

. 8 weeks of strict non-weight-bearing in a short leg cast

Explanation

Recent high-quality studies have demonstrated that early functional rehabilitation protocols (involving early protected weight-bearing and early range of motion in a functional brace) for acute Achilles tendon ruptures result in re-rupture rates that are equivalent to operative repair, while avoiding surgical wound complications.

Question 2135

Topic: 8. Foot and Ankle
A 45-year-old roofer falls from a height and sustains a closed, displaced intra-articular calcaneus fracture. CT scan reveals a Sanders Type III fracture. He is a heavy smoker (2 packs per day). What is the most appropriate definitive management considering his social history?
. ORIF via an extensile lateral approach
. Primary subtalar arthrodesis via an extensile lateral approach
. Immediate total calcanectomy
. ORIF via a minimally invasive sinus tarsi approach or non-operative management
. Immediate below-knee amputation

Correct Answer & Explanation

. ORIF via a minimally invasive sinus tarsi approach or non-operative management

Explanation

Heavy smoking is a major risk factor for catastrophic wound complications following an extensile lateral approach to the calcaneus, with some studies showing complication rates over 30%. Therefore, minimally invasive techniques (like the sinus tarsi approach) or non-operative management are preferred in non-compliant heavy smokers.

Question 2136

Topic: 8. Foot and Ankle

A 26-year-old hockey player sustains an external rotation injury to his right ankle. Radiographs show a fibular fracture 5 cm above the joint line and widening of the medial clear space. After ORIF of the fibula, the syndesmosis remains unstable. Which of the following is true regarding syndesmotic fixation?

. The hardware should always be removed before the patient is allowed to weight bear.
. Routine removal of asymptomatic static syndesmotic screws improves long-term functional outcomes.
. Fixation with a flexible suture-button device has been shown to have similar or slightly better functional outcomes compared to static screws.
. The syndesmotic screw should engage 4 cortices and be placed while the ankle is strictly immobilized in plantarflexion.
. Syndesmosis screws must be 4.5 mm rather than 3.5 mm to prevent hardware breakage.

Correct Answer & Explanation

. The hardware should always be removed before the patient is allowed to weight bear.

Explanation

Dynamic fixation using a suture-button construct for syndesmotic injuries has been shown to yield similar or slightly better functional outcomes, a quicker return to sports, and eliminates the need for routine hardware removal compared to traditional static screw fixation. Routine removal of asymptomatic syndesmotic screws is not supported by current evidence.

Question 2137

Topic: 8. Foot and Ankle

A 45-year-old man presents with burning pain and tingling in the plantar aspect of his right foot, which worsens with prolonged standing and at night. Tinel's sign is positive over the medial ankle, posterior to the medial malleolus. EMG/NCS confirms compression of the posterior tibial nerve. Which of the following structures forms the roof of the tarsal tunnel?

. Flexor retinaculum
. Extensor retinaculum
. Plantar fascia
. Deltoid ligament
. Spring ligament

Correct Answer & Explanation

. Flexor retinaculum

Explanation

The tarsal tunnel is a fibro-osseous space located posteromedial to the ankle. The roof of the tarsal tunnel is formed by the flexor retinaculum (laciniate ligament), while the medial malleolus, talus, and calcaneus form the floor. Release of the flexor retinaculum is performed during a tarsal tunnel decompression.

Question 2138

Topic: 8. Foot and Ankle

A 15-year-old female dancer complains of pain in her forefoot, specifically over the second metatarsal head. Radiographs show flattening, sclerosis, and fragmentation of the second metatarsal head. Which of the following conservative treatments is most appropriate initially?

. Metatarsal pad and stiff-soled shoe
. Cast immobilization for 12 weeks
. Immediate surgical debridement
. Corticosteroid injection
. Metatarsal head resection

Correct Answer & Explanation

. Metatarsal pad and stiff-soled shoe

Explanation

The patient has Freiberg's infraction, an avascular necrosis of the metatarsal head (most commonly the second metatarsal). Initial management is conservative and consists of activity modification, metatarsal pads to offload the affected head, and stiff-soled shoes or a walking boot. Surgical intervention is reserved for refractory cases.

Question 2139

Topic: 8. Foot and Ankle

A 24-year-old skier presents with lateral ankle pain and a snapping sensation over the lateral malleolus after a fall where his ankle was forcibly dorsiflexed. Physical exam reveals apprehension and a palpable pop over the lateral malleolus with resisted dorsiflexion and eversion. Which structure is most likely injured?

. Anterior talofibular ligament
. Calcaneofibular ligament
. Superior peroneal retinaculum
. Inferior peroneal retinaculum
. Peroneus tertius tendon

Correct Answer & Explanation

. Superior peroneal retinaculum

Explanation

The clinical presentation is classic for peroneal tendon subluxation. The primary restraint to peroneal tendon subluxation is the superior peroneal retinaculum (SPR). Injury or avulsion of the SPR (often combined with a shallow fibular groove) allows the peroneus brevis and longus tendons to subluxate anteriorly over the lateral malleolus during resisted dorsiflexion and eversion.

Question 2140

Topic: 8. Foot and Ankle

A 65-year-old man with post-traumatic end-stage ankle osteoarthritis is evaluated for a total ankle arthroplasty (TAA). He has an active lifestyle but does not participate in high-impact sports. Which of the following is considered an absolute contraindication to TAA?

. Age greater than 60 years
. History of prior ankle fracture
. Charcot neuroarthropathy of the ankle
. Concomitant subtalar osteoarthritis
. Body Mass Index of 28

Correct Answer & Explanation

. Charcot neuroarthropathy of the ankle

Explanation

Absolute contraindications to total ankle arthroplasty include Charcot neuroarthropathy, active or recent infection, severe avascular necrosis of the talus (>50%), inadequate soft tissue envelope, absent lower extremity sensation, and severe uncorrectable malalignment. Concomitant subtalar arthritis can be addressed with an arthrodesis, and older age is actually an ideal indication.

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