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8. Foot and Ankle MCQs

Practice Set 108 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 2141

Topic: 8. Foot and Ankle

A 60-year-old woman with longstanding, poorly controlled rheumatoid arthritis presents with a severe forefoot deformity characterized by hallux valgus and dorsal subluxation of the lesser MTP joints with painful plantar callosities. Which of the following surgical strategies is considered the classic and most reliable procedure for this severe rheumatoid forefoot deformity?

. First MTP joint arthrodesis and lesser metatarsal head resections
. First MTP joint silastic arthroplasty and lesser MTP joint capsular repairs
. First MTP joint chevron osteotomy and Weil osteotomies of lesser metatarsals
. Amputation of all five toes
. Percutaneous flexor tenotomies only

Correct Answer & Explanation

. First MTP joint arthrodesis and lesser metatarsal head resections

Explanation

The classic rheumatoid forefoot reconstruction (Hoffman procedure) involves arthrodesis of the first MTP joint to provide a stable medial column and resection of the lesser metatarsal heads to decompress the joints, reduce the dorsally dislocated toes, and alleviate painful plantar callosities.

Question 2142

Topic: 8. Foot and Ankle

A 12-year-old boy presents with frequent ankle sprains and a rigid, painful flatfoot. Clinical examination shows a lack of subtalar motion and peroneal spasticity. Oblique radiographs of the foot demonstrate an osseous bridge between the anterior process of the calcaneus and the navicular. Which of the following is the most appropriate initial operative management if conservative measures have failed?

. Triple arthrodesis
. Resection of the coalition with interposition of the extensor digitorum brevis muscle
. Subtalar arthrodesis
. Medial displacement calcaneal osteotomy
. Resection of the anterior process of the calcaneus without interposition

Correct Answer & Explanation

. Resection of the coalition with interposition of the extensor digitorum brevis muscle

Explanation

For a symptomatic calcaneonavicular coalition in a young patient without degenerative arthritic changes, resection of the bony bar with interposition of tissue (typically the extensor digitorum brevis muscle belly or fat) is the surgical treatment of choice to restore motion and relieve pain. Arthrodesis is reserved for failed resections or if significant degenerative changes are present.

Question 2143

Topic: 8. Foot and Ankle

A 55-year-old man presents with chronic, severe posterior heel pain. Examination reveals a prominent Haglund's deformity and tenderness at the Achilles tendon insertion. Radiographs show a large calcaneal spur within the tendon insertion. He has failed physical therapy and NSAIDs over the past 12 months. Surgery is planned. If more than 50% of the Achilles tendon insertion must be detached to resect the calcification and exostosis, what additional procedure is most strongly recommended?

. Flexor hallucis longus (FHL) tendon transfer
. Flexor digitorum longus (FDL) tendon transfer
. Peroneus brevis tendon transfer
. Tibialis anterior tendon transfer
. Gastrocnemius recession only

Correct Answer & Explanation

. Flexor hallucis longus (FHL) tendon transfer

Explanation

During surgical debridement for insertional Achilles tendinopathy, if more than 50% of the Achilles tendon footprint is detached to adequately resect the retrocalcaneal exostosis and intratendinous calcifications, augmentation is recommended to prevent catastrophic failure and restore plantarflexion strength. The Flexor Hallucis Longus (FHL) tendon transfer is the gold standard for this augmentation due to its proximity, strength, and favorable line of pull.

Question 2144

Topic: 8. Foot and Ankle

During open repair of an acute Achilles tendon rupture, care must be taken to repair the paratenon. What is the primary function of the paratenon in this region?

. Provide the primary blood supply to the tendon via the mesotenon.
. Enhance tendon gliding and reduce adhesions to the overlying skin.
. Resist sheer forces during terminal dorsiflexion.
. Anchor the tendon to the deep crural fascia.
. Prevent sural nerve entrapment.

Correct Answer & Explanation

. Enhance tendon gliding and reduce adhesions to the overlying skin.

Explanation

The paratenon is a sheath that surrounds the Achilles tendon, acting to reduce friction and allow gliding against surrounding tissues. Careful closure of the paratenon during open Achilles repair is recommended to minimize adhesions to the overlying skin and optimize gliding, which facilitates rehabilitation and reduces the risk of skin necrosis or wound breakdown. The primary blood supply comes from the musculotendinous junction, the osteotendinous junction, and vessels in the paratenon (specifically from the anterior aspect), but its main functional role is enhancing gliding.

Question 2145

Topic: 8. Foot and Ankle

A 62-year-old male presents with dorsal foot pain and limited dorsiflexion of the first metatarsophalangeal (MTP) joint. Radiographs show a dorsal osteophyte with more than 50% joint space narrowing, but the plantar half of the joint space is relatively preserved (Coughlin and Shurnas Grade 2). He has failed conservative management. What is the most appropriate surgical intervention?

. Moberg osteotomy
. First MTP arthrodesis
. Cheilectomy
. First MTP arthroplasty
. Keller resection arthroplasty

Correct Answer & Explanation

. Cheilectomy

Explanation

For Coughlin and Shurnas Grade 1 and 2 hallux rigidus (mild to moderate, with preservation of the plantar joint space), cheilectomy (removal of the dorsal osteophyte and the dorsal 30% of the metatarsal head) is the recommended initial surgical treatment. Arthrodesis is reserved for Grade 3 or 4 disease, or for patients who fail cheilectomy.

Question 2146

Topic: 8. Foot and Ankle

A 55-year-old female presents with progressive flattening of her left foot, medial pain, and inability to perform a single heel raise. Examination reveals hindfoot valgus that is passively correctable and forefoot abduction. In addition to posterior tibial tendon insufficiency, tearing of which of the following structures is most highly associated with the development of the forefoot abduction seen in this stage?

. Plantar fascia
. Short plantar ligament
. Spring ligament complex
. Deltoid ligament
. Bifurcate ligament

Correct Answer & Explanation

. Spring ligament complex

Explanation

The spring ligament (calcaneonavicular ligament) complex is a primary static stabilizer of the longitudinal arch. Its failure, along with posterior tibial tendon dysfunction, allows the talus to plantarflex and rotate medially, leading to uncovering of the talar head and clinical forefoot abduction. The stage described is Stage IIb Adult Acquired Flatfoot Deformity (AAFD), characterized by a passively correctable deformity with significant forefoot abduction.

Question 2147

Topic: Midfoot & Hindfoot
A 30-year-old male sustains a high-energy injury to his foot and is diagnosed with a Hawkins type III talar neck fracture. Which of the following best describes this injury and its associated risk of avascular necrosis (AVN)?
. Nondisplaced fracture; AVN risk is 0-10%
. Subtalar subluxation/dislocation; AVN risk is 20-50%
. Subtalar and tibiotalar dislocation; AVN risk is nearly 100%
. Subtalar, tibiotalar, and talonavicular dislocation; AVN risk is 100%
. Subtalar and tibiotalar dislocation; AVN risk is 50-70%

Correct Answer & Explanation

. Subtalar and tibiotalar dislocation; AVN risk is nearly 100%

Explanation

Hawkins classification for talar neck fractures: Type I: Nondisplaced (AVN 0-10%). Type II: Displaced with subtalar subluxation/dislocation (AVN 20-50%). Type III: Displaced with subtalar and tibiotalar dislocation (AVN near 100% in original series, modern series quote 70-100%). Type IV (added by Canale): Displaced with subtalar, tibiotalar, and talonavicular dislocation (AVN near 100%).

Question 2148

Topic: 8. Foot and Ankle

The Lisfranc ligament is critical for midfoot stability. Which of the following accurately describes the anatomic attachments of the Lisfranc ligament?

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

Correct Answer & Explanation

. Medial cuneiform to the base of the first metatarsal

Explanation

The Lisfranc ligament is a strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. There is no direct ligamentous connection between the bases of the first and second metatarsals, making this articulation particularly vulnerable to disruption.

Question 2149

Topic: 8. Foot and Ankle

A 40-year-old roofer falls 15 feet, sustaining a displaced, intra-articular calcaneus fracture (Sanders Type II). He is planned for open reduction and internal fixation via an extensile lateral approach. To minimize the risk of wound complications, which of the following principles must be adhered to during the approach?

. Creating a partial-thickness skin flap
. Elevating the flap strictly superficial to the sural nerve
. Handling the flap with forceps to ensure adequate tension
. Creating a full-thickness flap directly off the periosteum of the lateral calcaneal wall
. Making the horizontal limb of the incision directly over the peroneal tendons

Correct Answer & Explanation

. Creating a partial-thickness skin flap

Explanation

The extensile lateral approach to the calcaneus is associated with a high rate of wound healing complications (up to 25%). To minimize this risk, a 'no-touch' technique should be used, and the flap must be a full-thickness subperiosteal flap raised off the lateral wall of the calcaneus. The sural nerve and peroneal tendons should be contained within the elevated flap. Retractors (like K-wires into the talus) should be used instead of grasping the skin edges.

Question 2150

Topic: Midfoot & Hindfoot

A 60-year-old patient with poorly controlled diabetes mellitus presents with a red, hot, swollen foot. Radiographs demonstrate periarticular fragmentation, subluxation, and bony debris around the midfoot. According to the Eichenholtz classification, what stage of Charcot arthropathy is this, and what is the most appropriate initial treatment?

. Stage 0; observation
. Stage 1; total contact casting and non-weight bearing
. Stage 2; custom orthosis
. Stage 3; midfoot arthrodesis
. Stage 1; immediate midfoot arthrodesis

Correct Answer & Explanation

. Stage 0; observation

Explanation

Eichenholtz classification of Charcot arthropathy: Stage 1 (Developmental/Fragmentation): characterized by erythema, edema, heat, and radiographs showing bony fragmentation, joint subluxation/dislocation, and debris. Treatment is immobilization and offloading, typically with a total contact cast (TCC). Stage 2 (Coalescence): decreased swelling, absorption of debris, and early fusion. Stage 3 (Reconstruction): no inflammation, stable deformity. Stage 0 is the prodromal phase with clinical signs but normal radiographs.

Question 2151

Topic: 8. Foot and Ankle

During evaluation of an external rotation ankle injury, disruption of the distal tibiofibular syndesmosis is suspected. Which of the following ligaments provides the greatest resistance to lateral translation of the fibula relative to the tibia?

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

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

The syndesmosis consists of the AITFL, PITFL, interosseous ligament, and transverse ligament. Biomechanical studies (e.g., Ogilvie-Harris) have shown that the PITFL provides the greatest primary resistance to lateral displacement of the fibula (approx 42%), followed by the AITFL (approx 35%), and the interosseous ligament (22%).

Question 2152

Topic: 8. Foot and Ankle

A 14-year-old boy presents with frequent ankle sprains and rigid flatfeet. On examination, he has decreased subtalar motion and peroneal spasticity. Radiographs demonstrate the 'C-sign' on the lateral view. Which type of tarsal coalition does this finding most strongly suggest?

. Calcaneonavicular
. Talocalcaneal
. Talonavicular
. Calcaneocuboid
. Cubonavicular

Correct Answer & Explanation

. Calcaneonavicular

Explanation

The 'C-sign' on a lateral radiograph is formed by the medial outline of the talar dome and the posterior outline of the sustentaculum tali. It is highly indicative of a talocalcaneal coalition (specifically involving the middle facet). Calcaneonavicular coalitions often show the 'anteater nose' sign on the lateral view.

Question 2153

Topic: 8. Foot and Ankle

Chronic plantar fasciitis often involves degenerative changes rather than purely inflammatory ones. The pathologic changes are most commonly located at the origin of which of the following structures?

. Medial band of the plantar fascia on the medial calcaneal tuberosity
. Central band of the plantar fascia on the medial calcaneal tuberosity
. Lateral band of the plantar fascia on the lateral calcaneal tuberosity
. Flexor digitorum brevis origin on the calcaneus
. Abductor hallucis origin on the medial calcaneal tuberosity

Correct Answer & Explanation

. Medial band of the plantar fascia on the medial calcaneal tuberosity

Explanation

Plantar fasciitis is an enthesopathy (often characterized by mucoid degeneration rather than acute inflammation) that typically occurs at the origin of the central band of the plantar fascia from the medial tubercle of the calcaneus.

Question 2154

Topic: Forefoot

A 45-year-old woman is being evaluated for hallux valgus surgery. Her weight-bearing AP foot radiograph reveals a Hallux Valgus Angle (HVA) of 35 degrees and an Intermetatarsal Angle (IMA) of 16 degrees. The metatarsophalangeal joint is subluxated but reducible. Which of the following surgical procedures is most appropriate?

. Distal chevron osteotomy
. Proximal metatarsal osteotomy with a distal soft tissue procedure
. Akin osteotomy alone
. First MTP joint arthrodesis
. Lapidus procedure

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

An HVA of 35° and IMA of 16° indicates a moderate to severe hallux valgus deformity. A distal osteotomy (like a chevron) is generally indicated for mild deformities (IMA < 13°). For an IMA > 13° to 15°, a proximal osteotomy (e.g., crescentic or Ludloff) or a diaphyseal osteotomy (Scarf) combined with a distal soft tissue release (modified McBride) is indicated. A Lapidus procedure is preferred if there is first ray hypermobility or arthritis.

Question 2155

Topic: 8. Foot and Ankle

A 50-year-old woman complains of burning pain in her forefoot that radiates into her toes, typically worsening when wearing tight shoes. Compressing the metatarsal heads together while applying plantar pressure to the interspace elicits a palpable click and reproduces her pain. What is this clinical test called?

. Tinel's sign
. Silfverskiold test
. Mulder's sign
. Jack's test
. Coleman block test

Correct Answer & Explanation

. Tinel's sign

Explanation

Mulder's sign is a clinical test for Morton's neuroma. It involves squeezing the metatarsal heads together with one hand while applying dorsal-plantar pressure to the web space with the other. A palpable click (Mulder's click) and reproduction of symptoms indicate a positive test, caused by the enlarged nerve being displaced plantarward between the metatarsal heads.

Question 2156

Topic: 8. Foot and Ankle

A 65-year-old man presents with a 'slapping' foot gait and weakness in ankle dorsiflexion following a stumble. He denies significant pain but notes a mass over the anterior ankle. On examination, he has weak active dorsiflexion, but can still extend his toes. Which of the following is true regarding this condition?

. It most commonly occurs at the musculotendinous junction.
. Nonoperative management typically results in an unstable ankle joint.
. Extensor hallucis longus and extensor digitorum longus completely mask the deficit.
. It frequently occurs in the setting of chronic degeneration or systemic diseases like diabetes.
. Surgical repair requires a triceps surae lengthening in over 50% of cases.

Correct Answer & Explanation

. It most commonly occurs at the musculotendinous junction.

Explanation

Spontaneous rupture of the tibialis anterior tendon is relatively uncommon and typically occurs in older patients with chronic degenerative changes, often associated with diabetes or local steroid injections. It presents with foot drop or a slapping gait. Toe extensors (EHL, EDL) can provide weak dorsiflexion but do not fully mask the deficit. Nonoperative treatment (AFO) is often well-tolerated in low-demand, elderly patients.

Question 2157

Topic: 8. Foot and Ankle

An acute dislocation of the peroneal tendons usually involves forced dorsiflexion of the everted foot with strong reflex contraction of the peroneal muscles. Which structure is primarily injured or avulsed in this mechanism?

. Inferior extensor retinaculum
. Superior peroneal retinaculum (SPR)
. Calcaneofibular ligament
. Peroneus brevis tendon
. Posterior talofibular ligament

Correct Answer & Explanation

. Inferior extensor retinaculum

Explanation

The superior peroneal retinaculum (SPR) is the primary restraint to subluxation or dislocation of the peroneal tendons. Injury to the SPR, typically an avulsion from its fibular attachment (often with a small cortical fleck of bone), allows the tendons to dislocate anteriorly over the lateral malleolus.

Question 2158

Topic: 8. Foot and Ankle

A football player injures his great toe on artificial turf during a forced hyperextension mechanism. He has severe pain and swelling at the first MTP joint. 'Turf toe' represents an injury to which of the following structures?

. First metatarsal head articular cartilage
. Extensor hallucis longus tendon
. Plantar plate and capsuloligamentous complex
. Dorsal joint capsule
. Medial collateral ligament of the interphalangeal joint

Correct Answer & Explanation

. First metatarsal head articular cartilage

Explanation

'Turf toe' is a sprain of the first MTP joint resulting from forced hyperextension. It specifically involves attenuation or tearing of the plantar capsuloligamentous complex, including the plantar plate, sesamoid sling, and collateral ligaments.

Question 2159

Topic: 8. Foot and Ankle

Based on classic literature, which of the following best describes the typical location, morphology, and etiology of osteochondral lesions of the talus?

. Medial lesions are typically anterior, shallow, and trauma-related.
. Lateral lesions are typically posterior, deep, and insidious in onset.
. Medial lesions are typically posterior, deep, and often insidious or atraumatic in onset.
. Lateral lesions are typically anterior, deep, and atraumatic.
. Both medial and lateral lesions are uniformly anterior and traumatic.

Correct Answer & Explanation

. Medial lesions are typically anterior, shallow, and trauma-related.

Explanation

The classic mnemonic for OLTs is DIAL a PIMP: Dorsiflexion Inversion -> Anterior Lateral lesions (shallow, traumatic). Plantarflexion Inversion -> Medial Posterior lesions (deep, often insidious or less clearly related to a single acute trauma). Therefore, medial lesions are characteristically posterior, deep, and cup-shaped.

Question 2160

Topic: 8. Foot and Ankle

A 60-year-old female with severe, long-standing rheumatoid arthritis presents with debilitating forefoot pain. She has severe hallux valgus, lesser toe clawing, and dorsal dislocation of the lesser MTP joints. The metatarsal heads are prominent on the plantar aspect. What is the gold-standard surgical procedure for this severe rheumatoid forefoot deformity?

. Arthrodesis of the first MTP joint and resection arthroplasty of the lesser metatarsal heads
. Silastic arthroplasty of the first through fifth MTP joints
. Cheilectomy of the first MTP joint and PIP joint fusions
. Distal metatarsal osteotomies (Weil) of the lesser toes with a chevron osteotomy of the first metatarsal
. Keller procedure of the first MTP and closed reduction of lesser toes

Correct Answer & Explanation

. Arthrodesis of the first MTP joint and resection arthroplasty of the lesser metatarsal heads

Explanation

The classic, gold-standard surgical reconstruction for a severe rheumatoid forefoot with dislocated lesser MTP joints and severe hallux valgus is arthrodesis of the first MTP joint and resection of the lesser metatarsal heads (Hoffman procedure). This eliminates pain, realigns the first ray to provide medial column stability, and relieves plantar pressure from the dislocated lesser metatarsal heads.

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