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8. Foot and Ankle MCQs

Practice Set 110 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 2181

Topic: 8. Foot and Ankle

A 45-year-old roofer falls from a ladder, sustaining a severely comminuted, depressed intra-articular calcaneus fracture. It is treated non-operatively due to severe patient comorbidities. Six months later, he complains of a burning, neuropathic pain in the plantar aspect of his foot and toes that worsens with weight-bearing. Tinel's sign is strongly positive just posterior to the medial malleolus. What anatomical structure forms the roof of the fibro-osseous tunnel causing the compression of the involved nerve?

. Flexor retinaculum (laciniate ligament)
. Superior extensor retinaculum
. Inferior extensor retinaculum
. Superior peroneal retinaculum
. Plantar aponeurosis

Correct Answer & Explanation

. Flexor retinaculum (laciniate ligament)

Explanation

The patient is presenting with post-traumatic tarsal tunnel syndrome, a known complication of calcaneus fractures due to hindfoot varus malunion, loss of calcaneal height (settling), or scar tissue formation. The tibial nerve is compressed within the tarsal tunnel, the roof of which is formed by the flexor retinaculum (also known anatomically as the laciniate ligament), which spans between the medial malleolus and the medial calcaneus.

Question 2182

Topic: 8. Foot and Ankle

A 45-year-old male sustains a pronation-external rotation (PER) ankle fracture with lateral dislocation. Post-reduction, he notes numbness on the dorsal aspect of the foot (sparing the first web space) and weakness in active foot eversion. Which nerve is involved?

. Deep peroneal nerve
. Sural nerve
. Superficial peroneal nerve
. Saphenous nerve
. Tibial nerve

Correct Answer & Explanation

. Deep peroneal nerve

Explanation

The superficial peroneal nerve innervates the muscles of the lateral compartment of the leg (peroneus longus and brevis), which are responsible for eversion. It also provides sensation to the majority of the dorsum of the foot, with the exception of the first web space (deep peroneal nerve). Stretch injuries to this nerve can occur during significant rotational ankle injuries.

Question 2183

Topic: 8. Foot and Ankle

A collegiate football player sustains a direct blow to the lateral aspect of his knee, resulting in a fibular neck fracture and a subsequent complete foot drop due to common peroneal nerve injury. During his rehabilitation phase, return of function in which of the following muscles would serve as the earliest clinical indicator of nerve recovery?

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

Correct Answer & Explanation

. Tibialis anterior

Explanation

Following a common peroneal nerve injury at the fibular neck, the nerve regenerates proximally to distally. The tibialis anterior is the most proximally innervated muscle in the anterior compartment by the deep peroneal branch. Therefore, return of active ankle dorsiflexion (tibialis anterior function) is typically the earliest clinical sign of re-innervation.

Question 2184

Topic: 8. Foot and Ankle

A 22-year-old football player sustains a high-energy Lisfranc injury with lateral displacement of the second through fifth metatarsals. If he develops a neurological deficit secondary to this injury, what physical examination finding is most likely?

. Loss of sensation over the plantar aspect of the heel
. Inability to actively evert the foot
. Loss of sensation in the first dorsal web space
. Inability to actively plantarflex the great toe
. Loss of sensation over the lateral border of the foot

Correct Answer & Explanation

. Loss of sensation over the plantar aspect of the heel

Explanation

The deep peroneal nerve and dorsalis pedis artery run between the first and second metatarsals. A severe Lisfranc dislocation can compress or stretch this nerve, resulting in numbness in the first dorsal web space.

Question 2185

Topic: 8. Foot and Ankle
A 22-year-old male sustains a KD-III knee dislocation. Post-reduction, he exhibits completely absent ankle dorsiflexion and eversion. At 3 months follow-up, there is zero return of clinical function, and an EMG shows absent motor unit action potentials in the anterior compartment musculature. What is the most appropriate next step in management?
. Observation for an additional 3 months
. Immediate posterior tibial tendon transfer
. Nerve exploration and possible grafting or transfer
. Ankle arthrodesis
. Continuous passive motion and orthotic management

Correct Answer & Explanation

. Nerve exploration and possible grafting or transfer

Explanation

After a high-energy stretch injury like a knee dislocation, a common peroneal nerve palsy showing no clinical or electrodiagnostic recovery by 3 months warrants surgical exploration. Tendon transfers are typically reserved as salvage procedures if nerve reconstruction fails or presents late.

Question 2186

Topic: 8. Foot and Ankle

A 45-year-old man is 6 months status post ORIF of a severe intra-articular calcaneus fracture. He complains of burning pain on the plantar aspect of his foot that worsens at night. He has a strongly positive Tinel's sign posterior to the medial malleolus. What is the most likely diagnosis?

. Sural nerve entrapment
. Deep peroneal nerve neuroma
. Tarsal tunnel syndrome
. Complex regional pain syndrome type II
. Superficial peroneal nerve entrapment

Correct Answer & Explanation

. Sural nerve entrapment

Explanation

Tarsal tunnel syndrome involves compression of the tibial nerve behind the medial malleolus. It is a known late complication of calcaneus fractures, often resulting from post-traumatic scarring, altered hindfoot anatomy, or impingement from retained hardware.

Question 2187

Topic: 8. Foot and Ankle

A 30-year-old man suffers a "floating knee" injury (ipsilateral femur and tibia fractures) in a rollover collision. Postoperatively, he exhibits a complete foot drop and absent two-point discrimination in the first dorsal web space. Which nerve was injured, and where is its most common site of traumatic tethering?

. Superficial peroneal nerve; anterior compartment of the leg
. Deep peroneal nerve; fibular neck
. Tibial nerve; popliteal fossa
. Sural nerve; posterior to the lateral malleolus
. Saphenous nerve; Hunter's canal

Correct Answer & Explanation

. Superficial peroneal nerve; anterior compartment of the leg

Explanation

The clinical findings of foot drop and numbness in the first dorsal web space represent a deep peroneal nerve injury. This nerve is extremely vulnerable to stretch and compression as it wraps intimately around the fibular neck.

Question 2188

Topic: 8. Foot and Ankle
Because the patient shown in Figure 27 can no longer fit in shoes, treatment of the deformity should consist of
. physeal arrest.
. soft-tissue debulking.
. ray resection.
. Chopart amputation.
. distal phalanx amputation.

Correct Answer & Explanation

. ray resection.

Explanation

In local gigantism, a ray resection allows proper fitting of shoes. The ray resection narrows the foot and shortens the length. The foot may require further surgery with growth. Debulking, physeal arrest, and distal phalanx amputation are unlikely to be effective.

Question 2189

Topic: 8. Foot and Ankle
Which of the following rehabilitation methods has proven as effective as surgical treatment for the treatment of patellar tendinopathy (jumper’s knee)?
. Electrotherapy
. Concentric training
. Eccentric training
. Massage
. Taping

Correct Answer & Explanation

. Eccentric training

Explanation

Common treatments for patellar tendinopathy include rest, ice, electrotherapy, massage, taping and injection. None has been demonstrated to be effective. Eccentric training has proven to be as effective as surgical treatment. Achilles insertional tendinopathy has also proven to respond to eccentric training.

Question 2190

Topic: 8. Foot and Ankle
A newborn with bilateral talipes equinovarus undergoes serial manipulation and casting. What is the primary goal of manipulation?
. Rotation of the foot laterally around the fixed talus
. Simultaneous abduction of the metatarsals and dorsiflexion of the talus
. Lateral translation of the calcaneus
. Anterolateral translation of the navicular
. Dorsiflexion of the calcaneus with forefoot eversion

Correct Answer & Explanation

. Rotation of the foot laterally around the fixed talus

Explanation

Manipulative treatment and casting of talipes equinovarus has become popular because of disappointing surgical results and enthusiasm for the Ponseti method of manipulation. In this technique, the primary goal is to rotate the foot laterally around a talus that is held fixed by the manipulating surgeon’s hands. While the navicular may be rotated anterolaterally with this technique, the primary focus is on the calcaneus. The calcaneus is rotated laterally and superiorly, not translated. Some dorsiflexion of the calcaneus can be obtained by manipulation, but the primary focus is on the rotational relationship of the talus and calcaneus, not the degree of calcaneal dorsiflexion.

Question 2191

Topic: 8. Foot and Ankle

A 60-year-old male with long-standing, poorly controlled diabetes presents with a red, hot, and swollen left foot of 2 weeks duration. He denies any systemic symptoms or open wounds. Radiographs reveal fragmentation, periarticular debris, and subluxation at the tarsometatarsal joint.

What is the most appropriate initial management?

. Intravenous antibiotics and emergent surgical debridement
. Total contact casting and non-weight bearing
. Open reduction and internal fixation of the midfoot
. Midfoot arthrodesis with robust hardware
. Intra-articular corticosteroid injection

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The patient is presenting with acute Stage 1 (developmental/fragmentation) Charcot arthropathy (Eichenholtz classification). The clinical presentation of a red, hot, swollen foot in a diabetic patient without an open ulcer is highly suggestive of acute Charcot. The gold standard for initial management is immobilization with a total contact cast to offload the foot, prevent further deformity, and allow the acute inflammatory process to consolidate. Surgery is generally contraindicated in the acute phase due to high rates of hardware failure and complication.

Question 2192

Topic: Midfoot & Hindfoot
A 55-year-old female presents with medial ankle pain and a progressive flatfoot deformity. She cannot perform a single-leg heel raise. Passive correction of the hindfoot valgus is possible. Radiographs demonstrate a talonavicular uncoverage of 20% without arthritic changes. Which of the following surgical procedures is most appropriate?
. Tibialis posterior tendon debridement alone
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Subtalar arthrodesis
. Talonavicular arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy

Explanation

This patient has a flexible Stage IIA adult-acquired flatfoot deformity (posterior tibial tendon dysfunction). Because the deformity is flexible and there is mild forefoot abduction (<30% talonavicular uncoverage), joint-sparing procedures are indicated. The standard of care is a flexor digitorum longus (FDL) transfer to the navicular combined with a medial displacement calcaneal osteotomy (MDCO) to correct the mechanical axis. If severe forefoot abduction was present (>30% uncoverage, Stage IIB), a lateral column lengthening would also be indicated. Arthrodesis is reserved for rigid deformities or arthritis (Stage III).

Question 2193

Topic: 8. Foot and Ankle

A 45-year-old active male presents with chronic dorsal foot pain localized to the first metatarsophalangeal (MTP) joint. Radiographs show dorsal osteophytes with mild to moderate joint space narrowing and preservation of the plantar joint space (Coughlin and Shurnas Grade 2).

Non-operative management has failed. Which surgical intervention is the most appropriate first-line treatment?

. First MTP arthrodesis
. Cheilectomy
. Keller arthroplasty
. Total joint replacement
. Silastic implant arthroplasty

Correct Answer & Explanation

. Cheilectomy

Explanation

This patient has Grade 2 hallux rigidus. For active patients with mild to moderate disease (Grades 1 and 2), a cheilectomy (removal of the dorsal one-third of the metatarsal head and osteophytes) is the preferred initial surgical procedure, as it preserves motion and provides reliable pain relief. First MTP arthrodesis is the gold standard for severe, end-stage disease (Grades 3 and 4).

Question 2194

Topic: 8. Foot and Ankle

A 32-year-old male sustains a severe midfoot injury. Imaging shows a complete lateral displacement of the second through fifth metatarsals, while the first metatarsal remains in anatomic alignment with the medial cuneiform.

According to the Hardcastle and Myerson classification of Lisfranc injuries, this pattern is best described as:

. Type A (Total incongruity)
. Type B1 (Partial incongruity, medial displacement)
. Type B2 (Partial incongruity, lateral displacement)
. Type C1 (Divergent, partial)
. Type C2 (Divergent, total)

Correct Answer & Explanation

. Type B2 (Partial incongruity, lateral displacement)

Explanation

The Hardcastle and Myerson classification organizes Lisfranc injuries into three types: Type A (total incongruity/displacement of all 5 metatarsals in one direction), Type B (partial incongruity), and Type C (divergent). This specific case, where the 1st metatarsal is uninjured but the lesser metatarsals (2-5) are laterally displaced, is a Type B2 injury.

Question 2195

Topic: 8. Foot and Ankle

A 60-year-old male with end-stage post-traumatic ankle osteoarthritis is undergoing a tibiotalar arthrodesis.

What is the optimal position for the ankle fusion to maximize functional outcomes and gait?

. Neutral dorsiflexion, 5 degrees of valgus, and 5 to 10 degrees of external rotation
. 5 degrees of plantarflexion, neutral hindfoot, and neutral rotation
. 5 degrees of dorsiflexion, 5 degrees of varus, and 15 degrees of external rotation
. Neutral dorsiflexion, 5 degrees of varus, and neutral rotation
. 10 degrees of plantarflexion, 10 degrees of valgus, and 5 degrees of internal rotation

Correct Answer & Explanation

. Neutral dorsiflexion, 5 degrees of valgus, and 5 to 10 degrees of external rotation

Explanation

The optimal position for an ankle arthrodesis is neutral dorsiflexion (0 degrees), 0 to 5 degrees of hindfoot valgus, and 5 to 10 degrees of external rotation (matching the contralateral side). Plantarflexion leads to a back-knee (genu recurvatum) thrust during gait, while varus positioning locks the transverse tarsal joints, accelerating adjacent joint arthritis in the midfoot.

Question 2196

Topic: 8. Foot and Ankle

A 55-year-old female with poorly controlled type 2 diabetes mellitus presents with a warm, swollen, and erythematous left foot and ankle. She denies any systemic symptoms, fevers, or open wounds. White blood cell count and inflammatory markers are mildly elevated. Radiographs reveal fragmentation, periarticular debris, and subluxation of the tarsometatarsal joints.

Which of the following is the most appropriate initial management?

. Urgent open reduction and internal fixation of the midfoot
. Intravenous antibiotics and emergent bone biopsy
. Total contact casting and non-weight bearing
. Surgical exostectomy of the midfoot prominence
. Primary arthrodesis of the midfoot

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

This patient is presenting with acute Eichenholtz stage 1 (developmental/fragmentation) Charcot arthropathy, characterized by a red, hot, swollen foot with radiographic evidence of fragmentation, osteopenia, and subluxation. The mainstay of initial treatment is strict offloading and immobilization using a total contact cast (TCC). Surgery during the acute inflammatory phase carries a very high risk of hardware failure, infection, and worsening of the Charcot process. Arthrodesis or exostectomy is reserved for the chronic/consolidation phase (Stage 3) if there is an unbraceable deformity or recurrent ulceration.

Question 2197

Topic: Forefoot

A 50-year-old female complains of a painful bunion. Weight-bearing radiographs show a hallux valgus angle (HVA) of 38 degrees and an intermetatarsal angle (IMA) of 16 degrees. Clinical examination reveals no hypermobility of the first tarsometatarsal (TMT) joint and no evidence of degenerative joint disease. What is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue release
. First MTP joint arthrodesis
. Modified Lapidus procedure (first TMT arthrodesis)
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The patient has a moderate-to-severe hallux valgus deformity (IMA >13-15 degrees, HVA >30-40 degrees). A distal chevron osteotomy is generally reserved for mild deformities (IMA <13 deg) because it provides limited correction. For an IMA of 16 degrees, a proximal osteotomy (e.g., crescentic, Ludloff, or SCARF) combined with a distal soft tissue release is indicated to achieve adequate correction. A Lapidus procedure is preferred if there is first TMT hypermobility or arthritis. First MTP arthrodesis is used for severe deformity with concomitant arthritis.

Question 2198

Topic: Midfoot & Hindfoot
A 60-year-old female presents with a progressive, painful flatfoot deformity. She is unable to perform a single-leg heel raise on the affected side. Examination reveals a flexible pes planovalgus deformity. Radiographs demonstrate 40% talonavicular uncoverage but no significant degenerative joint disease. After failing 6 months of orthotics and bracing, which surgical procedure is most appropriate?
. Isolated gastrocnemius recession
. Flexor digitorum longus (FDL) transfer to the navicular combined with a medial displacement calcaneal osteotomy (MDCO)
. Triple arthrodesis
. Subtalar arthrodesis
. Ankle arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer to the navicular combined with a medial displacement calcaneal osteotomy (MDCO)

Explanation

The patient has Stage II posterior tibial tendon dysfunction (PTTD), defined by a painful, flexible flatfoot with an inability to perform a single-leg heel raise. Because the deformity is flexible and there is no arthritis, joint-sparing surgery is indicated. The gold standard is replacing the dysfunctional posterior tibial tendon with an FDL transfer, combined with a medial displacement calcaneal osteotomy (MDCO) to restore the biomechanical axis of the hindfoot and protect the transfer. Stage III (rigid flatfoot or arthritis) requires arthrodesis.

Question 2199

Topic: 8. Foot and Ankle

A 24-year-old athlete sustains a midfoot injury. Weight-bearing radiographs demonstrate subtle widening between the medial and middle cuneiforms and a 'fleck sign' at the base of the second metatarsal. The torn ligament responsible for this pathognomonic sign connects which two structures?

. Medial cuneiform to the base of the second metatarsal
. Middle cuneiform to the base of the second metatarsal
. Medial cuneiform to the base of the first 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 Lisfranc ligament is an interosseous ligament that spans from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. The 'fleck sign' represents a bony avulsion of this ligament and is highly indicative of a Lisfranc injury.

Question 2200

Topic: 8. Foot and Ankle

A 55-year-old man presents with dorsal foot pain and limited dorsiflexion of his great toe. Radiographs show a dorsal osteophyte at the first metatarsophalangeal (MTP) joint with preservation of the plantar joint space. He has failed conservative management. What is the most appropriate surgical treatment?

. First MTP joint arthrodesis
. Cheilectomy
. Keller arthroplasty
. Silicone silastic joint replacement
. Proximal phalanx osteotomy (Moberg)

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

The patient has Grade 2 hallux rigidus (dorsal osteophyte, preserved plantar cartilage, pain primarily at the end range of dorsiflexion). Cheilectomy (removal of the dorsal osteophyte and the dorsal third of the metatarsal head) is the treatment of choice for early to mid-stage hallux rigidus with preserved plantar articular cartilage.

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