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8. Foot and Ankle MCQs

Practice Set 111 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 2201

Topic: 8. Foot and Ankle

During an ankle fracture-dislocation with suspected syndesmotic injury, it is critical to understand the stabilizing structures. Which of the following ligaments provides the greatest resistance to lateral displacement of the fibula?

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

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

The posterior inferior tibiofibular ligament (PITFL) is the strongest component of the syndesmosis, providing approximately 42% of the resistance to lateral displacement of the fibula. The AITFL provides about 35%, and the interosseous ligament provides about 22%.

Question 2202

Topic: 8. Foot and Ankle

A 56-year-old man with long-standing, poorly controlled diabetes presents with a unilaterally warm, erythematous, and swollen foot for 3 weeks. Radiographs display marked osteopenia and periarticular fragmentation without signs of consolidation.

According to the Eichenholtz classification, what is the most appropriate initial management for this condition?

. Surgical arthrodesis of the midfoot
. Total contact casting and non-weight-bearing
. Intravenous antibiotics for 6 weeks
. Custom orthotics with arch support and full weight-bearing
. Open reduction and internal fixation

Correct Answer & Explanation

. Surgical arthrodesis of the midfoot

Explanation

The clinical presentation and radiographic findings (osteopenia, fragmentation, debris) represent Eichenholtz Stage 1 (Developmental/Fragmentation phase) of Charcot neuroarthropathy. The gold standard for initial management is immobilization with total contact casting (TCC) and strict non-weight-bearing to arrest the inflammatory process and prevent further deformity.

Question 2203

Topic: 8. Foot and Ankle

A 48-year-old male runner complains of chronic posterior heel pain that worsens with activity. MRI confirms insertional Achilles tendinopathy with a large retrocalcaneal exostosis (Haglund's deformity) and calcification within the tendon insertion. During surgical debridement, 60% of the Achilles tendon insertion is detached to remove the diseased tissue and bone. What is the most appropriate next step in surgical management?

. Primary repair of the Achilles tendon directly to the calcaneus using drill holes
. Transfer of the flexor hallucis longus (FHL) tendon to the calcaneus
. Transfer of the peroneus brevis tendon to the calcaneus
. V-Y tendon lengthening of the gastrocnemius
. Application of a hinged ankle-foot orthosis postoperatively without further augmentation

Correct Answer & Explanation

. Primary repair of the Achilles tendon directly to the calcaneus using drill holes

Explanation

In insertional Achilles tendinopathy, if more than 50% of the tendon insertion is detached during debridement of the diseased tendon and Haglund's exostosis, augmentation is indicated to prevent avulsion and restore plantarflexion strength. Flexor hallucis longus (FHL) transfer is the gold standard for this augmentation.

Question 2204

Topic: 8. Foot and Ankle

A 35-year-old construction worker falls from a roof, sustaining an intra-articular calcaneal fracture.

The Sanders classification is utilized to grade this injury. This classification system is based on the number and location of fracture lines through which anatomic structure on the coronal CT scan?

. Sustentaculum tali
. Anterior process of the calcaneus
. Posterior facet of the calcaneus
. Calcaneocuboid joint surface
. Middle facet of the calcaneus

Correct Answer & Explanation

. Sustentaculum tali

Explanation

The Sanders classification is based on coronal CT images through the widest portion of the posterior facet of the calcaneus. It dictates surgical decision-making by evaluating the number of primary fracture lines through this articular surface (Types I through IV).

Question 2205

Topic: Midfoot & Hindfoot

A 56-year-old male with uncontrolled type II diabetes presents with an acute, warm, swollen right foot. Radiographs reveal fragmentation, osteopenia, and subluxation exclusively involving the talonavicular and calcaneocuboid joints. The tarsometatarsal joints are entirely spared. According to the Brodsky anatomic classification of Charcot neuroarthropathy, what type of injury is this?

. Type 1
. Type 2
. Type 3a
. Type 3b
. Type 4

Correct Answer & Explanation

. Type 1

Explanation

In the Brodsky classification for Charcot arthropathy: Type 1 involves the tarsometatarsal (Lisfranc) joints (most common). Type 2 involves the hindfoot (Chopart) joints: talonavicular, calcaneocuboid, and subtalar joints. Type 3a involves the tibiotalar joint. Type 3b is a pathologic fracture of the calcaneal tuberosity.

Question 2206

Topic: 8. Foot and Ankle

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

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

Correct Answer & Explanation

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

Explanation

The Lisfranc ligament is an interosseous ligament that attaches from the lateral surface of the medial cuneiform to the medial surface of the base of the second metatarsal. Notably, there is no direct transverse ligamentous connection between the bases of the first and second metatarsals.

Question 2207

Topic: 8. Foot and Ankle

A 26-year-old male sustains a pronation-external rotation ankle fracture with syndesmotic disruption. He undergoes open reduction internal fixation, including the placement of two solid 3.5 mm trans-syndesmotic screws. According to current prospective literature, what is the recommendation regarding the routine removal of these syndesmotic screws prior to initiating weight-bearing?

. Routine removal is mandatory to prevent recurrent tibiofibular diastasis
. Routine removal significantly improves long-term ankle dorsiflexion
. Routine removal does not significantly alter functional outcomes compared to retaining the screws, even if the screws break
. Routine removal decreases the incidence of deep vein thrombosis
. Retained screws universally lead to symptomatic distal tibiofibular synostosis

Correct Answer & Explanation

. Routine removal does not significantly alter functional outcomes compared to retaining the screws, even if the screws break

Explanation

Recent level I and II evidence has shown no significant clinical or functional outcome differences between patients who have their syndesmotic screws routinely removed versus those who retain them, even in instances where the retained screws ultimately loosen or break. Routine removal is generally no longer mandated unless symptomatic.

Question 2208

Topic: 8. Foot and Ankle

A 15-year-old boy with Charcot-Marie-Tooth disease presents with a progressive cavovarus foot deformity. On examination, his hindfoot varus corrects to neutral when standing on a Coleman block, indicating a flexible hindfoot driven by forefoot pathology. Overactivity of which of the following tendons is the primary deforming force driving his plantarflexed first ray?

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

Correct Answer & Explanation

. Peroneus longus

Explanation

In Charcot-Marie-Tooth disease, there is early weakness of the tibialis anterior and peroneus brevis. The relative overpull of the intact peroneus longus forcefully plantarflexes the first ray, driving the forefoot-driven cavovarus deformity.

Question 2209

Topic: 8. Foot and Ankle

A 38-year-old male undergoes percutaneous repair of an acute Achilles tendon rupture. During the passage of sutures in the proximal stump, the surgeon must be particularly careful to avoid injury to a nerve. Which nerve is most at risk, and what is its typical anatomical relationship to the Achilles tendon in this region?

. Superficial peroneal nerve, medial to the tendon
. Deep peroneal nerve, anterior to the tendon
. Sural nerve, lateral to the tendon
. Saphenous nerve, medial to the tendon
. Tibial nerve, direct posterior to the tendon

Correct Answer & Explanation

. Sural nerve, lateral to the tendon

Explanation

The sural nerve crosses from midline to the lateral border of the Achilles tendon approximately 10 cm proximal to the calcaneal insertion. It is the structure most at risk during percutaneous or minimally invasive Achilles tendon repairs.

Question 2210

Topic: 8. Foot and Ankle
A 30-year-old male presents to the trauma bay with a visibly deformed knee after a motorcycle collision. Radiographs confirm a multi-ligamentous knee dislocation (KD-III). After prompt closed reduction, the patient's ankle-brachial index (ABI) is calculated to be 0.85, though distal pulses are palpable. What is the most appropriate next step in management?
. Immediate open surgical exploration of the popliteal artery
. Ankle-brachial index reassessment after 4 hours
. CT angiography of the lower extremity
. Application of a hinged knee brace and discharge planning
. Immediate four-compartment fasciotomies of the lower leg

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

In the setting of a knee dislocation, an ABI < 0.9 is highly suspicious for a vascular injury (such as a popliteal intimal flap) and mandates advanced imaging, typically CT angiography, to precisely locate and define the injury before definitive management.

Question 2211

Topic: 8. Foot and Ankle

A 62-year-old male complains of severe first metatarsophalangeal (MTP) joint pain present throughout the entire arc of motion. Radiographs show complete obliteration of the joint space, extensive dorsal and lateral osteophytes, and subchondral cystic changes. He has failed rigid-soled shoe modifications. What is the gold-standard surgical treatment?

. Dorsal cheilectomy
. First MTP arthrodesis
. Proximal phalanx (Moberg) osteotomy
. Keller resection arthroplasty
. Distal first metatarsal osteotomy

Correct Answer & Explanation

. First MTP arthrodesis

Explanation

The patient has Coughlin and Shurnas Grade 4 hallux rigidus (pain throughout motion, end-stage radiographic changes). First MTP arthrodesis is the most reliable, gold-standard procedure for pain relief and functional restoration in Grade 4 disease.

Question 2212

Topic: Midfoot & Hindfoot

A 55-year-old female presents with Stage IIb adult acquired flatfoot deformity, demonstrating a flexible hindfoot valgus and greater than 40% talonavicular uncoverage on AP weight-bearing radiographs. In addition to a flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy, which procedure is specifically indicated to address her profound forefoot abduction?

. First tarsometatarsal (Lapidus) arthrodesis
. Dorsiflexion osteotomy of the medial cuneiform
. Lateral column lengthening (Evans osteotomy)
. Subtalar arthrodesis
. Kidner procedure

Correct Answer & Explanation

. First tarsometatarsal (Lapidus) arthrodesis

Explanation

Stage IIb posterior tibial tendon dysfunction (PTTD) is characterized by severe forefoot abduction (>40% TN uncoverage). A lateral column lengthening (such as an Evans calcaneal osteotomy) is required to restore the lateral column length and swing the forefoot out of abduction.

Question 2213

Topic: 8. Foot and Ankle

A 32-year-old female sustains a Hawkins Type II fracture of the talar neck after a fall from a height. The surgeon counsels her on the significant risk of avascular necrosis (AVN). Which artery provides the primary, most abundant blood supply to the talar body that is typically disrupted in displaced talar neck fractures?

. Artery of the tarsal sinus
. Dorsalis pedis artery
. Artery of the tarsal canal
. Deltoid branch of the posterior tibial artery
. Peroneal artery

Correct Answer & Explanation

. Artery of the tarsal sinus

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, provides the dominant blood supply to the talar body. It enters the talar neck inferiorly and runs retrograde; thus, fractures through the neck frequently disrupt this critical vascular supply.

Question 2214

Topic: 8. Foot and Ankle
A patient with rheumatoid arthritis with both ankle and subtalar involvement was treated with tibiotalocalcaneal arthrodesis. What complication is unique to this type of fixation?
. Tibial stress fracture
. Late rotatory deformity
. Limb-length discrepancy
. Talar osteonecrosis
. Hardware failure

Correct Answer & Explanation

. Tibial stress fracture

Explanation

The interlocking screws at the proximal end of the rod can act as a stress riser and lead to fracture. Postoperative pain at this level should prompt inclusion of this diagnosis in the differential. Removing the screws following bone union can decrease the chances of this occurring. A short rod that avoids the diaphyseal area may also be beneficial. Rotatory deformity is controlled by the perpendicularly oriented distal transfixion screws. Talar osteonecrosis would be unusual since the dissection can be minimized with an intramedullary rod. Any type of hardware can fail if the construct does not lead to a solid arthrodesis.

Question 2215

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with a progressive flatfoot deformity. Examination reveals a flexible pes planovalgus, an inability to perform a single-leg heel rise, and > 40% uncovering of the talonavicular joint on weight-bearing AP radiographs. What is the most appropriate surgical management for this Stage IIb adult-acquired flatfoot?
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO) alone
. FDL transfer, MDCO, and lateral column lengthening (e.g., Evans osteotomy)
. Isolated talonavicular arthrodesis
. Triple arthrodesis
. Medial cuneiform plantarflexion osteotomy (Cotton) alone

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening (e.g., Evans osteotomy)

Explanation

Stage IIb adult-acquired flatfoot (posterior tibial tendon dysfunction) is characterized by a flexible deformity with significant forefoot abduction (typically >40% talonavicular uncoverage). An FDL transfer and MDCO are standard for Stage IIa, but the significant forefoot abduction in Stage IIb requires the addition of a lateral column lengthening procedure (such as an Evans calcaneal osteotomy) to adequately restore the medial column arch and foot alignment.

Question 2216

Topic: Ankle Trauma & Sports
A 14-year-old boy sustains an ankle injury while playing soccer. Radiographs reveal a Salter-Harris III fracture of the anterolateral distal tibia. Which ligament's avulsion force is fundamentally responsible for this specific fracture pattern?
. Anterior talofibular ligament (ATFL)
. Calcaneofibular ligament (CFL)
. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Deltoid ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

The patient has a Tillaux fracture, which is an avulsion fracture of the anterolateral aspect of the distal tibial epiphysis. It occurs during adolescence due to an external rotation force pulling on the anterior inferior tibiofibular ligament (AITFL). This happens because the distal tibial physis closes in a specific pattern: central, then medial, and finally lateral. The lateral physis is the last to close, making it vulnerable to avulsion by the AITFL.

Question 2217

Topic: 8. Foot and Ankle

When evaluating and treating a suspected Lisfranc injury, an understanding of the local anatomy is critical. Which of the following statements regarding the Lisfranc ligament complex is true?

. The dorsal Lisfranc ligament is the strongest component and most critical for midfoot stability.
. The Lisfranc ligament connects the medial cuneiform to the base of the third metatarsal.
. The plantar Lisfranc ligament is stronger and thicker than the dorsal Lisfranc ligament.
. There is a strong intermetatarsal ligament connecting the bases of the first and second metatarsals.
. The interosseous ligament is the weakest of the three Lisfranc ligament components.

Correct Answer & Explanation

. The dorsal Lisfranc ligament is the strongest component and most critical for midfoot stability.

Explanation

The Lisfranc ligament complex connects the medial cuneiform to the base of the second metatarsal, not the third. It consists of three components: dorsal, interosseous, and plantar. The interosseous component is the strongest, followed by the plantar component. The dorsal component is the weakest. A key anatomical feature contributing to the vulnerability of this joint is the lack of a direct intermetatarsal ligament connecting the bases of the first and second metatarsals.

Question 2218

Topic: 8. Foot and Ankle

A 45-year-old avid runner presents with severe posterior heel pain. MRI demonstrates a thickened Achilles tendon with marked intrasubstance degeneration 4 cm proximal to its insertion. There is no Haglund deformity. Six months of eccentric stretching and physical therapy have failed. Which of the following is the most appropriate surgical treatment?

. Calcaneal exostectomy and detachment/reattachment of the Achilles tendon
. Open tendon debridement and tubularization
. FHL transfer with extensive distal Achilles resection
. Lateral column lengthening
. Gastrocnemius recession and subtalar fusion

Correct Answer & Explanation

. Calcaneal exostectomy and detachment/reattachment of the Achilles tendon

Explanation

The patient has non-insertional Achilles tendinopathy, which typically occurs 2 to 6 cm proximal to the calcaneal insertion due to a zone of relative hypovascularity. After failure of prolonged nonoperative management, the surgical treatment of choice is longitudinal tenotomy, debridement of the degenerative tendinotic tissue, and tubularization of the remaining healthy tendon. Calcaneal exostectomy and detachment/reattachment are reserved for insertional tendinopathy with a Haglund deformity.

Question 2219

Topic: Midfoot & Hindfoot
A 58-year-old patient with long-standing poorly controlled diabetes presents with a swollen, erythematous, and warm foot. Radiographs demonstrate periarticular fragmentation, subluxation of the tarsometatarsal joints, and bony debris, but no signs of consolidation, fusion, or sclerosis. According to the Eichenholtz classification, what stage of Charcot arthropathy is this, and what is the current standard of care?
. Stage 0; rigid internal fixation
. Stage I; total contact casting and non-weight-bearing
. Stage II; customized accommodative orthoses
. Stage III; corrective midfoot arthrodesis
. Stage I; immediate open reduction and internal fixation

Correct Answer & Explanation

. Stage I; total contact casting and non-weight-bearing

Explanation

This presentation describes acute Stage I (Developmental/Fragmentation phase) Charcot arthropathy, characterized by clinical signs of inflammation (erythema, warmth, swelling) and radiographic evidence of fragmentation, joint subluxation/dislocation, and debris without consolidation. The standard of care during this acute, hyperemic phase is strict immobilization and offloading, almost universally utilizing a total contact cast (TCC), to prevent further mechanical destruction until the foot reaches Stage II (Coalescence).

Question 2220

Topic: 8. Foot and Ankle

A 28-year-old male presents with a progressive cavovarus foot deformity secondary to Charcot-Marie-Tooth disease. A Coleman block test is performed during the clinical examination, and the hindfoot completely corrects to a neutral/valgus position. What does this specific finding imply regarding the nature of the deformity?

. The hindfoot varus is entirely rigid and strictly requires a calcaneal osteotomy.
. The hindfoot varus is flexible and is secondarily driven by a rigidly plantarflexed first ray.
. A subtalar arthrodesis is unequivocally indicated to balance the foot.
. Tibialis posterior overactivity is the sole anatomical cause of the varus.
. The Achilles tendon is excessively lengthened, causing compensatory varus.

Correct Answer & Explanation

. The hindfoot varus is entirely rigid and strictly requires a calcaneal osteotomy.

Explanation

The Coleman block test is utilized to evaluate the flexibility of the hindfoot in a cavovarus foot. By placing the lateral border of the foot (heel and lateral metatarsals) on a block and allowing the first metatarsal to drop off the edge, the biomechanical influence of a rigidly plantarflexed first ray is eliminated. If the hindfoot corrects from varus to a neutral or valgus alignment on the block, it indicates that the hindfoot deformity is flexible and is being primarily driven by the forefoot pathology. Treatment should therefore prioritize addressing the forefoot (e.g., dorsiflexion osteotomy of the 1st metatarsal).

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