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8. Foot and Ankle MCQs

Practice Set 112 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 2221

Topic: 8. Foot and Ankle
In the surgical management of chronic, neglected Achilles tendon ruptures with a massive gap defect (> 6 cm), a flexor hallucis longus (FHL) tendon transfer is frequently the procedure of choice. What is the primary anatomical advantage of utilizing the FHL tendon over the flexor digitorum longus (FDL) or peroneus brevis for this specific reconstruction?
. The FHL is an exact synergistic and neurophysiological match for the gastrocnemius complex.
. The FHL provides a much larger, robust muscle belly that extends more distally, enhancing local blood supply to the reconstruction.
. The FHL has significantly less morbidity associated with harvest, as the great toe does not rely on it for any functional flexion.
. The FHL runs strictly superficial to the neurovascular bundle, making harvest at the ankle mathematically safer.
. The FHL is geometrically twice as long as the FDL, enabling it to bridge much larger gaps without tension.

Correct Answer & Explanation

. The FHL provides a much larger, robust muscle belly that extends more distally, enhancing local blood supply to the reconstruction.

Explanation

The FHL is the preferred tendon transfer for chronic, large-gap Achilles tendon ruptures primarily because its muscle belly extends very distally (often to the level of the tibiotalar joint). When transferred, this brings a robust, highly vascularized muscle belly directly into the hypovascular, scarred defect of the Achilles tendon, significantly enhancing the biologic healing potential. Furthermore, the FHL is biomechanically strong (the second strongest plantarflexor of the foot after the triceps surae) and shares an identical axis of pull.

Question 2222

Topic: Ankle Trauma & Sports

Following open reduction and internal fixation of a Weber C fibula fracture, the surgeon intraoperatively evaluates the integrity of the distal tibiofibular syndesmosis. Which of the following radiographic parameters on a standard non-rotated AP and mortise radiograph is considered the most reliable indicator of a well-reduced syndesmosis?

. Tibiofibular clear space of < 6 mm measured 1 cm proximal to the plafond on both AP and mortise views
. Tibiofibular overlap of > 1 mm measured on the AP view only
. Medial clear space > 4 mm measured on the mortise view
. Talar tilt angle < 5 degrees
. Absolute linear alignment of the distal fibula with the anterior tibial tubercle

Correct Answer & Explanation

. Tibiofibular clear space of < 6 mm measured 1 cm proximal to the plafond on both AP and mortise views

Explanation

The tibiofibular clear space, measured 1 cm proximal to the tibial plafond, should normally be < 6 mm on both AP and mortise radiographs. It is widely considered the most reliable plain radiographic parameter for evaluating syndesmotic integrity because, unlike the tibiofibular overlap (which is highly sensitive to the degree of leg rotation), the clear space remains relatively constant regardless of minor variations in rotation.

Question 2223

Topic: 8. Foot and Ankle

A 34-year-old female presents with a progressive cavovarus foot deformity. On examination, a Coleman block test is performed by placing her heel and lateral border of the foot on a block while allowing the first metatarsal to hang free. The hindfoot varus completely corrects. Which of the following is the most appropriate surgical intervention for her deformity?

. Lateralizing calcaneal osteotomy
. Dorsiflexion osteotomy of the 1st metatarsal
. Plantarflexion osteotomy of the 1st metatarsal
. Subtalar arthrodesis
. Triple arthrodesis

Correct Answer & Explanation

. Lateralizing calcaneal osteotomy

Explanation

A flexible hindfoot varus that corrects with a Coleman block test indicates the deformity is forefoot-driven, primarily due to a plantarflexed 1st ray. The appropriate treatment is a dorsiflexion osteotomy of the 1st metatarsal to correct the primary pathology.

Question 2224

Topic: 8. Foot and Ankle
A 55-year-old diabetic patient presents with a warm, swollen, and erythematous left foot and ankle. Radiographs reveal fragmentation, periarticular debris, and joint subluxation at the midfoot. According to the Eichenholtz classification, what stage of Charcot arthropathy is this, and what is the initial management?
. Stage 0; Intravenous antibiotics
. Stage I; Total contact casting and non-weight bearing
. Stage II; Primary arthrodesis of the midfoot
. Stage III; Custom accommodative footwear
. Stage I; Urgent surgical debridement and external fixation

Correct Answer & Explanation

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

Explanation

This clinical and radiographic picture (fragmentation, debris, subluxation) describes Eichenholtz Stage I (Developmental/Fragmentation stage) Charcot arthropathy. The gold standard initial management is immobilization with a total contact cast to prevent further deformity.

Question 2225

Topic: 8. Foot and Ankle

A 40-year-old patient underwent open reduction and internal fixation (ORIF) with syndesmotic screw fixation for an unstable ankle fracture. Postoperatively, malreduction of the syndesmosis is suspected. Which imaging modality and specific anatomical relationship provide the most accurate assessment of syndesmotic reduction?

. Weight-bearing AP radiograph; tibiofibular clear space
. Mortise radiograph; talocrural angle
. Axial CT scan; congruence of the fibula within the incisura fibularis
. Sagittal MRI; integrity of the posterior inferior tibiofibular ligament
. Stress radiograph; medial clear space widening

Correct Answer & Explanation

. Weight-bearing AP radiograph; tibiofibular clear space

Explanation

Axial CT scanning is the gold standard for assessing syndesmotic reduction, as plain radiographs have low sensitivity and specificity for malreduction. The assessment focuses on the anatomical relationship of the fibula centered within the tibial incisura.

Question 2226

Topic: 8. Foot and Ankle

A 45-year-old male presents with dorsal midfoot pain. Examination reveals pain with terminal hallux dorsiflexion but no pain in the mid-range of motion. Radiographs show a dorsal osteophyte on the 1st metatarsal head with relative preservation of the joint space. What is the most appropriate surgical treatment if non-operative management fails?

. First metatarsophalangeal (MTP) joint arthrodesis
. First MTP joint arthroplasty
. Cheilectomy
. Keller resection arthroplasty
. Proximal phalanx extension osteotomy (Moberg)

Correct Answer & Explanation

. Cheilectomy

Explanation

The patient has early-stage hallux rigidus (Coughlin and Shurnas Grade 1 or 2) with pain only at terminal dorsiflexion and preserved joint space. Cheilectomy (removal of the dorsal osteophyte and a portion of the dorsal metatarsal head) is the treatment of choice.

Question 2227

Topic: 8. Foot and Ankle

When comparing operative vs. non-operative management (using a functional rehabilitation protocol) for acute Achilles tendon ruptures, high-level evidence demonstrates which of the following regarding complication rates?

. Operative treatment has a higher rate of re-rupture but a lower rate of wound complications.
. Non-operative treatment has a higher rate of wound complications and a lower rate of re-rupture.
. Operative treatment has a significantly lower rate of re-rupture but a higher rate of overall complications (e.g., wound issues, nerve injury).
. There is no difference in re-rupture or complication rates between the two treatments.
. Non-operative treatment results in significantly decreased plantarflexion strength at 2 years compared to operative treatment.

Correct Answer & Explanation

. Operative treatment has a significantly lower rate of re-rupture but a higher rate of overall complications (e.g., wound issues, nerve injury).

Explanation

Recent meta-analyses indicate that operative management of Achilles ruptures slightly decreases the re-rupture rate compared to traditional non-operative management, but carries a significantly higher risk of complications such as infection and sural nerve injury. With modern functional rehab, functional outcomes and re-rupture rates are very similar.

Question 2228

Topic: Midfoot & Hindfoot
A 30-year-old male falls from a height and sustains a Hawkins Type III talar neck fracture. What best describes the displacement pattern and the approximate risk of avascular necrosis (AVN) of the talar body?
. Undisplaced fracture; <10% AVN risk
. Displacement of the subtalar joint only; 20-50% AVN risk
. Displacement of both the subtalar and tibiotalar joints; nearly 100% AVN risk
. Displacement of the subtalar, tibiotalar, and talonavicular joints; 50% AVN risk
. Extrusion of the talar body; 10-20% AVN risk

Correct Answer & Explanation

. Displacement of both the subtalar and tibiotalar joints; nearly 100% AVN risk

Explanation

A Hawkins Type III fracture is a talar neck fracture with subluxation or dislocation of both the subtalar and tibiotalar joints. Because all three major blood supplies to the talar body are disrupted, the risk of AVN is nearly 100%.

Question 2229

Topic: Midfoot & Hindfoot

A 25-year-old football player sustains a purely ligamentous Lisfranc injury.

Recent prospective randomized trials comparing open reduction internal fixation (ORIF) with primary arthrodesis for this specific injury pattern show which of the following advantages for primary arthrodesis?

. Lower rate of nonunion
. Better preservation of midfoot motion
. Decreased rate of hardware removal and fewer reoperations
. Shorter operative time and less blood loss
. Decreased risk of deep vein thrombosis

Correct Answer & Explanation

. Decreased rate of hardware removal and fewer reoperations

Explanation

For purely ligamentous Lisfranc injuries, level I evidence (e.g., Ly and Coetzee) has demonstrated that primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) results in superior functional outcomes, less need for hardware removal, and fewer reoperations compared to ORIF.

Question 2230

Topic: Midfoot & Hindfoot

In the pathogenesis of adult-acquired flatfoot deformity (posterior tibial tendon dysfunction), failure of static stabilizers occurs sequentially. Which ligamentous structure is considered the primary static stabilizer of the talonavicular joint and is typically the first to fail?

. Plantar fascia
. Long plantar ligament
. Bifurcate ligament
. Superomedial band of the spring ligament
. Inferior extensor retinaculum

Correct Answer & Explanation

. Superomedial band of the spring ligament

Explanation

The spring ligament (plantar calcaneonavicular ligament) complex, specifically the superomedial band, is the primary static stabilizer of the talonavicular joint. Its attenuation or rupture is a critical step in the progression of adult-acquired flatfoot deformity.

Question 2231

Topic: 8. Foot and Ankle
A 24-year-old male presents to the emergency department after a high-energy trauma with a grossly dislocated knee (Schenck KD-III). The knee is reduced in the ED. Pulses are palpable, but the Ankle-Brachial Index (ABI) is 0.85. What is the next most appropriate step in management?
. Immediate application of an external fixator
. Discharge with a knee immobilizer and outpatient MRI
. CT angiography (CTA) of the lower extremity
. Observation with serial ABIs every 4 hours
. Surgical exploration of the popliteal artery

Correct Answer & Explanation

. CT angiography (CTA) of the lower extremity

Explanation

In knee dislocations, an Ankle-Brachial Index (ABI) less than 0.9, even with palpable pulses or normal clinical vascular exam, is highly suspicious for a vascular intimal tear. Immediate advanced imaging with CT angiography (CTA) is mandated to evaluate the popliteal artery.

Question 2232

Topic: 8. Foot and Ankle

The deltoid ligament complex is crucial for medial ankle stability. Which component of the deltoid ligament is the primary restraint to lateral displacement (talar shift) and external rotation of the talus within the ankle mortise?

. Tibionavicular ligament
. Tibiocalcaneal ligament
. Superficial posterior tibiotalar ligament
. Deep anterior tibiotalar ligament
. Deep posterior tibiotalar ligament

Correct Answer & Explanation

. Deep posterior tibiotalar ligament

Explanation

The deep deltoid ligament, particularly the thick deep posterior tibiotalar ligament, is the strongest component of the deltoid complex and is the primary restraint to lateral talar shift and external rotation within the mortise.

Question 2233

Topic: 8. Foot and Ankle

During surgical fixation of a severe acute Lisfranc injury, the surgeon must restore the primary structural stabilizer of the tarsometatarsal articulation. Between which two bones does the true Lisfranc ligament travel?

. Medial cuneiform and base of the 1st metatarsal
. Medial cuneiform and base of the 2nd metatarsal
. Intermediate cuneiform and base of the 2nd metatarsal
. Lateral cuneiform and base of the 3rd metatarsal
. Navicular and medial cuneiform

Correct Answer & Explanation

. Medial cuneiform and base of the 2nd metatarsal

Explanation

The Lisfranc ligament is a stout interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is the largest and strongest ligament of the tarsometatarsal complex.

Question 2234

Topic: 8. Foot and Ankle

A 28-year-old male undergoes open reduction and internal fixation for a Weber C ankle fracture with syndesmotic disruption. Which of the following intraoperative fluoroscopic parameters is the most reliable indicator of accurate syndesmotic reduction?

. Tibiofibular clear space less than 6 mm on the AP view
. Tibiofibular overlap greater than 1 mm on the mortise view
. Medial clear space less than 4 mm on the lateral view
. Talocrural angle of 83 degrees on the mortise view
. Bilateral comparison of the tibiofibular clear space on the mortise view

Correct Answer & Explanation

. Bilateral comparison of the tibiofibular clear space on the mortise view

Explanation

Absolute radiographic measurements for syndesmotic reduction are highly variable due to rotational positioning. Comparison with the contralateral, uninjured ankle is the most reliable radiographic method to assess accurate syndesmotic reduction.

Question 2235

Topic: Forefoot

A 48-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and evidence of hypermobility at the first tarsometatarsal (TMT) joint.

Which surgical intervention is most appropriate?

. Distal chevron osteotomy
. Proximal closing wedge osteotomy
. First TMT joint arthrodesis (Lapidus)
. First metatarsophalangeal joint arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus)

Explanation

A first TMT joint arthrodesis (Lapidus procedure) is indicated for moderate to severe hallux valgus (IMA > 15 degrees) associated with first ray hypermobility. It permanently corrects the IMA and stabilizes the medial column.

Question 2236

Topic: 8. Foot and Ankle

During open reduction and internal fixation of a severe supination-external rotation ankle fracture, you note widening of the syndesmosis on the Cotton test. You decide to place a syndesmotic position screw. Which of the following ligaments provides the greatest resistance to diastasis of the distal tibiofibular syndesmosis?

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

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

The posterior inferior tibiofibular ligament (PITFL) provides the majority (approximately 42%) of the strength of the syndesmotic complex. The AITFL contributes approximately 35%, while the interosseous ligament provides about 22%.

Question 2237

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 42 degrees and an Intermetatarsal Angle (IMA) of 18 degrees. There is no evidence of first tarsometatarsal hypermobility or midfoot arthritis. What is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Akin osteotomy alone
. Proximal metatarsal osteotomy with distal soft tissue release
. First metatarsophalangeal (MTP) joint arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. Proximal metatarsal osteotomy with distal soft tissue release

Explanation

An IMA greater than 13 to 15 degrees is considered severe and typically requires a proximal metatarsal osteotomy (e.g., Ludloff, Scarf) or Lapidus procedure. A distal osteotomy alone is insufficient for this degree of intermetatarsal widening.

Question 2238

Topic: Midfoot & Hindfoot

A 30-year-old male sustains a purely ligamentous Lisfranc injury after falling from a horse. The first, second, and third tarsometatarsal (TMT) joints are diastased. Which of the following surgical treatments yields the best long-term functional outcome for this specific injury pattern?

. Primary arthrodesis of the medial three TMT joints
. Open reduction and internal fixation with transarticular screws
. Closed reduction and percutaneous pinning
. Dorsal bridge plating of the midfoot
. Non-weight-bearing cast immobilization for 8 weeks

Correct Answer & Explanation

. Primary arthrodesis of the medial three TMT joints

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the first, second, and third TMT joints has been shown to have superior functional outcomes and a lower reoperation rate compared to open reduction and internal fixation (ORIF).

Question 2239

Topic: Midfoot & Hindfoot

A 58-year-old male with poorly controlled type 2 diabetes mellitus presents with a swollen, erythematous, and warm right foot without any open ulcers. Plain radiographs are normal. MRI shows diffuse marrow edema in the midfoot. What is the most appropriate initial management?

. Intravenous broad-spectrum antibiotics
. Total contact casting and strict non-weight-bearing
. Midfoot exostectomy
. Primary midfoot arthrodesis
. Surgical debridement and bone biopsy

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

This patient presents with Eichenholtz stage 0 (pre-fragmentation) Charcot arthropathy, characterized by clinical signs of inflammation and MRI edema but normal X-rays. The standard of care is immediate offloading with a total contact cast to prevent deformity.

Question 2240

Topic: 8. Foot and Ankle

When performing a minimally invasive surgical repair of an acute Achilles tendon rupture, care must be taken to avoid injury to the sural nerve. At approximately what distance proximal to the calcaneal insertion does the sural nerve typically cross the lateral border of the Achilles tendon?

. 2 to 3 cm
. 5 to 7 cm
. 9 to 12 cm
. 15 to 17 cm
. 18 to 20 cm

Correct Answer & Explanation

. 9 to 12 cm

Explanation

The sural nerve courses distally in the posterior calf and crosses the lateral border of the Achilles tendon roughly 9 to 12 cm proximal to its calcaneal insertion, making it highly vulnerable during percutaneous or minimally invasive repairs in this zone.

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