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 2241
Topic: 8. Foot and Ankle
A 45-year-old runner complains of burning heel pain that radiates into the medial arch of the foot. Examination reveals a positive Tinel's sign posterior to the medial malleolus, and dorsiflexion-eversion exacerbates the symptoms. Which nerve is entrapped in this condition?
Correct Answer & Explanation
. Posterior tibial nerve
Explanation
This patient has tarsal tunnel syndrome, caused by the entrapment or compression of the posterior tibial nerve (or its branches) as it passes beneath the flexor retinaculum posterior to the medial malleolus.
Question 2242
Topic: 8. Foot and Ankle
A 35-year-old roofer sustains a severe axial load injury to his heel. Lateral radiographs demonstrate a depressed intra-articular calcaneus fracture. In a normal, uninjured foot, what is the expected range for Böhler's angle?
Correct Answer & Explanation
. 20 to 40 degrees
Explanation
Böhler's angle is formed by the intersection of a line drawn from the highest point of the anterior process to the highest point of the posterior facet, and a line from the posterior facet to the superior tuberosity. Its normal range is 20 to 40 degrees.
Question 2243
Topic: 8. Foot and Ankle
A 28-year-old skier presents with acute pain behind the lateral malleolus after catching his edge. He reports a snapping sensation on the lateral side of his ankle when dorsiflexing and everting his foot against resistance. Disruption of which anatomical structure is primarily responsible for his symptoms?
Correct Answer & Explanation
. Superior peroneal retinaculum (SPR)
Explanation
The patient is describing peroneal tendon subluxation, which is typically caused by forced dorsiflexion and eversion leading to a tear or avulsion of the superior peroneal retinaculum (SPR) from the posterior lateral malleolus.
Question 2244
Topic: 8. Foot and Ankle
A 24-year-old athlete sustains a hyperplantarflexion injury to the midfoot. Non-weight-bearing radiographs are normal, but weight-bearing views show a 3 mm diastasis between the base of the first and second metatarsals with no fractures. What is the most appropriate management?
Correct Answer & Explanation
. Open reduction and internal fixation or primary arthrodesis
Explanation
This patient has a purely ligamentous Lisfranc injury, which implies instability. Operative management (ORIF or primary arthrodesis) is indicated for any diastasis greater than 2 mm to prevent chronic pain and post-traumatic arthritis.
Question 2245
Topic: Forefoot
A 45-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle of 42 degrees, an intermetatarsal angle of 18 degrees, and clinical hypermobility of the first tarsometatarsal joint. Which of the following procedures is most appropriate?
Correct Answer & Explanation
. First tarsometatarsal arthrodesis (Lapidus procedure)
Explanation
A Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA > 15 degrees) combined with first ray hypermobility, as it addresses both the large deformity and the instability at the apex.
Question 2246
Topic: 8. Foot and Ankle
A 58-year-old male with poorly controlled diabetes presents with a swollen, warm, and erythematous right foot. Radiographs demonstrate early fragmentation of the midfoot with subluxation and bony debris. According to the Eichenholtz classification, what is the current stage and most appropriate management?
Correct Answer & Explanation
. Stage 1; total contact casting and non-weight-bearing
Explanation
Eichenholtz Stage 1 (development/fragmentation) is characterized by acute inflammation, bony fragmentation, and joint subluxation. The gold standard treatment is offloading with a total contact cast until the acute inflammatory phase resolves.
Question 2247
Topic: Forefoot
When performing an olecranon osteotomy for the surgical management of an intra-articular distal humerus fracture (AO/OTA type 13C), what is the optimal shape of the osteotomy to maximize stability and surface area for healing?
Correct Answer & Explanation
. Chevron osteotomy with the apex directed proximally
Explanation
A chevron osteotomy with the apex directed proximally is preferred because it increases the surface area for healing and provides intrinsic rotational stability compared to a transverse osteotomy. It should be directed into the 'bare area' of the greater sigmoid notch, where there is naturally less articular cartilage.
Question 2248
Topic: Forefoot
When performing an olecranon osteotomy for exposure of a complex distal humerus fracture, what type of osteotomy provides the best stability and surface area for subsequent repair?
Correct Answer & Explanation
. Chevron osteotomy with the apex pointing distally
Explanation
A chevron osteotomy with the apex pointing distally (into the ulnar shaft) provides superior rotational stability and a larger surface area for healing compared to a transverse osteotomy. It should be performed at the bare area of the greater sigmoid notch.
Question 2249
Topic: 8. Foot and Ankle
Os naviculare is present in which percentage of normal feet?
Correct Answer & Explanation
. 10% to 14%
Explanation
Accessory navicular is found in 10% to 14% of normal feet, is generally asymptomatic, and involves 3 radiographic types. Type I represents a small ossicle embedded within the posterior tibial tendon, type II is larger with a synchondrosis, and type III is fused to the navicular tuberosity. Approximately 50% of patients with symptoms have flexible flatfoot; however, os naviculare is not directly associated with pes planovalgus deformity.
Question 2250
Topic: 8. Foot and Ankle
Figure 26 shows the clinical photograph of a patient who has developed a residual limb ulcer following a traumatic transtibial amputation 2 years ago. What is the preferred treatment to resolve the ulcer?
Correct Answer & Explanation
. Perform local wound care in conjunction with modification of the prosthetic socket and cushioned liner.
Explanation
The first step in the treatment of an amputation residual limb (stump) ulcer is local wound care and adjustment of the residual limb-prosthetic interface, as well as adjusting prosthetic alignment. Surgical revision should be undertaken only when prosthetic modification is unsuccessful.
Question 2251
Topic: 8. Foot and Ankle
Which surgical procedure should be considered for treatment of chronic plantar fasciitis?
Correct Answer & Explanation
. Endoscopic or open plantar fasciotomy
Explanation
Surgical treatment is indicated for fewer than 5% of patients. It is not necessary to resect the heel spur because the spur is not attached to the plantar fascia and rarely contributes to a patient's pain. The open extensile approach is associated with a much longer recovery than the open or endoscopic approaches and is no longer justified. Multiple studies have demonstrated the efficacy of endoscopic and open plantar fasciotomy techniques.
Question 2252
Topic: 8. Foot and Ankle
A 28-year-old male is brought to the emergency department after a high-speed motorcycle collision. He is diagnosed with a KD III multi-ligament knee injury. His foot is warm and pink, with palpable but diminished dorsalis pedis and posterior tibial pulses. The Ankle-Brachial Index (ABI) of the injured extremity is measured at 0.82, while the contralateral side is 1.0. What is the most appropriate next step in management?
Correct Answer & Explanation
. CT angiography of the lower extremity
Explanation
Current guidelines for the management of suspected vascular injury following knee dislocation recommend measuring the Ankle-Brachial Index (ABI). An ABI of less than 0.90 is highly sensitive and specific for an arterial injury requiring intervention, and warrants an immediate CT angiogram (CTA). Immediate surgical exploration is indicated for 'hard signs' of vascular injury, such as absent pulses, active hemorrhage, expanding hematoma, or distal ischemia. Serial ABIs are appropriate only if the initial ABI is > 0.90.
Question 2253
Topic: Midfoot & Hindfoot
A 32-year-old male sustains a high-energy axial load injury to his foot resulting in a Hawkins Type III fracture of the talar neck. Based on the Hawkins classification system, which specific joints are disrupted in this injury pattern?
Correct Answer & Explanation
. Subtalar and tibiotalar joints
Explanation
The Hawkins classification of talar neck fractures predicts the risk of avascular necrosis based on the degree of dislocation. Type I is a nondisplaced fracture. Type II is a displaced fracture with subluxation or dislocation of the subtalar joint (the tibiotalar and talonavicular joints remain congruent). Type III is a displaced fracture with dislocation of both the subtalar and tibiotalar joints (the talar body extrudes, often posteriorly). Type IV (added by Canale and Kelly) involves dislocation of the subtalar, tibiotalar, and talonavicular joints.
Question 2254
Topic: 8. Foot and Ankle
A 52-year-old male presents with a severely displaced, intra-articular calcaneus fracture (Sanders Type III) after falling from a ladder. His past medical history is significant for poorly controlled Type 2 Diabetes Mellitus (HbA1c 9.5%), peripheral neuropathy, and smoking 2 packs of cigarettes per day. His soft tissues are significantly swollen with fracture blisters over the lateral hindfoot. What is the most appropriate management strategy for this patient?
Correct Answer & Explanation
. Non-operative management featuring cast-free early range of motion exercises and strict non-weight-bearing
Explanation
This patient possesses multiple severe risk factors for devastating soft tissue complications following an extensile lateral approach to the calcaneus, specifically heavy smoking and uncontrolled diabetes with neuropathy. In such high-risk patients, the incidence of wound necrosis, deep infection, and subsequent amputation following operative fixation is unacceptably high. Therefore, conservative management is indicated. The preferred non-operative protocol involves early, aggressive range of motion exercises without casting (to maximize subtalar mobility) and strict non-weight-bearing until clinical and radiographic healing occurs.
Question 2255
Topic: 8. Foot and Ankle
A 28-year-old male presents with a grossly deformed knee following a motorcycle crash. Plain radiographs reveal an anterior knee dislocation (KD-III). Following closed reduction, his dorsalis pedis and posterior tibial pulses are palpable and symmetric to the contralateral side. An Ankle-Brachial Index (ABI) is measured at 0.82. What is the most appropriate next step in management?
Correct Answer & Explanation
. Computed tomography angiography (CTA) of the lower extremity
Explanation
In the setting of a knee dislocation, vascular assessment is critical. While palpable pulses are reassuring, an ABI < 0.9 is highly sensitive for an occult arterial injury and mandates further advanced vascular imaging, most commonly a CT angiogram (CTA). Immediate surgical exploration is reserved for hard signs of vascular injury (e.g., absent pulses after reduction, expanding hematoma, pulsatile bleeding).
Question 2256
Topic: 8. Foot and Ankle
A 40-year-old male sustains an acute, traumatic knee dislocation (KD-IV) complicated by an incomplete common peroneal nerve palsy at presentation. Pulses are symmetric and ABI is 1.0. What is the expected prognosis of this specific nerve injury, and what is the most appropriate initial management?
Correct Answer & Explanation
. Poor prognosis for any recovery; immediate primary nerve repair is indicated
Explanation
Common peroneal nerve palsy following knee dislocation is typically a high-grade traction injury. While incomplete lesions have a better prognosis than complete lesions, overall functional recovery remains variable and frequently poor (about 20-40% full recovery). Initial management consists of observation, physical therapy to prevent contractures, and an AFO. Tendon transfers or nerve grafting are generally reserved for persistent deficits at 6 to 12 months.
Question 2257
Topic: 8. Foot and Ankle
The dorsal digital cutaneous nerve of the great toe shown in Figure 8 is a branch of what nerve?
Correct Answer & Explanation
. Medial branch of the superficial peroneal
Explanation
The dorsal digital cutaneous nerve of the great toe is a branch of the medial branch of the superficial peroneal nerve. The deep peroneal nerve supplies the first web space.
Question 2258
Topic: 8. Foot and Ankle
A B D … C E F G
Correct Answer & Explanation
. Talocalcaneal (TC) middle facet coalition
Explanation
The question refers to the 'anteater nose' sign or 'C-sign' associated with tarsal coalitions. A talocalcaneal middle facet coalition is often associated with the C-sign on lateral radiographs.
Question 2259
Topic: 8. Foot and Ankle
An orthotic that provides laterally based hindfoot posting support would be most useful for which of the following conditions? Review Topic
Correct Answer & Explanation
. Flexible cavovarus foot
Explanation
Lateral support in the form of hindfoot posting would be most beneficial for a patient with a flexible cavovarus foot.Cavovarus feet may be seen in multiple conditions, including Charcot-Marie-Tooth disease. The initial deformity is plantarflexion of the first ray, which is often followed by compensatory hindfoot varus. In flexible deformities, orthotics that post the lateral forefoot and lateral heel should be utilized.Schwend et al. review the etiology, diagnosis and management of the cavus foot in children. They note that shoe inserts with lateral support can be used in patients when there is flexibility to the hindfoot. Recession of the orthotic to accommodate a plantarflexed first ray is also beneficial.Illustration A shows an orthotic with lateral foot posting and a recessed area for the first metatarsal head. Illustration B shows an AP radiograph of the left foot demonstrative of an accessory navicular. This may be associated with a flatfoot deformity. Illustration C shows a lateral radiograph of a right foot with a middle facet coalition. This may give rise to a rigid, painful flatfoot deformity. Illustration D shows a lateral radiograph of a right foot with collapse of the medial longitudinal arch. This patient had a flexible flatfoot that was painful. Illustration E shows an AP radiograph of a left foot with evidence of metatarsus adductus. Note the alignment of the 2nd metatarsal axis relative to the proximal articular surface of the middle cuneiform. In this case, the metatarsus adductus angle (MAA) was 24 degrees (normal is < 20 degrees).Incorrect Answers:
Question 2260
Topic: 8. Foot and Ankle
A 30-year-old male sustains a Hawkins Type III talar neck fracture (fracture with subtalar and tibiotalar dislocation). Which of the following vessels provides the primary blood supply to the talar body and is almost universally disrupted in this injury pattern?
Correct Answer & Explanation
. Artery of the tarsal canal
Explanation
The talus has a tenuous, retrograde blood supply. The artery of the tarsal canal (a branch of the posterior tibial artery) supplies the majority of the talar body. In a Hawkins III fracture, the anastomotic vessels in the tarsal canal, sinus tarsi, and superior neck are disrupted, leading to a near 100% rate of avascular necrosis of the talar body.
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