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 2261
Topic: Ankle Trauma & Sports
A 50-year-old male sustains a severe pilon fracture. The preoperative CT scan demonstrates a large, displaced anterolateral distal tibial articular fragment (the Tillaux-Chaput fragment). Which of the following ligaments remains attached to this fragment and often dictates its displacement?
Correct Answer & Explanation
. Anterior inferior tibiofibular ligament (AITFL)
Explanation
The Tillaux-Chaput fragment is the anterolateral articular fragment of the distal tibia seen in pilon or transitional ankle fractures. It serves as the primary tibial attachment site for the Anterior Inferior Tibiofibular Ligament (AITFL). Its corresponding fibular avulsion counterpart is the Wagstaffe-Le Fort fragment.
Question 2262
Topic: 8. Foot and Ankle
A 45-year-old diabetic male with Charcot neuroarthropathy presents with a chronic foot ulcer and suspected osteomyelitis of the calcaneus. X-rays are inconclusive due to preexisting bony destruction. What is the most accurate nuclear imaging modality for confirming chronic osteomyelitis in this setting?
Correct Answer & Explanation
. Indium-111 labeled white blood cell scan combined with Technetium-99m sulfur colloid marrow scan
Explanation
In cases of distorted bony anatomy like Charcot arthropathy, a combined leukocyte (WBC) and marrow scan is the most specific nuclear imaging modality. It differentiates true infection (discordant increased WBC uptake) from reactive marrow changes (concordant uptake).
Question 2263
Topic: 8. Foot and Ankle
A 40-year-old construction worker sustains a displaced intra-articular calcaneus fracture (Sanders Type III). Which of the following is the most significant intraoperative factor determining the long-term clinical outcome after open reduction and internal fixation?
Correct Answer & Explanation
. Quality of the posterior facet articular reduction
Explanation
The anatomical reduction of the posterior facet articular surface is the most critical prognostic factor for functional outcomes. Failure to reduce the facet accurately significantly increases the risk of post-traumatic subtalar arthritis.
Question 2264
Topic: Midfoot & Hindfoot
A 25-year-old male sustains a severe inversion injury resulting in a Hawkins Type III talar neck fracture. What does this classification imply regarding the fracture displacement and the blood supply to the talar body?
Correct Answer & Explanation
. Displacement of the subtalar and tibiotalar joints; very high risk of AVN
Explanation
A Hawkins Type III fracture involves a talar neck fracture with dislocation of both the subtalar and tibiotalar joints. It carries a very high risk of avascular necrosis (frequently >80%) due to massive disruption of the talar body blood supply.
Question 2265
Topic: 8. Foot and Ankle
In evaluating a patient with a suspected intra-articular calcaneus fracture, lateral radiographs are obtained to measure Böhler's angle. Which of the following accurately describes the two lines used to construct this angle?
Correct Answer & Explanation
. A line from the highest point of the anterior process to the highest point of the posterior facet, and a line from the highest point of the posterior facet to the superior edge of the tuberosity
Explanation
Böhler's angle is measured on a lateral radiograph of the foot/calcaneus. It is formed by the intersection of two lines: one line drawn from the highest point of the anterior process to the highest point of the posterior facet, and a second line drawn from the highest point of the posterior facet to the highest point of the posterior tuberosity. The normal angle is 20 to 40 degrees. It is typically flattened (decreased) in intra-articular calcaneus fractures.
Question 2266
Topic: 8. Foot and Ankle
A 35-year-old male sustains a high-energy injury resulting in a displaced talar neck fracture with associated dislocation of the subtalar, tibiotalar, and talonavicular joints. According to the Hawkins classification, what is the type of fracture and the approximate risk of developing avascular necrosis (AVN) of the talar body?
Correct Answer & Explanation
. Hawkins Type II; 20-50% risk of AVN
Explanation
The Hawkins classification for talar neck fractures: Type I is nondisplaced (0-10% AVN). Type II is displaced with subtalar dislocation (20-50% AVN). Type III is displaced with both subtalar and tibiotalar dislocation (50-100% AVN). Type IV involves displacement with subtalar, tibiotalar, and talonavicular dislocation. A Type IV fracture virtually obliterates all extraosseous blood supply to the talus (artery of the tarsal canal, artery of the tarsal sinus, and deltoid branches), carrying a risk of AVN approaching 80-100%.
Question 2267
Topic: 8. Foot and Ankle
Regarding the evaluation of a mangled lower extremity and the decision between amputation and limb salvage, which of the following statements best reflects the findings of the Lower Extremity Assessment Project (LEAP) study?
Correct Answer & Explanation
. No single predictive scoring system (e.g., MESS, LSI) accurately predicts whether limb salvage or amputation will yield better functional outcomes.
Explanation
The landmark LEAP study demonstrated that traditional scoring systems (MESS, LSI, PSI) have low sensitivity and predictive value for determining the functional outcome of a mangled extremity. Furthermore, an initially insensate plantar foot does not preclude a good outcome with salvage, as sensation often returns. The study found no significant long-term difference in functional outcomes between the salvage and amputation groups, underscoring that no single score can dictate treatment; decisions must be highly individualized.
Question 2268
Topic: 8. Foot and Ankle
A 55-year-old patient is seeking a surgical consultation for a painful flatfoot deformity that has failed to respond to nonsteroidal anti-inflammatory drugs, shoe and activity modifications, and orthoses. The patient is of medium build, a nonsmoker, and has no history of diabetes mellitus. Radiographs are shown in Figures 43a through 43c. Based on these findings, treatment should consist of
Correct Answer & Explanation
. midfoot arthrodesis.
Explanation
The patient has a degenerative collapse of the midfoot through the tarsometatarsal joints with significant forefoot abduction; therefore, a midfoot arthrodesis is required to address the arthritic joints and deformity at the tarsometatarsal articulation. All of the other procedures correct hindfoot deformities and therefore would not be appropriate treatment.
Question 2269
Topic: 8. Foot and Ankle
A 35-year-old man who snowboards sustained the injury shown in Figures 4a through 4c. What is the mechanism of injury?
Correct Answer & Explanation
. Dorsiflexion, axial loading, inversion, and external rotation
Explanation
Fractures of the lateral process of the talus in snowboarders have been thought to result from pure dorsiflexion, inversion, and axial loading. In a cadaveric study, 10 cadavers were placed in fixed dorsiflexion and inversion with an axial load. This was combined with or without external rotation. No fractures occurred after axial loading in the dorsiflexed-inverted position. Fractures of the lateral process of the talus occurred in 75% of the specimens with the addition of external rotation.
Question 2270
Topic: 8. Foot and Ankle
In a patient with Charcot-Marie-Tooth (CMT) disease presenting with a progressive cavovarus foot deformity, which of the following specific muscle imbalances is the primary biomechanical driver of the hindfoot varus deformity?
Correct Answer & Explanation
. Strong peroneus brevis overpowering a weak tibialis posterior
Explanation
The cavovarus foot deformity in CMT is driven by specific muscle imbalances. The tibialis posterior and peroneus longus muscles are typically spared and relatively strong, whereas the tibialis anterior, peroneus brevis, and intrinsic muscles become weak. The hindfoot varus is primarily driven by the strong tibialis posterior overpowering the weak peroneus brevis. The forefoot cavus (plantarflexed first ray) is driven by the strong peroneus longus overpowering the weak tibialis anterior.
Question 2271
Topic: Midfoot & Hindfoot
A 28-year-old athlete sustains a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal joints. High-quality randomized controlled trials comparing primary arthrodesis of the medial three rays to open reduction and internal fixation (ORIF) for this specific injury pattern show primary arthrodesis is associated with which of the following?
Correct Answer & Explanation
. Lower rate of secondary surgeries
Explanation
For purely ligamentous Lisfranc injuries, primary arthrodesis of the medial three rays (first, second, and third TMT joints) has been shown to yield equivalent or better functional outcomes compared to ORIF, while significantly decreasing the rate of secondary surgeries (due to hardware removal or subsequent salvage arthrodesis for post-traumatic arthritis).
Question 2272
Topic: 8. Foot and Ankle
Recent meta-analyses evaluating operative versus nonoperative management of acute Achilles tendon ruptures utilizing modern, accelerated functional rehabilitation protocols demonstrate which of the following?
Correct Answer & Explanation
. There is no clinically significant difference in re-rupture rates between the two groups
Explanation
When modern functional rehabilitation protocols (early weight-bearing and early functional range of motion) are strictly employed, the re-rupture rates between operative and nonoperative management of acute Achilles tendon ruptures are not statistically different. Operative management is associated with a higher risk of soft tissue complications, such as infection and sural nerve injury.
Question 2273
Topic: Midfoot & Hindfoot
A 30-year-old male sustains a high-energy motor vehicle collision resulting in a Hawkins Type III talar neck fracture. By definition, which of the following joints are dislocated in this injury pattern, and what is the classic historical rate of avascular necrosis (AVN) of the talar body?
Correct Answer & Explanation
. Subtalar and tibiotalar joints; nearly 100% AVN risk
Explanation
The Hawkins classification for talar neck fractures: Type I is nondisplaced (0-15% AVN). Type II involves subluxation or dislocation of the subtalar joint (20-50% AVN). Type III involves dislocation of both the subtalar and tibiotalar joints (historically associated with a nearly 100% risk of AVN, though modern series report 70-100%). Type IV adds talonavicular joint dislocation.
Question 2274
Topic: 8. Foot and Ankle
A 55-year-old female is diagnosed with Stage IIB adult acquired flatfoot deformity (posterior tibial tendon dysfunction). Clinical examination reveals a flexible deformity with marked hindfoot valgus and significant forefoot abduction (uncovering of the talar head >40%). In addition to a flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO), which adjunctive procedure is most indicated to specifically correct the transverse plane (abduction) deformity?
Correct Answer & Explanation
. Lateral column lengthening (Evans osteotomy)
Explanation
Stage IIB adult acquired flatfoot deformity is characterized by a flexible deformity with significant forefoot abduction (transverse plane deformity). While an MDCO corrects the coronal plane (valgus) deformity, a lateral column lengthening (such as an Evans calcaneal osteotomy) is specifically indicated to correct the substantial transverse plane abduction by effectively lengthening the lateral column and rotating the midfoot back over the talus.
Question 2275
Topic: 8. Foot and Ankle
Osteochondral lesions of the talus frequently occur in distinct anatomical patterns associated with specific mechanisms of injury. Which of the following accurately describes the classical morphological characteristics and mechanism of a medial talar dome lesion?
Correct Answer & Explanation
. Posterior location, deep and cup-shaped, caused by plantarflexion and inversion
Explanation
The classical mnemonic for osteochondral lesions of the talus is 'DIAL a PIMP'. DIAL: Dorsiflexion Inversion = Anterior Lateral lesions (which are typically shallow and wafer-shaped). PIMP: Plantarflexion Inversion = Medial Posterior lesions (which are typically deep and cup-shaped). Therefore, medial lesions are characteristically posterior, deep/cup-shaped, and result from plantarflexion and inversion.
Question 2276
Topic: 8. Foot and Ankle
A 52-year-old male runner presents with dorsal foot pain and limited great toe dorsiflexion. Radiographs reveal moderate dorsal osteophytes and mild joint space narrowing at the first metatarsophalangeal (MTP) joint, consistent with Grade 2 hallux rigidus (Coughlin and Shurnas classification). He has 25 degrees of active dorsiflexion. Which of the following is the most appropriate initial surgical intervention if nonoperative management fails?
Correct Answer & Explanation
. Dorsal cheilectomy
Explanation
Grade 2 hallux rigidus features mild to moderate joint space narrowing, dorsal osteophytes, and preserved plantar cartilage with some maintained range of motion (>15-20 degrees dorsiflexion). If conservative measures fail, a dorsal cheilectomy (removal of the dorsal osteophytes and dorsal 20-30% of the metatarsal head) is the procedure of choice. Arthrodesis is reserved for Grade 3 (severe narrowing) or Grade 4 (pain throughout the entire range of motion).
Question 2277
Topic: 8. Foot and Ankle
The primary biomechanical stability of the Lisfranc complex relies heavily on the Lisfranc ligament. Which of the following accurately describes the anatomic origin and insertion of this critical structure?
Correct Answer & Explanation
. Plantar-lateral aspect of the medial cuneiform to the plantar-medial base of the second metatarsal
Explanation
The Lisfranc ligament is the strongest ligament in the midfoot, originating on the plantar-lateral aspect of the medial cuneiform and inserting on the plantar-medial aspect of the second metatarsal base. There is no direct ligamentous connection between the bases of the first and second metatarsals.
Question 2278
Topic: Midfoot & Hindfoot
A 52-year-old female is diagnosed with Stage IIB posterior tibial tendon dysfunction (PTTD), demonstrating a flexible flatfoot with severe forefoot abduction and greater than 30% talonavicular uncoverage on radiographs. In addition to a flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO), what additional procedure is biomechanically required to correct her specific deformity?
Correct Answer & Explanation
. Evans lateral column lengthening
Explanation
Stage IIB PTTD involves a flexible flatfoot with significant forefoot abduction (talonavicular uncoverage >30%). An Evans lateral column lengthening is required in addition to MDCO and FDL transfer to effectively correct the severe forefoot abduction.
Question 2279
Topic: 8. Foot and Ankle
At 6 weeks post-injury, a 28-year-old patient who underwent open reduction and internal fixation for a Hawkins Type II talar neck fracture undergoes routine follow-up radiographs. A distinct subchondral radiolucent band is noted in the dome of the talus. What is the clinical significance of this radiographic finding?
Correct Answer & Explanation
. It demonstrates subchondral osteopenia, which confirms intact vascularity to the talar dome
Explanation
The subchondral radiolucent band is known as Hawkins' sign. It represents subchondral osteopenia due to bone resorption, which is a physiologic process that can only occur if the vascular supply to the talar dome remains intact, making it a reliable negative predictor for AVN.
Question 2280
Topic: 8. Foot and Ankle
Recent high-quality, randomized controlled trials comparing operative versus non-operative management of acute Achilles tendon ruptures demonstrate which of the following regarding complication rates when patients undergo early functional rehabilitation?
Correct Answer & Explanation
. Non-operative management with early functional weight-bearing has an equivalent re-rupture rate to operative repair.
Explanation
Modern literature, notably the WILL trial and similar studies, shows that when early functional rehabilitation protocols are utilized, the re-rupture rates between operative and non-operative management of Achilles tendon ruptures are statistically equivalent.
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