Menu

8. Foot and Ankle MCQs

Practice Set 117 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 2321

Topic: 8. Foot and Ankle

Figures 25a through 25c show the radiographs, including a stress radiograph, of a 58-year-old woman who twisted her ankle on a step. She has no history of diabetes or vascular disease. Examination reveals a closed injury with moderate swelling about the ankle. Her neurologic examination is normal. She has a strong dorsalis pedis pulse and tenderness over the lateral malleolus and the medial side of her ankle. What is the most appropriate management? Review Topic

. MRI scan of the ankle
. Non-weight-bearing cast for 6 weeks
. Removable walking boot and progressive weight bearing
. Open reduction and internal fixation of the fibula
. Open reduction and internal fixation of the fibula with medial ligament repair

Correct Answer & Explanation

. Removable walking boot and progressive weight bearing

Explanation

The patient has a lateral malleolus fracture with an ankle mortise that is stable to a stress examination; therefore, surgical treatment is not indicated. In a stable lateral malleolus fracture, strict non-weight-bearing is not necessary, and a removable walking boot or walking cast can be used along with progressive weight bearing. The presence of tenderness or swelling medially at the ankle has been shown to be a poor indicator of medial-sided injury. The clinical utility of MRI scans in ankle fractures is controversial. Studies have used MRI scans to evaluate the competence of the deltoid ligament and have shown that the ligament may remain intact even with an increased medial clear space on a stress examination. In the patient, the stress examination does not show talar subluxation so the deltoid ligament is not incompetent.

Question 2322

Topic: 8. Foot and Ankle
A 25-year-old competitive skier sustains a twisting injury to the right ankle while skiing. She is unable to continue the activity secondary to severe lateral ankle pain. Examination reveals ecchymosis and fullness over the lateral malleolus with pain and weakness on active ankle dorsiflexion and external rotation. There is no medial-sided pain. Neurovascular examination is normal. An AP radiograph and MRI scan are shown in Figures 17a and 17b, respectively. Management should consist of
. ice, elevation, and progressive weight bearing as tolerated.
. a walking boot for 6 weeks.
. a short leg non-weight-bearing cast for 6 weeks.
. temporary syndesmotic screw fixation.
. repair of the peroneal retinaculum.

Correct Answer & Explanation

. repair of the peroneal retinaculum.

Explanation

The MRI scan shows a dislocated peroneus brevis tendon with disruption of the peroneal retinaculum. This injury is commonly seen in skiers and is the result of peroneal contraction with the ankle everted and dorsiflexed. Nonsurgical management is rarely successful; therefore, repair of the peroneal retinaculum is the treatment of choice.

Question 2323

Topic: 8. Foot and Ankle
A 28-year-old male sustains a high-energy knee dislocation (KD-III) that is reduced in the ER. His distal pulses are palpable, but the ankle-brachial index (ABI) is 0.85. What is the most appropriate next step in management?
. Immediate surgical exploration of the popliteal artery
. Observation with serial clinical exams every 4 hours
. CT angiography of the lower extremity
. Application of a spanning external fixator and discharge
. Duplex ultrasonography in 24 hours

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

In the setting of a knee dislocation, an ABI less than 0.9 indicates a high suspicion for vascular injury despite palpable pulses. A CT angiogram is the gold standard next step to evaluate for a popliteal artery intimal tear or occlusion.

Question 2324

Topic: 8. Foot and Ankle
A 34-year-old male sustains a Hawkins Type III talar neck fracture following a motor vehicle collision. Which of the following is the predominant blood supply to the talar body that is most consistently disrupted in this fracture pattern?
. Branches from the dorsalis pedis artery
. The artery of the tarsal sinus
. The artery of the tarsal canal
. Deltoid branches of the posterior tibial artery
. Perforating branches of the peroneal artery

Correct Answer & Explanation

. The artery of the tarsal canal

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, is the predominant blood supply to the body of the talus. It forms an anastomotic sling with the artery of the tarsal sinus (from the dorsalis pedis/anterior tibial artery). In a Hawkins Type III fracture (talar neck fracture with subtalar and tibiotalar dislocation), the artery of the tarsal canal, artery of the tarsal sinus, and often the deltoid branches are all disrupted, leading to a near 100% rate of avascular necrosis.

Question 2325

Topic: 8. Foot and Ankle

When evaluating a comminuted intra-articular calcaneus fracture to determine surgical strategy, the Sanders classification is utilized based on computed tomography (CT) imaging. Which anatomical structure determines the primary classification lines in this system?

. The subtalar joint anterior facet
. The subtalar joint middle facet
. The subtalar joint posterior facet
. The calcaneocuboid joint
. The sustentaculum tali

Correct Answer & Explanation

. The subtalar joint posterior facet

Explanation

The Sanders classification is based on the coronal CT section that displays the widest aspect of the posterior facet of the calcaneus. The posterior facet is divided into three columns by two lines, creating potential for 4 pieces (A, B, C, and the sustentacular fragment). The number and location of fracture lines through the posterior facet dictate the Sanders type (I through IV).

Question 2326

Topic: Midfoot & Hindfoot

A 22-year-old collegiate athlete sustains a purely ligamentous Lisfranc injury. Based on level I prospective randomized literature comparing primary arthrodesis versus open reduction and internal fixation (ORIF) for this specific injury type, what is a documented advantage of primary arthrodesis?

. Significantly lower rate of early deep infection
. Better short-term range of motion at the midfoot
. Decreased rate of secondary surgeries and hardware removal
. Faster time to full weight-bearing by 4 weeks
. Superior preservation of the subtalar joint mechanics

Correct Answer & Explanation

. Decreased rate of secondary surgeries and hardware removal

Explanation

Multiple studies (e.g., Ly and Coetzee, JBJS Am 2006) have demonstrated that for purely ligamentous Lisfranc injuries, primary arthrodesis of the medial 2 or 3 rays yields better functional outcomes (higher AOFAS scores) and significantly lower rates of secondary procedures compared to ORIF. Patients treated with ORIF often require hardware removal and later salvage arthrodesis due to post-traumatic arthritis.

Question 2327

Topic: 8. Foot and Ankle

A 26-year-old professional rugby player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs demonstrate a 3 mm diastasis between the base of the first and second metatarsals. The primary stabilizing ligament of this articulation originates on the lateral aspect of the medial cuneiform and inserts on which of the following structures?

. The base of the first metatarsal
. The base of the third metatarsal
. The base of the second metatarsal
. The navicular bone
. The middle cuneiform

Correct Answer & Explanation

. The base of the second metatarsal

Explanation

The Lisfranc ligament is an incredibly strong interosseous ligament that is the primary stabilizer of the tarsometatarsal joint complex. It originates from the lateral surface of the medial cuneiform and inserts distally and laterally onto the medial aspect of the base of the second metatarsal.

Question 2328

Topic: 8. Foot and Ankle

The majority of the blood supply to the body of the talus is provided by which of the following vessels?

. Artery of the sinus tarsi
. Artery of the tarsal canal
. Anterior tibial artery branches
. Deltoid branch of the posterior tibial artery
. Peroneal artery perforators

Correct Answer & Explanation

. Artery of the tarsal canal

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 neck and supplies the majority of the middle and lateral portions of the talar body. The artery of the sinus tarsi provides collateral supply, but is not the dominant contributor.

Question 2329

Topic: Midfoot & Hindfoot

In the management of Lisfranc injuries, prospective randomized trials have demonstrated that primary arthrodesis provides superior functional outcomes and lower reoperation rates compared to open reduction and internal fixation (ORIF) for which specific subset of patients?

. Bony Lisfranc injuries with large fracture fragments
. Purely ligamentous Lisfranc injuries of the first, second, and third tarsometatarsal joints
. Lisfranc injuries in pediatric patients
. Lisfranc injuries involving the fourth and fifth tarsometatarsal joints exclusively
. Lisfranc injuries presenting greater than 24 hours after trauma

Correct Answer & Explanation

. Purely ligamentous Lisfranc injuries of the first, second, and third tarsometatarsal joints

Explanation

Multiple landmark studies (e.g., Ly and Coetzee) have shown that for purely ligamentous Lisfranc injuries, primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) yields significantly better functional outcomes and lower rates of secondary surgeries (for hardware removal or salvage arthrodesis due to post-traumatic arthritis) compared to ORIF. The 4th and 5th TMT joints should remain mobile.

Question 2330

Topic: 8. Foot and Ankle

During an extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, a full-thickness soft tissue flap must be carefully elevated directly off the periosteum. Which of the following arteries is the primary blood supply to this large, delicate lateral flap?

. Dorsalis pedis artery
. Medial plantar artery
. Lateral calcaneal artery (branch of the peroneal artery)
. Medial calcaneal artery (branch of the posterior tibial artery)
. Anterior lateral malleolar artery

Correct Answer & Explanation

. Lateral calcaneal artery (branch of the peroneal artery)

Explanation

The lateral calcaneal artery, which is a terminal branch of the peroneal artery, supplies the angiosome of the lateral hindfoot. During an extensile lateral approach to the calcaneus, a full-thickness 'no-touch' flap containing the sural nerve, peroneal tendons, and the lateral calcaneal artery must be elevated subperiosteally to preserve its blood supply and minimize the high risk of wound necrosis.

Question 2331

Topic: 8. Foot and Ankle

A 26-year-old male sustains a midfoot injury during a rugby tackle. On physical examination, plantar ecchymosis is present. Radiographs demonstrate subtle widening between the 1st and 2nd metatarsal bases. The primary ligament ruptured in this injury pattern connects which two osseous structures?

. Medial cuneiform and the base of the 2nd metatarsal
. Lateral cuneiform and the base of the 2nd metatarsal
. Navicular and the base of the 1st metatarsal
. Medial cuneiform and the base of the 1st metatarsal
. Cuboid and the base of the 4th metatarsal

Correct Answer & Explanation

. Medial cuneiform and the base of the 2nd metatarsal

Explanation

Plantar ecchymosis is highly suggestive of a Lisfranc injury. The Lisfranc ligament is an interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal.

Question 2332

Topic: 8. Foot and Ankle
A 40-year-old female is brought in after an MVC with an obviously deformed knee. Radiographs reveal a complete anterior knee dislocation (KD-III). After closed reduction, she has palpable dorsalis pedis and posterior tibial pulses with brisk capillary refill. The Ankle-Brachial Index (ABI) is measured at 0.85. What is the mandatory next step in management?
. Apply a hinged knee brace and observe
. Perform serial vascular examinations every 4 hours
. Obtain immediate CT angiography of the lower extremity
. Order an urgent MRI of the knee to evaluate ligamentous injury
. Take the patient directly to the OR for popliteal artery exploration

Correct Answer & Explanation

. Obtain immediate CT angiography of the lower extremity

Explanation

In knee dislocations, an ABI < 0.9 is highly sensitive for a clinically significant vascular injury, even in the presence of palpable pulses (which can be present via collaterals or intimal flaps). This finding mandates advanced vascular imaging with a CT angiogram.

Question 2333

Topic: 8. Foot and Ankle
A patient with a below-the-knee amputation is being evaluated for a new prosthesis. He wants to improve his ability to walk on uneven surfaces. What modification to the prosthesis can be made to accommodate this request?
. Shorten the keel
. Lengthen the keel
. Change the keel to a split keel
. Change to a solid ankle, cushioned heel (SACH)
. Change to carbon fiber

Correct Answer & Explanation

. Change the keel to a split keel

Explanation

Changing from a solid keel to a keel with a sagittal split allows an amputee to navigate uneven terrain more easily. Changing the length of the keel affects the responsiveness of the prosthesis but does not address the surface conditions for ambulation. The SACH is not used as frequently anymore, because overload problems to the nonamputated foot have been observed.

Question 2334

Topic: 8. Foot and Ankle
Figure 24 shows the arthroscopic view of a patient with ankle impingement syndrome. This is commonly seen after high ankle sprains and represents fibrotic granulation thickening of what structure?
. Talar dome fragment
. Deltoid ligament
. Anterior inferior tibiofibular ligament
. Os trigonum
. Spring ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament

Explanation

Discussion: Chronic anterior inferior tibiofibular ligament sprains can lead to thickening and synovitis that catches or impinges dorsiflexion; patients often note painful clicking with dorsiflexion eversion. The other structures are not affected by this injury.

Question 2335

Topic: Forefoot
The Keller proximal phalanx resection procedure is most useful for which of the following conditions?
. Mild bunion deformity in a 35-year-old woman
. Severe bunion deformity in a patient with rheumatoid arthritis
. Recurrent juvenile bunion deformity
. Plantar neuropathic ulcer of the great toe
. Bunion deformity associated with a hypermobile first tarsometatarsal joint

Correct Answer & Explanation

. Plantar neuropathic ulcer of the great toe

Explanation

Discussion: A Keller proximal phalanx resection procedure usually results in reduced weight bearing under the first ray because of shortening of the toe and disruption of intrinsic flexor function. This can be an effective method of offloading a neuropathic ulcer under the great toe at the interphalangeal or metatarsophalangeal joint area. However, these features are generally undesirable in young active patients. The procedure has a high rate of recurrent deformity in patients with rheumatoid arthritis. It would exacerbate transfer metatarsalgia in a patient with a hypermobile first ray.

Question 2336

Topic: Midfoot & Hindfoot

A 52-year-old woman presents with medial foot pain and a progressive flatfoot deformity. On examination, she has a flexible hindfoot valgus and is unable to perform a single-leg heel raise. Weight-bearing radiographs reveal 50% uncoverage of the talar head on the AP view. Which of the following surgical interventions is most appropriate for this patient?

. Flexor digitorum longus transfer and medial displacement calcaneal osteotomy
. Gastrocnemius recession and isolated talonavicular arthrodesis
. Triple arthrodesis
. Flexor digitorum longus transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Primary subtalar arthrodesis with spring ligament repair

Correct Answer & Explanation

. Flexor digitorum longus transfer, medial displacement calcaneal osteotomy, and lateral column lengthening

Explanation

This patient has Stage IIB adult acquired flatfoot deformity, distinguished from Stage IIA by >40% talonavicular uncoverage (forefoot abduction). The addition of a lateral column lengthening to the FDL transfer and medial calcaneal osteotomy addresses this abduction deformity.

Question 2337

Topic: 8. Foot and Ankle

A 14-year-old boy presents with a rigid, painful flatfoot and a history of recurrent ankle sprains. Computed tomography scans reveal a talocalcaneal coalition involving 60% of the posterior facet. There are no degenerative changes in the surrounding joints. What is the most appropriate definitive management?

. Resection of the coalition with fat pad interposition
. Resection of the coalition with extensor digitorum brevis interposition
. Subtalar arthrodesis
. Triple arthrodesis
. Medial displacement calcaneal osteotomy

Correct Answer & Explanation

. Subtalar arthrodesis

Explanation

Resection of a talocalcaneal coalition is generally contraindicated if it involves >50% of the posterior facet due to the high risk of continued pain and joint instability. Isolated subtalar arthrodesis is the treatment of choice in this scenario.

Question 2338

Topic: Forefoot

A 65-year-old woman presents with severe bunion pain. Radiographs show a hallux valgus angle of 45 degrees, an intermetatarsal angle of 18 degrees, and obvious plantar gapping at the first tarsometatarsal (TMT) joint on the lateral weight-bearing view indicating hypermobility. Which of the following procedures is most appropriate?

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

Correct Answer & Explanation

. Lapidus procedure (First TMT arthrodesis)

Explanation

The Lapidus procedure (first TMT fusion) is indicated for severe hallux valgus, especially in the presence of first ray hypermobility. It provides powerful correction of the intermetatarsal angle and stabilizes the medial column.

Question 2339

Topic: 8. Foot and Ankle

A 22-year-old man with Charcot-Marie-Tooth disease presents with a progressive cavovarus foot deformity. A Coleman block test demonstrates that the hindfoot varus corrects to neutral when the first ray is allowed to drop off the block. What is the primary deforming force driving this patient's foot deformity?

. Plantarflexed first ray driven by an overactive peroneus longus
. Hindfoot varus driven by an overactive tibialis posterior
. Forefoot adduction driven by a contracted Achilles tendon
. Midfoot cavus driven by an overactive extensor hallucis longus
. Hindfoot varus driven by an overactive tibialis anterior

Correct Answer & Explanation

. Plantarflexed first ray driven by an overactive peroneus longus

Explanation

In Charcot-Marie-Tooth, the peroneus longus overpowers the weak tibialis anterior, causing a rigidly plantarflexed first ray. The Coleman block test proves the hindfoot varus is flexible and secondary to this forefoot deformity.

Question 2340

Topic: 8. Foot and Ankle

A 55-year-old man requires surgical intervention for chronic, recalcitrant insertional Achilles tendinopathy. Intraoperatively, extensive calcific degeneration requires debridement of 60% of the Achilles tendon insertion. Which of the following is the most appropriate next step in management?

. Direct repair of the remaining tendon using suture anchors
. V-Y fractional lengthening of the gastrocnemius
. Flexor hallucis longus (FHL) tendon transfer
. Flexor digitorum longus (FDL) tendon transfer
. Free tissue transfer with sural nerve graft

Correct Answer & Explanation

. Flexor hallucis longus (FHL) tendon transfer

Explanation

When >50% of the Achilles tendon insertion is debrided for insertional tendinopathy, augmentation is required to prevent rupture and restore plantarflexion strength. Flexor hallucis longus (FHL) transfer is the gold standard for this augmentation.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page