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8. Foot and Ankle MCQs

Practice Set 118 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 2341

Topic: 8. Foot and Ankle

A 58-year-old man with a 15-year history of poorly controlled type II diabetes presents with a unilaterally red, hot, and swollen left foot. He denies trauma. Radiographs reveal fragmentation, periarticular debris, and subluxation of the midfoot joints. He is afebrile with normal inflammatory markers. What is the most appropriate initial treatment?

. Total contact casting
. Intravenous antibiotics and surgical debridement
. Primary midfoot arthrodesis
. Below-knee amputation
. Custom orthotics and rigid sole shoe

Correct Answer & Explanation

. Total contact casting

Explanation

This patient has acute Eichenholtz Stage I Charcot neuroarthropathy. The mainstay of initial treatment for the acute, active phase is rigid immobilization and offloading, most effectively achieved with total contact casting (TCC).

Question 2342

Topic: Forefoot

Six months after undergoing a distal chevron osteotomy and modified McBride procedure for hallux valgus, a 45-year-old woman complains of pain and a deformity in the opposite direction. Examination reveals a flexible hallux varus deformity. Non-operative measures have failed. What is the most appropriate surgical treatment?

. First metatarsophalangeal joint arthrodesis
. Closing wedge osteotomy of the medial proximal phalanx
. Release of the medial capsule and abductor hallucis
. Extensor hallucis brevis (EHB) transfer and medial capsular release
. Flexor hallucis longus to extensor hallucis longus transfer

Correct Answer & Explanation

. Extensor hallucis brevis (EHB) transfer and medial capsular release

Explanation

For a flexible, iatrogenic hallux varus without degenerative joint changes, treatment involves medial soft tissue release and reconstruction of the lateral stabilizing structures, typically using an EHB tendon transfer.

Question 2343

Topic: 8. Foot and Ankle

A 64-year-old male presents with end-stage post-traumatic ankle osteoarthritis and is considering a total ankle arthroplasty (TAA). Which of the following is considered an absolute contraindication to performing a TAA?

. Age greater than 60 years
. Previous hardware in the distal tibia
. Body mass index of 28
. Osteoarthritis of the subtalar joint
. Charcot neuroarthropathy of the ankle joint

Correct Answer & Explanation

. Charcot neuroarthropathy of the ankle joint

Explanation

Absolute contraindications to total ankle arthroplasty include Charcot neuroarthropathy, active infection, severe uncorrectable malalignment, and absent lower extremity sensation. Subtalar arthritis is actually a relative indication for TAA over ankle fusion to preserve remaining hindfoot motion.

Question 2344

Topic: Forefoot

A 42-year-old male construction worker presents with severe pain and stiffness in his right great toe. Examination reveals palpable dorsal osteophytes and less than 10 degrees of dorsiflexion at the first MTP joint. Radiographs show joint space narrowing, subchondral sclerosis, and large dorsal osteophytes (Coughlin and Shurnas Grade 3 hallux rigidus). What is the most reliable surgical treatment for this patient?

. Dorsal cheilectomy
. First metatarsophalangeal joint arthrodesis
. First metatarsophalangeal joint hemiarthroplasty
. Moberg osteotomy
. Keller resection arthroplasty

Correct Answer & Explanation

. First metatarsophalangeal joint arthrodesis

Explanation

For young, active patients or heavy laborers with advanced (Grade 3 or 4) hallux rigidus, first MTP joint arthrodesis is the gold standard. It provides reliable pain relief and durability that arthroplasty or cheilectomy cannot match in this demographic.

Question 2345

Topic: 8. Foot and Ankle
A 30-year-old man sustains a high-energy motor vehicle collision resulting in a talar neck fracture with posterior dislocation of the talar body (Hawkins Type III). Which of the following arteries provides the predominant blood supply to the talar body and is disrupted in this injury?
. Artery of the tarsal canal
. Artery of the tarsal sinus
. Dorsalis pedis artery
. Peroneal artery
. Anterior tibial artery

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, supplies the majority of the talar body. In a Hawkins Type III fracture, the blood supply from the neck, sinus tarsi, and tarsal canal are all disrupted, leading to a near 100% rate of avascular necrosis.

Question 2346

Topic: 8. Foot and Ankle

A 28-year-old warehouse worker sustains a purely ligamentous Lisfranc injury involving the medial three tarsometatarsal joints. The injury is closed and neurovascularly intact, but radiographs show 3 mm of diastasis between the first and second metatarsal bases. What is the preferred surgical management?

. Closed reduction and percutaneous pinning (CRPP)
. Primary arthrodesis of the medial three TMT joints
. Open reduction and internal fixation with transarticular screws
. Dorsal bridge plating without joint preparation
. Suture button suspensionplasty isolated to the first webspace

Correct Answer & Explanation

. Primary arthrodesis of the medial three TMT joints

Explanation

Current literature demonstrates that purely ligamentous Lisfranc injuries treated with ORIF have unacceptably high rates of hardware failure and post-traumatic arthritis. Primary arthrodesis of the medial columns yields superior long-term functional outcomes.

Question 2347

Topic: Ankle Trauma & Sports
A 25-year-old gymnast undergoes a modified Broström-Gould procedure for chronic lateral ankle instability after failing extensive physical therapy. Which anatomical structure is advanced and sutured to the fibula to augment the primary repair in the 'Gould' modification?
. Peroneus brevis tendon
. Peroneus tertius tendon
. Inferior extensor retinaculum
. Superior peroneal retinaculum
. Plantaris tendon

Correct Answer & Explanation

. Inferior extensor retinaculum

Explanation

The standard Broström procedure involves direct anatomic repair of the ATFL and CFL. The Gould modification augments this repair by mobilizing the inferior extensor retinaculum and anchoring it to the distal fibula to reinforce the lateral complex.

Question 2348

Topic: 8. Foot and Ankle

During a minimally invasive percutaneous repair of an acute Achilles tendon rupture, the surgeon places percutaneous sutures proximally. Which nerve is at the greatest risk of iatrogenic injury during this proximal suture placement?

. Tibial nerve
. Sural nerve
. Superficial peroneal nerve
. Saphenous nerve
. Deep peroneal nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve crosses from medial to lateral posterior to the calf, sitting lateral to the Achilles tendon approximately 10 cm proximal to its insertion. It is highly susceptible to entrapment or injury during percutaneous or minimally invasive Achilles repair.

Question 2349

Topic: 8. Foot and Ankle

A 16-year-old female dancer complains of localized pain and swelling at the plantar aspect of her second metatarsophalangeal joint. Radiographs reveal sclerosis, flattening, and early fragmentation of the second metatarsal head. What is the diagnosis?

. Morton's neuroma
. Turf toe
. Freiberg's infraction
. Sesamoiditis
. Iselin's disease

Correct Answer & Explanation

. Freiberg's infraction

Explanation

Freiberg's infraction is avascular necrosis of the metatarsal head, most commonly affecting the second metatarsal in adolescent females (often dancers or athletes). It presents with localized pain, stiffness, and characteristic flattening of the articular surface.

Question 2350

Topic: 8. Foot and Ankle

A 55-year-old patient with long-standing diabetes presents with a swollen, erythematous, and warm unilateral foot and ankle. Radiographs reveal periarticular debris, fragmentation, and subluxation of the midfoot joints. What is the most appropriate initial management?

. Intravenous antibiotics and bone biopsy
. Total contact casting and non-weight bearing
. Open reduction and internal fixation
. Midfoot arthrodesis
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

This patient is in the acute fragmentation phase (Stage 1) of Eichenholtz Charcot arthropathy. The gold standard initial treatment is offloading with a total contact cast to prevent further deformity.

Question 2351

Topic: 8. Foot and Ankle
A 45-year-old woman presents with medial ankle pain and a progressively collapsing arch. Examination shows a flexible hindfoot valgus and inability to perform a single-leg heel rise. Radiographs demonstrate >50% uncovering of the talar head. Which of the following surgical interventions is most appropriate?
. Flexor digitorum longus transfer and medial displacement calcaneal osteotomy alone
. Flexor digitorum longus transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Subtalar arthrodesis
. Triple arthrodesis
. Spring ligament repair alone

Correct Answer & Explanation

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

Explanation

This represents Stage IIb adult acquired flatfoot deformity (AAFD), characterized by greater than 50% talonavicular uncovering indicating significant forefoot abduction. Treatment requires a lateral column lengthening (e.g., Evans osteotomy) in addition to FDL transfer and medial calcaneal osteotomy.

Question 2352

Topic: Forefoot

A 35-year-old woman presents with a painful bunion. Clinical examination reveals hypermobility of the first tarsometatarsal (TMT) joint. Radiographs show a hallux valgus angle of 45 degrees and an intermetatarsal angle of 18 degrees. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. First TMT arthrodesis (Lapidus procedure)
. First MTP arthrodesis
. Keller arthroplasty

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for moderate to severe hallux valgus associated with first ray hypermobility. It provides powerful correction of the intermetatarsal angle and stabilizes the medial column.

Question 2353

Topic: 8. Foot and Ankle

A 24-year-old professional football player sustains a purely ligamentous Lisfranc injury. Weight-bearing radiographs show 3 mm of widening between the first and second metatarsal bases. What is the most appropriate definitive management?

. Non-weight bearing cast for 6 weeks
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with screws
. Primary arthrodesis of the first, second, and third TMT joints
. Open reduction and tightrope fixation

Correct Answer & Explanation

. Primary arthrodesis of the first, second, and third TMT joints

Explanation

Recent evidence supports primary arthrodesis for purely ligamentous Lisfranc injuries, especially in active patients, due to lower rates of hardware failure and secondary procedures compared to ORIF. Purely bony injuries are typically managed with ORIF.

Question 2354

Topic: 8. Foot and Ankle

During the physical examination of a patient with a cavovarus foot deformity, the Coleman block test is performed. The hindfoot varus corrects to neutral when the lateral aspect of the foot is placed on the block while the first ray is allowed to drop off. This finding indicates that the hindfoot varus is:

. Fixed and requires a calcaneal osteotomy
. Driven by a plantarflexed first ray
. Caused by isolated subtalar joint arthritis
. Secondary to a contracted Achilles tendon
. Driven by a rigid midfoot abduction deformity

Correct Answer & Explanation

. Driven by a plantarflexed first ray

Explanation

The Coleman block test evaluates the flexibility of hindfoot varus in a cavovarus foot. If the hindfoot corrects when the plantarflexed first ray is allowed to drop off the block, the hindfoot varus is flexible and forefoot-driven, indicating the need for a dorsiflexion osteotomy of the first metatarsal.

Question 2355

Topic: Forefoot

A 62-year-old man presents with severe pain and stiffness in his right great toe. Examination shows less than 10 degrees of dorsiflexion and pain throughout the entire arc of motion. Radiographs reveal complete loss of joint space and large dorsal, medial, and lateral osteophytes at the first MTP joint. Which treatment offers the most reliable long-term pain relief?

. First MTP joint cheilectomy
. Moberg osteotomy
. First MTP joint arthrodesis
. Silicone implant arthroplasty
. Resection arthroplasty (Keller procedure)

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

This patient has Grade 4 hallux rigidus (pain throughout ROM, complete joint space loss). Arthrodesis is the gold standard for end-stage hallux rigidus, providing the most reliable long-term pain relief and functional improvement.

Question 2356

Topic: 8. Foot and Ankle

Which of the following is considered an absolute contraindication to a total ankle arthroplasty?

. Contralateral ankle arthrodesis
. End-stage osteoarthritis
. Severe peripheral neuropathy with absent protective sensation
. Age greater than 70 years
. Inflammatory arthritis

Correct Answer & Explanation

. Severe peripheral neuropathy with absent protective sensation

Explanation

Severe peripheral neuropathy (e.g., Charcot arthropathy) is an absolute contraindication to total ankle arthroplasty due to the high risk of catastrophic failure and infection. Inflammatory arthritis is actually a classic indication for TAA.

Question 2357

Topic: 8. Foot and Ankle

A 28-year-old dancer reports a recurrent snapping sensation over her lateral ankle. Examination reveals palpable subluxation of the peroneal tendons over the distal fibula with resisted eversion. Surgical exploration is most likely to reveal an injury to which of the following structures?

. Anterior talofibular ligament
. Calcaneofibular ligament
. Superior peroneal retinaculum
. Inferior extensor retinaculum
. Cervical ligament

Correct Answer & Explanation

. Superior peroneal retinaculum

Explanation

Peroneal tendon subluxation is primarily caused by an injury or incompetence of the superior peroneal retinaculum (SPR). Surgical treatment typically involves SPR repair and often deepening of the fibular retromalleolar groove.

Question 2358

Topic: Midfoot & Hindfoot

A 52-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. Clinical examination reveals an inability to perform a single-leg heel rise and forefoot abduction with "too many toes" visible from behind. Weight-bearing radiographs show greater than 50% talonavicular uncoverage but no arthritic changes in the hindfoot or midfoot. Which of the following is the most appropriate surgical management?

. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy (MDCO) only
. FDL transfer to the navicular, MDCO, and a lateral column lengthening
. Gastrocnemius recession and isolated FDL transfer
. Subtalar arthrodesis
. Triple arthrodesis

Correct Answer & Explanation

. FDL transfer to the navicular, MDCO, and a lateral column lengthening

Explanation

This patient has Stage IIB adult-acquired flatfoot deformity (posterior tibial tendon dysfunction), characterized by flexible hindfoot valgus and significant forefoot abduction (>40% or >50% talonavicular uncoverage). Surgical correction requires FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening to address the abduction.

Question 2359

Topic: 8. Foot and Ankle

A 24-year-old man with Charcot-Marie-Tooth disease presents with a painful cavovarus foot deformity. On examination, the hindfoot varus corrects to neutral when the patient stands with the lateral border of his foot on a block and the first ray suspended off the medial edge (Coleman block test). What is the primary anatomic driver of his hindfoot deformity, and what is the indicated bony procedure?

. Plantarflexed first ray; dorsiflexing first metatarsal osteotomy
. Weak peroneus brevis; lateralizing calcaneal osteotomy
. Tight Achilles tendon; triple arthrodesis
. Overactive tibialis posterior; subtalar arthrodesis
. Rigid hindfoot varus; closing wedge calcaneal osteotomy

Correct Answer & Explanation

. Plantarflexed first ray; dorsiflexing first metatarsal osteotomy

Explanation

A positive Coleman block test (hindfoot corrects to neutral) indicates a flexible hindfoot driven by a rigid, plantarflexed first ray. A dorsiflexing osteotomy of the first metatarsal is required to correct the forefoot-driven hindfoot varus deformity.

Question 2360

Topic: 8. Foot and Ankle

A 22-year-old collegiate football player sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial cuneiform and the base of the second metatarsal. He wishes to maximize his chances of returning to his pre-injury level of performance while minimizing the risk of post-traumatic arthritis. Which of the following treatments is most supported by recent literature for this specific injury pattern?

. Non-weight bearing cast immobilization for 8 weeks
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Open reduction and internal fixation (ORIF) with transarticular screws
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with a dorsal spanning plate

Correct Answer & Explanation

. Primary arthrodesis of the first, second, and third tarsometatarsal joints

Explanation

Studies (such as Ly and Coetzee) have demonstrated that primary arthrodesis for purely ligamentous Lisfranc injuries yields superior functional outcomes and lower rates of secondary surgeries compared to traditional ORIF.

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