Menu

8. Foot and Ankle MCQs

Practice Set 119 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 2361

Topic: Forefoot

A 28-year-old female runner complains of pain and stiffness localized to the dorsal aspect of her right first metatarsophalangeal (MTP) joint. Radiographs show a dorsal osteophyte but normal joint space width and no central cartilage loss (Grade 1 hallux rigidus). Nonoperative management has failed. Which of the following is the most appropriate surgical option?

. Keller arthroplasty
. Silastic implant arthroplasty
. First MTP joint arthrodesis
. Dorsal cheilectomy
. Proximal phalanx extension osteotomy (Moberg) alone

Correct Answer & Explanation

. Dorsal cheilectomy

Explanation

Dorsal cheilectomy is the surgical treatment of choice for early-stage (Grades 1 and 2) hallux rigidus with preserved joint space and pain primarily with dorsiflexion. It reliably relieves pain and preserves joint motion.

Question 2362

Topic: Forefoot

A 55-year-old woman presents with a painful bunion deformity. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 42 degrees, an intermetatarsal angle (IMA) of 18 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate to provide long-term correction?

. Distal chevron osteotomy
. Akin osteotomy
. Lapidus procedure (first TMT arthrodesis)
. Keller resection arthroplasty
. First MTP joint arthrodesis

Correct Answer & Explanation

. Lapidus procedure (first TMT arthrodesis)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus deformities (IMA > 15 degrees) and is especially preferred when there is concurrent first TMT joint hypermobility or arthritis.

Question 2363

Topic: 8. Foot and Ankle

A 14-year-old boy presents with a rigid, flat foot and recurrent ankle sprains. Computed tomography (CT) confirms a talocalcaneal coalition involving the middle facet, which comprises approximately 30% of the posterior subtalar joint surface. There are no signs of subtalar osteoarthritis. What is the most appropriate initial surgical intervention after conservative measures fail?

. Subtalar arthrodesis
. Resection of the coalition with soft tissue interposition
. Triple arthrodesis
. Calcaneal lengthening osteotomy
. Medial displacement calcaneal osteotomy

Correct Answer & Explanation

. Resection of the coalition with soft tissue interposition

Explanation

Resection with interposition (fat or tendon) is indicated for talocalcaneal coalitions involving less than 50% of the joint surface without degenerative changes. Arthrodesis is reserved for larger coalitions (>50%) or cases with significant arthritis.

Question 2364

Topic: 8. Foot and Ankle

During open reduction and internal fixation of a pronation-external rotation ankle fracture, a positive Cotton test confirms syndesmotic instability. The surgeon chooses to use flexible suture-button fixation rather than rigid syndesmotic screws. Based on current literature, what is the primary advantage of the suture-button construct?

. Decreased need for hardware removal and lower rates of malreduction
. Shorter required non-weight-bearing period postoperatively
. Elimination of the risk of late syndesmotic widening
. Lower material cost and shorter operative time
. Superior resistance to pure axial loading forces

Correct Answer & Explanation

. Decreased need for hardware removal and lower rates of malreduction

Explanation

Suture-button constructs permit physiologic motion of the syndesmosis, which leads to lower rates of required hardware removal and has been shown to reduce the incidence of syndesmotic malreduction compared to rigid screw fixation.

Question 2365

Topic: 8. Foot and Ankle

A 64-year-old man with poorly controlled type 2 diabetes mellitus and profound peripheral neuropathy sustains a displaced bimalleolar ankle fracture. What specialized surgical modification is strongly recommended in this patient population to prevent catastrophic postoperative complications such as Charcot arthropathy or fixation failure?

. Use of bioabsorbable fixation instead of metallic hardware
. Utilization of single 3.5mm one-third tubular plates with monocortical screws
. Augmented fixation (e.g., multiple syndesmotic screws, locking plates) and a prolonged non-weight-bearing period
. Immediate full weight-bearing in a total contact cast post-ORIF
. Primary below-knee amputation

Correct Answer & Explanation

. Augmented fixation (e.g., multiple syndesmotic screws, locking plates) and a prolonged non-weight-bearing period

Explanation

Diabetic patients with neuropathy have significantly higher rates of hardware failure and Charcot arthropathy following ankle fractures. Standard protocols recommend "maximized" augmented fixation constructs and doubling the standard duration of non-weight-bearing.

Question 2366

Topic: 8. Foot and Ankle
  • Chronic flatfoot deformity is most commonly associated with a contracture of the
. Plantar fascia
. Spring ligament
. Deltoid ligament
. Intrinsic tendons
. Gastorcnemius-solelus complex

Correct Answer & Explanation

. Gastorcnemius-solelus complex

Explanation

According to Mann a contracted Achilles tendon that limits dorsiflexion is the underlying pathology behind symptomatic (rigid) flatfoot. Due to chronic Achilles contracture there is over time attenuation of the spring ligament with progressive rocker bottom deformity.Deltoid ligament, plantar fascia, or intrinsic tendon contracture would not cause this deformity.

Question 2367

Topic: 8. Foot and Ankle

A 28-year-old male sustains a severe open right ankle injury following a motorcycle collision. In the emergency department, it is noted that his talus has been completely extruded and is missing. It is later recovered by paramedics at the scene. The talus is grossly intact but contaminated with soil. According to current orthopaedic trauma evidence, what is the most appropriate definitive management of the extruded talus?

. Immediate primary talectomy and tibiocalcaneal arthrodesis
. Talectomy, temporary antibiotic spacer, and delayed arthrodesis
. Rigorous sequential irrigation, debridement, and reimplantation
. Boiling the talus for 15 minutes followed by reimplantation
. Discarding the talus and performing a primary below-knee amputation

Correct Answer & Explanation

. Rigorous sequential irrigation, debridement, and reimplantation

Explanation

Historically, complete extrusion of the talus was treated with primary talectomy due to high expected rates of infection and avascular necrosis. However, modern evidence supports rigorous decontamination (copious sequential irrigation and debridement) followed by reimplantation. Multiple recent case series have demonstrated lower-than-expected rates of deep infection and clinically significant AVN, making reimplantation a viable and favored salvage option.

Question 2368

Topic: 8. Foot and Ankle

The lateral extensile approach to the calcaneus utilizes an L-shaped incision. The blood supply to the vulnerable corner of this full-thickness flap is primarily derived from which of the following arteries?

. Medial calcaneal artery
. Lateral calcaneal artery
. Sural artery
. Anterior tibial artery
. Perforating peroneal artery

Correct Answer & Explanation

. Lateral calcaneal artery

Explanation

The lateral calcaneal artery, a branch of the peroneal artery, supplies the critical corner of the L-shaped extensile lateral flap. Injury to this vessel during dissection significantly increases the risk of wound edge necrosis.

Question 2369

Topic: Midfoot & Hindfoot

In a purely ligamentous Lisfranc injury, which of the following treatments has been shown in prospective randomized trials to yield superior functional outcomes and lower reoperation rates?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation (ORIF)
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Conservative management in a non-weight-bearing cast
. Primary arthrodesis of all five tarsometatarsal joints

Correct Answer & Explanation

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

Explanation

Prospective randomized trials have demonstrated that primary arthrodesis of the medial column (1st-3rd TMT joints) for purely ligamentous Lisfranc injuries provides superior long-term functional outcomes compared to ORIF. ORIF has a higher rate of hardware failure and post-traumatic arthritis in purely ligamentous variants.

Question 2370

Topic: Ankle Trauma & Sports

A 28-year-old rugby player undergoes ORIF of a pronation-external rotation (PER) ankle fracture. Intraoperatively, the syndesmosis remains unstable after fibular fixation and requires screw fixation. Which of the following variables is the most significant predictor of poor long-term functional outcome?

. Using two syndesmotic screws instead of one
. Malreduction of the syndesmosis prior to fixation
. Retaining the screw beyond 12 weeks postoperatively
. Screw breakage within the syndesmosis prior to removal
. Using 3.5mm instead of 4.5mm screws

Correct Answer & Explanation

. Malreduction of the syndesmosis prior to fixation

Explanation

Accurate anatomical reduction of the distal tibiofibular syndesmosis is the single most critical factor determining long-term functional outcomes in syndesmotic injuries. Malreduction alters tibiotalar contact stresses, leading to early onset of post-traumatic osteoarthritis.

Question 2371

Topic: Midfoot & Hindfoot

A 24-year-old male sustains a purely ligamentous Lisfranc injury and is considering surgical intervention. Compared to primary arthrodesis, which of the following statements accurately characterizes open reduction and internal fixation (ORIF) for this specific injury pattern?

. Lower rate of subsequent hardware removal procedures
. Higher rate of return to pre-injury elite sporting activity
. Higher rate of post-traumatic osteoarthritis requiring secondary fusion
. Superior anatomical alignment on postoperative weight-bearing CT
. Shorter necessary period of postoperative immobilization

Correct Answer & Explanation

. Higher rate of post-traumatic osteoarthritis requiring secondary fusion

Explanation

Prospective studies (such as Coetzee and Ly) have shown that purely ligamentous Lisfranc injuries treated with ORIF have a high rate of post-traumatic arthritis requiring secondary midfoot fusion. Primary arthrodesis is increasingly favored for purely ligamentous variants to improve long-term outcomes and limit secondary surgeries.

Question 2372

Topic: Midfoot & Hindfoot

A 55-year-old female presents with progressive medial foot pain and a flatfoot deformity. Examination reveals a flexible hindfoot valgus and an inability to perform a single-leg heel rise. Weight-bearing radiographs demonstrate talonavicular uncoverage of 60%. Which of the following surgical strategies is most appropriate?

. FDL transfer to the navicular and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and lateral column lengthening
. Subtalar arthrodesis
. Triple arthrodesis
. Gastrocnemius recession alone

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

The patient has Stage IIb adult-acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage II indicates a flexible deformity. Stage IIa has minimal forefoot abduction, typically managed with FDL transfer and MDCO. Stage IIb is characterized by significant forefoot abduction (talonavicular uncoverage > 40-50%). Addition of a lateral column lengthening (e.g., Evans osteotomy) to the FDL transfer and MDCO is necessary to correct the severe forefoot abduction.

Question 2373

Topic: 8. Foot and Ankle

A 52-year-old male with poorly controlled diabetes presents with a swollen, erythematous, and warm right foot. He denies trauma. Radiographs show periarticular debris, joint subluxation, and fragmentation of the tarsometatarsal joints. According to the Eichenholtz classification, what is the optimal treatment at this stage?

. Immediate open reduction and internal fixation of the midfoot
. Total contact casting and non-weight-bearing
. Intravenous antibiotics and surgical debridement
. Primary midfoot arthrodesis
. Hindfoot nail stabilization

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation phase) of Charcot neuroarthropathy, characterized by acute inflammation, erythema, joint subluxation, and bony fragmentation. The standard of care for acute Stage I Charcot is immobilization in a total contact cast and strict non-weight-bearing to prevent further deformity until the acute inflammatory phase resolves (transition to Stage II - Coalescence). Surgery in the acute inflammatory phase carries high rates of failure and complication.

Question 2374

Topic: 8. Foot and Ankle
A 24-year-old male sustains a Hawkins Type III talar neck fracture. Which of the following arteries provides the majority of the blood supply to the body of the talus, placing it at highest risk for avascular necrosis in this injury pattern?
. Anterior tibial artery
. Artery of the tarsal canal
. Artery of the tarsal sinus
. Deltoid branch of the posterior tibial artery
. Dorsalis pedis artery

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, is the dominant blood supply to the body of the talus. It forms an anastomotic sling with the artery of the tarsal sinus (from the anterior tibial/dorsalis pedis and peroneal arteries). In a Hawkins Type III fracture (talar neck fracture with subluxation/dislocation of both the subtalar and tibiotalar joints), the major blood supplies are disrupted, leading to an AVN risk approaching 80-100%.

Question 2375

Topic: 8. Foot and Ankle

When assessing a patient with a lower extremity deformity, the mechanical axis deviation (MAD) is measured. Which of the following accurately describes the relationship between the mechanical and anatomic axes of the normal femur and tibia?

. The femoral anatomic axis is 5-7 degrees valgus to the mechanical axis; the tibial anatomic axis is parallel to its mechanical axis.
. The femoral anatomic axis is parallel to its mechanical axis; the tibial anatomic axis is 5-7 degrees varus to its mechanical axis.
. The femoral anatomic axis is 5-7 degrees varus to the mechanical axis; the tibial anatomic axis is parallel to its mechanical axis.
. Both the femoral and tibial anatomic axes are parallel to their respective mechanical axes.
. Both the femoral and tibial anatomic axes are 5-7 degrees valgus to their respective mechanical axes.

Correct Answer & Explanation

. The femoral anatomic axis is 5-7 degrees valgus to the mechanical axis; the tibial anatomic axis is parallel to its mechanical axis.

Explanation

In a normal lower extremity, the mechanical axis of the femur runs from the center of the femoral head to the center of the knee. The anatomic axis of the femur runs down the intramedullary canal, meaning it is typically 5 to 7 degrees valgus relative to the mechanical axis. For the tibia, the mechanical and anatomic axes are normally parallel (or co-linear), running from the center of the knee down the intramedullary canal to the center of the ankle.

Question 2376

Topic: 8. Foot and Ankle

A 45-year-old male presents with a neglected Achilles tendon rupture that occurred 4 months ago. On examination, he has a palpable gap of 6 cm and profound plantarflexion weakness. The surgeon decides to perform an open reconstruction. Which of the following tendon transfers is most commonly utilized to augment this repair?

. Flexor digitorum longus (FDL)
. Flexor hallucis longus (FHL)
. Tibialis anterior
. Peroneus brevis
. Plantaris

Correct Answer & Explanation

. Flexor hallucis longus (FHL)

Explanation

For chronic or neglected Achilles tendon ruptures with a large defect (typically > 5 cm), primary repair is often impossible without excessive tension. Flexor hallucis longus (FHL) tendon transfer is the procedure of choice for augmentation. The FHL is preferred because of its strength (strongest deep plantar flexor), its axis of pull, its proximity to the Achilles, and its phase of contraction (in phase with the triceps surae).

Question 2377

Topic: Midfoot & Hindfoot

A 30-year-old female sustains a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal joints. Which of the following is true regarding the surgical management of this specific injury pattern compared to open reduction and internal fixation (ORIF)?

. Primary arthrodesis is associated with superior functional outcomes and a lower rate of secondary surgeries.
. ORIF has a significantly lower rate of hardware removal.
. Primary arthrodesis results in a higher rate of deep infection.
. ORIF allows for earlier return to impact sports.
. There is no difference in outcomes between ORIF and primary arthrodesis for purely ligamentous injuries.

Correct Answer & Explanation

. Primary arthrodesis is associated with superior functional outcomes and a lower rate of secondary surgeries.

Explanation

Level I evidence (e.g., Ly and Coetzee) has demonstrated that primary arthrodesis of the medial two or three tarsometatarsal joints for purely ligamentous Lisfranc injuries yields superior functional outcomes and requires fewer secondary surgeries compared to ORIF. ORIF in purely ligamentous injuries frequently fails or requires secondary hardware removal, often eventually necessitating a salvage arthrodesis.

Question 2378

Topic: Midfoot & Hindfoot

A 32-year-old male sustains a purely ligamentous Lisfranc injury during a football game. Based on prospective randomized data comparing open reduction internal fixation (ORIF) to primary arthrodesis for purely ligamentous Lisfranc injuries, primary arthrodesis has been shown to have a lower reoperation rate and equivalent or better functional outcomes. If primary arthrodesis is performed, which joints are typically fused?

. Tarsometatarsal joints 1 through 3
. Tarsometatarsal joints 1 through 5
. Naviculocuneiform and calcaneocuboid joints
. Tarsometatarsal joints 2 through 4
. Tarsometatarsal joints 4 and 5

Correct Answer & Explanation

. Tarsometatarsal joints 1 through 3

Explanation

Primary arthrodesis for purely ligamentous Lisfranc injuries typically involves the medial and middle columns (tarsometatarsal joints 1, 2, and 3). The lateral column (TMT 4 and 5) must be preserved and left unfused (or stabilized temporarily with K-wires) to maintain essential forefoot mobility and accommodate uneven ground during the gait cycle.

Question 2379

Topic: Midfoot & Hindfoot

A 55-year-old male with long-standing poorly controlled type 2 diabetes and peripheral neuropathy presents with a red, hot, swollen foot for 3 weeks. He denies any trauma or fever. Radiographs show periarticular osteopenia, fragmentation of the talonavicular joint, and subluxation, but no osteomyelitis. What Eichenholtz stage of Charcot arthropathy is this, and what is the standard initial treatment?

. Stage 0; Immediate open reduction and internal fixation
. Stage 1; Total contact casting and non-weight bearing
. Stage 2; Custom Charcot Restraint Orthotic Walker (CROW) boot
. Stage 3; Midfoot arthrodesis with a beaming technique
. Stage 1; Intravenous antibiotics and surgical debridement

Correct Answer & Explanation

. Stage 1; Total contact casting and non-weight bearing

Explanation

Eichenholtz Stage 1 (development/fragmentation) is characterized clinically by a red, hot, swollen foot and radiographically by periarticular osteopenia, fragmentation, debris formation, and subluxation. The standard of care for acute active Charcot (Stage 0 and Stage 1) is immobilization with a total contact cast (TCC) and restricted weight-bearing to prevent further deformity until the acute inflammatory phase resolves (transition to Stage 2/3).

Question 2380

Topic: 8. Foot and Ankle

A 6-year-old boy is brought to the clinic by his parents due to an in-toeing gait. He frequently sits in a 'W' position. On physical examination, his hips exhibit 85 degrees of internal rotation and 10 degrees of external rotation. The thigh-foot angle is +10 degrees. There is no pain or limitation in activities. What is the most appropriate management?

. Immediate proximal femoral derotation osteotomy
. Denis Browne night splinting
. Reassurance and observation
. Medial hamstring lengthening
. Distal tibial derotation osteotomy

Correct Answer & Explanation

. Reassurance and observation

Explanation

The clinical picture describes classic increased femoral anteversion, common in children ages 3-6. The thigh-foot angle is normal (+10 degrees), ruling out tibial torsion. The vast majority of cases resolve spontaneously by age 8-10 as normal derotation occurs with growth. Reassurance and observation is the standard of care. Bracing and special shoes are ineffective. Surgery (proximal femoral osteotomy) is rarely indicated, and only for severe, symptomatic cases in children over age 8-10.

Test Yourself

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

On this Page