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8. Foot and Ankle MCQs

Practice Set 120 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 2381

Topic: Midfoot & Hindfoot
A 55-year-old female presents with a flexible, acquired flatfoot deformity secondary to Stage IIb posterior tibial tendon dysfunction. Radiographs demonstrate >40% talonavicular uncoverage and severe forefoot abduction. The planned procedure includes a flexor digitorum longus (FDL) transfer to the navicular. To optimally address the severe transverse plane deformity (forefoot abduction), which structural osteotomy is most commonly indicated?
. Medializing calcaneal osteotomy (MCO)
. Lateral column lengthening (Evans osteotomy)
. Plantarflexion opening wedge medial cuneiform osteotomy (Cotton)
. Closing wedge cuboid osteotomy
. First metatarsal corrective osteotomy

Correct Answer & Explanation

. Lateral column lengthening (Evans osteotomy)

Explanation

Stage IIb posterior tibial tendon dysfunction (PTTD) is characterized by a flexible flatfoot with significant forefoot abduction (>40% talonavicular uncoverage on AP radiograph). A lateral column lengthening (Evans osteotomy) effectively corrects the severe transverse plane deformity by pushing the forefoot into adduction. A medializing calcaneal osteotomy (MCO) primarily corrects hindfoot valgus (coronal plane) but has limited effect on severe transverse plane abduction.

Question 2382

Topic: 8. Foot and Ankle
A 14-year-old boy with Charcot-Marie-Tooth disease presents with bilateral progressive cavovarus feet. Examination reveals a plantarflexed first ray and a positive Coleman block test indicating a flexible hindfoot. During the surgical reconstruction, which specific tendon transfer is utilized to remove the primary deforming force driving the first ray plantarflexion while augmenting foot eversion?
. Peroneus longus to peroneus brevis transfer
. Split anterior tibial tendon transfer (SPLATT)
. Posterior tibial tendon transfer through the interosseous membrane
. Flexor hallucis longus transfer to the Achilles tendon
. Extensor hallucis longus transfer to the first metatarsal neck (Jones procedure)

Correct Answer & Explanation

. Peroneus longus to peroneus brevis transfer

Explanation

In Charcot-Marie-Tooth disease, the peroneus longus (PL) is typically relatively strong compared to a weak anterior tibialis, leading to a rigidly plantarflexed first ray (which drives the hindfoot into varus). Transferring the PL to the peroneus brevis (PB) removes this deforming plantarflexion force on the first metatarsal and simultaneously augments the weak PB to assist in eversion.

Question 2383

Topic: 8. Foot and Ankle

A 24-year-old athlete sustains a purely ligamentous Lisfranc injury. Weight-bearing radiographs show a 3 mm diastasis between the medial cuneiform and the base of the second metatarsal. Current evidence suggests that which of the following treatments provides the most predictable long-term functional outcome for this specific injury pattern?

. Closed reduction and non-weight-bearing cast for 8 weeks
. Closed reduction and percutaneous K-wire fixation
. Open reduction and internal fixation (ORIF) with transarticular screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Suture-button suspensionplasty only

Correct Answer & Explanation

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

Explanation

For purely ligamentous Lisfranc injuries, multiple studies have demonstrated that primary arthrodesis yields superior functional outcomes and lower reoperation rates compared to ORIF. ORIF is generally preferred for bony fracture-dislocations.

Question 2384

Topic: Midfoot & Hindfoot

A 55-year-old patient with long-standing diabetes presents with a warm, swollen, and erythematous left foot. Radiographs demonstrate periarticular debris, fragmentation of the navicular, and subluxation of the midtarsal joints. There are no systemic signs of infection. What is the most appropriate initial management?

. Intravenous antibiotics and emergent surgical debridement
. Total contact casting and non-weight-bearing
. Primary arthrodesis of the midfoot
. Custom orthotic shoe wear and weight-bearing as tolerated
. Percutaneous pinning of the midtarsal joints

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

This patient is in the acute fragmentation phase (Eichenholtz Stage I) of Charcot arthropathy. The gold standard of initial treatment is strict offloading and immobilization using a total contact cast until the acute inflammatory phase resolves.

Question 2385

Topic: 8. Foot and Ankle

A 58-year-old patient with long-standing diabetes presents with an acutely swollen, erythematous, and warm foot but denies significant pain. Radiographs demonstrate periarticular debris, bony fragmentation, and early subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what is the most appropriate initial management?

. Total contact casting and non-weight-bearing
. Urgent arthrodesis of the tarsometatarsal joints
. Intravenous antibiotics and surgical debridement
. Excision of developing bony prominences
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation phase) of Charcot neuroarthropathy. The gold standard of initial treatment is strict offloading and immobilization using a total contact cast to prevent further deformity until the acute inflammatory phase resolves (Stage II).

Question 2386

Topic: 8. Foot and Ankle

A 25-year-old football player sustains a pure ligamentous Lisfranc injury. Which of the following statements regarding the normal anatomy of the Lisfranc ligament is correct?

. It connects the plantar base of the second metatarsal to the medial cuneiform
. It connects the first and second metatarsal bases
. It is located primarily on the dorsal aspect of the midfoot
. It is the weakest and thinnest ligament of the tarsometatarsal joint complex
. It attaches the intermediate cuneiform to the first metatarsal

Correct Answer & Explanation

. It connects the plantar base of the second metatarsal to the medial cuneiform

Explanation

The primary Lisfranc ligament is a strong interosseous ligament that originates from the lateral aspect of the medial cuneiform and attaches to the medial aspect of the plantar base of the second metatarsal. There is no direct ligamentous connection between the bases of the first and second metatarsals.

Question 2387

Topic: 8. Foot and Ankle

During the extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, a full-thickness subperiosteal flap is created. Which artery provides the primary blood supply to the corner of this flap and must be protected to prevent wound necrosis?

. Dorsalis pedis artery
. Lateral tarsal artery
. Medial calcaneal artery
. Lateral calcaneal artery
. Peroneal artery

Correct Answer & Explanation

. Lateral calcaneal artery

Explanation

The lateral calcaneal artery, a branch of the peroneal artery, supplies the apex of the extensile lateral flap. A 'no touch' subperiosteal elevation technique is strictly advised to protect this vascular supply and minimize the risk of wound edge necrosis.

Question 2388

Topic: 8. Foot and Ankle

In evaluating coronal plane alignment of the lower extremity on a standing long-leg radiograph, the mechanical axis line connects the center of the femoral head to the center of the ankle mortise. In a normally aligned knee, where should this line pass?

. Exactly through the center of the knee joint
. 8-10 mm medial to the center of the knee joint
. 8-10 mm lateral to the center of the knee joint
. Through the medial collateral ligament origin
. Through the lateral collateral ligament origin

Correct Answer & Explanation

. 8-10 mm medial to the center of the knee joint

Explanation

The normal mechanical axis line of the lower extremity passes approximately 8 to 10 mm medial to the center of the knee joint. This medial deviation naturally loads the medial compartment slightly more than the lateral compartment.

Question 2389

Topic: 8. Foot and Ankle
A 34-year-old male sustains a highly displaced Hawkins type III talar neck fracture. During the surgical approach for open reduction and internal fixation, the surgeon utilizes a dual-incision technique. What is the primary anatomical rationale for preserving the deep deltoid ligament during the medial approach to the talus?
. It prevents late-onset subtalar instability
. It prevents postoperative varus malunion of the talar neck
. It protects the deltoid branch of the posterior tibial artery, which is often the sole remaining blood supply to the talar body
. It minimizes the risk of iatrogenic injury to the posterior tibial nerve
. It preserves the origin of the artery of the tarsal sinus

Correct Answer & Explanation

. It protects the deltoid branch of the posterior tibial artery, which is often the sole remaining blood supply to the talar body

Explanation

In displaced talar neck fractures (especially Hawkins II and III), the blood supply from the artery of the tarsal canal and tarsal sinus is often disrupted. The deltoid branch of the posterior tibial artery, which supplies the medial body of the talus, may be the only remaining intact blood supply. The deep deltoid ligament must be meticulously preserved during medial exposure to protect this critical vascular contribution and minimize the risk of avascular necrosis.

Question 2390

Topic: 8. Foot and Ankle

A 22-year-old football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs show no overt diastasis, but an MRI confirms an isolated tear of the primary Lisfranc ligament. Which of the following correctly describes the anatomic attachments of the primary Lisfranc ligament?

. Dorsal aspect of the medial cuneiform to the base of the 2nd metatarsal
. Plantar-lateral aspect of the medial cuneiform to the plantar-medial base of the 2nd metatarsal
. Base of the 2nd metatarsal to the intermediate cuneiform
. Plantar aspect of the medial cuneiform to the base of the 1st metatarsal
. Base of the 2nd metatarsal to the lateral cuneiform

Correct Answer & Explanation

. Plantar-lateral aspect of the medial cuneiform to the plantar-medial base of the 2nd metatarsal

Explanation

The primary Lisfranc ligament is an interosseous ligament that runs from the plantar-lateral aspect of the medial cuneiform to the plantar-medial aspect of the base of the second metatarsal. It is the strongest of the ligaments stabilizing the second tarsometatarsal joint. There is no direct ligamentous connection between the first and second metatarsal bases.

Question 2391

Topic: 8. Foot and Ankle

A 24-year-old downhill skier presents with severe lateral ankle pain and a palpable snapping sensation behind the lateral malleolus after an acute forceful dorsiflexion-inversion injury. Static and dynamic ultrasound confirms anterior dislocation of the peroneal tendons out of the retromalleolar groove. What is the primary anatomical restraint that is disrupted in this condition?

. Calcaneofibular ligament
. Inferior extensor retinaculum
. Superior peroneal retinaculum
. Anterior talofibular ligament
. Lateral talocalcaneal ligament

Correct Answer & Explanation

. Superior peroneal retinaculum

Explanation

The superior peroneal retinaculum (SPR) is the primary restraint preventing anterior subluxation and dislocation of the peroneus longus and brevis tendons from the retromalleolar groove. Forceful dorsiflexion of an inverted foot leads to violent contraction of the peroneal muscles, which can tear or strip the SPR off its fibular attachment, resulting in tendon dislocation.

Question 2392

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male with severe peripheral neuropathy presents with a globally swollen, erythematous, and warm right foot. He denies fevers, chills, or an open wound. Radiographs reveal prominent subchondral osteopenia, bony fragmentation, joint debris, and subluxation of the midfoot. According to the Eichenholtz classification, what is the appropriate stage of this Charcot arthropathy and the most appropriate initial management?

. Stage 0; Intravenous antibiotics and surgical debridement
. Stage 1; Total contact casting and strictly non-weight bearing
. Stage 2; Corrective midfoot arthrodesis
. Stage 3; Custom accommodating footwear and bracing
. Stage 4; Below-knee amputation

Correct Answer & Explanation

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

Explanation

The clinical and radiographic presentation defines Stage 1 (Developmental/Fragmentation) of the Eichenholtz classification for Charcot arthropathy. It is characterized by erythema, swelling, warmth, osteopenia, fragmentation, joint subluxation, and debris. The gold standard for initial management of Stage 1 Charcot is immobilization and offloading, most effectively achieved with a total contact cast (TCC). Surgery is generally contraindicated during this acute, hyperemic phase.

Question 2393

Topic: Midfoot & Hindfoot
A 52-year-old female presents with stage IIB acquired adult flatfoot deformity (posterior tibial tendon dysfunction). Clinical and radiographic evaluation demonstrates a flexible hindfoot valgus and severe forefoot abduction with >40% talonavicular uncoverage on the weight-bearing AP view. Which of the following surgical combinations is most appropriate to comprehensively correct her deformity?
. Flexor digitorum longus (FDL) transfer to the navicular and a medializing calcaneal osteotomy (MCO) only
. FDL transfer to the navicular, MCO, and a lateral column lengthening (e.g., Evans osteotomy)
. Triple arthrodesis (subtalar, talonavicular, and calcaneocuboid)
. Isolated subtalar arthrodesis
. Tibialis anterior tendon transfer and first tarsometatarsal arthrodesis

Correct Answer & Explanation

. FDL transfer to the navicular, MCO, and a lateral column lengthening (e.g., Evans osteotomy)

Explanation

Stage IIB adult acquired flatfoot deformity is characterized by a flexible deformity with profound forefoot abduction (indicated by >40% talonavicular uncoverage). To correct this multi-planar deformity, an FDL transfer and medializing calcaneal osteotomy (which correct the hindfoot valgus) must be combined with a lateral column lengthening (Evans osteotomy) or a medial cuneiform osteotomy (Cotton) to definitively correct the forefoot abduction. Stage IIA (no significant abduction) may be treated with FDL transfer and MCO alone. Stage III (rigid) requires a triple or double arthrodesis.

Question 2394

Topic: 8. Foot and Ankle

During open reduction and internal fixation of a severe pronation-external rotation ankle fracture, the surgeon assesses the stability of the distal tibiofibular syndesmosis. The syndesmotic complex consists of several ligaments. Which of the following ligaments is biomechanically considered the strongest and provides the greatest resistance against diastasis of the syndesmosis?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Interosseous ligament (IOL)
. Inferior transverse ligament (ITL)
. Deltoid ligament

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

Biomechanical studies have demonstrated that the posterior inferior tibiofibular ligament (PITFL) is the strongest ligament of the syndesmotic complex, contributing approximately 42% of the resistance to fibular displacement (diastasis). The anterior inferior tibiofibular ligament (AITFL) provides about 35%, the interosseous ligament provides about 22%, and the inferior transverse ligament provides the remaining stability.

Question 2395

Topic: Midfoot & Hindfoot

A 55-year-old female presents with progressive flatfoot deformity. She has pain along the medial ankle and is unable to perform a single-leg heel rise. Examination shows a flexible hindfoot valgus and greater than 40% uncovering of the talonavicular joint on a weight-bearing AP foot radiograph. Which of the following surgical strategies is most appropriate for this stage of deformity?

. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO) only
. FDL transfer, MDCO, and lateral column lengthening
. Triple arthrodesis
. Talonavicular arthrodesis alone
. Gastrocnemius recession and subtalar arthroereisis

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible deformity with significant forefoot abduction (>30-40% talonavicular uncoverage). Treatment requires FDL transfer, an MDCO (to correct hindfoot valgus), and a lateral column lengthening (such as an Evans calcaneal osteotomy) to correct the severe forefoot abduction. Stage IIa lacks the severe abduction and can be treated without the lateral column lengthening.

Question 2396

Topic: Midfoot & Hindfoot
A 52-year-old diabetic male with severe peripheral neuropathy presents with a red, hot, swollen right foot mimicking cellulitis. Radiographs reveal extensive periarticular debris, fragmentation of the subchondral bone, and subluxation of the tarsometatarsal joints. Based on the Eichenholtz classification, what stage is this?
. Stage 0; pre-fragmentation
. Stage I; fragmentation
. Stage II; coalescence
. Stage III; remodeling
. Stage IV; ulceration

Correct Answer & Explanation

. Stage I; fragmentation

Explanation

Eichenholtz Stage I is the developmental or fragmentation phase of Charcot arthropathy. It is characterized clinically by a red, hot, swollen foot and radiographically by subchondral fragmentation, debris formation, and joint subluxation/dislocation. Stage II (coalescence) shows absorption of fine debris and early fusion. Stage III (remodeling) shows rounding of bone ends and sclerosis.

Question 2397

Topic: 8. Foot and Ankle

A 22-year-old football player sustains an axial load to a plantarflexed foot. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the first and second metatarsals. What specific ligamentous structure, known as the primary stabilizer of this joint complex, is ruptured?

. Plantar ligament connecting the medial cuneiform to the base of the 2nd metatarsal
. Dorsal ligament connecting the medial cuneiform to the base of the 2nd metatarsal
. Interosseous ligament connecting the medial and middle cuneiforms
. Plantar ligament connecting the middle cuneiform to the base of the 2nd metatarsal
. Peroneus longus tendon insertion

Correct Answer & Explanation

. Plantar ligament connecting the medial cuneiform to the base of the 2nd metatarsal

Explanation

The Lisfranc ligament is an interosseous ligament, but its primary functional bundle is located on the plantar aspect. It originates from the lateral aspect of the medial cuneiform and attaches to the medial base of the second metatarsal. It is the thickest and strongest ligament of the Lisfranc complex and the primary stabilizer against dorsal dislocation of the second metatarsal base.

Question 2398

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs demonstrate a Hallux Valgus Angle (HVA) of 45 degrees, an Intermetatarsal Angle (IMA) of 18 degrees, a congruent first MTP joint, and hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures provides the most reliable long-term correction?

. Distal chevron osteotomy
. Scarf 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 (arthrodesis of the first tarsometatarsal joint) is highly indicated for patients with a severe hallux valgus deformity (IMA > 15-20 degrees) in the setting of first ray hypermobility. Distal osteotomies (like the Chevron) are inadequate for large IMA corrections. MTP arthrodesis is reserved for severe deformity combined with significant MTP degenerative joint disease.

Question 2399

Topic: 8. Foot and Ankle

A 34-year-old male smoker sustains a displaced intra-articular calcaneus fracture. Open reduction and internal fixation via an extensile lateral approach is planned. Which of the following intraoperative techniques is most critical for minimizing the risk of postoperative wound necrosis?

. Using a continuous absorbable suture for skin closure
. Dissecting a full-thickness flap directly on the periosteum without the use of a tourniquet
. Avoiding the sural nerve during the initial vertical limb incision
. Creating a full-thickness subperiosteal flap and using a 'no-touch' K-wire retraction technique
. Operating within 24 hours of the injury regardless of soft tissue swelling

Correct Answer & Explanation

. Creating a full-thickness subperiosteal flap and using a 'no-touch' K-wire retraction technique

Explanation

Wound complications are famously high with the extensile lateral approach to the calcaneus, particularly in smokers. The lateral flap's blood supply relies on the lateral calcaneal artery. To preserve this vascularity, the flap must be elevated as a single full-thickness subperiosteal layer. Furthermore, a 'no-touch' technique using K-wires driven into the talus and fibula to retract the flap prevents focal tissue ischemia caused by hand-held or self-retaining retractors.

Question 2400

Topic: 8. Foot and Ankle
A 30-year-old male sustains a Hawkins Type III talar neck fracture after a fall from height. Which of the following describes the dominant blood supply to the talar body that is disrupted in this injury pattern?
. Artery of the tarsal canal, a branch of the posterior tibial artery
. Artery of the tarsal sinus, a branch of the dorsalis pedis artery
. Deltoid artery, a branch of the anterior tibial artery
. Medial plantar artery, a branch of the posterior tibial artery
. Perforating peroneal artery

Correct Answer & Explanation

. Artery of the tarsal canal, a branch of the posterior tibial artery

Explanation

The primary blood supply to the talar body is the artery of the tarsal canal, which is a branch of the posterior tibial artery. It supplies the majority of the talar body. The artery of the tarsal sinus (from the dorsalis pedis/anterior tibial and perforating peroneal arteries) and the deltoid artery (medial aspect) provide collateral supply but the artery of the tarsal canal is the most critical and is highly vulnerable to disruption in displaced talar neck fractures (Hawkins II-IV), leading to avascular necrosis (AVN).

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