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8. Foot and Ankle MCQs

Practice Set 122 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 2421

Topic: 8. Foot and Ankle

A 42-year-old recreational athlete sustains an acute Achilles tendon rupture. He elects for non-operative management with a functional rehabilitation protocol. Compared to traditional surgical repair, current high-quality literature demonstrates that functional non-operative management is associated with:

. A significantly higher re-rupture rate
. Equivalent re-rupture rates but higher rates of sural nerve injury
. Equivalent re-rupture rates with a significantly lower risk of soft tissue complications
. Greater functional plantar flexion strength at 2 years
. Higher rates of deep vein thrombosis

Correct Answer & Explanation

. Equivalent re-rupture rates with a significantly lower risk of soft tissue complications

Explanation

Recent high-quality Level I evidence demonstrates that when a dynamic, functional rehabilitation protocol (early weight-bearing and early ROM) is utilized, the re-rupture rates between non-operative and operative management of Achilles ruptures are statistically equivalent. However, the non-operative group avoids the soft tissue, wound, and nerve complications inherent to surgery.

Question 2422

Topic: Midfoot & Hindfoot

A 22-year-old gymnast sustains a hyperplantarflexion injury to her midfoot. Weight-bearing radiographs show 3 mm of widening between the medial and middle cuneiforms with no associated fractures. What is the most appropriate definitive management for this purely ligamentous injury?

. Closed reduction and non-weight-bearing cast for 6 weeks
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Open reduction and internal fixation (ORIF) with transarticular screws
. Open reduction and temporary K-wire fixation
. Conservative management in a walking boot

Correct Answer & Explanation

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

Explanation

Purely ligamentous Lisfranc injuries have a high rate of failure, hardware breakage, and post-traumatic arthritis with ORIF. Primary arthrodesis is the preferred treatment as it yields significantly better long-term functional outcomes in pure ligamentous variants.

Question 2423

Topic: 8. Foot and Ankle

A 20-year-old collegiate basketball player sustains an acute, non-displaced Zone 2 fifth metatarsal base fracture (Jones fracture). Operative fixation with a solid intramedullary screw is planned. What is the most critical anatomical factor to consider when selecting the screw size to prevent iatrogenic lateral cortex blowout?

. Length of the first metatarsal
. Angle of the fourth metatarsocuboid joint
. Plantar curvature and medullary canal diameter of the fifth metatarsal
. Distance from the sural nerve branch
. Thickness of the plantar fascia lateral cord insertion

Correct Answer & Explanation

. Plantar curvature and medullary canal diameter of the fifth metatarsal

Explanation

The fifth metatarsal has a natural plantar and lateral bow. Using a rigid intramedullary screw that is too long or too large in diameter fails to accommodate this curvature, straightening the bone and causing a lateral cortex blowout or fracture distraction.

Question 2424

Topic: 8. Foot and Ankle

During an extensile lateral approach for the open reduction and internal fixation of a severe intra-articular calcaneus fracture, the surgeon must carefully elevate the full-thickness flap. Which artery provides the primary blood supply to the corner of this flap?

. Lateral calcaneal artery
. Medial calcaneal artery
. Sural artery
. Dorsalis pedis artery
. Posterior tibial artery

Correct Answer & Explanation

. Lateral calcaneal artery

Explanation

The lateral extensile approach to the calcaneus relies heavily on the lateral calcaneal artery, a terminal branch of the peroneal artery. Subperiosteal, full-thickness 'no-touch' dissection is critical to preserve this blood supply and prevent devastating flap necrosis.

Question 2425

Topic: 8. Foot and Ankle
A 28-year-old construction worker falls from a height and sustains a Hawkins type III talar neck fracture. Which vascular supply to the talar body is disrupted in a true type III injury?
. Artery of the tarsal canal
. Deltoid branches
. Artery of the tarsal sinus
. All of the above
. None of the above

Correct Answer & Explanation

. All of the above

Explanation

A Hawkins type III fracture involves dislocation of the subtalar, tibiotalar, and talonavicular joints. This massive displacement completely disrupts all three primary blood supplies to the talar body (tarsal canal, deltoid, and tarsal sinus arteries), resulting in an extremely high risk of avascular necrosis.

Question 2426

Topic: Midfoot & Hindfoot
A 25-year-old female sustains a Hawkins type III talar neck fracture following a motor vehicle collision. Which of the following best describes the specific pattern of dislocation and the associated risk of avascular necrosis (AVN)?
. Subtalar dislocation only with 50% AVN risk
. Subtalar and tibiotalar dislocations with up to 100% AVN risk
. Subtalar, tibiotalar, and talonavicular dislocations with 100% AVN risk
. Undisplaced fracture with 10% AVN risk
. Subtalar and talonavicular dislocations with 50% AVN risk

Correct Answer & Explanation

. Subtalar, tibiotalar, and talonavicular dislocations with 100% AVN risk

Explanation

A Hawkins Type III fracture involves a talar neck fracture with both subtalar and tibiotalar dislocations. This severe disruption of the blood supply leads to an avascular necrosis rate approaching 100% in some series.

Question 2427

Topic: 8. Foot and Ankle

A 22-year-old male presents with severe midfoot pain after falling from a horse with his foot caught in the stirrup. Examination reveals plantar midfoot ecchymosis. Radiographs show a 3 mm diastasis between the bases of the first and second metatarsals. What is the primary stabilizing ligament of the Lisfranc joint complex that is compromised in this injury?

. A ligament connecting the medial cuneiform to the second metatarsal base
. A ligament connecting the medial cuneiform to the first metatarsal base
. A ligament connecting the middle cuneiform to the second metatarsal base
. A ligament connecting the cuboid to the third metatarsal base
. The dorsal tarsometatarsal ligaments

Correct Answer & Explanation

. A ligament connecting the medial cuneiform to the second metatarsal base

Explanation

The Lisfranc ligament is an intra-articular interosseous ligament that connects the medial cuneiform to the base of the second metatarsal. It is the strongest and most critical primary stabilizer of the tarsometatarsal joint complex.

Question 2428

Topic: 8. Foot and Ankle
What is the peak period of onset in children with pauciarticular juvenile rheumatoid arthritis?
. Before age 2 years
. Between the ages of 2 and 4 years
. Between the ages of 4 and 8 years
. Between the ages of 8 and 12 years
. During adolescence

Correct Answer & Explanation

. Between the ages of 2 and 4 years

Explanation

Approximately one half of patients with juvenile rheumatoid arthritis (JRA) have the pauciarticular form, which by definition includes only patients with fewer than five joints involved. The peak period of onset is between the ages of 2 and 4 years, with half of the affected children coming to medical attention before age 4 years. The knee is most often affected, with the ankle-subtalar and elbow joints next in frequency.

Question 2429

Topic: 8. Foot and Ankle
What are the most common portals for arthroscopic surgery of the ankle?
. Anterolateral, anteromedial, posterolateral
. Anterocentral, trans-Achilles, posterolateral
. Anterocentral, anterolateral, posteromedial
. Anterocentral, anteromedial, trans-Achilles
. Anteromedial, anterolateral, trans-Achilles

Correct Answer & Explanation

. Anterolateral, anteromedial, posterolateral

Explanation

The most commonly used portals are the anterolateral, anteromedial, and posterolateral portals. They have been shown to be the safest areas for portal placement, allowing no penetration of neurovascular structures. All the other portals involve placing another structure at risk.

Question 2430

Topic: Midfoot & Hindfoot
A 32-year-old man falls from a height and sustains a Hawkins Type III talar neck fracture. What joint disruptions characterize this injury, and what is the approximate risk of developing avascular necrosis (AVN) of the talar body?
. Subtalar subluxation; 50% AVN risk
. Subtalar and tibiotalar dislocation; nearly 100% AVN risk
. Talonavicular subluxation; 20% AVN risk
. Subtalar, tibiotalar, and talonavicular dislocation; 100% AVN risk
. Undisplaced fracture; 10% AVN risk

Correct Answer & Explanation

. Subtalar, tibiotalar, and talonavicular dislocation; 100% AVN risk

Explanation

A Hawkins Type III fracture involves a fracture of the talar neck with dislocation of both the subtalar and tibiotalar joints. Because of the severe disruption of the retrograde blood supply to the talar body, the risk of AVN is exceedingly high, approaching 80-100%.

Question 2431

Topic: 8. Foot and Ankle
Six weeks after ORIF of a Hawkins Type III talar neck fracture, an AP radiograph of the ankle shows a subchondral radiolucent band in the dome of the talus. What does this radiographic finding indicate?
. Impending avascular necrosis
. Osteomyelitis of the talar body
. Intact vascularity and revascularization of the talar body
. Hardware loosening and failure
. Subchondral collapse

Correct Answer & Explanation

. Intact vascularity and revascularization of the talar body

Explanation

This finding is known as the Hawkins sign. The subchondral radiolucent band represents subchondral atrophy from disuse, which can only occur if there is an intact blood supply to the bone. It strongly suggests that avascular necrosis will not occur.

Question 2432

Topic: 8. Foot and Ankle

A surgeon harvests the sural nerve to be used as a cable graft for a 5 cm ulnar nerve gap in the forearm. The patient must be informed preoperatively of which expected, unavoidable sensory deficit following this harvest?

. Loss of sensation over the medial malleolus
. Loss of sensation over the lateral aspect of the foot and lateral heel
. Loss of sensation over the first web space of the foot
. Loss of sensation over the plantar aspect of the heel
. Loss of sensation over the anterior ankle

Correct Answer & Explanation

. Loss of sensation over the lateral aspect of the foot and lateral heel

Explanation

The sural nerve provides sensory innervation to the lateral and posterior aspect of the distal third of the leg, the lateral malleolus, the lateral aspect of the foot, and the lateral heel. Harvesting this nerve for grafting results in an unavoidable sensory deficit in these areas, which patients must be counseled about preoperatively.

Question 2433

Topic: 8. Foot and Ankle

A 30-year-old male develops isolated anterior compartment syndrome of the leg following a high-energy tibia fracture. If decompression is delayed, which of the following specific sensory and motor deficits is most likely to be present on physical examination?

. Weakness in ankle plantarflexion and numbness over the lateral border of the foot
. Weakness in ankle dorsiflexion and numbness in the first dorsal web space
. Weakness in great toe flexion and numbness over the medial malleolus
. Weakness in foot eversion and numbness over the dorsum of the foot
. Weakness in knee extension and numbness over the patella

Correct Answer & Explanation

. Weakness in ankle dorsiflexion and numbness in the first dorsal web space

Explanation

The anterior compartment of the leg contains the tibialis anterior, extensor hallucis longus, extensor digitorum longus, and peroneus tertius muscles, as well as the deep peroneal nerve and anterior tibial artery. Ischemia to this compartment results in weakness of ankle dorsiflexion and great toe extension, along with diminished sensation in the autonomous zone of the deep peroneal nerve (the first dorsal web space).

Question 2434

Topic: 8. Foot and Ankle
A patient sustains a Hawkins Type III talar neck fracture. Which of the following accurately describes the displacement pattern and the associated risk of avascular necrosis (AVN)?
. Subtalar subluxation with a 20-30% risk of AVN
. Talonavicular dislocation only with a 50% risk of AVN
. Non-displaced fracture with a <10% risk of AVN
. Subtalar and tibiotalar dislocation with a 70-100% risk of AVN
. Subtalar, tibiotalar, and talonavicular dislocation with a 100% risk of AVN

Correct Answer & Explanation

. Subtalar and tibiotalar dislocation with a 70-100% risk of AVN

Explanation

A Hawkins Type III fracture involves a displaced talar neck fracture with both subtalar and tibiotalar joint dislocation. This disrupts multiple blood supplies to the talus, carrying an AVN risk of approximately 70-100%.

Question 2435

Topic: 8. Foot and Ankle

A 45-year-old construction worker undergoes open reduction and internal fixation of a displaced intra-articular calcaneus fracture via an extensile lateral approach. Which nerve is at the greatest risk of iatrogenic injury during the inferior limb of this incision?

. Deep peroneal nerve
. Medial plantar nerve
. Sural nerve
. Saphenous nerve
. Superficial peroneal nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve crosses the lateral border of the foot and is at high risk of transection or traction injury during the development of the full-thickness flap in an extensile lateral approach to the calcaneus.

Question 2436

Topic: 8. Foot and Ankle
A 35-year-old male sustains a high-energy motor vehicle collision resulting in an isolated Hawkins Type III talus neck fracture. Which of the following vessels provides the dominant blood supply to the talar body, placing it at the highest risk of avascular necrosis (AVN) in this injury pattern?
. Artery of the tarsal canal
. Artery of the tarsal sinus
. Deltoid branch of the posterior tibial artery
. Dorsalis pedis artery
. Perforating peroneal artery

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 talus inferiorly through the neck. Disruption of this vessel, along with others in displaced talar neck fractures (Hawkins III involves subtalar, tibiotalar, and talonavicular dislocation), drastically increases the risk of AVN.

Question 2437

Topic: 8. Foot and Ankle

The Lisfranc ligament complex is critical for providing stability to the midfoot, particularly the tarsometatarsal joints. Anatomically, from which to which bones does the primary, strongest intra-articular band of the Lisfranc ligament attach?

. Lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal
. Medial aspect of the lateral cuneiform to the base of the third metatarsal
. Plantar aspect of the middle cuneiform to the base of the second metatarsal
. Anterior aspect of the navicular to the base of the second metatarsal
. Lateral aspect of the medial cuneiform to the medial aspect of the base of the first metatarsal

Correct Answer & Explanation

. Lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal

Explanation

The Lisfranc ligament is a stout interosseous ligament that runs from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. There is no direct ligamentous connection between the first and second metatarsal bases, making this ligament crucial for midfoot stability.

Question 2438

Topic: 8. Foot and Ankle

A 21-year-old collegiate basketball player sustains a zone 2 proximal fifth metatarsal fracture (Jones fracture). To maximize return to play, operative fixation with a solid intramedullary screw is planned. To ensure the screw threads completely bypass the fracture site without breaching the medial or plantar cortex, what is the ideal starting point for the guidewire on the fifth metatarsal tuberosity?

. "High and inside" (dorsal and medial)
. "Low and inside" (plantar and medial)
. Plantar to the peroneus brevis insertion
. Directly through the articular cartilage of the cuboid facet
. Dorsal to the extensor digitorum longus insertion

Correct Answer & Explanation

. "High and inside" (dorsal and medial)

Explanation

The ideal starting point for intramedullary screw fixation of a Jones fracture is "high and inside" (dorsal and medial) on the fifth metatarsal tuberosity. Because the fifth metatarsal has a lateral and plantar bow, a starting point that is too lateral or plantar will result in eccentric screw placement and potential medial or plantar cortical breach.

Question 2439

Topic: Forefoot

A 28-year-old professional football player sustains an acute hyperextension injury to his first metatarsophalangeal (MTP) joint (Turf Toe). MRI demonstrates a complete rupture of the plantar plate. Which of the following is considered an absolute indication for operative repair rather than conservative management?

. Traumatic hallux valgus deformity
. Grade II sprain of the capsuloligamentous complex without frank instability
. Grade I injury with localized plantar tenderness
. Proximal sesamoid retraction of 2 mm compared to the contralateral side
. Pain resolving within 2 weeks of conservative management

Correct Answer & Explanation

. Traumatic hallux valgus deformity

Explanation

Operative indications for turf toe (plantar plate injury) include a large intra-articular bony avulsion, diastasis of a bipartite sesamoid, a sesamoid fracture with diastasis, traumatic hallux valgus, frank vertical instability, or failure of conservative treatment. Traumatic hallux valgus indicates complete failure of the medial stabilizing structures requiring surgical repair.

Question 2440

Topic: 8. Foot and Ankle

A 31-year-old male undergoes ORIF of a Weber C fibula fracture. Intraoperative external rotation stress testing reveals widening of the medial clear space, confirming a syndesmotic injury. A solid syndesmotic screw is planned. According to standard AO principles, what is an acceptable technique for screw placement?

. Engaging 3 or 4 cortices, placed 2-4 cm proximal to the joint line
. Engaging 2 cortices, placed exactly 1 cm proximal to the joint line
. Engaging 4 cortices, placed directly across the articular surface
. Engaging 3 cortices, placed 5-7 cm proximal to the joint line
. Engaging 2 cortices, placed 1 cm distal to the joint line into the talus

Correct Answer & Explanation

. Engaging 3 or 4 cortices, placed 2-4 cm proximal to the joint line

Explanation

Syndesmotic screws are typically placed 2 to 4 cm proximal to the tibial plafond, parallel to the joint line, and angled 20-30 degrees anteriorly. Engaging either 3 cortices (tibia + fibula near cortex) or 4 cortices (both fibula and both tibia cortices) are both accepted techniques with similar long-term clinical outcomes.

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