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8. Foot and Ankle MCQs

Practice Set 124 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 2461

Topic: 8. Foot and Ankle

A 35-year-old equestrian falls from a horse, sustaining a 'nutcracker' fracture of the cuboid with 4 mm of lateral column shortening. What is the most appropriate surgical management?

. Isolated percutaneous pinning of the calcaneocuboid joint
. Primary arthrodesis of the calcaneocuboid joint
. Open reduction, structural bone grafting, and internal fixation
. Excision of the cuboid and soft tissue interposition
. External fixation with distraction histogenesis

Correct Answer & Explanation

. Open reduction, structural bone grafting, and internal fixation

Explanation

A 'nutcracker' fracture of the cuboid involves compression of the cuboid between the calcaneus and the 4th/5th metatarsals, leading to lateral column shortening. Symptomatic shortening (>3 mm) alters foot biomechanics, leading to midfoot abductus. The standard of care is ORIF with structural bone grafting (often from the iliac crest or allograft) to restore lateral column length.

Question 2462

Topic: 8. Foot and Ankle

A 28-year-old football player sustains a midfoot injury. An AP radiograph reveals a small bony avulsion fragment in the space between the bases of the first and second metatarsals (Fleck sign). From which anatomic structure did this fragment avulse?

. Lateral aspect of the medial cuneiform
. Medial aspect of the second metatarsal base
. Plantar aspect of the middle cuneiform
. Medial aspect of the first metatarsal base
. Dorsal aspect of the second metatarsal base

Correct Answer & Explanation

. Medial aspect of the second metatarsal base

Explanation

The 'Fleck sign' represents an avulsion of the Lisfranc ligament. The Lisfranc ligament connects the lateral aspect of the medial cuneiform to the medial aspect of the second metatarsal base. The avulsion fragment (Fleck sign) typically originates from the medial base of the second metatarsal.

Question 2463

Topic: 8. Foot and Ankle

A 45-year-old roofer falls from a ladder and sustains an intra-articular calcaneus fracture. On the lateral radiograph, the Crucial Angle of Gissane is measured. An abnormal increase in this angle typically indicates which of the following mechanical derangements?

. Collapse of the posterior facet into the calcaneal body
. Plantarflexion of the calcaneal tuberosity
. Medial translation of the sustentaculum tali
. Impaction of the anterior process of the calcaneus
. Avulsion of the Achilles tendon insertion

Correct Answer & Explanation

. Collapse of the posterior facet into the calcaneal body

Explanation

The Crucial Angle of Gissane is formed by the intersection of the downward slope of the posterior facet and the upward slope of the anterior process. An increase in this angle (normally 100-130 degrees) usually indicates collapse of the posterior facet (the posterior facet is driven plantarly), which flattens the angle.

Question 2464

Topic: Midfoot & Hindfoot
A 55-year-old patient with poorly controlled type 2 diabetes presents with a swollen, erythematous, and warm left foot. Radiographs demonstrate periarticular fragmentation, bony debris, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what is the current stage of this patient's Charcot arthropathy?
. Stage 0 (Prodromal)
. Stage I (Developmental)
. Stage II (Coalescence)
. Stage III (Reconstruction)
. Stage IV (Remodeling)

Correct Answer & Explanation

. Stage I (Developmental)

Explanation

Eichenholtz Stage I (Developmental/Fragmentation) is characterized clinically by a red, hot, swollen foot and radiographically by bony debris, fragmentation, subluxation/dislocation, and osteopenia. Stage II (Coalescence) shows absorption of debris and early fusion. Stage III (Reconstruction) shows consolidation, remodeling, and smoothing of bone edges.

Question 2465

Topic: Midfoot & Hindfoot

A 35-year-old male is involved in a high-speed motor vehicle collision and sustains a purely ligamentous Chopart joint dislocation. Which two specific articulations comprise the Chopart joint line?

. Talonavicular and calcaneocuboid
. Naviculocuneiform and calcaneocuboid
. Tarsometatarsal and intercuneiform
. Talocalcaneal and talonavicular
. Cuneocuboid and cuboidometatarsal

Correct Answer & Explanation

. Talonavicular and calcaneocuboid

Explanation

The Chopart joint, or transverse tarsal joint, connects the hindfoot to the midfoot. It is composed of two articulations: the talonavicular joint medially and the calcaneocuboid joint laterally.

Question 2466

Topic: 8. Foot and Ankle
A 24-year-old snowboarder presents with lateral ankle pain after a hard landing. Radiographs are negative, but CT reveals a comminuted fracture of the lateral process of the talus. Which of the following is the most appropriate management for a displaced (>2mm) fracture of this structure?
. Non-weight bearing cast for 6 weeks
. Excision of the fragments
. Open reduction and internal fixation
. Subtalar arthrodesis
. Hindfoot intramedullary nailing

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

Displaced (>2mm) or large fractures of the lateral process of the talus (snowboarder's fracture) are best treated with ORIF to restore the subtalar joint surface and prevent early post-traumatic arthritis. Small comminuted fragments that are not amenable to fixation may be excised.

Question 2467

Topic: 8. Foot and Ankle

A 35-year-old man injures his foot while missing a step. An AP radiograph shows a small bony avulsion fragment in the space between the medial cuneiform and the base of the second metatarsal. This 'fleck sign' represents an avulsion of a ligament that connects which two structures?

. First metatarsal and second metatarsal
. Medial cuneiform and second metatarsal base
. Medial cuneiform and first metatarsal base
. Intermediate cuneiform and second metatarsal base
. Navicular and medial cuneiform

Correct Answer & Explanation

. Intermediate cuneiform and second metatarsal base

Explanation

The Lisfranc ligament is a strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. The 'fleck sign' is a small bony avulsion from the base of the second metatarsal indicating rupture of this ligament.

Question 2468

Topic: 8. Foot and Ankle

A 60-year-old patient with poorly controlled type 2 diabetes and profound peripheral neuropathy sustains a trimalleolar ankle fracture. Which of the following modifications to standard internal fixation is most appropriate to minimize complications in this patient?

. Use of bioabsorbable screws
. Immediate post-operative weight bearing
. Utilization of multiple syndesmotic screws or enhanced rigid fixation
. Avoidance of fibular plating
. Non-operative management in a bivalved cast

Correct Answer & Explanation

. Utilization of multiple syndesmotic screws or enhanced rigid fixation

Explanation

Diabetic patients with peripheral neuropathy are at high risk for hardware failure, Charcot arthropathy, and skin breakdown. Standard fixation is often inadequate. Enhanced rigid fixation (e.g., locking plates, multiple syndesmotic screws, trans-articular Kirschner wires, or tibiotalocalcaneal nailing) and prolonged non-weight bearing (often double the standard time) are recommended.

Question 2469

Topic: 8. Foot and Ankle

A 25-year-old man presents with medial ankle pain and swelling after an external rotation injury. Radiographs show a widening of the medial clear space but no medial malleolar fracture. Which of the following is the most appropriate next step in radiographic evaluation?

. MRI of the ankle
. CT of the ankle without contrast
. Full-length tibia/fibula radiographs
. Weight-bearing AP foot radiograph
. Contralateral ankle radiographs

Correct Answer & Explanation

. Full-length tibia/fibula radiographs

Explanation

Medial clear space widening without a medial malleolus fracture indicates a deltoid ligament rupture and a syndesmotic injury. An external rotation force often transmits proximally, causing a proximal third fibula fracture (Maisonneuve fracture). Full-length tibia/fibula radiographs are required to identify this fracture.

Question 2470

Topic: 8. Foot and Ankle

A 30-year-old woman is evaluated for a severe ankle fracture-dislocation. Attempts at closed reduction in the emergency department are unsuccessful. Radiographs show a posterior subluxation of the talus with the proximal fibular fragment entrapped behind the posterior tubercle of the tibia. What is the eponym for this specific injury?

. Tillaux fracture
. Maisonneuve fracture
. Wagstaffe fracture
. Bosworth fracture
. Dupuytren fracture

Correct Answer & Explanation

. Bosworth fracture

Explanation

A Bosworth fracture-dislocation is a rare injury characterized by a severe external rotation force resulting in a fibular fracture where the proximal fibular fragment becomes locked behind the posterior tubercle of the distal tibia. Closed reduction is typically impossible, necessitating urgent open reduction.

Question 2471

Topic: 8. Foot and Ankle

A 42-year-old equestrian sustains a foot injury when her foot is crushed while plantarflexed. Radiographs show a comminuted fracture of the cuboid with lateral column shortening. Which of the following best describes the pathomechanics of this 'nutcracker' fracture?

. Avulsion by the peroneus brevis
. Forced eversion and abduction of the forefoot
. Forced inversion and plantarflexion
. Direct dorsal impact
. Axial loading of the heel

Correct Answer & Explanation

. Forced eversion and abduction of the forefoot

Explanation

A 'nutcracker' fracture of the cuboid occurs when severe abduction and eversion forces are applied to the forefoot, compressing the cuboid between the calcaneus and the base of the fourth and fifth metatarsals. Treatment involves restoring lateral column length.

Question 2472

Topic: Midfoot & Hindfoot

A 28-year-old man is involved in a motor vehicle collision and sustains a displaced fracture of the talar head. Which joint is most directly impacted and at risk for post-traumatic arthritis as a result of this injury?

. Tibiotalar joint
. Talocalcaneal (subtalar) joint
. Talonavicular joint
. Calcaneocuboid joint
. Naviculocuneiform joint

Correct Answer & Explanation

. Talonavicular joint

Explanation

Talar head fractures directly involve the talonavicular joint, a crucial component of the transverse tarsal (Chopart) joint complex. Displaced fractures require open reduction and internal fixation to restore the congruity of the talonavicular joint and prevent stiffness and early arthritis.

Question 2473

Topic: 8. Foot and Ankle

A 65-year-old woman with severe hallux rigidus is scheduled for a first metatarsophalangeal (MTP) joint arthrodesis. To optimize her postoperative gait and shoe wear, what is the ideal position for fusion of the first MTP joint?

. Neutral dorsiflexion and neutral valgus
. 10 to 15 degrees of valgus and 10 to 15 degrees of dorsiflexion relative to the floor
. 25 degrees of valgus and 0 degrees of dorsiflexion
. 5 degrees of varus and 20 degrees of dorsiflexion
. 10 to 15 degrees of valgus and 10 to 15 degrees of plantarflexion

Correct Answer & Explanation

. 10 to 15 degrees of valgus and 10 to 15 degrees of dorsiflexion relative to the floor

Explanation

The ideal position for first MTP arthrodesis is approximately 10-15 degrees of valgus and 10-15 degrees of dorsiflexion relative to the floor (which often correlates to about 20-25 degrees of dorsiflexion relative to the first metatarsal shaft). This position accommodates normal shoe wear and allows for optimal roll-off during the gait cycle.

Question 2474

Topic: 8. Foot and Ankle

A 35-year-old woman presents with persistent lateral foot pain 4 weeks after an inversion ankle injury initially diagnosed as an ankle sprain. Examination reveals maximal tenderness 2 cm anterior and inferior to the lateral malleolus. Radiographs demonstrate a displaced fracture of the anterior process of the calcaneus. Which ligament's avulsion is most commonly responsible for this injury?

. Anterior talofibular ligament
. Calcaneofibular ligament
. Bifurcate ligament
. Cervical ligament
. Interosseous talocalcaneal ligament

Correct Answer & Explanation

. Bifurcate ligament

Explanation

Fractures of the anterior process of the calcaneus are often avulsion fractures caused by tension on the bifurcate ligament during a forced inversion and plantarflexion injury. The bifurcate ligament connects the anterior calcaneus to both the cuboid and navicular.

Question 2475

Topic: 8. Foot and Ankle

A 45-year-old weekend warrior sustains an acute Achilles tendon rupture. Non-operative management is chosen. To ensure healing in the most appropriate position and prevent elongation, the ankle is initially placed in a cast in resting equinus. During ultrasound evaluation to confirm apposition of the tendon ends, what is the maximum acceptable gap between the tendon ends when the ankle is placed in 20 degrees of plantarflexion?

. 0 mm (ends must touch)
. 5 mm
. 10 mm
. 15 mm
. 20 mm

Correct Answer & Explanation

. 5 mm

Explanation

When managing an acute Achilles tendon rupture non-operatively, ultrasound is often used to ensure the tendon ends approximate adequately in equinus. The maximum acceptable gap between the tendon ends is typically cited as 5 mm. A gap larger than this increases the risk of elongation, weakness, or non-healing, prompting consideration for surgical repair.

Question 2476

Topic: 8. Foot and Ankle

A 24-year-old professional snowboarder presents with acute lateral ankle pain after a hard landing. Radiographs of the ankle are mostly unremarkable except for a tiny osseous fleck inferior to the lateral malleolus. A subsequent CT scan reveals a displaced fracture of the lateral process of the talus. Which of the following best describes the typical mechanism for this specific injury?

. Plantarflexion and forceful eversion
. Dorsiflexion and forceful inversion
. Plantarflexion and forceful inversion
. Dorsiflexion and forceful eversion
. Direct axial crush injury to the hindfoot

Correct Answer & Explanation

. Dorsiflexion and forceful inversion

Explanation

Fractures of the lateral process of the talus, commonly known as 'snowboarder's fractures,' typically occur from an axial load combined with dorsiflexion and forceful inversion. This mechanism shears the lateral process against the fibula. They are often missed on standard radiographs, mimicking lateral ankle sprains, and frequently require a CT scan for accurate diagnosis and surgical planning.

Question 2477

Topic: 8. Foot and Ankle

A 35-year-old industrial worker sustains a severe crush injury to the foot. The physical exam reveals tense swelling, severe pain with passive stretch of the toes, and decreased two-point discrimination. Intracompartmental pressure monitoring is ordered to evaluate for foot compartment syndrome. To ensure all distinct fascial compartments of the foot are evaluated, how many compartments must ideally be considered?

. 3
. 5
. 7
. 9
. 11

Correct Answer & Explanation

. 9

Explanation

The foot contains 9 distinct fascial compartments: the medial, lateral, superficial, calcaneal, four interosseous compartments, and the central compartment. Accurate diagnosis and treatment of foot compartment syndrome may require decompression of these compartments, typically via a dual dorsal incision approach or a medial approach, to prevent long-term sequelae such as claw toes and chronic pain.

Question 2478

Topic: 8. Foot and Ankle

In the surgical management of a trimalleolar ankle fracture, recent biomechanical and clinical studies have emphasized the importance of fixing the posterior malleolus, even if it involves less than 25% of the articular surface. What is the primary biomechanical advantage of open reduction and internal fixation of the posterior malleolus in this setting?

. It significantly increases the tibiotalar articular contact area to prevent osteoarthritis
. It restores the tension of the posteroinferior tibiofibular ligament (PITFL), thereby maximizing syndesmotic stability
. It acts as a buttress to prevent the anterior subluxation of the talus during weight-bearing
. It decreases the risk of sural nerve entrapment in the posterior fracture line
. It dynamically unloads the deltoid ligament by stabilizing the medial clear space

Correct Answer & Explanation

. It restores the tension of the posteroinferior tibiofibular ligament (PITFL), thereby maximizing syndesmotic stability

Explanation

Fixation of the posterior malleolus directly restores the footprint of the posteroinferior tibiofibular ligament (PITFL). Biomechanical studies demonstrate that anatomic fixation of the posterior malleolus restores syndesmotic stability better than or equal to syndesmotic screws alone, making it a critical step in stabilizing the syndesmosis in trimalleolar fractures.

Question 2479

Topic: 8. Foot and Ankle

A 45-year-old male is brought to the emergency department after an ankle injury. Radiographs reveal a severe fracture-dislocation of the ankle. Closed reduction under conscious sedation is attempted but is completely unsuccessful, with the ankle remaining rigidly dislocated. Radiographs show the proximal fibular shaft fragment located posterior to the tibia. This specific injury pattern is best described as which of the following?

. Bosworth fracture-dislocation
. Tillaux fracture
. Wagstaffe-Le Fort avulsion
. Maisonneuve fracture
. Chopart dislocation

Correct Answer & Explanation

. Bosworth fracture-dislocation

Explanation

A Bosworth fracture-dislocation is an irreducible fracture-dislocation of the ankle where the proximal fibular fragment becomes entrapped behind the posterior lateral tubercle of the tibia. This mechanical block prevents closed reduction, necessitating emergent open reduction and internal fixation.

Question 2480

Topic: Forefoot

A professional football lineman sustains a severe hyperextension injury to his first metatarsophalangeal (MTP) joint ('turf toe'). Which of the following physical or radiographic findings is considered a definitive indication for surgical intervention?

. A Grade 1 sprain with localized plantar swelling
. A Grade 2 sprain with pain elicited upon maximal passive extension
. A Grade 3 sprain with significant proximal retraction of the sesamoids on radiography
. Presence of a bipartite tibial sesamoid on contralateral comparison views
. Dorsal osteophyte formation indicative of early hallux rigidus

Correct Answer & Explanation

. A Grade 3 sprain with significant proximal retraction of the sesamoids on radiography

Explanation

Operative indications for a turf toe injury (plantar plate rupture) include a Grade 3 injury characterized by gross instability, complete tear of the plantar plate with significant proximal retraction of the sesamoids, large intra-articular loose bodies, or persistent pain and instability preventing push-off in an elite athlete after conservative care.

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