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8. Foot and Ankle MCQs

Practice Set 127 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 2521

Topic: Forefoot
A 55-year-old female presents with symptomatic hallux valgus. Radiographs reveal a hallux valgus angle (HVA) of 35 degrees, an intermetatarsal angle (IMA) of 13 degrees, and a distal metatarsal articular angle (DMAA) of 22 degrees (normal < 10 degrees). The MTP joint is congruous. Which of the following procedures is most appropriate to correct her deformity while minimizing the risk of recurrence?
. Distal chevron osteotomy
. Proximal crescentic osteotomy
. Lapidus procedure
. Biplanar chevron osteotomy (e.g., Reverdin-Green)
. Akin osteotomy alone

Correct Answer & Explanation

. Biplanar chevron osteotomy (e.g., Reverdin-Green)

Explanation

This patient has moderate hallux valgus with a significantly elevated DMAA and a congruous MTP joint. Correcting the IMA alone without addressing the abnormal DMAA will create an incongruous joint and inevitably lead to early recurrence. A distal biplanar osteotomy (such as a Reverdin-Green or modified biplanar Chevron) is required to translate the metatarsal head laterally while simultaneously rotating the articular surface to correct the DMAA.

Question 2522

Topic: Midfoot & Hindfoot

A 45-year-old construction worker falls from a height of 6 feet, sustaining an acute, purely ligamentous Lisfranc injury with lateral subluxation of the 1st through 3rd tarsometatarsal joints. Which of the following statements regarding primary arthrodesis compared to Open Reduction Internal Fixation (ORIF) for this specific injury pattern is supported by current Level I evidence?

. ORIF provides a statistically significant improvement in functional outcomes at 2 years.
. Primary arthrodesis results in fewer planned secondary surgeries.
. ORIF has a significantly lower rate of early hardware failure.
. Primary arthrodesis restores midfoot arch height significantly better than ORIF.
. There is no difference in the rate of postoperative degenerative joint disease requiring fusion.

Correct Answer & Explanation

. Primary arthrodesis results in fewer planned secondary surgeries.

Explanation

Multiple RCTs (e.g., Ly and Coetzee, 2006) demonstrate that for purely ligamentous Lisfranc injuries, primary arthrodesis results in similar or superior long-term functional outcomes but with a significantly lower rate of planned secondary surgeries. ORIF frequently requires hardware removal or late conversion to arthrodesis due to post-traumatic arthritis.

Question 2523

Topic: 8. Foot and Ankle
A 32-year-old male sustains a Hawkins Type III talar neck fracture following a motor vehicle collision. Which of the following describes the correct positioning to obtain a Canale view radiograph to optimally assess the talar neck alignment?
. Ankle in maximum dorsiflexion, foot pronated 15 degrees, tube angled 15 degrees cephalad
. Ankle in maximum equinus, foot pronated 15 degrees, tube angled 75 degrees cephalad
. Ankle in neutral, foot supinated 15 degrees, tube angled 45 degrees cephalad
. Ankle in maximum equinus, foot pronated 15 degrees, tube angled 75 degrees caudad
. Ankle in neutral, foot internally rotated 15 degrees, tube angled 15 degrees caudad

Correct Answer & Explanation

. Ankle in maximum equinus, foot pronated 15 degrees, tube angled 75 degrees cephalad

Explanation

The Canale view is essential for visualizing varus/valgus alignment of the talar neck. It is properly obtained by placing the ankle in maximum equinus (plantarflexion), pronating the foot approximately 15 degrees, and directing the x-ray beam 75 degrees cephalad from the horizontal.

Question 2524

Topic: 8. Foot and Ankle

A 65-year-old male with chronic Achilles tendinopathy presents with an acute on chronic rupture leaving a 6 cm defect. The surgeon elects to perform a local tendon transfer. Which of the following best describes the biomechanical rationale for choosing the Flexor Hallucis Longus (FHL) over the Flexor Digitorum Longus (FDL) for this transfer?

. The FHL is in-phase while the FDL is out-of-phase during the normal gait cycle.
. The FHL provides greater plantarflexion strength and its axis of pull is more closely aligned with the native Achilles.
. The FHL harvest avoids morbidity by not addressing the knot of Henry.
. The FHL tendon has a significantly longer excursion, allowing easier bridging of large gaps.
. The FDL transfer inevitably results in severe symptomatic lesser toe deformities.

Correct Answer & Explanation

. The FHL provides greater plantarflexion strength and its axis of pull is more closely aligned with the native Achilles.

Explanation

Both the FHL and FDL are in-phase synergists with the Achilles tendon. The FHL is the preferred transfer because it is approximately twice as strong as the FDL, has a highly vascularized muscle belly that aids in healing, and its axis of pull (directly posterior to the ankle joint) more closely replicates that of the Achilles.

Question 2525

Topic: 8. Foot and Ankle

A 40-year-old male presents with chronic, functionally limiting ankle pain. Weight-bearing radiographs demonstrate asymmetric medial joint space narrowing of the tibiotalar joint with a varus tibial anterior surface (TAS) angle of 82 degrees. The lateral joint space is completely preserved, and he has a flexible hindfoot. What is the most appropriate surgical indication for a supramalleolar osteotomy (SMO) in this patient?

. Age greater than 50 years with a rigid deformity
. Diffuse bone-on-bone tibiotalar arthritis
. Concomitant rigid hindfoot valgus deformity
. Asymmetric ankle arthritis with a correctable varus deformity and preserved lateral joint cartilage
. Presence of chronic syndesmotic instability

Correct Answer & Explanation

. Asymmetric ankle arthritis with a correctable varus deformity and preserved lateral joint cartilage

Explanation

Supramalleolar osteotomy (SMO) is a joint-preserving procedure indicated for young, active patients with asymmetric (typically medial) ankle arthritis driven by an extra-articular distal tibial deformity (like varus). By correcting the mechanical axis, load is transferred to the preserved lateral cartilage, alleviating pain and delaying the need for arthroplasty or arthrodesis.

Question 2526

Topic: 8. Foot and Ankle

During a precise open reduction and internal fixation of a subtle midfoot injury, the surgeon must restore the critical stabilizing structure of the Lisfranc complex. The primary Lisfranc ligament anatomically connects which of the following osseous structures?

. Base of the first metatarsal to the medial cuneiform
. 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
. Anterior navicular to the medial cuneiform
. Plantar aspect of the cuboid to the base of the fourth 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 robust interosseous ligament that connects the lateral surface of the medial cuneiform to the medial base of the second metatarsal. It is critical for the stability of the tarsometatarsal articulation and midfoot arch.

Question 2527

Topic: Midfoot & Hindfoot
A 60-year-old woman presents with a painful, severe flatfoot deformity. Physical examination reveals an inability to perform a single-leg heel rise, and the hindfoot valgus deformity cannot be passively corrected to neutral. What is the most appropriate surgical management for this stage of disease?
. Flexor digitorum longus (FDL) transfer to the navicular
. FDL transfer combined with a medial displacement calcaneal osteotomy
. FDL transfer, calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis
. Isolated subtalar arthrodesis

Correct Answer & Explanation

. Triple arthrodesis

Explanation

The patient has a rigid, non-correctable hindfoot valgus, diagnostic of Stage III adult acquired flatfoot deformity. A triple arthrodesis (fusion of the subtalar, talonavicular, and calcaneocuboid joints) is required to correct rigid multi-planar deformities.

Question 2528

Topic: Forefoot

A 40-year-old woman presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. Clinical examination demonstrates notable hypermobility at the first tarsometatarsal (TMT) joint. Which of the following procedures is most strongly indicated?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue release
. First TMT arthrodesis (Lapidus procedure) with distal soft tissue release
. First metatarsophalangeal (MTP) arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure) with distal soft tissue release

Explanation

The Lapidus procedure (first TMT arthrodesis) is ideal for correcting a large intermetatarsal angle, especially in the presence of first ray hypermobility. It definitively addresses the apex of the deformity while stabilizing the medial column.

Question 2529

Topic: 8. Foot and Ankle

A patient with post-traumatic end-stage ankle arthritis is undergoing an ankle arthrodesis. To maximize gait efficiency and limit the development of degenerative changes in adjacent hindfoot joints, what is the optimal position for the arthrodesis?

. Neutral dorsiflexion, 5 degrees of varus, 10 degrees of internal rotation
. 5 degrees of plantarflexion, neutral heel, neutral rotation
. Neutral dorsiflexion, 0 to 5 degrees of valgus, 5 to 10 degrees of external rotation
. 10 degrees of dorsiflexion, 5 degrees of valgus, neutral rotation
. 5 degrees of plantarflexion, 5 degrees of valgus, 15 degrees of external rotation

Correct Answer & Explanation

. Neutral dorsiflexion, 0 to 5 degrees of valgus, 5 to 10 degrees of external rotation

Explanation

The optimal position for ankle arthrodesis is neutral dorsiflexion, 0 to 5 degrees of hindfoot valgus, and 5 to 10 degrees of external rotation. This specific alignment mimics a functional plantigrade foot and prevents excessive compensatory stress on the transverse tarsal joints.

Question 2530

Topic: Midfoot & Hindfoot

In a lateral subtalar dislocation, the injury is often irreducible by closed means. Which of the following structures most commonly blocks the closed reduction of a lateral subtalar dislocation?

. Extensor digitorum brevis
. Posterior tibial tendon
. Flexor hallucis longus
. Anterior tibial tendon
. Peroneus brevis tendon

Correct Answer & Explanation

. Posterior tibial tendon

Explanation

Lateral subtalar dislocations are commonly irreducible due to the interposition of the posterior tibial tendon around the talar neck. In contrast, medial subtalar dislocations are typically blocked by the extensor digitorum brevis, extensor retinaculum, or the talonavicular joint capsule.

Question 2531

Topic: 8. Foot and Ankle

Which of the following descriptions accurately characterizes the anatomical origin and insertion of the Lisfranc ligament?

. Plantar-lateral aspect of the medial cuneiform to the medial base of the second metatarsal
. Dorsal aspect of the medial cuneiform to the dorsal base of the second metatarsal
. Plantar aspect of the middle cuneiform to the base of the second metatarsal
. Medial aspect of the lateral cuneiform to the base of the third metatarsal
. Plantar aspect of the medial cuneiform to the plantar base of the first metatarsal

Correct Answer & Explanation

. Plantar-lateral aspect of the medial cuneiform to the medial base of the second metatarsal

Explanation

The Lisfranc ligament is the largest and strongest interosseous ligament of the midfoot. It originates from the lateral, plantar surface of the medial cuneiform and inserts on the medial aspect of the base of the second metatarsal.

Question 2532

Topic: Midfoot & Hindfoot

A 55-year-old female presents with Stage IIb posterior tibial tendon dysfunction. Clinical exam shows a flexible hindfoot valgus and significant forefoot abduction with greater than 30% uncoverage of the talonavicular joint. In addition to a flexor digitorum longus transfer and a medial displacement calcaneal osteotomy, which additional procedure is most appropriate?

. Subtalar arthrodesis
. Talonavicular arthrodesis
. Lateral column lengthening
. First tarsometatarsal arthrodesis
. Medial cuneiform opening wedge osteotomy

Correct Answer & Explanation

. Lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction is characterized by significant forefoot abduction (>30% talonavicular uncoverage). A lateral column lengthening (such as an Evans osteotomy) is required to restore the lateral column length and correct the forefoot abduction.

Question 2533

Topic: 8. Foot and Ankle

A 13-year-old boy presents with a rigid, painless flatfoot and a history of frequent ankle sprains. Lateral radiographs demonstrate an elongated anterior process of the calcaneus, known as the 'anteater nose sign.' Which of the following is the most appropriate initial surgical management if conservative therapy fails?

. Subtalar arthrodesis
. Triple arthrodesis
. Resection of the calcaneonavicular bar with interposition of the extensor digitorum brevis
. Resection of the talocalcaneal bar with interposition of the flexor hallucis longus
. Lateral column lengthening

Correct Answer & Explanation

. Resection of the calcaneonavicular bar with interposition of the extensor digitorum brevis

Explanation

The 'anteater nose sign' is pathognomonic for a calcaneonavicular coalition. When conservative treatment fails in a young patient without arthritic changes, resection of the coalition with interposition of the extensor digitorum brevis is the standard of care.

Question 2534

Topic: Midfoot & Hindfoot

A 40-year-old marathon runner with chronic heel pain continues to have symptoms despite 6 months of stretching and orthotics. The pain is maximal over the medial heel and is associated with weakness in active abduction of the fifth toe. Entrapment of which of the following nerves is the most likely diagnosis?

. Medial plantar nerve
. Sural nerve
. First branch of the lateral plantar nerve
. Saphenous nerve
. Deep peroneal nerve

Correct Answer & Explanation

. First branch of the lateral plantar nerve

Explanation

Baxter's nerve is the first branch of the lateral plantar nerve. Entrapment mimics plantar fasciitis but often presents with chronic medial heel pain and motor weakness of the abductor digiti minimi.

Question 2535

Topic: 8. Foot and Ankle

In displaced intra-articular calcaneus fractures, the sustentacular (anteromedial) fragment remains relatively constant in its anatomic position relative to the talus. Which ligamentous attachment is primarily responsible for preventing the displacement of this fragment?

. Calcaneofibular ligament
. Spring ligament
. Interosseous talocalcaneal ligament
. Bifurcate ligament
. Long plantar ligament

Correct Answer & Explanation

. Interosseous talocalcaneal ligament

Explanation

The sustentaculum tali fragment remains in a constant anatomical position because it is firmly tethered to the talus by the strong interosseous talocalcaneal ligament and the deltoid ligament.

Question 2536

Topic: Forefoot

A 60-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 45 degrees, an Intermetatarsal Angle (IMA) of 18 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate?

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

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus procedure)

Explanation

For severe hallux valgus (IMA > 15 degrees, HVA > 40 degrees) accompanied by first TMT hypermobility, a Lapidus procedure (first TMT arthrodesis) provides powerful, stable correction and addresses the underlying hypermobility.

Question 2537

Topic: 8. Foot and Ankle
A 22-year-old male sustains a Hawkins Type III talar neck fracture. Which of the following statements regarding the blood supply to the talar body and the risk of avascular necrosis (AVN) is most accurate?
. The artery of the sinus tarsi provides the predominant blood supply to the talar body; AVN risk is 10-20%.
. The artery of the tarsal canal provides the predominant blood supply to the talar body; AVN risk approaches 90-100%.
. The dorsalis pedis artery provides the predominant blood supply to the talar body; AVN risk is 40-50%.
. The deltoid branch provides the predominant blood supply to the talar body; AVN risk approaches 90-100%.
. The anterior tibial artery provides the predominant blood supply to the talar body; AVN risk is 10-20%.

Correct Answer & Explanation

. The artery of the tarsal canal provides the predominant blood supply to the talar body; AVN risk approaches 90-100%.

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. A Hawkins Type III fracture is a talar neck fracture with both subtalar and tibiotalar dislocations. This severe injury disrupts the major blood supplies (tarsal canal, sinus tarsi, and superior neck vessels), leading to an AVN risk of nearly 90-100%.

Question 2538

Topic: 8. Foot and Ankle

A 22-year-old football player sustains a twisting injury to his midfoot. Weight-bearing radiographs reveal a 3 mm widening between the bases of the first and second metatarsals, with a small avulsion fracture off the base of the second metatarsal. What is the most appropriate management for this athlete?

. Non-weight bearing in a short leg cast for 6 weeks
. Rigid carbon-fiber shoe insert and immediate return to play
. Open reduction and internal fixation or primary arthrodesis
. Closed reduction and percutaneous pinning
. Corticosteroid injection into the Lisfranc joint

Correct Answer & Explanation

. Open reduction and internal fixation or primary arthrodesis

Explanation

This patient has a displaced Lisfranc injury with a classic fleck sign indicating avulsion of the Lisfranc ligament. In competitive athletes with displaced injuries (>2 mm diastasis), operative stabilization via ORIF or primary arthrodesis is required to restore stable midfoot anatomy.

Question 2539

Topic: 8. Foot and Ankle

A 25-year-old athlete presents with midfoot pain after an axial load to a plantarflexed foot. Weight-bearing radiographs demonstrate a 3 mm diastasis between the base of the first and second metatarsals. The primary ligament injured in this condition connects which two structures?

. Medial cuneiform to the second metatarsal base
. Medial cuneiform to the first metatarsal base
. Middle cuneiform to the second metatarsal base
. Lateral cuneiform to the cuboid
. Navicular to the medial cuneiform

Correct Answer & Explanation

. Medial cuneiform to the second metatarsal base

Explanation

The Lisfranc ligament is a critical interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is essential for the stability of the tarsometatarsal joint complex.

Question 2540

Topic: 8. Foot and Ankle

A 35-year-old roofer falls and sustains a displaced intra-articular calcaneus fracture. An extensile lateral approach is planned. Which of the following structures is most at risk during the inferior limb of the incision?

. Superficial peroneal nerve
. Deep peroneal nerve
. Sural nerve
. Posterior tibial artery
. Saphenous nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve crosses the lateral aspect of the hindfoot and is at significant risk of injury during the inferior limb of the extensile lateral approach to the calcaneus. Careful full-thickness flap elevation is critical to protect it.

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