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8. Foot and Ankle MCQs

Practice Set 128 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 2541

Topic: Midfoot & Hindfoot

A 55-year-old patient with long-standing diabetes presents with a swollen, warm, and erythematous foot. Radiographs reveal fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent?

. Stage 0 (Prodromal)
. Stage 1 (Development/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Reconstruction/Consolidation)
. Stage 4 (Ulceration)

Correct Answer & Explanation

. Stage 1 (Development/Fragmentation)

Explanation

Eichenholtz Stage 1 (Fragmentation) is characterized clinically by a warm, swollen, erythematous foot and radiographically by joint subluxation, bony fragmentation, and debris. Stage 2 shows coalescence with absorption of debris, and Stage 3 shows bony remodeling.

Question 2542

Topic: 8. Foot and Ankle

A 25-year-old athlete complains of midfoot pain after a forced plantarflexion injury. A weight-bearing radiograph demonstrates 2 mm of widening between the first and second metatarsal bases and a 'fleck sign'. Which of the following ligaments is primarily disrupted?

. Plantar ligament between the medial cuneiform and 1st metatarsal
. Dorsal ligament between the medial and intermediate cuneiforms
. Interosseous ligament between the medial cuneiform and 2nd metatarsal base
. Plantar ligament between the 1st and 2nd metatarsal bases
. Interosseous ligament between the 1st and 2nd metatarsal bases

Correct Answer & Explanation

. Interosseous ligament between the medial cuneiform and 2nd metatarsal base

Explanation

The 'fleck sign' represents an avulsion fracture at the attachment of the Lisfranc ligament. The true Lisfranc ligament is the strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal.

Question 2543

Topic: 8. Foot and Ankle

A 40-year-old roofer falls from a ladder and sustains an intra-articular calcaneus fracture. Preoperative radiographs reveal a Bohler's angle of 5 degrees. What is the primary functional purpose of restoring Bohler's angle during surgical fixation?

. Restore the gastrosoleus complex lever arm
. Prevent post-traumatic subtalar arthritis
. Prevent varus malalignment of the calcaneal tuberosity
. Decompress the tarsal tunnel medially
. Prevent subluxation of the peroneal tendons

Correct Answer & Explanation

. Restore the gastrosoleus complex lever arm

Explanation

Restoring Bohler's angle correlates directly with restoring the height of the calcaneus and the normal length-tension relationship of the Achilles tendon. This is critical for recovering the plantarflexion lever arm and normalizing gait mechanics.

Question 2544

Topic: Midfoot & Hindfoot
A 22-year-old snowboarder sustains a forced dorsiflexion injury of the ankle, resulting in a Hawkins type III talar neck fracture. According to the Hawkins classification, this fracture pattern involves subluxation or dislocation of which specific joints?
. Subtalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Tibiotalar and talonavicular joints
. Subtalar and talonavicular joints only

Correct Answer & Explanation

. Subtalar, tibiotalar, and talonavicular joints

Explanation

In the Hawkins classification for talar neck fractures, Type I is nondisplaced, Type II involves subtalar subluxation/dislocation, Type III involves subtalar and tibiotalar subluxation/dislocation, and Type IV (Canale modification) involves subtalar, tibiotalar, and talonavicular disruption.

Question 2545

Topic: 8. Foot and Ankle

A 25-year-old male sustains a high-energy knee dislocation (KD-IV). Following closed reduction, his dorsalis pedis and posterior tibial pulses are palpable but asymmetric compared to the uninjured side. The Ankle-Brachial Index (ABI) is 0.85. What is the most appropriate next step in management?

. Discharge with strict return precautions
. Immediate open exploration of the popliteal artery
. CT angiography of the lower extremity
. Application of a spanning external fixator
. Duplex ultrasonography in 24 hours

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

In the setting of a knee dislocation with an abnormal ABI (< 0.9) or asymmetric pulses, advanced imaging with CT angiography (CTA) is mandated to rule out a vascular intimal tear or occlusion. Hard signs of arterial injury (absent pulses, expanding hematoma, active pulsatile bleeding) would necessitate immediate open exploration, but an ABI of 0.85 with palpable pulses requires CTA first.

Question 2546

Topic: 8. Foot and Ankle

A 30-year-old male sustains a high-energy traumatic knee dislocation. Following closed reduction, distal pulses are palpable but slightly asymmetric. At what resting Ankle-Brachial Index (ABI) threshold is a CT angiogram or vascular surgery consultation absolutely indicated?

. < 0.9
. < 1.0
. < 1.1
. < 0.8
. < 0.7

Correct Answer & Explanation

. < 0.9

Explanation

An Ankle-Brachial Index (ABI) of less than 0.9 in the setting of a knee dislocation is highly suggestive of a major arterial injury (e.g., popliteal artery). This finding mandates advanced vascular imaging (CT angiogram) or immediate vascular surgery consultation.

Question 2547

Topic: 8. Foot and Ankle

During the surgical fixation of an intra-articular calcaneus fracture via an extensile lateral approach, the surgeon's goal is to reduce the lateral tuberosity and posterior facet fragments to the 'constant' medial (sustentacular) fragment. Which of the following best describes the anatomical structures that typically prevent displacement of this constant fragment?

. The Achilles tendon and the strong plantar fascia
. The deltoid ligament and the talocalcaneal interosseous ligament
. The bifurcate ligament and the extensor digitorum brevis origin
. The spring ligament and the superficial fibers of the deltoid ligament
. The long and short plantar ligaments

Correct Answer & Explanation

. The deltoid ligament and the talocalcaneal interosseous ligament

Explanation

In calcaneus fractures, the sustentacular (anteromedial) fragment is considered the 'constant fragment' because it remains tightly bound in its anatomical position relative to the talus. This stability is maintained by the strong medial talocalcaneal ligaments, deep fibers of the deltoid ligament medially, and the robust talocalcaneal interosseous ligament located laterally within the tarsal canal.

Question 2548

Topic: 8. Foot and Ankle

A 25-year-old male is brought to the emergency department after a motorcycle collision. He sustained a complete multiligamentous knee dislocation (Schenck KD-IV), which was immediately reduced upon arrival. Post-reduction, he has no active bleeding or expanding hematoma, and distal pulses are palpable but slightly diminished. His ankle-brachial index (ABI) is measured at 0.85. What is the most appropriate next step in management?

. Immediate surgical exploration of the popliteal artery
. Computed tomography angiography (CTA) of the lower extremity
. Observation with serial ABI measurements every 2 hours
. Magnetic resonance angiography (MRA) of the lower extremity
. Application of an external fixator and immediate discharge

Correct Answer & Explanation

. Computed tomography angiography (CTA) of the lower extremity

Explanation

An ABI less than 0.90 after a knee dislocation is a 'soft sign' of vascular injury and mandates further advanced imaging, most commonly a CT angiogram (CTA). Immediate surgical exploration is reserved for 'hard signs' of vascular injury, such as an expanding or pulsatile hematoma, absent distal pulses, or active pulsatile bleeding.

Question 2549

Topic: 8. Foot and Ankle
A 29-year-old female sustains a Hawkins III talar neck fracture following a fall from height. What is the approximate rate of avascular necrosis (AVN) of the talar body associated with this injury, and which major vascular supply is primarily disrupted?
. 0-10%; artery of the tarsal canal
. 20-50%; deltoid artery branch
. 50-70%; dorsalis pedis artery
. 80-100%; artery of the tarsal canal
. 80-100%; peroneal artery branches

Correct Answer & Explanation

. 80-100%; artery of the tarsal canal

Explanation

A Hawkins III fracture involves a talar neck fracture with dislocation of both the subtalar and tibiotalar joints. This severe displacement disrupts all three major blood supplies to the talus, particularly the artery of the tarsal canal (branch of the posterior tibial artery), leading to an AVN rate approaching 80-100%.

Question 2550

Topic: 8. Foot and Ankle
Figure 9 is the radiograph of a 24-year-old amateur marathon runner who has ankle pain. She previously sustained a metatarsal stress fracture. In addition to asking about her training routine and the type of footwear she uses, the orthopaedic surgeon should inquire about this patient's history of nutrition and
. genetics.
. rheumatology.
. menstruation.
. cardiovascular health.

Correct Answer & Explanation

. menstruation.

Explanation

Several studies have reported an increased incidence of stress fractures in female athletes, including fractures of the foot and ankle in runners. The female athlete triad describes a condition involving decreased bone density, anorexia, and amenorrhea. In addition to asking about this woman's exercise routine, the orthopaedic surgeon should obtain a comprehensive menstrual and dietary history in the context of multiple stress fractures.

Question 2551

Topic: 8. Foot and Ankle
A 28-year-old male sustains a Hawkins type III talar neck fracture. Which of the following blood vessels provides the most significant blood supply to the body of the talus and is at highest risk of disruption leading to avascular necrosis (AVN)?
. Artery of the tarsal canal
. Artery of the tarsal sinus
. Deltoid branch of the posterior tibial artery
. Anterior tibial 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, is the dominant blood supply to the body of the talus. In talar neck fractures (especially Hawkins Types II, III, and IV), this vessel is frequently disrupted, leading to a high risk of avascular necrosis.

Question 2552

Topic: 8. Foot and Ankle

The Lisfranc ligament is a critical stabilizing interosseous ligament in the midfoot. Which two osseous structures does it connect?

. Medial cuneiform and the base of the first metatarsal
. Medial cuneiform and the base of the second metatarsal
. Middle cuneiform and the base of the second metatarsal
. Lateral cuneiform and the base of the third metatarsal
. Cuboid and the base of the fourth metatarsal

Correct Answer & Explanation

. Medial cuneiform and the base of the second metatarsal

Explanation

The Lisfranc ligament connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the strongest of the tarsometatarsal ligaments and its integrity is critical for the stability of the midfoot arch. There is no direct ligamentous connection between the first and second metatarsal bases.

Question 2553

Topic: 8. Foot and Ankle

A 55-year-old female undergoes a medializing calcaneal osteotomy, flexor digitorum longus (FDL) transfer, and a lateral column lengthening (Evans osteotomy) for stage IIB adult-acquired flatfoot deformity. Which of the following complications is most specifically associated with the lateral column lengthening portion of this procedure?

. Sural nerve entrapment
. Nonunion of the calcaneocuboid joint
. Calcaneocuboid joint subluxation and arthritis
. Tarsal tunnel syndrome
. Anterior tibial tendon rupture

Correct Answer & Explanation

. Calcaneocuboid joint subluxation and arthritis

Explanation

Lateral column lengthening (Evans calcaneal osteotomy) inserts a bone graft in the anterior calcaneus to correct forefoot abduction. The most specific and challenging complication associated with this procedure is increased pressure across the calcaneocuboid (CC) joint, which can lead to CC joint subluxation, postoperative pain, and eventual CC arthritis.

Question 2554

Topic: Midfoot & Hindfoot
A 58-year-old male with poorly controlled type 2 diabetes presents with a swollen, erythematous right foot. Radiographs reveal fragmentation of the midfoot joints, periarticular debris, and joint subluxation. According to the Eichenholtz classification, the patient is currently in Stage I (Fragmentation). What is the hallmark radiographic finding of the subsequent stage (Stage II)?
. Normal radiographs with mild soft tissue swelling
. Progressive bony destruction and active osteomyelitis
. Coalescence, absorption of fine debris, and early sclerosis
. Complete bony consolidation and joint remodeling
. Osteolysis and profound periosteal elevation

Correct Answer & Explanation

. Coalescence, absorption of fine debris, and early sclerosis

Explanation

The Eichenholtz classification of Charcot arthropathy consists of three stages. Stage I (Developmental/Fragmentation) involves joint edema, fragmentation, and debris. Stage II (Coalescence) is marked by the absorption of fine debris, fusion of larger fragments, and early sclerosis as the inflammatory phase resolves. Stage III (Reconstruction) involves bony consolidation, remodeling, and rounding of bone ends.

Question 2555

Topic: Midfoot & Hindfoot

A 30-year-old male sustains a strictly ligamentous Lisfranc injury. Based on randomized controlled trials comparing primary arthrodesis versus open reduction and internal fixation (ORIF) for purely ligamentous Lisfranc injuries, primary arthrodesis is associated with which of the following outcomes?

. Higher functional scores and a lower rate of secondary surgeries
. A higher rate of post-traumatic osteoarthritis in the adjacent joints
. Lower functional scores but a faster return to competitive sports
. No difference in functional scores but a significantly higher risk of deep infection
. Decreased preservation of the medial longitudinal arch

Correct Answer & Explanation

. Higher functional scores and a lower rate of secondary surgeries

Explanation

Level I evidence (e.g., Ly and Coetzee, Henning et al.) has demonstrated that for purely ligamentous Lisfranc injuries, primary arthrodesis results in superior functional outcomes and significantly lower rates of secondary surgeries (such as hardware removal or salvage arthrodesis for post-traumatic arthritis) compared to ORIF.

Question 2556

Topic: Midfoot & Hindfoot

A 55-year-old male with long-standing poorly controlled diabetes presents with a warm, swollen, erythematous right foot. He denies trauma or fever. Radiographs show early fragmentation of the navicular and cuneiforms. Blood work reveals a normal erythrocyte sedimentation rate (ESR). What is the most appropriate initial management?

. Intravenous antibiotics and emergent surgical debridement
. Total contact casting and non-weight bearing
. Primary midfoot arthrodesis to prevent collapse
. Incisional biopsy and culture of the midfoot
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

This is a classic presentation of acute Charcot neuroarthropathy (Eichenholtz Stage I - Fragmentation phase). The normal ESR helps differentiate this from acute osteomyelitis. The gold standard initial management for acute Charcot arthropathy is immobilization in a total contact cast (TCC) and protected weight bearing to arrest the inflammatory process and prevent further bone destruction and deformity. Surgery is generally contraindicated in the acute phase.

Question 2557

Topic: 8. Foot and Ankle
A 28-year-old male is 6 weeks post-operative from open reduction and internal fixation of a Hawkins Type III talar neck fracture. An AP radiograph of the ankle demonstrates a subchondral radiolucent band in the dome of the talus. What does this radiographic finding signify?
. Impending nonunion of the talar neck
. Early avascular necrosis of the talar body
. Revascularization and preserved blood supply to the talar body
. Infectious osteomyelitis of the talus
. Post-traumatic osteoarthritis of the tibiotalar joint

Correct Answer & Explanation

. Revascularization and preserved blood supply to the talar body

Explanation

The subchondral radiolucent band seen on the AP ankle view at 6-8 weeks post-injury is known as Hawkins' sign. It represents subchondral bone resorption (disuse osteopenia), a process that requires an intact vascular supply. Therefore, the presence of a Hawkins sign is a highly reliable prognostic indicator of revascularization and the absence of widespread avascular necrosis (AVN) of the talar body.

Question 2558

Topic: Midfoot & Hindfoot
A 45-year-old obese female presents with progressive medial foot pain and an inability to perform a single-leg heel rise. Examination reveals a flexible pes planovalgus deformity. She has failed 6 months of orthotics and physical therapy. What is the most appropriate surgical management for this stage of her condition?
. Gastrocnemius recession and subtalar arthrodesis
. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Tibialis anterior tendon transfer and lateral column lengthening
. Spring ligament reconstruction alone

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy

Explanation

The patient has Stage II adult-acquired flatfoot deformity (posterior tibial tendon dysfunction), characterized by medial pain, a flexible deformity, and inability to perform a single heel rise. The standard surgical treatment for Stage II disease after failed conservative management involves a flexor digitorum longus (FDL) tendon transfer to replace the diseased posterior tibial tendon, combined with a medial displacement calcaneal osteotomy (MDCO) to correct the valgus malalignment. Triple arthrodesis is reserved for Stage III (rigid) deformity.

Question 2559

Topic: 8. Foot and Ankle

A 14-year-old male presents with recurrent ankle sprains and a rigid flat foot. Oblique radiographs of the foot demonstrate an 'anteater nose' sign. Which of the following is the most likely diagnosis?

. Talocalcaneal coalition
. Calcaneonavicular coalition
. Accessory navicular syndrome
. Muller-Weiss disease
. Kohler disease

Correct Answer & Explanation

. Calcaneonavicular coalition

Explanation

The 'anteater nose' sign on an oblique radiograph of the foot is a classic finding of a calcaneonavicular coalition. It represents an elongation of the anterior process of the calcaneus extending toward the navicular. Talocalcaneal coalitions are typically best visualized on a Harris axial view or CT scan, and may demonstrate the 'C-sign' on a lateral radiograph.

Question 2560

Topic: 8. Foot and Ankle

The Lisfranc ligament is an essential stabilizing structure of the tarsometatarsal joint complex. From which two bony structures does the primary intra-articular band of the Lisfranc ligament span?

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

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the largest and strongest ligament of the tarsometatarsal joint complex and is critical for midfoot stability. There is no direct ligamentous connection between the first and second metatarsal bases.

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