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8. Foot and Ankle MCQs

Practice Set 131 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 2601

Topic: 8. Foot and Ankle
A 50-year-old laborer sustained an isolated closed injury to his heel after falling 11 feet off a wall. A radiograph and a CT scan are shown in Figures 4a and 4b. To minimize the patientโ€™s temporary disability and allow him to return to work most rapidly, management should consist of
. cast immobilization for 6 weeks, followed by physical therapy.
. early range of motion with progressive weight bearing after 6 weeks.
. open reduction and internal fixation.
. open reduction and primary subtalar arthrodesis.
. closed reduction and percutaneous pinning.

Correct Answer & Explanation

. open reduction and primary subtalar arthrodesis.

Explanation

With a severe articular injury to the calcaneus, the ability to achieve satisfactory results with open reduction and internal fixation diminishes. An arthrodesis is often needed to allow a person who works as a laborer to return to work. Recent literature suggests that this can be successfully performed primarily, improving the odds of an earlier return to the labor force at 1 year.

Question 2602

Topic: 8. Foot and Ankle
Figure 29 shows the radiograph of a 25-year-old woman who has had a 3-month history of ankle pain after sustaining an inversion injury to the ankle. She reports occasional catching, but no sense of instability. Examination reveals ligament stability. Management should consist of
. a non-weight-bearing short leg cast.
. open reduction and internal fixation.
. no weight bearing with motor exercises for 8 weeks.
. debridement, curettage, and drilling.
. an ankle brace or taping when participating in athletic activity.

Correct Answer & Explanation

. a non-weight-bearing short leg cast.

Explanation

Osteochondral lesions of the talar dome can have a traumatic or nontraumatic etiology. Most authors cite a probable traumatic etiology for lateral lesions. Stage I and II lesions, which are composed of compressed subchondral bone or a partially detached osteochondral fragment, can be treated initially in a non-weight-bearing short leg cast for 6 weeks. Stage III medial lesions can also be treated in the same manner. If symptoms persist, the treatment of choice is debridement of the fracture, curettage of the lesion, and drilling of the subchondral bone. This treatment also applies to lateral stage III and all stage IV lesions. If the fragment is at least one third of the size of the talar dome, management should consist of open reduction and internal fixation. In patients with more chronic lesions (4 to 6 months of persistent pain), the threshold to proceed with surgery is lower, even in a stage II lesion. Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 205-226.

Question 2603

Topic: 8. Foot and Ankle

A 47-year-old man with Charcot-Marie-Tooth (CMT) disease was treated with a fifth metatarsal head resection for a symptomatic bunionette 2 years ago. What is the most likely complication seen at this time?

Foot & Ankle 2009 Practice Questions: Set 1 (Solved) - Figure 2

. Transfer lesion to the fourth metatarsal head
. Fifth toe fixed claw toe deformity
. Ulceration at the level of the resected head
. Peroneal atrophy
. Charcot arthropathy with midfoot collapse and forefoot abduction

Correct Answer & Explanation

. Transfer lesion to the fourth metatarsal head

Explanation

CMT is characterized by a cavovarus foot position that increases weight-bearing stresses along the lateral border. Removal of the fifth metatarsal head carries the risk of creating a transfer lesion at the fourth metatarsal head, particularly with a cavovarus foot. Claw toes are common in CMT, but the fifth toe would be flail in this situation. Ulceration is unlikely given the lack of underlying bone. Peroneal atrophy is associated with CMT but would not be a complication of this procedure. Charcot arthropathy is a neuropathic process frequently seen in individuals with diabetes mellitus. Kitaoka HB, Holiday AD Jr: Metatarsal head resection for bunionette: Long-term followup. Foot Ankle 1991;11:345-349.

Question 2604

Topic: 8. Foot and Ankle

When performing surgery on a patient with insertional Achilles tendinitis and a Haglund's deformity, how much of the Achilles tendon insertion can be safely detached without having to consider reattachment with bone anchors?

. 10%
. 33%
. 50%
. 66%
. 75%

Correct Answer & Explanation

. 50%

Explanation

The Achilles tendon insertion encompasses a broad area on the posterior area of the calcaneus. A biomechanical study has shown that up to 50% of the Achilles tendon insertion point can be detached before the strength of the attachment point starts to weaken. It is recommended that if more than this amount is detached to remove the posterior superior calcaneal prominence, consideration should be given to either securing the tendon to the bone with suture anchors or performing a tendon transfer. Kolodziej P, Glisson RR, Nunley JA: Risk of avulsion of the Achilles tendon after partial excision for treatment of insertional tendinitis and Haglund's deformity: A biomechanical study. Foot Ankle Int 1999;20:433-437.

Question 2605

Topic: 8. Foot and Ankle

A 66-year-old patient with type 1 diabetes mellitus has a deep, nonhealing ulcer under the first metatarsal head and a necrotic tip of the great toe. He has been under the direction of a wound care clinic for 4 months, and has had orthotics and shoe wear changes. What objective findings are indicative of the patient's ability to heal the wound postoperatively?

. Absolute toe pressures of 55 mm Hg
. Transcutaneous oxygen level of 20 mm Hg
. Arterial brachial indices (ABI) of 1.2 at the level of surgery
. ABI 0.3 at the level of surgery
. Albumin level of 2.5

Correct Answer & Explanation

. Absolute toe pressures of 55 mm Hg

Explanation

Absolute toe pressures greater than 40 to 50 mm Hg are a good sign of healing potential. An ABI of greater than 0.45 favors healing, but indices greater than 1 are falsely positive due to calcifications in the vessels. Normal albumin is an overall indication of nutritional status. A transcutaneous oxygen level should be greater than 40 mm Hg for healing. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 113-122.

Question 2606

Topic: 8. Foot and Ankle

A 23-year-old college basketball player reports persistent lateral ankle pain after sustaining an inversion injury 6 months ago. Examination reveals pain over the anterolateral ankle, absence of swelling, and no clinical instability. Management consisting of vigorous physical therapy fails to provide relief, and a intra-articular corticosteroid injection provides only temporary relief. Radiographs obtained at the time of injury and subsequent AP and varus stress views are normal. A recent MRI scan fails to show any abnormalities. Management should now include

. cast immobilization.
. arthroscopy.
. continued physical therapy.
. a repeat corticosteroid injection.
. a short course of oral steroids.

Correct Answer & Explanation

. arthroscopy.

Explanation

Because the patient has failed to respond to appropriate nonsurgical management and imaging studies are normal, the use of arthroscopy not only aids in the diagnosis of chronic ankle pain, but is also helpful in its treatment. In patients with this condition, typical findings include synovitis in the lateral gutter and fibrosis along the talofibular articulation; syndesmosis chondromalacia of the talus and ankle also may be found. In patients with anterior soft-tissue impingement, approximately 84% who have a poor response to nonsurgical management will have a good to excellent response after arthroscopic synovectomy and debridement. Ferkel RD, Fasulo GJ: Arthroscopic treatment of ankle injuries. Orthop Clin North Am 1994;25:17-32.

Question 2607

Topic: 8. Foot and Ankle

A 17-year-old girl with Charcot-Marie-Tooth disease reports the development of progressive instability when walking on uneven surfaces. Her involved heel is positioned in varus when viewed from behind. Examination reveals that she walks on the outer border of the involved foot. She has full passive motion of the ankle and hindfoot joints. She is able to dorsiflex the ankle against resistance. The heel varus fully corrects with the Coleman block test. Standing radiographs reveal a cavus deformity with valgus of the forefoot. She would like to avoid using an ankle-foot orthosis. What is the best surgical option?

Foot & Ankle Board Review 2009: High-Yield MCQs (Set 2) - Figure 2

. Dorsiflexion osteotomy of the first metatarsal
. Dorsiflexion osteotomy of the first metatarsal combined with anterior transfer of the tibialis posterior
. Triplanar osteotomy at the apex of the deformity
. Triplanar osteotomy at the apex of the deformity combined with valgus calcaneal osteotomy
. Triplanar osteotomy at the apex of the deformity combined with anterior transfer of the tibialis posterior

Correct Answer & Explanation

. Dorsiflexion osteotomy of the first metatarsal

Explanation

This deformity is early in the disease process. The foot is still flexible, as evidenced by correction with the Coleman block test. A simple dorsiflexion osteotomy of the first metatarsal should provide a plantigrade foot. More complex osteotomies are required later in the disease process when the foot is not flexible and the deformity does not correct with the Coleman block test. The patient may also require a tibialis anterior transfer later in the disease process but not at the present time. Richardson EG (ed): Orthopaedic Knowledge Upate: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 135-144.

Question 2608

Topic: 8. Foot and Ankle

A 25-year-old man has ankle instability and a lateral foot callosity. Radiographs are shown in Figures 49a through 49c. Management options are best determined by the

. patient's response to physical therapy.
. patient's response to casting.
. patient's response to selective injections.
. results of Coleman block testing.
. results of Semmes-Weinstein monofilament testing.

Correct Answer & Explanation

. results of Coleman block testing.

Explanation

The patient has a cavovarus deformity that has resulted in lateral foot overload and stressing of the lateral ligaments. Further treatment depends on the ability to correct the deformity. The Coleman block test indicates whether a deformity is fixed or supple. A supple deformity will respond to orthotic management or soft-tissue procedures, while a fixed deformity requires corrective osteotomy or fusion. Physical therapy, casting, and injection will not address the underlying pathophysiology. There is no indication that this is a neuropathic problem.

Question 2609

Topic: 8. Foot and Ankle

During a posterior approach to the right Achilles tendon, the surgeon encounters a nerve running with the small saphenous vein as shown in Figure 22. This nerve innervates what part of the foot?

Foot & Ankle Board Review 2009: High-Yield MCQs (Set 2) - Figure 26

. Posterior heel
. Plantar-lateral foot
. Plantar-medial foot
. Dorso-lateral foot
. Dorso-medial foot

Correct Answer & Explanation

. Dorso-lateral foot

Explanation

The sural nerve runs with the small saphenous vein on the posterior leg just lateral to the Achilles tendon. It is formed by contributions from both the tibial and common peroneal nerves and provides sensation on the dorso-lateral aspect of the foot. Aktan Ikiz ZA, Ucerler H, Bilge O: The anatomic features of the sural nerve with an emphasis on its clinical importance. Foot Ankle Int 2005;26:560-567.

Question 2610

Topic: 8. Foot and Ankle

A newborn with bilateral talipes equinovarus undergoes serial manipulation and casting. What is the primary goal of manipulation?

Pediatrics 2004 Practice Questions: Set 1 (Solved) - Figure 17

. Rotation of the foot laterally around the fixed talus
. Simultaneous abduction of the metatarsals and dorsiflexion of the talus
. Lateral translation of the calcaneus
. Anterolateral translation of the navicular
. Dorsiflexion of the calcaneus with forefoot eversion

Correct Answer & Explanation

. Rotation of the foot laterally around the fixed talus

Explanation

Manipulative treatment and casting of talipes equinovarus has become popular because of disappointing surgical results and enthusiasm for the Ponseti method of manipulation. In this technique, the primary goal is to rotate the foot laterally around a talus that is held fixed by the manipulating surgeon's hands. While the navicular may be rotated anterolaterally with this technique, the primary focus is on the calcaneus. The calcaneus is rotated laterally and superiorly, not translated. Some dorsiflexion of the calcaneus can be obtained by manipulation, but the primary focus is on the rotational relationship of the talus and calcaneus, not the degree of calcaneal dorsiflexion. Ponseti IV: Common errors in the treatment of congenital clubfoot. Int Orthop 1997;21:137-141.

Question 2611

Topic: 8. Foot and Ankle

Figure 1 shows the radiograph of a 60-year-old woman who underwent a previous operation for great toe pain 20 years ago. She has had increasing pain over the past 5 years and now reports pain with any motion, swelling, and clicking. She also reports pain under the ball of foot. What is the most appropriate management to alleviate her metatarsalgia and great toe pain?

Foot & Ankle 2009 Practice Questions: Set 1 (Solved) - Figure 1

. Orthotic with Morton's extension
. In situ great toe fusion with implant removal
. Keller resection arthroplasty
. Implant removal with structural bone grafting and metatarsophalangeal (MTP) fusion
. Implant removal, bone grafting, and titanium total toe implants

Correct Answer & Explanation

. Implant removal with structural bone grafting and metatarsophalangeal (MTP) fusion

Explanation

The patient has a failed Silastic implant. Nonsurgical management will not work at this point. A Keller resection will only exacerbate her metatarsalgia. Implant removal with structural bone grafting and MTP fusion is the most appropriate choice because restoration of length is needed to alleviate the forefoot pain and bone grafting is required to fuse the MTP joint because there is an abundance of osteolysis. Total toe implants do not offer good long-term outcomes and are very difficult to fit into the large exploded-out cavity of the proximal phalanx. Hecht PJ, Gibbons MJ, Wapner KL, et al: Arthrodesis of the first metatarsophalangeal joint to salvage failed silicone implant arthroplasty. Foot Ankle Int 1997;18:383-390.

Question 2612

Topic: 8. Foot and Ankle

What is the reported failure rate for surgical treatment of a Morton's neuroma?

Foot & Ankle 2000 Practice Questions: Set 1 (Solved) - Figure 22

. Less than 1%
. 5%
. 15%
. 30%
. 50%

Correct Answer & Explanation

. 15%

Explanation

The reported failure rate is in the range of 15%, which may be the result of incorrect diagnosis, improper web space selection, or formation of a stump neuroma. Therefore, the procedure should be approached with caution, measures should be taken to ensure that the diagnosis is accurate, and nonsurgical options should be exhausted. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 101-111. Beskin JL: Nerve entrapment syndromes of the foot and ankle. J Am Acad Orthop Surg 1997;5:261-269.

Question 2613

Topic: 8. Foot and Ankle

Which of the following is considered the most useful screening method for the evaluation of protective foot sensation in a patient with diabetes mellitus?

. Sharp two-point discrimination
. Light touch sensation
. Hot and cold sensation
. Vibratory sensation
. 5.07 Semmes-Weinstein monofilament sensation

Correct Answer & Explanation

. 5.07 Semmes-Weinstein monofilament sensation

Explanation

Patients with diabetes mellitus should be screened for the presence of protective foot sensation. In the absence of protective foot sensation, patients are at increased risk for the development of neuropathic ulcerations and neuropathic arthropathy. The most reliable screening tool for the presence of protective sensation is the ability to feel the 5.07 Semmes-Weinstein monofilament. Pinzur MS, Shields N, Trepman E, Dawson P, Evans A: Current practice patterns in the treatment of Charcot foot. Foot Ankle Int 2000;21:916-920.

Question 2614

Topic: 8. Foot and Ankle

A 27-year-old woman with Down syndrome has a severe bunion with pain and deformity in the left forefoot. Nonsurgical management has failed to provide relief. She does not use any assistive ambulatory devices. A radiograph is shown in Figure 21. Treatment should now consist of

Foot & Ankle Board Review 2000: High-Yield MCQs (Set 2) - Figure 15

. distal chevron bunionectomy.
. proximal first metatarsal osteotomy with distal soft-tissue realignment.
. double osteotomy of the first metatarsal with distal soft-tissue realignment.
. arthrodesis of the first metatarsophalangeal joint.
. Keller bunionectomy.

Correct Answer & Explanation

. arthrodesis of the first metatarsophalangeal joint.

Explanation

The patient requires an arthrodesis of the first metatarsophalangeal joint because of the abnormal neuromuscular forces. The more traditional bunionectomies such as a distal chevron bunionectomy, a proximal first metatarsal osteotomy, and a double osteotomy have a high failure rate because of the underlying Down syndrome. The Keller procedure is indicated for older, sedentary individuals and has little role in the management of a neuromuscular bunion. Coughlin MJ, Abdo RV: Arthodesis of the first metatarsophalangeal joint with Vitallium plate fixation. Foot Ankle Int 1994;15:18-28.

Question 2615

Topic: 8. Foot and Ankle

A patient notes pain under the first metatarsophalangeal joint following a soccer injury. The MRI scans shown in Figures 27a and 27b reveal what pathologic finding?

. Sesamoid fracture
. Phalangeal fracture
. Osteochondral lesion
. Disruption of the plantar plate
. Rupture of the flexor hallucis tendon

Correct Answer & Explanation

. Disruption of the plantar plate

Explanation

The MRI scans show a complete disruption of the sesamoid complex with proximal retraction of the medial sesamoid and high signal originating from the site normally occupied by the plantar plate (metatarsophalangeal ligament). This injury is the result of a hyperextension injury and is a severe variant of a turf toe. Watson TS, Anderson RB, Davis WH: Periarticular injuries to the hallux metatarsophalangeal joint in athletes. Foot Ankle Clin 2000;5:687-713.

Question 2616

Topic: 8. Foot and Ankle

An 20-year-old elite college football player has ecchymosis, swelling, and pain on the lateral side of his foot after a game. Radiographs are shown in Figures 31a through 31c. Management should consist of

. open reduction and internal fixation with a plate and screws.
. open treatment with calcaneal bone graft.
. percutaneous screw fixation with a 4.5-mm screw.
. weight-bearing cast for 8 weeks.
. spanning external fixation.

Correct Answer & Explanation

. percutaneous screw fixation with a 4.5-mm screw.

Explanation

Metaphyseal-diaphyseal junction fractures of the fifth metatarsal require careful evaluation. In athletes, early intervention with a 4.5-mm intramedullary screw correlates with an earlier return to activity. One study examining the failure of surgically managed Jones fractures revealed that use of anything other than a 4.5-mm malleolar screw for internal fixation correlated with failure. Glasgow MT, Naranja RJ Jr, Glasgow SG, et al: Analysis of failed surgical management of fractures of the base of the fifth metatarsal distal to the tuberosity: The Jones fracture. Foot Ankle Int 1996;17:449-457.

Question 2617

Topic: 8. Foot and Ankle

A 50-year-old woman has a painful hallux valgus and a painful callus beneath the second metatarsal head. A radiograph is shown in Figure 46. To correct these problems, treatment of the great toe deformity should consist of

Foot & Ankle Board Review 2000: High-Yield MCQs (Set 4) - Figure 14

. excision of the base of the phalanx of the great toe with dorsiflexion osteotomy of the second metatarsal.
. osteotomy of the proximal phalanx of the great toe.
. distal first metatarsal osteotomy with soft-tissue realignment of the great toe.
. fusion of the metatarsal cuneiform joint with soft-tissue realignment of the first metatarsophalangeal joint.
. joint replacement arthroplasty of the first metatarsophalangeal joint.

Correct Answer & Explanation

. fusion of the metatarsal cuneiform joint with soft-tissue realignment of the first metatarsophalangeal joint.

Explanation

The patient has a significant hallux valgus and instability of the first ray, causing transfer metatarsalgia to the second metatarsal head. Therefore, the best procedure is fusion of the metatarsal cuneiform joint with soft-tissue realignment of the first metatarsophalangeal joint. This procedure provides the best chance of relieving symptoms under the second metatarsal head, as well as correcting the hallux valgus.

Question 2618

Topic: 8. Foot and Ankle

Figures 17a and 17b show the radiographs of a 32-year-old professional athlete who sustained an injury to the first metatarsal. A view of the opposite noninjured side is shown in Figure 17c. Management of the fracture should consist of

. open reduction and internal fixation.
. a postoperative stiff-soled shoe with weight bearing as tolerated.
. a postoperative shoe with no weight bearing for 3 weeks.
. a short leg cast with no weight bearing.
. percutaneous pinning.

Correct Answer & Explanation

. open reduction and internal fixation.

Explanation

Parameters for first metatarsal fracture management are different than for shaft fractures of the central second, third, and fourth metatarsals. The first metatarsal carries a greater load and if malunited, can create transfer lesions by virtue of uneven weight distribution; therefore, nonsurgical management is not indicated for this patient. Percutaneous pinning is not as likely to result in an anatomic reduction as open reduction and internal fixation. As his livelihood depends on an expeditious return to function, the choice of open reduction and internal fixation allows for earlier motion and rehabilitation. Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 64-65.

Question 2619

Topic: 8. Foot and Ankle

A 16-year-old girl has had pain and swelling along the medial arch of her left foot for the past 3 months. She also reports pain from shoe wear and while running. Nonsteroidal anti-inflammatory drugs have failed to provide relief. Radiographs are shown in Figures 40a through 40c. What is the next most appropriate step in management?

. Resection of the tarsal coalition
. Open reduction and internal fixation of the navicular fracture
. Surgical resection of the accessory navicular
. Corticosteroid injection
. Custom-molded orthosis

Correct Answer & Explanation

. Custom-molded orthosis

Explanation

Nonsurgical management of a symptomatic accessory navicular should be attempted prior to surgery. Good relief is often obtained with a semi-rigid orthosis with a medial arch support. Myerson MS: Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, p 655.

Question 2620

Topic: 8. Foot and Ankle

A newborn has been referred for evaluation of a deformed foot. Prenatal and birth history are unremarkable. Examination reveals a rocker bottom appearance to the foot, and a longitudinal arch cannot be created. A palpable lump is appreciated on the plantar medial surface. What is the best course of action?

Foot & Ankle Board Review 2000: High-Yield MCQs (Set 2) - Figure 32

. Parental education and reassurance
. Serial casting of the forefoot
. Complete peritalar release
. Lengthening of the Achilles tendon and soft-tissue balancing
. Reverse last shoes

Correct Answer & Explanation

. Serial casting of the forefoot

Explanation

The patient has congenital vertical talus. The navicular is irreducibly dorsally dislocated on the talus with the talar head prominent on the plantar medial aspect of the foot. Initial management involves corrective casting for 3 months to stretch the dorsal tendons, skin, and neurovascular structures. Surgical reconstruction is often needed and is indicated when the patient is age 6 to 12 months. Reconstruction requires both bony and soft-tissue procedures. Napiontek M: Congenital vertical talus: A retrospective and critical review of 32 feet operated on by peritalar reduction. J Pediatr Orthop 1995;4:179-187.

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