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8. Foot and Ankle MCQs

Practice Set 143 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 2841

Topic: 8. Foot and Ankle
In the Eichenholtz classification of Charcot neuroarthropathy of the foot and ankle, which of the following radiographic and clinical findings characterizes Stage II (Coalescence)?
. Profound joint effusion and erythema with completely normal initial radiographs
. Active bone resorption, fragmentation of subchondral bone, and abundant loose debris
. Absorption of fine debris, early fusion of fracture fragments, and resolution of erythema
. Remodeling and rounding of bone ends with a stable, rock-bottom deformity
. Frank ulceration over the medial eminence with underlying osteomyelitis

Correct Answer & Explanation

. Active bone resorption, fragmentation of subchondral bone, and abundant loose debris

Explanation

The Eichenholtz classification has three distinct stages. Stage I (Developmental/Fragmentation) is characterized by acute inflammation (erythema, swelling), joint subluxation, debris formation, and fragmentation. Stage II (Coalescence) is marked by a decrease in clinical inflammation, absorption of fine debris, and early sclerosis/fusion of the larger bone fragments. Stage III (Reconstruction/Consolidation) features rounding and remodeling of bone ends, with mature arthrosis and stable deformity.

Question 2842

Topic: 8. Foot and Ankle

The Lisfranc ligament complex provides essential stability to the midfoot, and its rupture can lead to significant functional impairment. The primary component of the Lisfranc ligament is an interosseous ligament that connects which two osseous structures?

. 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 is the largest and most critical of the ligamentous structures stabilizing the tarsometatarsal articulation. It originates on the lateral aspect of the medial cuneiform and inserts onto the medial aspect of the base of the second metatarsal. There is no direct transverse intermetatarsal ligament between the bases of the first and second metatarsals, making the Lisfranc ligament the sole direct connection anchoring the second metatarsal base to the medial column of the midfoot.

Question 2843

Topic: 8. Foot and Ankle

A 56-year-old male with poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm left foot without open ulcerations. Radiographs show periarticular fragmentation and debris at the tarsometatarsal joints. According to the Eichenholtz classification, what is the appropriate stage and initial management?

. Stage 0; rigid shoe gear
. Stage 1; total contact casting
. Stage 2; Charcot Restraint Orthotic Walker (CROW)
. Stage 3; surgical arthrodesis
. Stage 1; immediate midfoot arthrodesis

Correct Answer & Explanation

. Stage 1; total contact casting

Explanation

The patient is in Eichenholtz Stage 1 (Development/Fragmentation), characterized clinically by a red, hot, swollen foot and radiographically by periarticular fragmentation, debris, and subluxation/dislocation. The gold standard for initial treatment is offloading and immobilization, most effectively achieved with a total contact cast (TCC), which limits disease progression.

Question 2844

Topic: 8. Foot and Ankle

Recent high-quality randomized controlled trials comparing operative repair to non-operative management (with functional rehabilitation) for acute Achilles tendon ruptures have demonstrated which of the following regarding clinical outcomes?

. Operative management has a significantly higher rate of re-rupture
. Non-operative management has an unacceptably high re-rupture rate preventing its routine use
. There is no significant difference in re-rupture rates when early functional weight-bearing rehabilitation is utilized
. Operative management provides significantly better long-term plantar flexion strength
. Non-operative management leads to a higher rate of sural nerve injury

Correct Answer & Explanation

. There is no significant difference in re-rupture rates when early functional weight-bearing rehabilitation is utilized

Explanation

Modern meta-analyses and RCTs (such as those by Willits et al.) have shown that when non-operative management of Achilles tendon ruptures is paired with an early functional rehabilitation and weight-bearing protocol, the re-rupture rates are not significantly different from operative repair. Furthermore, non-operative management entirely avoids surgical complications such as wound breakdown, infection, and sural nerve injury.

Question 2845

Topic: 8. Foot and Ankle

A 22-year-old football player sustains a midfoot injury.

To accurately assess the integrity of the Lisfranc complex, the surgeon must understand its anatomy. Which of the following accurately describes the attachments of the primary Lisfranc ligament?

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

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is an intra-articular interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the strongest and most crucial ligament for the stability of the tarsometatarsal joint complex. There is notably no intermetatarsal ligament between the first and second metatarsal bases.

Question 2846

Topic: 8. Foot and Ankle

A 32-year-old collegiate football player sustains a purely ligamentous Lisfranc injury. Weight-bearing radiographs demonstrate 3 mm of widening between the medial cuneiform and the base of the second metatarsal.

According to recent prospective randomized trials, which treatment modality yields the best long-term functional outcome and lowest rate of reoperation for this specific injury pattern?

. Closed reduction and percutaneous Kirschner wire fixation
. Open reduction and internal fixation with transarticular screws
. Open reduction and internal fixation with dorsal bridge plating
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Conservative management with a non-weight-bearing cast for 6 weeks

Correct Answer & Explanation

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

Explanation

In the setting of purely ligamentous Lisfranc injuries, multiple studies (including classic randomized controlled trials by Ly and Coetzee) have demonstrated that primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) yields superior functional outcomes, faster return to pre-injury activity levels, and significantly lower reoperation rates compared to ORIF with transarticular screws. Hardware removal and post-traumatic arthritis are significant complications associated with ORIF in purely ligamentous injuries.

Question 2847

Topic: Midfoot & Hindfoot
A 55-year-old female presents with a progressive flatfoot deformity, lateral hindfoot pain, and inability to perform a single-leg heel rise. Clinical exam shows a flexible hindfoot valgus and forefoot abduction. Radiographs show >40% uncoverage of the talonavicular joint. Diagnosis of Stage IIB posterior tibial tendon dysfunction (PTTD) is made. Which of the following surgical interventions is most critical to correct the specific forefoot abduction deformity in this stage?
. Medial displacement calcaneal osteotomy (MDCO)
. Flexor digitorum longus (FDL) transfer to the navicular
. Lateral column lengthening (Evans osteotomy)
. Spring ligament reconstruction
. Triple arthrodesis

Correct Answer & Explanation

. Lateral column lengthening (Evans osteotomy)

Explanation

Stage IIB PTTD is characterized by a flexible flatfoot with significant forefoot abduction (>40% talonavicular uncoverage). While an FDL transfer replaces the function of the diseased posterior tibial tendon, and a medial displacement calcaneal osteotomy (MDCO) corrects hindfoot valgus, the lateral column lengthening (Evans osteotomy) is specifically required to correct the forefoot abduction deformity by lengthening the lateral column and pivoting the navicular back over the talar head.

Question 2848

Topic: 8. Foot and Ankle

A 22-year-old male sustains a severe inversion injury to his ankle. He complains of pain over the lateral aspect of the foot. On examination, he has focal tenderness over the dorsal cuboid. Radiographs reveal a 'nutcracker' fracture of the cuboid. What is the classic mechanism of injury for this specific fracture pattern?

. Extreme dorsiflexion and axial loading of the midfoot
. Direct crush injury to the dorsum of the foot
. Forceful plantarflexion and inversion causing avulsion of the calcaneocuboid ligament
. Forced plantarflexion and severe abduction, crushing the cuboid between the calcaneus and the 4th/5th metatarsals
. Isolated extreme pronation of the forefoot relative to the hindfoot

Correct Answer & Explanation

. Forced plantarflexion and severe abduction, crushing the cuboid between the calcaneus and the 4th/5th metatarsals

Explanation

The 'nutcracker' fracture of the cuboid is a classic compression fracture. The mechanism is severe forced abduction of the forefoot with the foot in a plantarflexed position. This forceful movement mechanically compresses (or 'crushes') the cuboid between the anterior articular surface of the calcaneus and the bases of the 4th and 5th metatarsals. This leads to shortening of the lateral column of the foot, which must often be corrected surgically to prevent long-term abduction deformity and painful nonunion/malunion.

Question 2849

Topic: Midfoot & Hindfoot
A 32-year-old male sustains a Hawkins Type III talar neck fracture following a high-speed motor vehicle collision. Which of the following accurately describes the displacement pattern and the approximate historical risk of avascular necrosis (AVN) for this specific injury type?
. Displaced talar neck fracture with subtalar dislocation; 20-50% risk of AVN.
. Displaced talar neck fracture with subtalar and tibiotalar dislocation; nearly 100% risk of AVN.
. Displaced talar neck fracture with subtalar, tibiotalar, and talonavicular dislocation; 100% risk of AVN.
. Nondisplaced talar neck fracture; 0-10% risk of AVN.
. Displaced talar neck fracture with talonavicular dislocation only; 50% risk of AVN.

Correct Answer & Explanation

. Displaced talar neck fracture with subtalar and tibiotalar dislocation; nearly 100% risk of AVN.

Explanation

Hawkins Type III is a displaced talar neck fracture with dislocation of both the subtalar and tibiotalar joints. The risk of AVN in Type III fractures is exceptionally high, historically reported as up to 100% (though modern series may show ~85-90%). Type I is nondisplaced (~0-15% AVN). Type II has subtalar dislocation (~20-50% AVN). Type IV involves the talonavicular joint in addition to the subtalar and tibiotalar joints.

Question 2850

Topic: 8. Foot and Ankle

A 35-year-old patient with Charcot-Marie-Tooth disease presents with a bilateral cavovarus foot deformity. On examination, the clinician performs a Coleman block test. When the lateral aspect of the foot rests on the block and the first ray is allowed to drop off into a recess, the hindfoot varus corrects completely to neutral. What does this specific finding indicate?

. Tibialis posterior overactivity is driving the hindfoot varus.
. Weakness of the peroneus brevis is the primary deforming force.
. The hindfoot varus is flexible and primarily driven by a plantarflexed first ray.
. There is a fixed Achilles tendon contracture causing varus.
. The patient has advanced, rigid subtalar joint arthritis.

Correct Answer & Explanation

. The hindfoot varus is flexible and primarily driven by a plantarflexed first ray.

Explanation

The Coleman block test evaluates the flexibility of the hindfoot in a cavovarus foot. If the hindfoot varus corrects to neutral when the first ray drops off the block, it indicates that the hindfoot deformity is flexible and is secondarily driven by the fixed forefoot pronation (specifically, a plantarflexed first ray). If the hindfoot remains in varus, the hindfoot deformity is rigid/fixed.

Question 2851

Topic: 8. Foot and Ankle

A 10-year-old boy presents with a painful, rigid flatfoot and a history of recurrent ankle sprains. Examination shows a profound limitation of subtalar motion. Lateral weight-bearing radiographs of the foot demonstrate the 'C-sign'. Which of the following is the most likely diagnosis?

. Calcaneonavicular coalition
. Talocalcaneal coalition
. Cubonavicular coalition
. Accessory navicular
. Congenital vertical talus

Correct Answer & Explanation

. Talocalcaneal coalition

Explanation

The 'C-sign' on a lateral radiograph is a continuous C-shaped arc formed by the medial outline of the talar dome and the posterior outline of the sustentaculum tali. It is highly indicative of a talocalcaneal (subtalar) coalition. Calcaneonavicular coalition is typically seen on a 45-degree internal oblique radiograph as the 'anteater nose' sign.

Question 2852

Topic: 8. Foot and Ankle



A 28-year-old male sustains a severe crush injury to his right leg and undergoes emergent four-compartment fasciotomies. Postoperatively, the anterior compartment muscles are found to be completely necrotic and require radical debridement. Which of the following physical deficits will this patient inevitably exhibit as a direct result?

. Inability to actively plantarflex the ankle
. Profound weakness in active foot eversion
. Loss of active ankle dorsiflexion
. Inability to actively flex the toes
. Sensory loss over the entire plantar aspect of the foot

Correct Answer & Explanation

. Loss of active ankle dorsiflexion

Explanation

The anterior compartment of the leg contains the tibialis anterior, extensor hallucis longus, extensor digitorum longus, and peroneus tertius muscles. The primary function of these muscles is dorsiflexion of the ankle and extension of the toes. Complete necrosis and debridement of this compartment will result in foot drop (loss of active ankle dorsiflexion). Eversion is lateral compartment; plantarflexion/toe flexion is posterior compartment.

Question 2853

Topic: 8. Foot and Ankle

A 30-year-old female sustains a midfoot injury after falling from a horse. Radiographs demonstrate diastasis between the bases of the 1st and 2nd metatarsals. In a normal anatomic state, the native Lisfranc ligament originates and inserts on which two bony structures?

. Lateral aspect of the medial cuneiform to the medial aspect of the base of the 2nd metatarsal
. Base of the 1st metatarsal directly to the base of the 2nd metatarsal
. Medial aspect of the middle cuneiform to the base of the 2nd metatarsal
. Plantar aspect of the medial cuneiform to the base of the 1st metatarsal
. Lateral cuneiform to the base of the 3rd metatarsal

Correct Answer & Explanation

. Lateral aspect of the medial cuneiform to the medial aspect of the base of the 2nd metatarsal

Explanation

The Lisfranc ligament is a stout, obliquely oriented intra-articular ligament that acts as the primary stabilizer of the second tarsometatarsal joint complex. It connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. Importantly, there is no direct ligamentous connection between the bases of the first and second metatarsals.

Question 2854

Topic: 8. Foot and Ankle

A 42-year-old weekend warrior sustains a sudden "pop" in his posterior calf while lunging for a tennis ball.

He is diagnosed with an acute Achilles tendon rupture via a positive Thompson test. He opts for non-operative management utilizing an early functional rehabilitation protocol. Based on modern Level I evidence, how does this approach compare to operative repair?

. It has a significantly higher rate of deep vein thrombosis
. It carries a significantly higher risk of permanent sural nerve dysfunction
. It demonstrates equivalent rerupture rates while completely avoiding surgical complications like infection
. It results in significantly superior plantar flexion strength and return to play metrics at 2 years
. It demands a much longer period of strict non-weight-bearing cast immobilization

Correct Answer & Explanation

. It demonstrates equivalent rerupture rates while completely avoiding surgical complications like infection

Explanation

Historically, traditional cast immobilization for Achilles ruptures had higher rerupture rates than surgery. However, modern Level I randomized trials (e.g., Willits et al.) have demonstrated that non-operative management coupled with anearly functional rehabilitation protocol(early weight-bearing in a functional orthosis and early ROM) yields rerupture rates that are statistically equivalent to operative repair. The primary advantage of the non-operative functional approach is the complete avoidance of surgical complications, such as wound breakdown, deep infection, and iatrogenic sural nerve injury.

Question 2855

Topic: 8. Foot and Ankle

A 24-year-old football player sustains a high-energy hyperplantarflexion injury to his midfoot. Weight-bearing radiographs suggest a subtle Lisfranc injury.

Which of the following anatomic descriptions accurately characterizes the primary strong band of the Lisfranc ligament complex?

. It connects the medial cuneiform to the base of the first metatarsal
. It connects the medial cuneiform to the base of the second metatarsal
. It connects the middle cuneiform to the base of the second metatarsal
. It connects the lateral cuneiform to the base of the third metatarsal
. It connects the cuboid to the base of the fourth metatarsal

Correct Answer & Explanation

. It connects the medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is an oblique, interosseous ligament that originates on the lateral aspect of the medial cuneiform and inserts on the medial aspect of the base of the second metatarsal. It is critical for midfoot stability because there is no direct intermetatarsal ligamentous connection between the bases of the first and second metatarsals.

Question 2856

Topic: Midfoot & Hindfoot
A 55-year-old patient with long-standing, poorly controlled diabetes mellitus presents with an acute, red, hot, and swollen right foot. Radiographs demonstrate extensive osteopenia, periarticular fragmentation, bony debris, and midfoot subluxation. According to the Eichenholtz classification of Charcot neuroarthropathy, which stage does this represent?
. Stage 0 (High risk/Inflammatory)
. Stage I (Development/Fragmentation)
. Stage II (Coalescence)
. Stage III (Consolidation/Reconstruction)
. Stage IV (Ulceration/Infection)

Correct Answer & Explanation

. Stage I (Development/Fragmentation)

Explanation

The Eichenholtz classification describes the radiographic evolution of Charcot arthropathy. Stage I (Development or Fragmentation) is characterized by acute inflammation clinically, and radiographs showing osteopenia, periarticular fragmentation, subluxation/dislocation, and bony debris. Stage 0 lacks radiographic findings but has clinical swelling. Stage II (Coalescence) shows absorption of fine debris and early fusion. Stage III (Consolidation) shows remodeling and fixed deformity.

Question 2857

Topic: 8. Foot and Ankle
A 28-year-old male sustains a severe hyper-dorsiflexion injury to his ankle in a motor vehicle accident, resulting in a Hawkins Type III talar neck fracture. Which of the following arteries provides the predominant blood supply to the body of the talus, placing it at significant risk for avascular necrosis in this injury?
. Artery of the sinus tarsi
. Anterior tibial artery
. Dorsalis pedis
. Artery of the tarsal canal
. Peroneal artery

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal, which is a branch of the posterior tibial artery, provides the dominant blood supply to the talar body. In a Hawkins Type III fracture (talar neck fracture with subtalar and tibiotalar dislocation), the blood supply from the artery of the tarsal canal, the artery of the sinus tarsi, and capsular vessels are disrupted, leading to an avascular necrosis (AVN) rate approaching 100%.

Question 2858

Topic: 8. Foot and Ankle

A 30-year-old male sustains a severe midfoot sprain. Radiographs reveal widening between the bases of the first and second metatarsals.

The primary ligamentous stabilizer disrupted in this classic Lisfranc injury connects which two osseous structures?

. Medial cuneiform to 1st metatarsal base
. Medial cuneiform to 2nd metatarsal base
. Middle cuneiform to 2nd metatarsal base
. Lateral cuneiform to 3rd metatarsal base
. Navicular to medial cuneiform

Correct Answer & Explanation

. Medial cuneiform to 2nd metatarsal base

Explanation

The Lisfranc ligament is the strongest ligament in the tarsometatarsal joint complex. It courses obliquely from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It acts as the primary stabilizer of the second metatarsal base. Disruption results in the classic widening between the first and second rays, often with an avulsion fragment ('fleck sign').

Question 2859

Topic: Midfoot & Hindfoot
A 60-year-old diabetic patient presents with a warm, swollen, erythematous foot. Radiographs reveal fragmentation of bone, periarticular debris, subluxation, and joint dislocation. There is no active consolidation. Which stage of the Eichenholtz classification for Charcot arthropathy does this represent?
. Stage 0 (Prodromal)
. Stage I (Developmental/Fragmentation)
. Stage II (Coalescence)
. Stage III (Consolidation)
. Stage IV (Remodeling)

Correct Answer & Explanation

. Stage I (Developmental/Fragmentation)

Explanation

The Eichenholtz classification describes the natural history of Charcot neuroarthropathy. Stage I (Developmental/Fragmentation) is characterized by acute inflammation, osteopenia, joint subluxation/dislocation, bone fragmentation, and intra-articular debris. Stage II (Coalescence) shows decreased inflammation and early absorption of debris. Stage III (Consolidation) shows remodeling and robust bony fusion. Stage 0 was later added (Shibata) to denote the acute inflammatory phase prior to radiographic fragmentation.

Question 2860

Topic: 8. Foot and Ankle

A 30-year-old male sustains an axial load to a plantarflexed foot. On physical examination, there is pronounced plantar ecchymosis and localized pain with passive pronation and abduction of the forefoot.

The primary stabilizing ligament of the disrupted joint complex connects which two osseous structures?

. Medial cuneiform and second metatarsal base
. Middle cuneiform and second metatarsal base
. Medial cuneiform and first metatarsal base
. Cuboid and fourth metatarsal base
. Navicular and medial cuneiform

Correct Answer & Explanation

. Medial cuneiform and second metatarsal base

Explanation

Plantar ecchymosis in the midfoot is the pathognomonic sign of a Lisfranc injury. The Lisfranc ligament is an interosseous ligament that represents the strongest and most critical stabilizer of the tarsometatarsal complex. It runs obliquely from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. There is notably no direct transverse ligamentous connection between the bases of the first and second metatarsals.

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