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8. Foot and Ankle MCQs

Practice Set 144 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 2861

Topic: Midfoot & Hindfoot
A 55-year-old patient with poorly controlled type II diabetes presents with a red, hot, swollen right foot. Inflammatory markers are normal and an MRI confirms no osteomyelitis. Radiographs reveal prominent periarticular osseous debris, fragmentation of the navicular and cuneiforms, and subluxation of the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, what stage does this clinical and radiographic picture represent?
. Stage 0
. Stage I
. Stage II
. Stage III
. Stage IV

Correct Answer & Explanation

. Stage I

Explanation

The Eichenholtz classification describes the natural history of Charcot arthropathy. Stage 0 is the acute inflammatory stage without radiographic changes. Stage I (Development/Fragmentation) is characterized clinically by a hot, swollen foot and radiographically by osteopenia, periarticular fragmentation, bony debris, and subluxation/dislocation. Stage II (Coalescence) shows absorption of fine debris, fusion of larger fragments, and early sclerosis. Stage III (Consolidation) shows remodeling, rounding of bone ends, and stable deformity.

Question 2862

Topic: 8. Foot and Ankle



A 24-year-old football player sustains a midfoot injury after an axial load to a plantarflexed foot. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the first and second metatarsals. Where does the primary interosseous Lisfranc ligament normally originate and insert?

. Medial cuneiform to the base of the first metatarsal
. Lateral aspect of the medial cuneiform to the medial 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

. Lateral aspect of the medial cuneiform to the medial base of the second metatarsal

Explanation

The Lisfranc ligament is the critical interosseous ligament providing stability to the tarsometatarsal joint complex. It runs obliquely from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. Rupture of this ligament leads to diastasis between the first and second metatarsal bases (the 'fleck sign' is an avulsion of this ligament).

Question 2863

Topic: 8. Foot and Ankle

A 30-year-old construction worker sustains an axial load to a plantarflexed foot. Weight-bearing radiographs demonstrate a 3 mm diastasis between the base of the first and second metatarsals. Which of the following correctly describes the primary anatomy of the Lisfranc ligament?

. Connects the medial cuneiform to the base of the first metatarsal
. Connects the medial cuneiform to the base of the second metatarsal
. Connects the middle cuneiform to the base of the second metatarsal
. Connects the lateral cuneiform to the cuboid
. Connects the base of the first metatarsal to the base of the second metatarsal

Correct Answer & Explanation

. Connects the medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is an oblique, strong intraosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It provides critical stability to the midfoot.

Question 2864

Topic: 8. Foot and Ankle

A 45-year-old weekend warrior feels a sudden 'pop' in his heel while accelerating to play a tennis ball. On examination, squeezing the calf does not result in plantar flexion of the foot. This specific clinical maneuver (Simmonds-Thompson test) evaluates the integrity of which of the following structures?

. Posterior tibial tendon
. Peroneus brevis tendon
. Achilles tendon
. Plantaris tendon
. Flexor hallucis longus

Correct Answer & Explanation

. Achilles tendon

Explanation

The Simmonds-Thompson test (calf squeeze test) is used to diagnose Achilles tendon ruptures. A positive test (absence of passive plantar flexion upon calf compression) indicates a complete rupture of the Achilles tendon.

Question 2865

Topic: 8. Foot and Ankle

An athlete sustains a hyperplantarflexion injury to the midfoot. Radiographs demonstrate widening of the space between the medial and middle cuneiforms.

The primary stabilizing ligament of the Lisfranc joint complex attaches to which two bones?

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

Correct Answer & Explanation

. Medial cuneiform and second metatarsal base

Explanation

The Lisfranc ligament is an interosseous ligament that runs from 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 stabilizing ligament of the tarsometatarsal complex.

Question 2866

Topic: Midfoot & Hindfoot
A 32-year-old male sustains a severe inversion injury resulting in a displaced fracture of the talar neck with subluxation of the subtalar joint, while the tibiotalar joint remains congruous. According to the Hawkins classification, what type of injury is this and what is the approximate rate of avascular necrosis (AVN)?
. Type I, 0-10%
. Type II, 20-50%
. Type III, 80-100%
. Type IV, 100%
. Type II, 80-100%

Correct Answer & Explanation

. Type III, 80-100%

Explanation

Hawkins Classification of talar neck fractures: Type I is nondisplaced (0-10% AVN). Type II involves displacement with subtalar subluxation/dislocation (20-50% AVN). Type III involves displacement with both subtalar and tibiotalar dislocation (nearly 100% AVN). Type IV adds talonavicular subluxation/dislocation.

Question 2867

Topic: Midfoot & Hindfoot
A 55-year-old male with poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm left foot. Radiographs demonstrate periarticular fragmentation, subluxation, and bony debris at the midfoot. According to the Eichenholtz classification, this presentation is most consistent with which stage?
. Stage 0
. Stage I (Development)
. Stage II (Coalescence)
. Stage III (Reconstruction)
. Stage IV (Resolution)

Correct Answer & Explanation

. Stage I (Development)

Explanation

The Eichenholtz classification of Charcot arthropathy: Stage 0 (pre-fragmentation) - erythema, edema, normal radiographs. Stage I (Development/Fragmentation) - severe edema, erythema, bony fragmentation, joint subluxation/dislocation, debris. Stage II (Coalescence) - decreased edema, absorption of fine debris, early fusion. Stage III (Reconstruction) - remodeling and consolidation of bone.

Question 2868

Topic: 8. Foot and Ankle

Osteochondral lesions (OCDs) of the talus frequently occur following ankle sprains. Based on classic descriptions of these injuries, what is the typical morphology and mechanism for an anterolateral talar dome lesion?

. Shallow, wafer-shaped, and caused by inversion and dorsiflexion
. Deep, cup-shaped, and caused by inversion and plantarflexion
. Shallow, wafer-shaped, and typically non-traumatic/insidious in origin
. Deep, cup-shaped, and caused by eversion and external rotation
. Usually bilaterally symmetric and asymptomatic

Correct Answer & Explanation

. Deep, cup-shaped, and caused by inversion and plantarflexion

Explanation

The mnemonic 'DIAL a PIMP' is classically used for talar dome lesions. DIAL = Dorsiflexion, Inversion -> AnteroLateral. PIMP = Plantarflexion, Inversion -> PosterioMedial. Anterolateral lesions are typically traumatic, shallow, wafer-shaped, and more likely to displace. Posteromedial lesions are often deeper, cup-shaped, less likely to displace, and may not have a clear history of trauma.

Question 2869

Topic: Forefoot

A 55-year-old woman presents with a symptomatic hallux valgus deformity. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 42 degrees, an intermetatarsal angle (IMA) of 16 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. First TMT joint arthrodesis (Lapidus procedure)
. Metatarsophalangeal (MTP) joint arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus procedure)

Explanation

A first tarsometatarsal (TMT) joint arthrodesis, also known as a Lapidus procedure, is indicated for moderate to severe hallux valgus deformities (IMA > 15 degrees) that are accompanied by hypermobility of the first ray. It corrects the deformity at the apex (the TMT joint) and provides stability. A distal chevron is for mild deformities without hypermobility.

Question 2870

Topic: 8. Foot and Ankle
A 30-year-old male sustains a traumatic knee dislocation (Schenck KD-III) after a severe hyperextension injury. Upon presentation, his knee is grossly reduced but extremely unstable. The Ankle-Brachial Index (ABI) is 0.85 in the affected limb and 1.1 in the contralateral limb. What is the most appropriate next step in management?
. Immediate closed reduction and application of a spanning external fixator
. Observation and serial Doppler examinations every 4 hours
. CT angiography of the lower extremity
. Immediate surgical exploration of the popliteal artery
. MRI of the knee to evaluate ligamentous injury

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

In the setting of a knee dislocation, vascular assessment is paramount. An Ankle-Brachial Index (ABI) less than 0.90 is highly sensitive for an arterial injury (such as a popliteal artery intimal tear or occlusion) and mandates advanced imaging, typically a CT angiogram, or immediate vascular surgery consultation. While immediate surgical exploration is indicated for hard signs of vascular injury (e.g., active hemorrhage, expanding hematoma, pulselessness), an asymmetric ABI <0.9 without hard signs is a firm indication for a CT angiogram.

Question 2871

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a swollen, erythematous, and warm right foot without open ulcerations. He is afebrile with a normal WBC count. Radiographs reveal fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints.

According to the Eichenholtz classification, what is the best initial management?

. Intravenous antibiotics and emergent irrigation and debridement
. Total contact casting and restricted weight-bearing
. Primary midfoot arthrodesis with robust internal fixation
. Surgical exostectomy of prominent bone to prevent ulceration
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and restricted weight-bearing

Explanation

This patient is in the acute fragmentation phase (Stage 1) of Eichenholtz Charcot arthropathy. The classic presentation mimics infection (red, hot, swollen), but the absence of systemic signs and an intact skin envelope point toward Charcot. The mainstay of treatment in the acute fragmentation stage is immobilization and offloading, typically achieved via a total contact cast (TCC). Surgery during the acute inflammatory phase carries a high risk of failure and is generally contraindicated unless severe instability threatens the soft tissue envelope.

Question 2872

Topic: 8. Foot and Ankle

A 24-year-old football player sustains a hyperplantarflexion injury to his midfoot. Physical examination reveals plantar ecchymosis. Radiographs show a 3 mm diastasis between the base of the first and second metatarsals. Which of the following anatomically describes the Lisfranc ligament, which is presumed to be injured?

. It connects the medial cuneiform to the base of the first metatarsal.
. It connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal.
. It connects the intermediate cuneiform to the base of the second metatarsal.
. It connects the plantar aspect of the first metatarsal to the plantar aspect of the second metatarsal.
. It connects the navicular to the medial cuneiform.

Correct Answer & Explanation

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

Explanation

The Lisfranc ligament is a large, oblique interosseous ligament that is crucial for the stability of the midfoot. It originates on the lateral aspect of the medial cuneiform and inserts onto the medial base of the second metatarsal. Notably, there is no direct ligamentous connection between the bases of the first and second metatarsals, which makes the Lisfranc ligament the critical stabilizing structure uniting the medial column with the central column.

Question 2873

Topic: 8. Foot and Ankle

A 55-year-old male with long-standing poorly controlled type 2 diabetes presents with a red, hot, swollen, and painless left foot. He has a small, superficial, uninfected ulcer on the plantar surface. Radiographs show soft tissue swelling but no bony destruction. MRI demonstrates bone marrow edema in the midfoot without discrete fluid collections. What is the most appropriate initial management?

. Intravenous antibiotics and observation
. Incision and drainage
. Total contact casting and non-weight bearing
. Below-knee amputation
. Arthrodesis of the midfoot joints

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The patient is presenting with acute Stage 0 (Eichenholtz) Charcot arthropathy. In the acute phase (characterized by erythema, edema, and warmth), the goal is to prevent structural deformity. The gold standard for initial management of an acute Charcot foot is strict offloading and immobilization, most effectively achieved with a total contact cast (TCC). Antibiotics are not indicated unless there is a confirmed superimposed infection.

Question 2874

Topic: Midfoot & Hindfoot
A 55-year-old diabetic patient presents with a swollen, erythematous, and warm foot. Assuming radiographs initially revealed midfoot fragmentation and subluxation, and follow-up radiographs 4 months later demonstrate absorption of fine bone debris and early fusion of large fragments. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?
. Stage 0 (Inflammatory)
. Stage I (Development/Fragmentation)
. Stage II (Coalescence)
. Stage III (Remodeling/Consolidation)
. Stage IV (Chronic Deformity)

Correct Answer & Explanation

. Stage I (Development/Fragmentation)

Explanation

The Eichenholtz classification describes the natural history of Charcot neuroarthropathy. Stage 0 is the inflammatory phase (erythema, edema, warmth, normal radiographs or mild osteopenia). Stage I (Fragmentation) is characterized by joint subluxation, debris formation, and fragmentation. Stage II (Coalescence) is marked by the absorption of fine debris, early sclerosis, and fusion of larger fragments as the acute inflammation subsides. Stage III (Consolidation/Remodeling) shows remodeling of the bone ends, decreased sclerosis, and a stable (though often deformed) joint.

Question 2875

Topic: 8. Foot and Ankle

A 35-year-old female sustains a twisting injury to her ankle. Radiographs reveal a transverse fracture of the medial malleolus and a spiral fracture of the proximal third of the fibula (Maisonneuve fracture). For this specific fracture pattern to occur, which of the following ligamentous structures MUST be completely disrupted?

. Anterior talofibular ligament
. Calcaneofibular ligament
. Syndesmotic ligament complex and interosseous membrane
. Spring ligament
. Cervical ligament

Correct Answer & Explanation

. Syndesmotic ligament complex and interosseous membrane

Explanation

A Maisonneuve fracture is a pronounced variation of a pronation-external rotation (PER) injury. The mechanism involves external rotation of the talus, which either avulses the medial malleolus or ruptures the deltoid ligament, then disrupts the anterior inferior tibiofibular ligament, tears up the interosseous membrane all the way to the proximal fibula, and exits as a high fibular fracture. Therefore, the syndesmotic complex and the interosseous membrane up to the level of the fracture are intrinsically disrupted.

Question 2876

Topic: 8. Foot and Ankle

A 25-year-old male sustains a midfoot injury. Weight-bearing radiographs demonstrate widening of the interval between the medial and middle cuneiforms.

The Lisfranc ligament connects which of the following two structures?

. First metatarsal base and medial cuneiform
. Second metatarsal base and medial cuneiform
. Second metatarsal base and middle cuneiform
. First metatarsal base and second metatarsal base
. Third metatarsal base and lateral cuneiform

Correct Answer & Explanation

. Second metatarsal base and medial cuneiform

Explanation

The Lisfranc ligament is an interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is critical for the stability of the midfoot arch, as there is no direct ligamentous connection between the bases of the first and second metatarsals.

Question 2877

Topic: 8. Foot and Ankle

A 40-year-old recreational athlete sustains an acute Achilles tendon rupture. During surgical repair, the surgeon must be careful to avoid injuring the sural nerve. At approximately what distance proximal to the calcaneal insertion does the sural nerve typically cross the lateral border of the Achilles tendon?

. 2 cm
. 6 cm
. 10 cm
. 15 cm
. 20 cm

Correct Answer & Explanation

. 10 cm

Explanation

The sural nerve crosses the lateral border of the Achilles tendon approximately 10 cm (range 9-12 cm) proximal to its insertion on the calcaneal tuberosity. It is highly susceptible to injury during percutaneous or minimally invasive Achilles repairs in this region.

Question 2878

Topic: 8. Foot and Ankle

A 24-year-old athlete sustains a hyperplantarflexion injury to the midfoot. Radiographs show widening between the 1st and 2nd metatarsal bases. The primary stabilizing ligament of this joint originates from and inserts into which of the following structures?

. Medial cuneiform to 1st metatarsal base
. Medial cuneiform to 2nd metatarsal base
. Intermediate cuneiform to 2nd metatarsal base
. Lateral cuneiform to 2nd metatarsal base
. Medial cuneiform to 3rd metatarsal base

Correct Answer & Explanation

. Medial cuneiform to 2nd metatarsal base

Explanation

The Lisfranc ligament is the largest and most important of the ligaments stabilizing the tarsometatarsal joint. It originates on the lateral aspect of the medial cuneiform and inserts on the medial aspect of the base of the second metatarsal. Rupture of this ligament leads to diastasis between the first and second rays.

Question 2879

Topic: Midfoot & Hindfoot

A 55-year-old patient with long-standing, poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm right foot. Radiographs reveal periarticular fragmentation, bony debris, and early subluxation of the midfoot joints. Laboratory markers for infection are negative. According to the Eichenholtz classification, what is the current stage of this patient's Charcot arthropathy and the most appropriate initial management?

. Stage 0; rigid internal fixation
. Stage 1; total contact casting and non-weight-bearing
. Stage 2; custom orthotic shoe wear
. Stage 3; midfoot arthrodesis
. Stage 1; immediate operative debridement

Correct Answer & Explanation

. Stage 1; total contact casting and non-weight-bearing

Explanation

Eichenholtz Stage 1 is the developmental or fragmentation stage of Charcot arthropathy. It is clinically characterized by a hot, red, swollen foot. Radiographically, there is bony fragmentation, joint subluxation/dislocation, and debris. The cornerstone of treatment in the acute fragmentation stage is immediate offloading and immobilization, typically achieved with a total contact cast (TCC) to halt the progression of deformity until the joint coalesces.

Question 2880

Topic: 8. Foot and Ankle

A 45-year-old recreational tennis player sustains an acute, complete rupture of his Achilles tendon.

He considers non-operative management. Based on recent, high-level randomized controlled trials evaluating functional rehabilitation protocols, how does non-operative management compare to open surgical repair?

. Non-operative management has a significantly higher rate of re-rupture.
. Non-operative management has a significantly higher rate of deep infection.
. Non-operative management with functional bracing yields equivalent re-rupture rates compared to surgery.
. Non-operative management results in a permanent 50% decrease in plantarflexion strength.
. Non-operative management carries an increased risk of iatrogenic sural nerve injury.

Correct Answer & Explanation

. Non-operative management with functional bracing yields equivalent re-rupture rates compared to surgery.

Explanation

Recent high-quality evidence (such as the Willits et al. trial) demonstrates that non-operative management of acute Achilles tendon ruptures using an early functional mobilization and bracing protocol results in re-rupture rates that are statistically equivalent to open surgical repair, while avoiding surgical complications like infection and nerve injury.

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