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8. Foot and Ankle MCQs

Practice Set 145 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 2881

Topic: 8. Foot and Ankle

A 40-year-old recreational basketball player feels a sudden 'pop' in his posterior ankle while jumping. On examination, he has a positive Thompson test. If non-operative management is chosen, what is the most appropriate initial immobilization position?

. Short leg cast in maximum dorsiflexion
. Short leg cast in neutral position
. Short leg cast in 20 degrees of plantarflexion
. Long leg cast in knee flexion and ankle dorsiflexion
. Rigid walking boot with immediate full weight-bearing in neutral

Correct Answer & Explanation

. Short leg cast in 20 degrees of plantarflexion

Explanation

The patient has an acute Achilles tendon rupture. Non-operative management typically begins with immobilization in a resting equinus position (usually about 20-30 degrees of plantarflexion) to approximate the torn tendon ends. This position is progressively adjusted towards neutral over a period of weeks using a cast or a functional orthosis with heel wedges.

Question 2882

Topic: Ankle Trauma & Sports

A 34-year-old man suffers an ankle injury after slipping on ice. Radiographs reveal a transverse fracture of the medial malleolus and a short oblique fracture of the lateral malleolus starting at the level of the joint line. According to the Lauge-Hansen classification, what is the most likely mechanism of injury?

. Supination-Adduction (SAD)
. Supination-External Rotation (SER)
. Pronation-Abduction (PAB)
. Pronation-External Rotation (PER)
. Axial loading

Correct Answer & Explanation

. Supination-External Rotation (SER)

Explanation

The Lauge-Hansen Supination-External Rotation (SER) injury is the most common type of ankle fracture. The sequence of injury is: 1) Anterior inferior tibiofibular ligament (AITFL) rupture, 2) Short oblique/spiral fracture of the fibula at the level of the syndesmosis, 3) Posterior inferior tibiofibular ligament (PITFL) rupture or posterior malleolus fracture, 4) Medial malleolus transverse fracture or deltoid ligament rupture. The short oblique fibula fracture at the joint line is characteristic of SER injuries.

Question 2883

Topic: 8. Foot and Ankle

The Lisfranc ligament is a critical stabilizing structure of the midfoot. Between which two bones does the primary interosseous Lisfranc ligament traverse?

. 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 is a strong 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 tarsometatarsal joint complex, particularly because there is no transverse intermetatarsal ligament between the bases of the first and second metatarsals.

Question 2884

Topic: Midfoot & Hindfoot
A 55-year-old female presents with medial ankle pain and a progressive flatfoot deformity. On examination, she has a flexible flatfoot, valgus hindfoot that corrects on a toe-raise, and she is unable to perform a single-limb heel rise on the affected side. According to the Johnson and Strom classification (modified by Myerson), what stage of Posterior Tibial Tendon Dysfunction (PTTD) does she have?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage II

Explanation

Stage I PTTD involves tenosynovitis with mild pain but no deformity; the patient can still perform a single heel rise. Stage II involves a flexible flatfoot deformity, and the patient is unable to perform a single heel rise. Stage III involves a rigid, fixed flatfoot deformity. Stage IV involves deltoid ligament incompetence with a rigid flatfoot and ankle valgus tilt.

Question 2885

Topic: 8. Foot and Ankle

A 42-year-old recreational basketball player sustains an acute Achilles tendon rupture. He opts for nonoperative management. Based on current high-level evidence, which of the following statements best describes the outcomes of functional rehabilitation compared to surgical repair?

. Surgical repair results in significantly superior functional scores at 1 year.
. Traditional cast immobilization yields similar re-rupture rates as surgical repair.
. Early functional weight-bearing protocols have re-rupture rates equivalent to surgical repair.
. Surgical repair has a lower rate of iatrogenic nerve injury than nonoperative management.
. Nonoperative management has a higher rate of deep vein thrombosis.

Correct Answer & Explanation

. Early functional weight-bearing protocols have re-rupture rates equivalent to surgical repair.

Explanation

Recent randomized controlled trials and meta-analyses have demonstrated that when nonoperative management employs early functional rehabilitation and early weight-bearing (functional bracing), the re-rupture rates are equivalent to those of surgical repair, while avoiding the risks of wound complications and surgical site infections.

Question 2886

Topic: 8. Foot and Ankle

A 24-year-old football player sustains a high-energy hyperplantarflexion midfoot injury. Weight-bearing radiographs show a 2.5 mm widening between the base of the first and second metatarsals. An avulsion fracture ('Fleck sign') is seen.

The structure avulsed normally attaches to which two bones?

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

Correct Answer & Explanation

. Medial cuneiform and base of the second metatarsal

Explanation

The 'Fleck sign' represents an avulsion of the Lisfranc ligament. This critical, stout ligament originates on the lateral aspect of the medial cuneiform and inserts on the medial aspect of the base of the second metatarsal. It is the primary stabilizer of the midfoot, as there is no direct ligamentous connection between the first and second metatarsal bases.

Question 2887

Topic: 8. Foot and Ankle

A 28-year-old male sustains a severe axial load to his plantarflexed foot. Radiographs demonstrate a subtle widening between the first and second metatarsal bases and a small avulsion fracture in the first intermetatarsal space (fleck sign).

The intact Lisfranc ligament is anatomically attached to which two osseous structures?

. First metatarsal base and medial cuneiform
. Second metatarsal base and medial cuneiform
. Second metatarsal base and middle cuneiform
. Cuboid and the fourth metatarsal base
. Navicular and the medial cuneiform

Correct Answer & Explanation

. Second metatarsal base and medial cuneiform

Explanation

The Lisfranc ligament is an incredibly strong, thick interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is the primary stabilizer of the second tarsometatarsal joint. A 'fleck sign' in the first intermetatarsal space represents an avulsion of this ligament and is highly indicative of a Lisfranc injury.

Question 2888

Topic: Midfoot & Hindfoot
A 55-year-old patient with poorly controlled type 2 diabetes mellitus presents with a severely swollen, red, and warm right foot. There are no open ulcers or breaks in the skin. Radiographs demonstrate joint fragmentation, subluxation of the tarsometatarsal joints, and periarticular bone debris. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent?
. Stage 0 (Inflammatory)
. Stage I (Developmental/Fragmentation)
. Stage II (Coalescence)
. Stage III (Reconstruction/Consolidation)
. Stage IV (Ulceration)

Correct Answer & Explanation

. Stage I (Developmental/Fragmentation)

Explanation

The Eichenholtz classification describes the natural history of Charcot arthropathy. Stage I (Fragmentation) is characterized clinically by acute inflammation (erythema, swelling, warmth) and radiographically by joint subluxation, osteocartilaginous fragmentation, and debris formation. Stage II (Coalescence) shows absorption of fine debris and early fusion. Stage III (Consolidation) shows remodeling and stable deformity. Stage 0 was added later by Shibata and represents clinical inflammation with completely normal radiographs.

Question 2889

Topic: Forefoot

A 45-year-old female presents with a painful bunion and clinically evident hypermobility of the first tarsometatarsal (TMT) joint. Weight-bearing radiographs demonstrate a hallux valgus angle of 40 degrees and an intermetatarsal angle (IMA) of 18 degrees.

Which surgical procedure is most appropriate to comprehensively address her pathology?

. Distal chevron osteotomy
. Akin osteotomy
. Proximal opening wedge osteotomy alone
. First tarsometatarsal arthrodesis (Lapidus procedure)
. Keller resection arthroplasty

Correct Answer & Explanation

. First tarsometatarsal arthrodesis (Lapidus procedure)

Explanation

The patient has a severe hallux valgus deformity (IMA > 15 degrees) combined with first TMT joint hypermobility. The Lapidus procedure (arthrodesis of the first tarsometatarsal joint) addresses both the severe metatarsus primus varus and the hypermobility of the first ray at its apex, making it the most appropriate and biomechanically sound choice for this specific clinical scenario.

Question 2890

Topic: 8. Foot and Ankle

Which of the following ligaments provides the primary and strongest stabilizing force to the Lisfranc joint complex in the midfoot?

. The dorsal ligament connecting the medial cuneiform and second metatarsal base
. The plantar ligament connecting the medial cuneiform and second metatarsal base
. The interosseous ligament connecting the medial cuneiform and second metatarsal base
. The dorsal ligament connecting the lateral cuneiform and third metatarsal
. The plantar ligament connecting the navicular and medial cuneiform

Correct Answer & Explanation

. The interosseous ligament connecting the medial cuneiform and second metatarsal base

Explanation

The Lisfranc ligament is an interosseous ligament that courses from 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 complex and provides the primary stabilizing force. The dorsal ligaments are the weakest, making dorsal dislocation the most common direction of injury.

Question 2891

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a swollen, erythematous, and warm foot. Radiographs demonstrate periarticular osteopenia, osseous debris, and fragmentation of the midfoot. According to the Eichenholtz classification of Charcot arthropathy, what is the most appropriate initial treatment?

. Arthrodesis with rigid internal fixation
. Total contact casting and non-weight bearing
. Accommodative shoe wear and orthotics
. Exostectomy of the medial column
. Intravenous antibiotics for 6 weeks

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation), characterized by erythema, swelling, debris, and fragmentation. The standard of care is immediate immobilization and offloading using total contact casting (TCC) until the acute inflammatory phase resolves and coalescence (Stage II) begins.

Question 2892

Topic: Midfoot & Hindfoot
A 60-year-old female presents with medial ankle pain and a progressive flatfoot deformity. Examination reveals flexible hindfoot valgus and an inability to perform a single-leg heel rise. Radiographs demonstrate no arthritic changes in the subtalar or talonavicular joints. According to the Johnson and Strom classification, what stage of posterior tibial tendon dysfunction does this represent?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage II

Explanation

Stage II posterior tibial tendon dysfunction (PTTD) is characterized by a flexible flatfoot deformity, an inability to perform a single-leg heel rise, and the absence of degenerative joint changes. Stage I has normal alignment and preserved heel rise. Stage III is a rigid deformity with hindfoot arthritis. Stage IV involves lateral ankle instability and deltoid ligament compromise.

Question 2893

Topic: 8. Foot and Ankle

An orthopaedic surgeon is treating a newborn with idiopathic clubfoot (congenital talipes equinovarus) using the Ponseti method. The first manipulation involves correcting the cavus deformity. Which of the following describes the correct anatomic manipulation to achieve this step?

. Pronating the forefoot to align with the hindfoot
. Supinating the forefoot and elevating the first ray to align with the hindfoot
. Plantarflexing the first ray while abducting the midfoot
. Simultaneous dorsiflexion of the midfoot and hindfoot
. Eversion of the calcaneus while supinating the forefoot

Correct Answer & Explanation

. Supinating the forefoot and elevating the first ray to align with the hindfoot

Explanation

The first step of the Ponseti method is to correct the cavus deformity. This is achieved by supinating the forefoot (elevating the first ray) so that the forefoot is aligned with the varus hindfoot. Once the cavus is corrected and the foot is supinated, the entire foot is gradually abducted around the lateral aspect of the head of the talus to correct the adductus and varus deformities. The equinus is corrected last, typically requiring a percutaneous Achilles tenotomy.

Question 2894

Topic: 8. Foot and Ankle

A 24-year-old female sustains a purely ligamentous Lisfranc injury following a fall from a horse. The first and second metatarsals are significantly widened on weight-bearing radiographs. What surgical intervention has been shown in prospective randomized trials to provide superior functional outcomes and lower reoperation rates for this specific injury pattern compared to ORIF?

. Closed reduction and percutaneous K-wire fixation
. Open reduction and internal fixation with cortical screws
. Primary arthrodesis of the involved tarsometatarsal joints
. Dorsal bridge plating without joint preparation
. Suture-button suspension arthroplasty

Correct Answer & Explanation

. Primary arthrodesis of the involved tarsometatarsal joints

Explanation

For purely ligamentous Lisfranc injuries, multiple randomized controlled trials (such as by Ly and Coetzee) have demonstrated that primary arthrodesis of the first, second, and third tarsometatarsal joints yields superior short- and mid-term functional outcomes and significantly lower rates of planned and unplanned reoperations (such as hardware removal or salvage fusion) when compared to open reduction and internal fixation (ORIF). Bony fracture-dislocations of the Lisfranc joint may still be treated well with ORIF.

Question 2895

Topic: Midfoot & Hindfoot

A 55-year-old male with long-standing, poorly controlled diabetes presents with a swollen, erythematous, and warm left foot without open wounds or signs of systemic sepsis.

Radiographs demonstrate significant soft tissue edema, osteopenia, and early periarticular fragmentation at the midfoot. According to the Eichenholtz classification, what is the most appropriate initial treatment for this stage of his condition?

. Total contact casting and strict non-weight-bearing
. Immediate midfoot arthrodesis with robust internal fixation
. Intravenous antibiotics and surgical debridement
. Prescription of custom accommodative orthotic footwear
. Excision of the fragmented bone (exostectomy)

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The patient is presenting with acute Eichenholtz Stage I (developmental/fragmentation stage) Charcot arthropathy, characterized by a red, hot, swollen foot, osteopenia, subluxation, and bony fragmentation. The standard of care for acute Stage I Charcot is immediate offloading and immobilization using a total contact cast (TCC). Surgery is generally contraindicated in the acute inflammatory phase due to poor bone stock and high failure rates.

Question 2896

Topic: 8. Foot and Ankle

A 24-year-old collegiate football lineman sustains a severe hyperplantarflexion injury to his midfoot. He complains of inability to bear weight. Physical examination notes significant midfoot swelling and plantar ecchymosis. Weight-bearing radiographs show 3 mm of widening between the base of the first and second metatarsals. The injured ligament pathognomonic for this condition connects which of the following osseous structures?

. Base of the 1st metatarsal to the base of the 2nd metatarsal
. Medial cuneiform to the base of the 2nd metatarsal
. Medial cuneiform to the intermediate cuneiform
. Intermediate cuneiform to the base of the 2nd metatarsal
. Lateral cuneiform to the cuboid

Correct Answer & Explanation

. Medial cuneiform to the base of the 2nd metatarsal

Explanation

The Lisfranc ligament is a stout, strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. There is no direct transverse ligamentous connection between the bases of the first and second metatarsals, making this region reliant on the Lisfranc ligament for stability.

Question 2897

Topic: 8. Foot and Ankle
A 55-year-old male with long-standing, poorly controlled type II diabetes presents with a diffusely swollen, erythematous, and warm right foot that is insensate to monofilament testing. Radiographs demonstrate florid fragmentation of the tarsal bones, joint subluxations, and significant periarticular osseous debris. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent?
. Stage 0 (Inflammatory)
. Stage I (Developmental/Fragmentation)
. Stage II (Coalescence)
. Stage III (Reconstruction/Consolidation)
. Stage IV (Chronic)

Correct Answer & Explanation

. Stage I (Developmental/Fragmentation)

Explanation

The Eichenholtz classification details the natural history of Charcot neuroarthropathy. Stage I (Developmental/Fragmentation) is clinically characterized by a red, hot, swollen foot. Radiographs classically show joint space narrowing, fragmentation, subluxation/dislocation, and bony debris. Stage 0 is the clinical pre-fragmentation phase (normal x-rays). Stage II involves absorption of debris and early fusion. Stage III involves remodeling and a stable, albeit deformed, joint.

Question 2898

Topic: 8. Foot and Ankle
A 40-year-old roofer falls 15 feet from a ladder, landing directly on his heels. He sustains a closed, displaced intra-articular fracture of the calcaneus. When evaluating his lateral radiograph, which of the following geometric changes is most classically associated with the typical deformity pattern of this injury?
. Increased Böhler's angle
. Decreased angle of Gissane
. Decreased Böhler's angle
. Increased calcaneal pitch
. Plantarflexion of the talar head

Correct Answer & Explanation

. Decreased Böhler's angle

Explanation

On a normal lateral radiograph of the foot, Böhler's angle is typically between 20° and 40°. In a displaced intra-articular calcaneus fracture, the posterior facet is commonly driven downward (depressed) into the cancellous body of the calcaneus, resulting in a flattening of the calcaneus and a severely decreased or even negative Böhler's angle. The angle of Gissane (normally 100° to 130°) is typically increased, not decreased, due to strut collapse.

Question 2899

Topic: Midfoot & Hindfoot



A 55-year-old male with poorly controlled diabetes mellitus and severe peripheral neuropathy presents with a globally swollen, erythematous, and warm left foot. He denies any inciting trauma. Radiographs show periarticular debris and subtle fragmentation at the tarsometatarsal joints. Which of the following is the most appropriate initial management?

. Immediate open reduction and internal fixation to restore arch alignment
. Total contact casting and strict non-weight-bearing precautions
. Admission for intravenous antibiotics and surgical debridement of the joints
. Corticosteroid injection into the affected tarsometatarsal joints to reduce inflammation
. Guillotine amputation at the transmalleolar level to prevent sepsis

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing precautions

Explanation

The patient is presenting with acute Charcot arthropathy (Eichenholtz stage 0 or 1). The clinical picture mimics infection, but the lack of an ulcer or systemic signs points to Charcot. The mainstay of initial treatment during the acute inflammatory phase is immobilization (usually via total contact casting) and non-weight-bearing to arrest the destructive process and prevent further deformity.

Question 2900

Topic: Forefoot

A 40-year-old female presents with a symptomatic hallux valgus deformity that has failed conservative shoe wear modification. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 35 degrees and a 1-2 intermetatarsal angle (IMA) of 16 degrees. Clinical exam shows a stable first tarsometatarsal (TMT) joint without hypermobility. Which of the following surgical procedures is most biomechanically appropriate?

. Distal chevron osteotomy
. Proximal metatarsal osteotomy combined with distal soft tissue reconstruction
. First TMT joint arthrodesis (Lapidus procedure)
. First metatarsophalangeal (MTP) joint arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. Proximal metatarsal osteotomy combined with distal soft tissue reconstruction

Explanation

An intermetatarsal angle (IMA) greater than 13-15 degrees represents a moderate-to-severe deformity. A proximal osteotomy (e.g., Ludloff, crescentic, or proximal chevron) combined with a distal soft tissue release provides superior corrective power for larger IMAs. Distal osteotomies are reserved for mild deformities (IMA < 13 degrees). A Lapidus is indicated if first ray hypermobility is present.

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