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8. Foot and Ankle MCQs

Practice Set 147 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 2921

Topic: 8. Foot and Ankle

A 2-week-old infant is brought to the clinic for management of a rigid idiopathic clubfoot using the Ponseti method. What is the essential first maneuver performed during the application of the initial corrective cast?

. Dorsiflexion of the ankle to correct equinus
. Pronation of the forefoot to correct forefoot adduction
. Supination of the forefoot with elevation of the first ray to correct the cavus
. Eversion of the calcaneus to correct hindfoot varus
. External rotation of the foot while blocking the calcaneus

Correct Answer & Explanation

. Supination of the forefoot with elevation of the first ray to correct the cavus

Explanation

The Ponseti method addresses clubfoot deformity in a specific sequence (CAVE: Cavus, Adductus, Varus, Equinus). The first step is to correct the cavus deformity. This is achieved by supinating the forefoot (specifically elevating the first ray) to align the forefoot with the already pronated hindfoot. Subsequent casts correct adductus and varus by laterally directing the forefoot against the talar head, and equinus is corrected last (often requiring a percutaneous Achilles tenotomy).

Question 2922

Topic: 8. Foot and Ankle

The Lisfranc ligament is a critical stabilizing structure of the tarsometatarsal joint complex. Which of the following best describes its anatomic origin and insertion?

. Medial aspect of the medial cuneiform to the medial aspect of the first metatarsal base
. Lateral aspect of the medial cuneiform to the medial aspect of the second metatarsal base
. Medial aspect of the middle cuneiform to the lateral aspect of the second metatarsal base
. Lateral aspect of the medial cuneiform to the base of the third metatarsal
. Distal aspect of the navicular to the base of the second metatarsal

Correct Answer & Explanation

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

Explanation

The Lisfranc ligament is an intra-articular interosseous ligament that provides vital stability to the midfoot. It originates from the lateral aspect of the medial cuneiform and inserts onto the medial aspect of the base of the second metatarsal. Notably, there is no direct intermetatarsal ligament connecting the bases of the first and second metatarsals, making this link crucial for structural integrity.

Question 2923

Topic: 8. Foot and Ankle

A 14-year-old boy presents with rigid flat feet and lateral ankle pain. Radiographs demonstrate a 'C sign'.

This finding is most strongly indicative of which of the following conditions?

. Calcaneonavicular coalition
. Talocalcaneal coalition
. Talonavicular coalition
. Cubonavicular coalition
. Accessory navicular

Correct Answer & Explanation

. Talocalcaneal coalition

Explanation

The 'C sign' on a lateral radiograph of the foot is formed by the continuous outline of the medial talar dome and the inferior sustentaculum tali. It indicates the presence of a talocalcaneal (subtalar) coalition. Calcaneonavicular coalition is typically identified by the 'anteater nose' sign on an oblique view.

Question 2924

Topic: 8. Foot and Ankle

A 35-year-old female sustains a midfoot sprain. Weight-bearing radiographs demonstrate subtle widening between the medial and middle cuneiforms. The true Lisfranc ligament acts as the primary stabilizer of the second tarsometatarsal joint. What are the specific anatomic attachments of the Lisfranc ligament?

. Medial aspect of the medial cuneiform to the base of the first metatarsal
. Lateral aspect of the medial cuneiform to the base of the second metatarsal
. Anterior aspect of the middle cuneiform to the base of the second metatarsal
. Medial aspect of the intermediate cuneiform to the base of the first metatarsal
. Plantar aspect of the lateral cuneiform to the base of the third metatarsal

Correct Answer & Explanation

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

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 the strongest and most important ligament for stabilizing the second tarsometatarsal joint. There is no direct ligamentous connection between the base of the first and second metatarsals.

Question 2925

Topic: 8. Foot and Ankle

A 42-year-old male sustains an acute, closed mid-substance Achilles tendon rupture playing basketball.

He is evaluating operative versus nonoperative management. Based on high-level randomized controlled trials employing modern early functional rehabilitation protocols, which of the following is true?

. Operative treatment offers a significantly lower rerupture rate than nonoperative treatment
. Operative treatment is associated with higher overall complication rates, such as deep infection
. Nonoperative treatment results in significantly less plantarflexion strength long-term
. Nonoperative treatment necessitates strict immobilization in a cast for a minimum of 12 weeks
. Operative treatment completely eliminates the risk of tendon elongation

Correct Answer & Explanation

. Operative treatment is associated with higher overall complication rates, such as deep infection

Explanation

Recent high-quality randomized controlled trials (such as Willits et al.) have demonstrated that when modern early functional weight-bearing rehabilitation protocols are used, the rerupture rates between nonoperative and operative treatment of acute Achilles tendon ruptures are statistically similar (often both around 3-5%). However, operative treatment carries an increased risk of surgical complications, including infection, wound breakdown, and sural nerve injury. Plantarflexion strength outcomes are generally comparable with early functional rehab.

Question 2926

Topic: 8. Foot and Ankle

A 58-year-old male with poorly controlled type 2 diabetes presents with a unilaterally swollen, red, and warm right foot. There are no open ulcers.

Radiographs show severe fragmentation of the tarsometatarsal joints, periarticular debris, and joint subluxation. ESR and CRP are within normal limits. Based on the Eichenholtz classification, what stage is this patient in, and what is the standard initial treatment?

. Stage 0; Custom diabetic footwear
. Stage 1; Total contact casting
. Stage 2; Midfoot arthrodesis
. Stage 3; Charcot Restraint Orthotic Walker (CROW)
. Stage 1; Intravenous antibiotics and I&D

Correct Answer & Explanation

. Stage 1; Total contact casting

Explanation

The clinical and radiographic presentation is classic for acute Charcot neuroarthropathy. The normal inflammatory markers help distinguish this from acute osteomyelitis. Eichenholtz Stage 1 (Developmental/Fragmentation) is characterized by erythema, swelling, warmth, and radiographs showing osteopenia, fragmentation, joint subluxation, and debris. The gold standard treatment for Stage 1 Charcot is strict immobilization and offloading, typically using a total contact cast (TCC) until the erythema, warmth, and swelling resolve, and radiographs show consolidation (Stage 2/3).

Question 2927

Topic: 8. Foot and Ankle
A 28-year-old male presents with a severely swollen foot after a high-speed motor vehicle collision. Radiographs demonstrate a displaced fracture of the talar neck. Further imaging reveals that the body of the talus is dislocated from both the subtalar joint and the tibiotalar joint, while the talonavicular joint remains congruent. According to the Hawkins classification, what is the fracture type, and what is the approximate risk of developing avascular necrosis (AVN) of the talar body?
. Nondisplaced; 0-10%
. Subtalar dislocation; 20-50%
. Subtalar and tibiotalar dislocation; 80-100%
. Subtalar, tibiotalar, and talonavicular dislocation; 20-50%
. Subtalar dislocation; 100%

Correct Answer & Explanation

. Subtalar and tibiotalar dislocation; 80-100%

Explanation

Hawkins classification for talar neck fractures: Type I is nondisplaced (AVN 0-10%). Type II has subtalar subluxation/dislocation (AVN 20-50%). Type III has both subtalar and tibiotalar dislocation (AVN risk is historically ~80-100%). Type IV adds talonavicular subluxation/dislocation to a Type III pattern. Because this fracture involves dislocation of both the subtalar and ankle (tibiotalar) joints, it is a Type III fracture.

Question 2928

Topic: 8. Foot and Ankle

When evaluating the optimal management of acute, completely displaced mid-substance Achilles tendon ruptures, extensive meta-analyses comparing open surgical repair to non-operative management (utilizing strict functional bracing protocols) have demonstrated that surgical repair is statistically associated with which of the following comparative outcome profiles?

. Higher rate of deep vein thrombosis
. Decreased risk of re-rupture but increased risk of wound complications
. Increased risk of re-rupture and sural nerve injury
. Equivalent re-rupture risk but decreased return to play
. Slower recovery of plantarflexion strength

Correct Answer & Explanation

. Decreased risk of re-rupture but increased risk of wound complications

Explanation

Historically and in comprehensive meta-analyses, operative repair of the Achilles tendon offers a lower rate of re-rupture compared to non-operative treatment, but at the cost of a higher risk of soft tissue complications, including superficial and deep infections, wound breakdown, and sural nerve injury. Recent studies utilizing early functional mobilization protocols for non-operative treatment have shown rerupture rates approaching those of surgery, but the classic board answer tradeoff remains lower rerupture risk vs. higher wound complication risk.

Question 2929

Topic: 8. Foot and Ankle

A 28-year-old professional football player sustains an axial load to his plantarflexed foot. Weight-bearing radiographs demonstrate a 4 mm diastasis between the base of the first and second metatarsals. He is diagnosed with a Lisfranc injury. Which of the following ligaments is primarily disrupted in this classic injury pattern?

. Plantar ligament extending from the medial cuneiform to the base of the first metatarsal
. Dorsal ligament extending from the middle cuneiform to the base of the second metatarsal
. Plantar ligament extending from the medial cuneiform to the base of the second metatarsal
. Dorsal ligament extending from the medial cuneiform to the base of the second metatarsal
. Interosseous ligament between the bases of the first and second metatarsals

Correct Answer & Explanation

. Plantar ligament extending from the medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is an oblique, stout ligament extending from the plantar-lateral aspect of the medial cuneiform to the plantar-medial base of the second metatarsal. It is the critical stabilizer of the tarsometatarsal articulation. There is no transverse ligament directly connecting the bases of the first and second metatarsals.

Question 2930

Topic: Midfoot & Hindfoot
A 58-year-old man with long-standing diabetic peripheral neuropathy presents with a swollen, erythematous, and warm right foot without ulcerations. He reports minimal pain but his midfoot arch has collapsed over the past month. Radiographs demonstrate fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints. Which of the following is the most appropriate initial management for the acute phase of this condition?
. Immediate open reduction and midfoot arthrodesis
. Intravenous antibiotics for 6 weeks followed by bracing
. Total contact casting with strict non-weight-bearing
. Custom orthotic inserts and modified deep-toe box shoes
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting with strict non-weight-bearing

Explanation

This patient is presenting with acute Eichenholtz Stage I Charcot arthropathy (fragmentation stage). The hallmark of treatment for acute Charcot neuroarthropathy is strict offloading and immobilization to prevent further deformity until the active inflammatory process resolves (Stage III - consolidation). Total contact casting is the gold standard for achieving this.

Question 2931

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic patient presents with a warm, swollen, and erythematous foot. Initial radiographs reveal fragmentation of the midfoot bones, periarticular debris, and early joint subluxation, but no signs of consolidation. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?

. Stage 0 (Inflammation)
. Stage 1 (Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Reconstruction)
. Stage 4 (Consolidation)

Correct Answer & Explanation

. Stage 1 (Fragmentation)

Explanation

The Eichenholtz classification outlines the natural history of Charcot arthropathy. Stage 0 is the inflammatory phase (normal x-rays, localized erythema/swelling). Stage 1 is the Fragmentation/Development phase, characterized by joint debris, subluxation, dislocation, and osteochondral fragmentation. Stage 2 is Coalescence, involving absorption of debris and early fusion of fragments. Stage 3 is Reconstruction, characterized by rounding of bone ends, remodeling, and decreased sclerosis.

Question 2932

Topic: 8. Foot and Ankle

A 58-year-old male with poorly controlled type 2 diabetes presents with a swollen, erythematous, and warm left foot. Radiographs reveal fragmentation of the tarsometatarsal joints, periarticular debris, and joint subluxation, but no skin ulceration. According to the Eichenholtz classification, what is the most appropriate initial management for this patient?

. Immediate open reduction and internal fixation of the midfoot
. Total contact casting and non-weight-bearing
. Intravenous antibiotics for 6 weeks
. Primary arthrodesis of the tarsometatarsal joints
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

The patient is in Stage 1 (Fragmentation/Developmental phase) of Charcot neuroarthropathy, characterized by a red, hot, swollen foot with radiographic evidence of osteopenia, fragmentation, and subluxation. The gold standard of treatment in the acute phase is immobilization and strict offloading, typically achieved with a total contact cast, to prevent further deformity until the active inflammatory process subsides.

Question 2933

Topic: Midfoot & Hindfoot

A 55-year-old male with poorly controlled type 2 diabetes presents with a unilaterally swollen, red, and warm right foot. He denies any ulceration or systemic signs of infection. Radiographs demonstrate fragmentation of the midfoot bones, subchondral debris, and joint subluxation. According to the Eichenholtz classification, the patient is currently in Stage I (Developmental). What is the gold standard initial management?

. Total contact casting
. Immediate midfoot arthrodesis
. Intravenous antibiotics
. Below-knee amputation
. Calcaneal sliding osteotomy

Correct Answer & Explanation

. Total contact casting

Explanation

The clinical presentation is highly consistent with acute Charcot arthropathy (Eichenholtz Stage I: Developmental/Fragmentation). The primary goal during the acute phase is to prevent further deformity and allow the inflammatory process to subside. The gold standard treatment is immediate offloading and immobilization using a total contact cast (TCC). Surgery is generally contraindicated during the acute, hyperemic phase due to poor bone quality and high failure rates.

Question 2934

Topic: 8. Foot and Ankle

A 40-year-old male sustains an acute, complete rupture of the Achilles tendon while playing tennis. He opts for non-operative management utilizing functional rehabilitation with early range of motion. Compared to traditional open surgical repair, which of the following best describes the expected outcome of his non-operative approach based on recent prospective trials?

. Decreased risk of overall complication rate, but an increased risk of sural nerve injury
. Equivalent return to sport rates, but an increased risk of deep infection
. Higher overall complication rate, but equal plantarflexion strength
. Decreased soft-tissue complication rate with a slightly higher risk of re-rupture
. Higher rate of deep vein thrombosis with equivalent re-rupture risk

Correct Answer & Explanation

. Decreased soft-tissue complication rate with a slightly higher risk of re-rupture

Explanation

Recent high-level evidence (such as the Willits et al. trial) demonstrates that functional rehabilitation (early weight-bearing and ROM) for non-operative management of acute Achilles tendon ruptures yields functional outcomes similar to surgical repair. The non-operative approach avoids surgical complications (infection, wound breakdown, sural nerve injury) but carries a slightly higher re-rupture rate compared to operative management, though this gap has narrowed significantly with modern functional bracing protocols.

Question 2935

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a swollen, erythematous, and warm left foot. Radiographs demonstrate periarticular debris, fragmentation, and joint subluxation at the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent?

. Stage 0
. Stage 1
. Stage 2
. Stage 3
. Stage 4

Correct Answer & Explanation

. Stage 1

Explanation

Eichenholtz Stage 1 (Development/Fragmentation) is characterized by clinical erythema, swelling, and warmth, with radiographic features of bone fragmentation, debris, joint subluxation, and fracture. Stage 2 (Coalescence) shows absorption of debris and early fusion. Stage 3 (Reconstruction) shows consolidation and remodeling. Stage 0 is the clinical high-risk foot with no radiographic changes.

Question 2936

Topic: Midfoot & Hindfoot
A 32-year-old female falls from a height and sustains a talar neck fracture with subtalar and tibiotalar joint dislocation, but the talonavicular joint remains intact. What is the Hawkins classification of this fracture and the approximate associated risk of avascular necrosis (AVN)?
. Hawkins Type II, 20-50% AVN risk
. Hawkins Type III, 50-100% AVN risk
. Hawkins Type IV, 50-100% AVN risk
. Hawkins Type II, 0-10% AVN risk
. Hawkins Type III, 20-50% AVN risk

Correct Answer & Explanation

. Hawkins Type III, 50-100% AVN risk

Explanation

Hawkins Type I: Nondisplaced (0-10% AVN). Type II: Subtalar dislocation/subluxation (20-50% AVN). Type III: Subtalar and tibiotalar dislocation (50-100% AVN). Type IV: Subtalar, tibiotalar, and talonavicular dislocation (50-100% AVN). The scenario describes a Type III fracture.

Question 2937

Topic: Forefoot

A 60-year-old male presents with dorsal midfoot pain and limited dorsiflexion of the great toe. Radiographs demonstrate dorsal osteophytes and joint space narrowing at the first metatarsophalangeal (MTP) joint, consistent with Coughlin and Shurnas Grade 3 hallux rigidus. Conservative management has failed. What is the most reliable surgical treatment for long-term pain relief?

. Cheilectomy
. Moberg osteotomy
. First MTP joint arthrodesis
. Keller resection arthroplasty
. Synthetic hemiarthroplasty

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

For advanced (Grade 3 or 4) hallux rigidus with severe pain and functional limitation, arthrodesis of the first MTP joint is the gold standard and most reliable surgical procedure for definitive pain relief. Cheilectomy is indicated for earlier grades (Grade 1 and 2) with primarily dorsal impingement pain.

Question 2938

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic male presents with a massively swollen, warm, and erythematous right foot. He denies any recent trauma or open wounds. Laboratory studies reveal a normal white blood cell count and normal inflammatory markers. Radiographs demonstrate fragmentation and subluxation at the tarsometatarsal joints. What is the most appropriate initial management for this condition?

. Intravenous broad-spectrum antibiotics
. Total contact casting and non-weight bearing
. Urgent arthrodesis of the midfoot
. Below-knee amputation
. Magnetic resonance imaging to definitively rule out osteomyelitis

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

This patient is presenting with acute Charcot arthropathy (Eichenholtz stage 0 or 1), characterized by a swollen, warm, erythematous foot with radiographic evidence of joint fragmentation, in the setting of normal inflammatory markers. The mainstay of initial treatment for acute Charcot arthropathy is strict immobilization and off-loading, typically achieved with a total contact cast (TCC). This prevents progressive deformity while the acute inflammatory phase resolves. Surgery is contraindicated during the acute inflammatory phase due to the high risk of hardware failure and worsening bone destruction.

Question 2939

Topic: 8. Foot and Ankle
A 28-year-old female is involved in a high-speed collision. She sustains a talar neck fracture with complete subluxation of the subtalar joint; however, the tibiotalar (ankle) joint remains congruous. Based on the Hawkins classification, what is the approximate risk of avascular necrosis (AVN) of the talar body?
. 0-10%
. 20-50%
. 70-100%
. 100%

Correct Answer & Explanation

. 20-50%

Explanation

The patient has a Hawkins Type II talar neck fracture, defined by subluxation or dislocation of the subtalar joint with an intact ankle joint. The reported risk of AVN for Hawkins Type II fractures is classically between 20% and 50%. Type I (nondisplaced) has a 0-10% risk, Type III (dislocation of both subtalar and ankle joints) has a 70-100% risk, and Type IV (Type III plus talonavicular dislocation) also carries an extraordinarily high risk nearing 100%.

Question 2940

Topic: 8. Foot and Ankle

A 25-year-old running back sustains a forceful plantarflexion injury to his foot. A weight-bearing AP radiograph reveals a 3 mm diastasis between the base of the first and second metatarsals. He is diagnosed with a Lisfranc injury. Which ligament represents the primary structural stabilizer of this joint complex?

. Dorsal Lisfranc ligament
. Plantar Lisfranc ligament
. Interosseous Lisfranc ligament
. Spring ligament
. Long plantar ligament

Correct Answer & Explanation

. Interosseous Lisfranc ligament

Explanation

The Lisfranc ligament complex connects the medial cuneiform to the base of the second metatarsal. It consists of three bands: dorsal, interosseous, and plantar. The interosseous Lisfranc ligament is the thickest, strongest, and primary structural stabilizer of the complex. The plantar band is the second strongest, while the dorsal band is the weakest and often the first to fail during hyperplantarflexion injuries.

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