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8. Foot and Ankle MCQs

Practice Set 148 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 2941

Topic: 8. Foot and Ankle

A 35-year-old recreational athlete sustains an acute tear of his Achilles tendon during a tennis match. After discussing the risks and benefits, he chooses non-operative management utilizing a modern early functional rehabilitation protocol. Historically, compared to primary open surgical repair, non-operative management carries a significantly higher risk of which of the following complications?

. Deep vein thrombosis
. Sural nerve entrapment
. Re-rupture of the tendon
. Deep surgical site infection
. Loss of extreme ankle plantarflexion strength

Correct Answer & Explanation

. Re-rupture of the tendon

Explanation

Historically, non-operative treatment of acute Achilles tendon ruptures was associated with a higher rate of re-rupture compared to surgical repair, while surgery carries higher risks of wound complications, infections, and sural nerve injury. It should be noted, however, that recent high-quality studies using aggressive early functional rehabilitation protocols have demonstrated that the re-rupture rate in non-operative patients approaches that of operative patients.

Question 2942

Topic: 8. Foot and Ankle

A 24-year-old football player falls forward over his plantar-flexed foot. He complains of severe midfoot pain. Radiographs demonstrate a small avulsion fracture at the base of the second metatarsal.

The ligament primarily injured in this pathology originates from which structure and inserts onto which structure?

. Medial cuneiform to the base of the second metatarsal.
. Lateral cuneiform to the base of the third metatarsal.
. Cuboid to the base of the fourth metatarsal.
. Navicular to the medial cuneiform.
. Base of the first metatarsal to the base of the second metatarsal.

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal.

Explanation

The Lisfranc ligament is an interosseous ligament connecting the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the keystone structure stabilizing the tarsometatarsal joint complex. An avulsion off the base of the 2nd MT (the 'fleck sign') is pathognomonic for a Lisfranc injury.

Question 2943

Topic: 8. Foot and Ankle
A 58-year-old patient with poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm right foot. Radiographs reveal extensive periarticular debris, fragmentation of the tarsal bones, and early subluxation at the midfoot. According to the Eichenholtz classification, what stage of Charcot arthropathy is this, and what is the most appropriate initial treatment?
. Stage 0; urgent open reduction and internal fixation.
. Stage I; total contact casting and strict non-weight bearing.
. Stage II; custom orthotic footwear.
. Stage III; midfoot arthrodesis.
. Stage I; immediate intravenous antibiotics and surgical debridement.

Correct Answer & Explanation

. Stage I; total contact casting and strict non-weight bearing.

Explanation

Eichenholtz Stage I (Development/Fragmentation) is characterized by acute inflammation, osteopenia, fragmentation, joint subluxation, and debris. Standard initial treatment in this acute phase is strict immobilization with a total contact cast (TCC) and restricted weight-bearing to prevent progressive collapse until the acute inflammation subsides and transitions to Stage II (Coalescence).

Question 2944

Topic: 8. Foot and Ankle

A 40-year-old weekend warrior sustains an acute Achilles tendon rupture. Nonoperative management is chosen. Which of the following protocols has been shown to result in outcomes similar to surgical repair regarding re-rupture rates?

. Prolonged cast immobilization in equinus for 12 weeks
. Early functional rehabilitation with weight-bearing in a functional brace
. Non-weight-bearing in a neutral cast for 8 weeks
. Immediate full weight-bearing without a brace
. Immobilization in a boot with the ankle in dorsiflexion

Correct Answer & Explanation

. Early functional rehabilitation with weight-bearing in a functional brace

Explanation

Recent literature shows that early functional rehabilitation protocols (early weight-bearing in a functional brace with a heel lift) for acute Achilles tendon ruptures result in re-rupture rates comparable to operative treatment, while avoiding surgical complications.

Question 2945

Topic: 8. Foot and Ankle

A 25-year-old male injures his midfoot when falling from a horse with his foot caught in the stirrup. Radiographs show a widening of the space between the base of the 1st and 2nd metatarsals. Which ligament is primarily ruptured in a classical Lisfranc injury?

. Ligament connecting the 1st metatarsal to the medial cuneiform
. Ligament connecting the 2nd metatarsal base to the medial cuneiform
. Ligament connecting the 2nd metatarsal base to the intermediate cuneiform
. Plantar fascia
. Spring ligament

Correct Answer & Explanation

. Ligament connecting the 2nd metatarsal base to the medial cuneiform

Explanation

The Lisfranc ligament connects the medial cuneiform to the base of the second metatarsal. It is a critical stabilizing structure of the midfoot, and its rupture leads to instability.

Question 2946

Topic: 8. Foot and Ankle

A 42-year-old male undergoes percutaneous repair of an acute Achilles tendon rupture.

Postoperatively, he has numbness along the lateral aspect of his foot. The nerve most likely injured during this procedure typically crosses the lateral border of the Achilles tendon at what average distance proximal to the calcaneal insertion?

. 2 to 3 cm
. 5 to 7 cm
. 9 to 12 cm
. 15 to 18 cm
. 20 to 22 cm

Correct Answer & Explanation

. 9 to 12 cm

Explanation

The sural nerve provides sensation to the posterolateral lower leg and the lateral aspect of the foot. It is at particular risk during percutaneous or minimally invasive Achilles tendon repairs. Anatomical studies show that the sural nerve typically crosses from medial to lateral across the lateral border of the Achilles tendon at an average distance of 9.8 to 10.5 cm proximal to its calcaneal insertion.

Question 2947

Topic: 8. Foot and Ankle

A 24-year-old collegiate football player sustains a complete knee dislocation on the field. In the emergency department, the knee is successfully reduced. Pulses are palpable symmetrically, and the foot is well-perfused. An Ankle-Brachial Index (ABI) is calculated to be 0.85.

What is the most appropriate next step in management?

. Discharge with urgent outpatient MRI
. Continued clinical observation with serial ABIs every 4 hours
. Immediate CT angiography of the lower extremity
. Immediate surgical exploration of the popliteal artery
. Application of a knee-spanning external fixator

Correct Answer & Explanation

. Immediate CT angiography of the lower extremity

Explanation

In the setting of a knee dislocation, vascular assessment is critical due to the high risk of popliteal artery injury. Even if pulses are palpable, an ABI should be measured. An ABI > 0.9 can typically be observed with serial exams. An ABI < 0.9 (such as 0.85 in this case) warrants advanced vascular imaging, with CT angiography being the modern gold standard to identify an intimal tear or occlusion that could lead to delayed thrombosis.

Question 2948

Topic: 8. Foot and Ankle

During operative fixation of a traumatic Lisfranc injury, the surgeon places the traditional 'home run screw' to recreate the primary restraint of the tarsometatarsal articulation. What is the correct anatomical trajectory for this screw?

. From the base of the first metatarsal into the intermediate cuneiform
. From the medial cuneiform into the base of the second metatarsal
. From the intermediate cuneiform into the base of the first metatarsal
. From the base of the second metatarsal into the medial cuneiform
. From the medial cuneiform into the base of the third metatarsal

Correct Answer & Explanation

. From the medial cuneiform into the base of the second metatarsal

Explanation

The Lisfranc ligament is the strongest interosseous ligament in the tarsometatarsal joint complex, functioning as the primary stabilizer. It originates from the lateral surface of the medial cuneiform and inserts into the medial surface of the base of the second metatarsal. The 'home run screw' is placed from medial to lateral, starting at the medial cuneiform and aiming into the base of the second metatarsal to anatomically recreate this restraint.

Question 2949

Topic: Midfoot & Hindfoot
A 32-year-old male falls from a ladder and sustains a Hawkins Type III fracture of the talar neck. By definition, a Hawkins Type III injury involves a talar neck fracture accompanied by which of the following patterns of dislocation?
. Subluxation of the subtalar joint only
. Dislocation of the tibiotalar joint only
. Dislocation of both the subtalar and tibiotalar joints
. Dislocation of the subtalar, tibiotalar, and talonavicular joints
. Extrusion of the talar body with an intact talonavicular joint

Correct Answer & Explanation

. Dislocation of both the subtalar and tibiotalar joints

Explanation

The Hawkins classification describes talar neck fractures: Type I is nondisplaced; Type II involves subtalar subluxation or dislocation; Type III involves dislocation of both the subtalar and tibiotalar (ankle) joints (the talar body extrudes posteromedially); Type IV (added by Canale) involves dislocation of the subtalar, tibiotalar, and talonavicular joints. The risk of avascular necrosis (AVN) increases substantially with each grade, approaching 100% in Type III/IV if not reduced urgently.

Question 2950

Topic: 8. Foot and Ankle

A 58-year-old male with long-standing, poorly controlled type II diabetes presents with a unilaterally swollen, red, and warm left foot. He denies any constitutional symptoms, and his white blood cell count is normal. Radiographs reveal fragmentation and early subluxation at the tarsometatarsal joint. Skin is intact with no ulceration. What is the most appropriate initial management?

. Total contact casting and strict non-weight bearing
. Urgent open reduction and internal fixation of the midfoot
. Administration of broad-spectrum intravenous antibiotics
. Below-knee amputation
. Immediate prescription of custom-molded orthotic shoes

Correct Answer & Explanation

. Total contact casting and strict non-weight bearing

Explanation

The patient's presentation is classic for acute (Eichenholtz Stage 1 - Development/Fragmentation) Charcot neuroarthropathy. The hallmark is a red, hot, swollen foot in a patient with peripheral neuropathy, often mimicking infection. Because there is no ulcer or systemic sign of infection, osteomyelitis is less likely, and antibiotics are not indicated. The gold standard initial management to arrest the progressive bony destruction and deformity is immobilization via a Total Contact Cast (TCC) and offloading.

Question 2951

Topic: 8. Foot and Ankle

A 30-year-old athlete sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs show 3mm of widening between the medial and middle cuneiforms. What is the primary stabilizing structure of the Lisfranc joint complex?

. Dorsal tarsometatarsal ligament
. Plantar ligament connecting the medial cuneiform to the base of the second metatarsal
. Peroneus longus tendon
. Plantar fascia
. Interosseous ligament between the first and second metatarsals

Correct Answer & Explanation

. Plantar ligament connecting the medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is an intra-articular ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is the strongest and primary stabilizer of the Lisfranc joint complex. The dorsal ligaments are relatively weak, predisposing the joint to dorsal dislocation during hyperplantarflexion.

Question 2952

Topic: 8. Foot and Ankle

A 25-year-old football player presents with severe midfoot pain after an axial load was applied to his plantarflexed foot. Weight-bearing radiographs demonstrate widening between the medial and middle cuneiforms without associated fractures. What is the most appropriate surgical management for this purely ligamentous injury variant?

. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Closed reduction and prolonged non-weight bearing cast immobilization
. Open reduction and internal fixation with dorsal bridge plating
. Open reduction and internal fixation with transarticular screws
. Percutaneous Kirschner wire fixation

Correct Answer & Explanation

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

Explanation

The scenario describes a purely ligamentous Lisfranc injury. Multiple studies have shown that primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) for purely ligamentous Lisfranc injuries yields superior patient-reported functional outcomes and lower revision rates compared to traditional ORIF.

Question 2953

Topic: 8. Foot and Ankle

A 55-year-old male with poorly controlled diabetes mellitus presents with a unilaterally swollen, erythematous, and warm foot without open ulcerations. Radiographs show early periarticular fragmentation and joint subluxation at the tarsometatarsal joints. Inflammatory markers (WBC, CRP, ESR) are normal. What is the most appropriate initial management for this condition?

. Urgent surgical debridement and extensive arthrodesis
. Intravenous empiric antibiotics
. Total contact casting and strict non-weight bearing
. Prescription of a custom orthotic depth shoe
. Intra-articular corticosteroid injection

Correct Answer & Explanation

. Total contact casting and strict non-weight bearing

Explanation

The clinical picture describes acute Eichenholtz Stage 1 (fragmentation) Charcot neuroarthropathy. With normal inflammatory markers and no ulcer, the primary differential is active Charcot versus infection; the diagnosis is Charcot. The gold standard for initial management of acute Charcot is offloading and immobilization, most effectively achieved with a Total Contact Cast (TCC) until the extremity progresses to the coalescence/consolidation phases.

Question 2954

Topic: 8. Foot and Ankle

A 30-year-old football player sustains a foot injury characterized by plantar ecchymosis and pain with pronation/abduction of the forefoot. A subtle widening is noted between the medial and middle cuneiforms. The primary stabilizing ligament injured in this scenario originates from the:

. Plantar aspect of the medial cuneiform and inserts on the base of the second metatarsal.
. Plantar aspect of the middle cuneiform and inserts on the base of the first metatarsal.
. Dorsal aspect of the medial cuneiform and inserts on the base of the second metatarsal.
. Cuboid and inserts on the base of the fourth metatarsal.
. Navicular and inserts on the base of the first metatarsal.

Correct Answer & Explanation

. Plantar aspect of the medial cuneiform and inserts on the base of the second metatarsal.

Explanation

The clinical picture (plantar ecchymosis) is pathognomonic for a Lisfranc injury. The Lisfranc ligament is the critical stabilizing structure of the midfoot. It is a stout interosseous ligament that runs obliquely from the lateral plantar aspect of the medial cuneiform to the medial plantar aspect of the base of the second metatarsal. There is no direct ligamentous connection between the first and second metatarsal bases, making the Lisfranc ligament essential for stability.

Question 2955

Topic: 8. Foot and Ankle

When treating a rigid idiopathic clubfoot using the Ponseti method of serial casting, which component of the deformity must be corrected first?

. Equinus of the ankle
. Varus of the hindfoot
. Adductus of the forefoot
. Cavus of the midfoot
. Tibial torsion

Correct Answer & Explanation

. Cavus of the midfoot

Explanation

The Ponseti method follows a strict sequence of correction summarized by the mnemonic CAVE: Cavus, Adductus, Varus, and Equinus. The very first step involves elevating the first ray to correct the cavus deformity of the midfoot, bringing the forefoot into alignment with the hindfoot. Once cavus is corrected, the foot is sequentially abducted to correct adductus and varus, while counter-pressure is held over the lateral aspect of the head of the talus. Finally, equinus is addressed, often requiring a percutaneous Achilles tenotomy.

Question 2956

Topic: 8. Foot and Ankle

A 55-year-old male with long-standing, poorly controlled type 2 diabetes presents with a unilateral red, hot, and swollen foot. There are no open ulcers or signs of systemic toxicity. Radiographs show periarticular fragmentation and joint subluxation at the midfoot.

What is the most appropriate initial management?

. Incision and drainage
. Excision of fragmented bone
. Primary midfoot arthrodesis
. Total contact casting
. Intravenous broad-spectrum antibiotics

Correct Answer & Explanation

. Total contact casting

Explanation

The patient is presenting with acute Charcot arthropathy (Eichenholtz Stage I: Fragmentation). The hallmark clinical presentation mimics infection (red, hot, swollen), but without an open ulcer, an acute Charcot process is the primary diagnosis. The gold standard initial treatment for an acute Charcot foot is strict immobilization and offloading, optimally achieved with a total contact cast (TCC), until the inflammatory phase resolves (Stage II: Coalescence).

Question 2957

Topic: 8. Foot and Ankle

A 25-year-old elite collegiate football player sustains a purely ligamentous Lisfranc injury to his right foot.

Based on level 1 evidence (prospective randomized trials such as those by Coetzee and Ly), which of the following surgical treatments offers the best clinical outcomes and lowest reoperation rates for this specific injury pattern?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation (ORIF) with transarticular screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Primary arthrodesis of all five tarsometatarsal joints
. Flexible fixation utilizing suture buttons alone

Correct Answer & Explanation

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

Explanation

For purely ligamentous Lisfranc injuries, level 1 evidence (Ly and Coetzee, JBJS 2006) demonstrates that primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) yields significantly better clinical outcomes and lower reoperation rates compared to ORIF. ORIF is associated with high rates of hardware failure and subsequent post-traumatic arthritis necessitating late arthrodesis in purely ligamentous injuries.

Question 2958

Topic: 8. Foot and Ankle

A 32-year-old female falls from a height and sustains a Denis Zone 3 sacral fracture. Based on this specific anatomical classification, she is at highest risk for which of the following neurological deficits?

. Foot drop (L5 nerve root palsy)
. Quadriceps weakness (L4 nerve root palsy)
. Bowel and bladder dysfunction (S2-S4 root injury)
. Isolated loss of the Achilles tendon reflex (S1 root palsy)
. Lateral thigh paresthesia (Lateral femoral cutaneous nerve palsy)

Correct Answer & Explanation

. Bowel and bladder dysfunction (S2-S4 root injury)

Explanation

The Denis classification of sacral fractures divides the sacrum into three zones. Zone 1 involves the sacral ala (lateral to the foramina) and can involve L5. Zone 2 involves the sacral foramina (risk of sciatica). Zone 3 is central, involving the sacral canal. Zone 3 fractures carry the highest risk (over 50%) of cauda equina syndrome, manifesting as bowel, bladder, and sexual dysfunction due to injury to the S2-S4 nerve roots.

Question 2959

Topic: 8. Foot and Ankle
An obese 62-year-old man reports a 10-year history of progressive flatfoot deformity and a 3-month history of a painful callus along the plantar medial midfoot that has not improved with custom shoe wear, pedorthics, and callus care. There is no hindfoot motion, but functional ankle motion remains. He does not have diabetes mellitus. Radiographs are shown in Figures 27a and 27b. What is the best surgical option at this point?
. Exostectomy
. Lateral column lengthening
. Medial slide calcaneal osteotomy
. Talonavicular arthrodesis
. Triple arthrodesis

Correct Answer & Explanation

. Triple arthrodesis

Explanation

The deformity is long-standing, the hindfoot is immobile, and the radiographs reveal severe degenerative arthritis involving the entire hindfoot, severe deformity, and talonavicular dislocation. The "exostosis" responsible for the callus is the talar head; resection would severely destabilize the foot. Degenerative arthritis and fixed deformity preclude lateral column lengthening, medial slide calcaneal osteotomy, and talonavicular arthrodesis. Triple arthrodesis is the only viable option.

Question 2960

Topic: 8. Foot and Ankle

Figure 50 shows the radiograph of a 26-year-old man who sustained an isolated open injury to his foot. Examination reveals no gross contamination in the wound. There is a palpable dorsalis pedis pulse and sensation is present on the dorsal and plantar aspects of the foot. Initial treatment should consist of wound debridement, antibiotics, and

General Orthopedics Board Review 2026: High-Yield MCQs (Set 6) - Figure 10

. talectomy.
. reimplantation of the talus.
. reimplantation of the talus with acute triple arthrodesis.
. Syme amputation.
. transtibial amputation.

Correct Answer & Explanation

. reimplantation of the talus.

Explanation

The radiograph shows a complete extrusion of the talus. Reimplantation of the talus after wound debridement has been reported to be safe and successful, and provides for flexibility with any future reconstructive procedures. Smith CS, Nork SE, Sangeorzan BJ: The extruded talus: Results of reimplantation. J Bone Joint Surg Am 2006;88:2418-2424.

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