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 281
Topic: 8. Foot and Ankle
Treatment of a patient with lumbar level myelomeningocele who has a vertical talus should consist of:
Correct Answer & Explanation
. Open reduction of the vertical talus
Explanation
Open reduction of the vertical talus will most likely prevent problems. With observation only, the patient is likely to stand or walk and develop pressure problems. Talectomy will not produce the most usable foot. Achilles tenotomy will not produce significant correction by itself. Triple arthrodesis will concentrate stress and lead to ulcers.
Question 282
Topic: 8. Foot and Ankle
A newborn infant in the nursery must be seen because of his foot. The dorsum of the foot rests against the tibia. The heel moves up when the forefoot moves down. Power is present in all muscles. The foot has an arch and the leg lengths are equal. The diagnosis is:
Correct Answer & Explanation
. C alcaneovalgus foot
Explanation
Calcaneovalgus foot has all of these findings and resolves spontaneously. Fibular hemimelia typically has less calcaneus attitude and more valgus and shortening. Vertical talus entails loss of an arch and loss of cohesive movement of the foot as a whole. There is no evidence of muscle weakness. There is no evidence of a neuropathic component.
Question 283
Topic: 8. Foot and Ankle
A 3-year-old girl is brought in for evaluation of leg alignment. She has bilateral foot progression angles of 35° internal. Her thigh-foot angles are 40° internal. Her hip rotation in the prone position is 50° external and 30° internal. The metaphysealdiaphyseal angle is 2° on each side. Recommended treatment includes:
Correct Answer & Explanation
. Observation
Explanation
The tibial torsion described has an excellent chance of resolution over time. Observation is indicated. This child has tibial torsion. The Denis Browne bar has not been proven to affect the natural history of tibial torsion. The knee-ankle-foot orthoses are used for genu varum, which is not the primary problem in this case. A femoral osteotomy is rarely used to correct femoral anteversion in older children. A tibial osteotomy is rarely used to correct tibial torsion in older children.
Question 284
Topic: 8. Foot and Ankle
A newborn baby has a foot that is dorsiflexed and in valgus. The differential diagnosis includes all of the following conditions except:
Correct Answer & Explanation
. Tibial hemimelia
Explanation
The foot in a patient with tibial hemimelia does not resemble the other four conditions described; the foot is in equinus and varus. Calcaneovalgus foot is dorsiflexed and everted through the axis of the ankle joint. A vertical talus has excessive forefoot dorsiflexion and valgus. A patient with an L5 myelomeningocele may have this appearance due to activity of the dorsiflexors and evertors, with absent power in the plantarflexors and invertors. Due to the posteromedial bow in the tibia, the foot may appear dorsiflexed and in valgus.
Question 285
Topic: 8. Foot and Ankle
Which of the following conditions is not associated with an increased risk of congenital vertical talus?
Correct Answer & Explanation
. C erebral palsy
Explanation
Patients with cerebral palsy do not have an increased risk of congenital vertical talus, but they may develop an acquired neuromuscular vertical talus. Patients with myelomeningocele have approximately a 5% to 10% risk of vertical talus, far above that of the general population. Arthrogryposis is associated with an increased risk of vertical talus. Nail patella syndrome is associated with an increased risk of vertical talus. Sacral agenesis is associated with an increased risk of vertical talus.
Question 286
Topic: Midfoot & Hindfoot
A 55-year-old poorly controlled diabetic man presents with a swollen, erythematous, but painless foot. Radiographs show dissolution of the tarsometatarsal joints with early fragmentation and debris. What is the most critical initial management?
Correct Answer & Explanation
. Total contact casting
Explanation
The patient has acute Charcot arthropathy (Eichenholtz stage I). The most critical initial non-operative management is strict immobilization and offloading, typically achieved with a total contact cast, to halt progressive bone destruction and deformity.
Question 287
Topic: 8. Foot and Ankle
A 30-year-old man suffers a displaced talar neck fracture (Hawkins Type III). Which of the following blood vessels provides the primary vascular supply to the talar body, placing it at high risk for avascular necrosis in this injury?
Correct Answer & Explanation
. Artery of the tarsal canal
Explanation
The artery of the tarsal canal (a major branch of the posterior tibial artery) provides the dominant blood supply to the talar body. Disruption of this network in displaced talar neck fractures (especially Hawkins Types II-IV) leads to a high rate of avascular necrosis.
Question 288
Topic: 8. Foot and Ankle
A 24-year-old athlete sustains a hyperplantarflexion injury to his foot. Weight-bearing radiographs show a 3 mm diastasis between the base of the first and second metatarsals. An MRI confirms a complete rupture of the Lisfranc ligament. Which of the following accurately describes the anatomy of this ligament?
Correct Answer & Explanation
. Connects the medial cuneiform to the base of the second metatarsal plantarly
Explanation
The Lisfranc ligament is a strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is critical for the stability of the midfoot and is located on the plantar aspect of the joint.
Question 289
Topic: 8. Foot and Ankle
A 15-month-old child has bowing of the legs. Examination reveals a 3 cm distance between the femoral condyles and a thigh-foot angle of 20° internal. Radiographs reveal 10° varus of the mechanical axis, no evidence of skeletal dysplasia, and a metaphyseal-diaphyseal angle of 9° on each side. Recommended treatment is:
Correct Answer & Explanation
. Re-examination in 6 months
Explanation
Although a diagnosis of Blount disease cannot be made at this time, the disease cannot be ruled out. The patient should be rechecked in 6 months by an experienced examiner. However, if the parents are reliable, they can be told that they do not need to return if the child's legs develop a normal shape in 6 months. The diagnosis of pathologic varus cannot be made; therefore, no treatment is indicated. The findings described are not outside of normal limits; surgery is not necessary. No pathologic diagnosis has yet been made. In addition, stapling is not an indicated form of treatment for such a young child. Although a pathologic condition has not been diagnosed, one cannot be ruled out either at this stage.
Question 290
Topic: 8. Foot and Ankle
Prior to treatment, this pathologic finding characterizes clubfoot:
Correct Answer & Explanation
. The talar head and neck are deviated medially.
Explanation
The talar head and neck are deviated medially. This deformity cannot be corrected surgically but may improve with growth. The dome of the talus is not originally flattened, but it may become this way after repeated manipulation. The navicular is positioned more medially than normal and may touch the medial malleolus. The foot has either a normal arch or a cavus deformity (the opposite of a rocker bottom). The rocker bottom foot may develop as a result of over-vigorous manipulation of a clubfoot against a tight heelcord. The tendoachilles inserts are more medially positioned than normal on the calcaneus.
Question 291
Topic: 8. Foot and Ankle
In the surgical correction of a clubfoot, the following clinical or radiographic finding indicates that a child should have a plantar release:
Correct Answer & Explanation
. Plantarflexion of the first ray
Explanation
Plantarflexion of the first ray, especially if the first ray is not colinear with the talus on the lateral radiograph, should serve as an indication for a plantar release. Anterior extrusion of the talus is common because of the tightness of the Achilles tendon and the posterior capsule. Inferior subluxation of the calcaneocuboid joint is not a feature of clubfoot. Medial subluxation of the calcaneocuboid joint, in combination with the clinical appearance of a curved lateral border of the foot, should serve as an indication for a lateral release, not a plantar release. Inability to dorsiflex the ankle is an indication for a posterior release.
Question 292
Topic: Midfoot & Hindfoot
In the Eichenholtz classification of Charcot neuroarthropathy, which of the following radiographic findings is most characteristic of Stage 2 (Coalescence)?
Correct Answer & Explanation
. Absorption of fine bone debris, fusion of fragments, and early sclerosis
Explanation
Eichenholtz Stage 2 (Coalescence) is marked by the absorption of fine intra-articular debris, early fusion of larger bone fragments, and subchondral sclerosis. Stage 1 is fragmentation, and Stage 3 is remodeling.
Question 293
Topic: 8. Foot and Ankle
A 22-year-old athlete sustains a midfoot injury. Weight-bearing radiographs demonstrate a 3 mm widening between the base of the first and second metatarsals. The injured Lisfranc ligament normally connects which two osseous structures?
Correct Answer & Explanation
. 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 base of the second metatarsal, providing critical stability to the midfoot.
Question 294
Topic: 8. Foot and Ankle
A 35-year-old male sustains a Hawkins Type III talar neck fracture. What is the approximate reported rate of avascular necrosis (AVN) of the talar body associated with this specific injury pattern?
Correct Answer & Explanation
. 80-100%
Explanation
A Hawkins Type III fracture involves a talar neck fracture with dislocation of both the subtalar and tibiotalar joints. Because this disrupts the major blood supplies to the talus, the rate of AVN is exceedingly high, approaching 80-100%.
Question 295
Topic: 8. Foot and Ankle
Which ligament is specifically disrupted in a classic Lisfranc injury?
Correct Answer & Explanation
. The ligament between the medial cuneiform and the base of the second metatarsal
Explanation
The Lisfranc ligament connects the medial cuneiform to the base of the second metatarsal. Its disruption leads to instability of the tarsometatarsal joint complex, as there is no direct intermetatarsal ligament between the first and second metatarsals.
Question 296
Topic: 8. Foot and Ankle
The major blood supply to the body of the talus is provided by the artery of the tarsal canal, which is a branch of which artery?
Correct Answer & Explanation
. Posterior tibial artery
Explanation
The artery of the tarsal canal is a branch of the posterior tibial artery and provides the dominant blood supply to the body of the talus. Disruption of this supply in talar neck fractures carries a high risk of avascular necrosis.
Question 297
Topic: 8. Foot and Ankle
All of the following are consistent with tibial hemimelia (TH) except:
Correct Answer & Explanation
. Knee valgus
Explanation
All of the answers are consistent with tibial hemimelia (TH) except for knee valgus. The knee is typically in varus due to a present fibula in TH. The foot is typically also in equinovarus, and the leg segment is shortened. Knee disarticulation is the best treatment for a complete TH.
Question 298
Topic: 8. Foot and Ankle
A 7-year-old boy presents with bilateral high arches. His parents report that they are having difficulty finding shoes that comfortably fit him. The patient denies any foot pain. The father had similar problems with his feet and was diagnosed with a "mild" neurologic condition. On exam, the child has bilateral pes cavus with a supple hindfoot. Treatment of the feet at this time should consist of:
Correct Answer & Explanation
. Soft tissue procedures alone
Explanation
The child has a supple deformity secondary to C harcot-Marie-Tooth disease that will progress if untreated. Soft tissue procedures, which may consist of claw toe correction, plantar release, and possibly tendon transfer, are recommended for children younger than 8 years old who have a supple hindfoot. The calcaneal osteotomy is reserved for patients with a rigid hindfoot. Triple arthrodesis is a salvage procedure reserved for a fixed, painful foot in older children. Bracing and observation are not preferred options due to the progressive nature of the disease, and the lack of ability to apply corrective forces to the foot in cavus.
Question 299
Topic: 8. Foot and Ankle
A 17-year-old man with C harcot-Marie-Tooth disease (C MT) presents with pain in his right foot. He has had no treatment for the foot in the past. On exam, he is noted to have a rigid pes cavus with hindfoot varus, as well as some weakness in the anterior tibialis and peroneal muscles. Radiographs display the above deformity with degenerative changes in the subtalar joint. Treatment of the foot should consist of:
Correct Answer & Explanation
. Triple arthrodesis
Explanation
The patient has a rigid, painful deformity with radiographic signs of arthritis. A triple arthrodesis is his best chance at a pain-free, plantigrade foot. Observation will not solve his pain due to the deformity and degenerative changes in the foot. Nonsteroidal anti-inflammatory drugs (NSAIDs) may help with his pain, however, the degeneration in the foot will continue to progress. Because the patient has a rigid deformity, soft tissue procedures will not alleviate the pain.
Question 300
Topic: 8. Foot and Ankle
Which of the following is not a feature of the foot deformity in C harcot- Marie-Tooth disease (C MT):
Correct Answer & Explanation
. Hindfoot valgus
Explanation
Hindfoot varus develops to counter forefoot pronation due to weakness of evertors with preservation of inverter muscle strength. The first metatarsal plantarflexes relative to the other metatarsals, leading to pronation of the forefoot. Plantarflexion of the first metatarsal occurs as part of the windlass mechanism as the intrinsics and plantar fascia contract. As the intrinsics weaken, the toe extensors pull the metatarsophalangeal (MTP) joint into hyperextension as part of the claw toe deformity. When the MTP joint hyperextends, the strength of the long toe flexors pulls the interphalangeal joint into flexion contributing to the claw toe deformity.
Test Yourself
Switch to an interactive, timed exam simulation to truly master this topic.