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8. Foot and Ankle MCQs

Practice Set 150 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 2981

Topic: 8. Foot and Ankle

A 40-year-old male presents with an acute Achilles tendon rupture. He is treated nonoperatively with an early functional rehabilitation protocol. Compared to surgical repair, what are the expected complication rates regarding re-rupture and wound complications?

. Higher re-rupture rate, higher risk of wound complications.
. Higher re-rupture rate, lower risk of wound complications.
. Similar re-rupture rate, lower risk of wound complications.
. Lower re-rupture rate, higher risk of wound complications.
. Lower re-rupture rate, similar risk of wound complications.

Correct Answer & Explanation

. Similar re-rupture rate, lower risk of wound complications.

Explanation

Recent high-quality randomized controlled trials have demonstrated that when an early functional rehabilitation protocol (early weight-bearing and active mobilization) is utilized, the re-rupture rates between nonoperative and operative treatment of acute Achilles tendon ruptures are statistically similar. Operative treatment carries a significantly higher risk of complications such as infection, skin necrosis, and sural nerve injury. Therefore, nonoperative management with functional rehab offers similar efficacy with a lower risk of wound complications.

Question 2982

Topic: 8. Foot and Ankle
A 30-year-old male sustains a severe inversion injury to his ankle in an MVC. Radiographs and CT demonstrate a Hawkins III fracture of the talar neck. Which of the following arteries, providing the predominant blood supply to the talar body, is most likely disrupted in this injury?
. Artery of the tarsal canal
. Deltoid branch of the posterior tibial artery
. Artery of the sinus tarsi
. Dorsalis pedis artery
. Peroneal artery

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal (a branch of the posterior tibial artery) provides the major blood supply to the talar body. A Hawkins III fracture (dislocation of subtalar and tibiotalar joints) confers a nearly 100% risk of avascular necrosis due to complete vascular disruption.

Question 2983

Topic: 8. Foot and Ankle

A 25-year-old professional football player suffers a hyper-plantarflexion injury to his midfoot. Weight-bearing radiographs demonstrate widening between the first and second metatarsals.

Anatomically, the critical structure injured in this pattern (the Lisfranc ligament) connects which two bony structures?

. Medial cuneiform to the base of the first metatarsal
. Medial cuneiform to the base of the second metatarsal
. Intermediate cuneiform to the base of the second metatarsal
. Lateral cuneiform to the cuboid
. Navicular to the base of the first metatarsal

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The primary Lisfranc ligament is an interosseous ligament that originates on the lateral aspect of the medial cuneiform and inserts on the medial base of the second metatarsal. There is no direct ligamentous connection between the bases of the 1st and 2nd metatarsals.

Question 2984

Topic: 8. Foot and Ankle

A 28-year-old male sustains an acute, primarily ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal joints after a severe twisting injury to the foot. Prospective randomized studies suggest which of the following treatments provides the best functional outcomes for this specific injury pattern?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with screws
. Primary arthrodesis of the affected TMT joints
. Non-weight bearing cast for 8 weeks
. Bridge plating of the first and second TMT joints

Correct Answer & Explanation

. Primary arthrodesis of the affected TMT joints

Explanation

Level 1 evidence has demonstrated that primary arthrodesis of the medial 2 or 3 rays yields superior functional outcomes and lower revision rates compared to ORIF for purely ligamentous Lisfranc injuries.

Question 2985

Topic: Midfoot & Hindfoot

A 54-year-old male with poorly controlled diabetes presents with a swollen, erythematous, and warm right foot. He denies fever or open wounds. Radiographs show periarticular fragmentation, subluxation of the tarsometatarsal joints, and debris. According to the Eichenholtz classification, what stage does this represent, and what is the standard initial treatment?

. Stage 0; Intravenous antibiotics
. Stage 1 (Developmental); Total contact casting and non-weight bearing
. Stage 2 (Coalescence); Surgical arthrodesis
. Stage 3 (Reconstruction); Custom orthotic wear
. Stage 1 (Developmental); Emergent surgical debridement

Correct Answer & Explanation

. Stage 1 (Developmental); Total contact casting and non-weight bearing

Explanation

This patient has an acute Charcot arthropathy in the developmental/fragmentation stage (Eichenholtz Stage 1). The gold standard initial treatment is immobilization in a total contact cast and strict non-weight bearing to prevent further deformity until the acute inflammatory phase resolves.

Question 2986

Topic: 8. Foot and Ankle
A 62-year-old diabetic patient presents with a warm, swollen, red, and painful midfoot. Plain radiographs show subtle osteopenia, joint subluxation, and fragmentation of the midfoot bones, consistent with early Charcot neuroarthropathy. There are no skin breaks or signs of infection. What is the most critical initial step in management to prevent further progression and deformity?
. Surgical fusion of the midfoot joints
. Intravenous antibiotics for empiric osteomyelitis
. Total contact casting (TCC)
. Ankle-foot orthosis (AFO) with rocker bottom sole
. Offloading shoe with custom orthotics

Correct Answer & Explanation

. Total contact casting (TCC)

Explanation

This patient's presentation (warm, swollen, red, painful midfoot with radiographic changes of osteopenia, subluxation, and fragmentation in a diabetic) is classic for acute Charcot neuroarthropathy (Eichenholtz Stage I). The most critical initial step in management for acute Charcot is aggressive offloading and immobilization to prevent further bone destruction and deformity. Total Contact Casting (TCC) is considered the gold standard for this stage, as it provides maximal immobilization, pressure distribution, and edema control. Surgical fusion (option A) is typically reserved for severe, unstable deformities or failed conservative treatment in later stages. Empiric antibiotics (option B) are not indicated without signs of infection. AFOs (option D) and offloading shoes (option E) are generally used for stable Charcot deformities (Eichenholtz Stage II/III) or for maintenance after the acute phase.

Question 2987

Topic: Midfoot & Hindfoot

A 50-year-old male falls from a ladder, sustaining a calcaneal fracture. Radiographs show a severely comminuted intra-articular fracture with significant subtalar joint involvement (tongue-type). He has no other injuries. Which factor is most important in determining the functional outcome of this fracture?

. Patient's age.
. Presence of an open wound.
. Quality of the reduction of the subtalar joint.
. Duration of non-weight-bearing.
. Type of fixation used.

Correct Answer & Explanation

. Quality of the reduction of the subtalar joint.

Explanation

For intra-articular calcaneal fractures, the quality of the reduction of the subtalar joint articular surface is the most critical factor influencing long-term functional outcome and the development of post-traumatic subtalar arthritis. Anatomical reduction and stable fixation, when indicated, are paramount. While age and soft tissue status (open wound) are important, and the duration of non-weight-bearing and type of fixation play roles, none supersede the importance of restoring the joint congruity. A poor reduction significantly increases the risk of chronic pain, stiffness, and arthritis, irrespective of other factors.

Question 2988

Topic: 8. Foot and Ankle

A 20-year-old male falls during a basketball game, sustaining an acute Achilles tendon rupture. Examination reveals a palpable gap in the tendon and a positive Thompson test. Which of the following is the most appropriate management in a young, active individual?

. Non-weight-bearing cast for 8 weeks.
. Surgical repair.
. Platelet-rich plasma (PRP) injection.
. Ultrasound-guided percutaneous repair.
. Immediate weight-bearing in a walking boot.

Correct Answer & Explanation

. Surgical repair.

Explanation

For an acute Achilles tendon rupture in a young, active individual, surgical repair is generally favored. Surgical repair provides a lower re-rupture rate and potentially better functional outcomes compared to non-operative treatment, especially in high-demand patients. Non-operative management with cast immobilization is an option, particularly for older, less active patients, but carries a higher re-rupture rate. While PRP injections are being studied, they are not a primary definitive treatment. Ultrasound-guided percutaneous repair is a minimally invasive surgical option but still falls under surgical repair. Immediate weight-bearing is contraindicated for an acute rupture.

Question 2989

Topic: 8. Foot and Ankle

A 30-year-old male sustains a Lisfranc injury (tarsometatarsal joint complex) after a motor vehicle accident. Radiographs show diastasis between the first and second metatarsal bases, and displacement. Which of the following is the most appropriate management for this injury?

. Non-operative management with a short leg cast and non-weight-bearing for 6-8 weeks.
. Open reduction and internal fixation (ORIF) with screws.
. Primary arthrodesis of the tarsometatarsal joints.
. External fixation.
. Cortical screw fixation across the first metatarsal and medial cuneiform only.

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF) with screws.

Explanation

Lisfranc injuries, especially with displacement and instability, are serious foot injuries that can lead to significant long-term disability if not treated adequately. Open reduction and internal fixation (ORIF) with screws is the gold standard for displaced and unstable Lisfranc injuries. The goal is anatomical reduction and stable fixation of the tarsometatarsal joints to restore the arch and prevent post-traumatic arthritis. Non-operative management is reserved for truly non-displaced, stable injuries, which must be confirmed with stress radiographs. Primary arthrodesis may be considered for highly comminuted or chronically symptomatic joints, but not typically as the primary approach for acute, reconstructible injuries. External fixation is usually temporary for severe open injuries. Fixing only the first ray is insufficient for a global Lisfranc injury.

Question 2990

Topic: 8. Foot and Ankle

A 48-year-old female presents with a chronic posterior malleolus non-union of her ankle fracture, leading to persistent pain and instability. What is the most likely long-term complication if this is left untreated?

. Avascular necrosis of the talus.
. Chronic ankle instability.
. Development of post-traumatic arthritis.
. Peroneal tendonitis.
. Tarsal tunnel syndrome.

Correct Answer & Explanation

. Development of post-traumatic arthritis.

Explanation

The posterior malleolus is a weight-bearing portion of the ankle joint and contributes significantly to ankle stability and congruity, especially when it involves more than 25-30% of the articular surface. A chronic non-union of the posterior malleolus, particularly if displaced or involving a significant portion of the articular surface, will lead to altered biomechanics, joint incongruity, and progressive degeneration of the ankle joint, ultimately resulting in post-traumatic arthritis. While chronic instability is a symptom, arthritis is the major long-term pathological consequence. Avascular necrosis of the talus is more common with talar neck fractures. Peroneal tendonitis and tarsal tunnel syndrome are less direct consequences of a posterior malleolus non-union.

Question 2991

Topic: 8. Foot and Ankle
A 60-year-old male with a history of diabetes and peripheral neuropathy sustains a foot injury. He presents with a plantar ulcer and radiographic evidence of a midfoot collapse and bone fragmentation consistent with Charcot neuroarthropathy. Which of the following is the most appropriate management principle?
. Immediate surgical reconstruction of the foot.
. Non-weight-bearing in a total contact cast until resolution of acute inflammation.
. Amputation due to the severity of the condition.
. Aggressive debridement of the ulcer and antibiotic therapy only.
. Strict bed rest for 3 months.

Correct Answer & Explanation

. Non-weight-bearing in a total contact cast until resolution of acute inflammation.

Explanation

Charcot neuroarthropathy in the acute 'Eichenholtz Stage I' (fragmentation/destruction) or 'rocker-bottom' foot with ulceration requires aggressive non-operative management initially. This primarily involves strict non-weight-bearing in a total contact cast (TCC) to protect the foot, reduce inflammation, and allow for healing, often for several months. Surgical reconstruction is considered only after the acute inflammatory phase has subsided ('Stage III coalescence') and the foot is stable, and only for specific indications such as severe deformity preventing bracing or recurrent ulceration. Amputation is a last resort. Debridement and antibiotics are essential for the ulcer but do not address the Charcot process itself. Strict bed rest is not practical or necessary; controlled weight-bearing in a TCC is the key.

Question 2992

Topic: 8. Foot and Ankle

A 28-year-old male sustains a traumatic knee dislocation. After successful reduction, he has a palpable popliteal pulse, but decreased sensation in the foot and weakness of ankle dorsiflexion. Which nerve injury is most likely involved?

. Femoral nerve.
. Obturator nerve.
. Sciatic nerve.
. Common peroneal nerve.
. Tibial nerve.

Correct Answer & Explanation

. Common peroneal nerve.

Explanation

Knee dislocations are high-energy injuries associated with a high risk of neurovascular damage. The common peroneal nerve is the most frequently injured nerve in knee dislocations, especially posterolateral dislocations. Injury to the common peroneal nerve typically manifests as weakness of ankle dorsiflexion (foot drop) and eversion, and sensory loss over the dorsum of the foot and lateral leg. While the popliteal pulse is palpable, nerve injury can occur independently of major vascular injury. Femoral and obturator nerves are less commonly injured. Sciatic nerve injury is less specific to knee dislocation compared to common peroneal. Tibial nerve injury would cause weakness of ankle plantarflexion and toe flexion, and sensory loss on the plantar foot.

Question 2993

Topic: 8. Foot and Ankle

A 50-year-old male sustains an isolated unstable ankle fracture-dislocation. After successful closed reduction, the ankle mortise is still widened, especially medially. Which of the following is the most likely additional injury?

. Syndesmotic injury.
. Posterior tibial tendon rupture.
. Fibular head fracture.
. Talus osteochondral lesion.
. Calcaneal fracture.

Correct Answer & Explanation

. Syndesmotic injury.

Explanation

Widening of the ankle mortise, particularly medially after reduction of an ankle fracture-dislocation (assuming the malleoli are addressed or the fracture doesn't explain the widening), strongly suggests a syndesmotic injury (disruption of the tibiofibular ligaments). This instability needs to be addressed surgically, typically with syndesmotic screws or a suture-button device, to stabilize the distal tibiofibular joint. Other injuries listed are possible but do not directly explain the mortise widening after reduction. Posterior tibial tendon rupture, fibular head fracture, talus osteochondral lesion, and calcaneal fracture do not typically result in persistent ankle mortise widening.

Question 2994

Topic: Midfoot & Hindfoot
A 28-year-old male falls from a ladder and sustains a Hawkins Type III fracture of the talar neck. Which of the following best describes the expected rate of avascular necrosis (AVN) of the talar body?
. 0-10%
. 20-50%
. 50-75%
. Nearly 100%
. AVN does not occur in Type III

Correct Answer & Explanation

. Nearly 100%

Explanation

Hawkins Type III fractures involve dislocation of the talar body from both the subtalar and tibiotalar joints. This disrupts all three major blood supplies to the talar body, leading to an AVN rate approaching 100%.

Question 2995

Topic: 8. Foot and Ankle

A 24-year-old athlete sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs reveal a 3 mm widening between the base of the 1st and 2nd metatarsals. What is the primary stabilizing structure disrupted in this injury?

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

Correct Answer & Explanation

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

Explanation

The Lisfranc ligament is a critical interosseous ligament connecting the medial cuneiform to the base of the second metatarsal. Disruption of this ligament destabilizes the tarsometatarsal joint complex, often leading to lateral displacement of the lesser metatarsals.

Question 2996

Topic: 8. Foot and Ankle

A 33-year-old roofer falls 15 feet, landing directly on his heels. Radiographs show a displaced intra-articular calcaneal fracture with a severely flattened Bohler's angle. What are the normal anatomic landmarks used to measure Bohler's angle?

. Anterior process to highest point of posterior facet, and highest point of posterior facet to superior tuberosity
. Medial malleolus to lateral malleolus, and lateral malleolus to calcaneal tuberosity
. Sustentaculum tali to anterior process, and anterior process to posterior facet
. Inferior calcaneal border to the metatarsal bases
. Talonavicular joint line to the calcaneocuboid joint line

Correct Answer & Explanation

. Anterior process to highest point of posterior facet, and highest point of posterior facet to superior tuberosity

Explanation

Bohler's angle is determined on a lateral radiograph by drawing a line from the highest point of the anterior process to the highest point of the posterior facet, and another line from the posterior facet to the superior edge of the calcaneal tuberosity. The normal angle is 20 to 40 degrees.

Question 2997

Topic: Ankle Trauma & Sports

A 26-year-old male sustains an external rotation injury to his ankle. Radiographs show a widened medial clear space and a proximal fibular shaft fracture (Maisonneuve). What is the most appropriate intraoperative test to assess the integrity of the distal tibiofibular syndesmosis after fibular fixation?

. Anterior drawer test
. Cotton test (lateral hook test)
. Squeeze test
. Talar tilt test
. Thompson test

Correct Answer & Explanation

. Cotton test (lateral hook test)

Explanation

The Cotton test, or lateral hook test, is performed intraoperatively by grasping the fibula with a bone hook and applying a lateral force under fluoroscopy. Widening of the syndesmosis under stress confirms instability requiring syndesmotic fixation.

Question 2998

Topic: 8. Foot and Ankle
A 30-year-old male sustains a Hawkins Type III talar neck fracture following a high-energy motor vehicle collision. Which of the following vessels provides the primary blood supply to the talar body, placing it at high risk for avascular necrosis (AVN) in this injury?
. Artery of the tarsal canal
. Artery of the tarsal sinus
. Dorsalis pedis artery
. Deltoid branch of the posterior tibial artery
. Anterior tibial artery

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, is the dominant blood supply to the talar body. A Hawkins Type III fracture involves the talar neck with dislocation of both the subtalar and tibiotalar joints, completely disrupting this critical blood supply.

Question 2999

Topic: 8. Foot and Ankle
A 33-year-old roofer falls from a height, sustaining a closed Sanders Type III calcaneus fracture. If operative intervention via an extensile lateral approach is chosen, what is the most critical clinical indicator of appropriate surgical timing to minimize wound necrosis?
. Surgery performed within 24 hours of the injury
. Resolution of swelling indicated by the skin wrinkle sign
. Waiting exactly 21 days post-injury
. Normalization of Bohler's angle on serial radiographs
. Absence of pain with passive great toe extension

Correct Answer & Explanation

. Resolution of swelling indicated by the skin wrinkle sign

Explanation

The extensile lateral approach to the calcaneus has a notoriously high risk of wound dehiscence and infection. Surgery must be delayed (often 10-14 days) until acute soft tissue swelling subsides, reliably indicated by the appearance of skin wrinkles on the lateral hindfoot.

Question 3000

Topic: 8. Foot and Ankle

A 22-year-old football player sustains an axial load to a plantarflexed foot. Weight-bearing radiographs demonstrate a 3 mm diastasis between the medial cuneiform and the base of the second metatarsal. Rupture of which specific structure is the primary cause of this diastasis?

. Anterior talofibular ligament
. Spring ligament
. Interosseous ligament between the medial cuneiform and 2nd metatarsal
. Plantar fascia
. Bifurcate ligament

Correct Answer & Explanation

. Interosseous ligament between the medial cuneiform and 2nd metatarsal

Explanation

The Lisfranc ligament is an interosseous ligament connecting the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. Its disruption results in instability of the tarsometatarsal joint complex, requiring surgical stabilization.

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