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8. Foot and Ankle MCQs

Practice Set 152 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 3021

Topic: Midfoot & Hindfoot
A 55-year-old obese woman presents with medial ankle pain and a progressive flatfoot deformity. Examination reveals an inability to perform a single-leg heel raise, flexible hindfoot valgus, and forefoot abduction. According to the Johnson and Strom classification (modified by Myerson), what stage of posterior tibial tendon dysfunction (PTTD) does this represent?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage II

Explanation

Johnson and Strom Stage I PTTD presents with pain and tenosynovitis but no deformity and intact heel raise. Stage II is characterized by a flexible flatfoot deformity (hindfoot valgus, forefoot abduction) and inability to perform a single-leg heel raise. Stage III is a rigid deformity. Stage IV involves deltoid incompetence and ankle valgus tilt.

Question 3022

Topic: 8. Foot and Ankle

A 60-year-old patient with long-standing poorly controlled diabetes presents with a unilaterally swollen, erythematous, and warm foot. Peripheral pulses are bounding. Radiographs reveal prominent periarticular debris, fragmentation of the navicular, and subluxation of the midtarsal joint. There are no skin ulcerations. What is the most appropriate initial management?

. Urgent operative irrigation and debridement
. Total contact casting (TCC)
. Primary midfoot arthrodesis
. Below-knee amputation
. Intravenous antibiotics for 6 weeks

Correct Answer & Explanation

. Total contact casting (TCC)

Explanation

The presentation is classic for acute Stage I (developmental/fragmentation stage) Charcot neuroarthropathy. Because there is no ulcer or infection, the mainstay of treatment in the acute phase is strict offloading and immobilization to prevent further deformity, best achieved with Total Contact Casting (TCC) until the extremity transitions to the coalescent stage.

Question 3023

Topic: Midfoot & Hindfoot
A 52-year-old obese woman presents with a flexible, painful flatfoot deformity. Examination shows she is unable to perform a single-leg heel rise on the affected side. Weight-bearing radiographs reveal more than 40% uncovering of the talonavicular joint and significant forefoot abduction. According to the Johnson and Strom classification modified by Myerson, what is the most appropriate surgical management for this Stage IIb Posterior Tibial Tendon Dysfunction (PTTD)?
. Medial displacement calcaneal osteotomy and Flexor Digitorum Longus (FDL) transfer alone
. Lateral column lengthening, FDL transfer, and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Isolated subtalar arthrodesis
. Talonavicular arthrodesis alone

Correct Answer & Explanation

. Lateral column lengthening, FDL transfer, and medial displacement calcaneal osteotomy

Explanation

Stage IIb PTTD is characterized by a flexible flatfoot with significant forefoot abduction (typically >40% talonavicular uncovering). Surgical correction requires addressing both the valgus hindfoot and the abducted forefoot. This is best achieved with a lateral column lengthening (e.g., Evans osteotomy) to correct the abduction, combined with FDL transfer and often a medial displacement calcaneal osteotomy. Arthrodesis is reserved for Stage III (rigid deformity).

Question 3024

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic patient presents with a massively swollen, erythematous, and warm left foot. Radiographs reveal periarticular fragmentation, bony debris, and subluxation at the tarsometatarsal joints. Which Eichenholtz stage does this represent, and what is the standard of care?

. Stage 0; MRI and immediate open reduction internal fixation
. Stage 1; Total contact casting and strict non-weight bearing
. Stage 2; Custom orthosis and weight bearing as tolerated
. Stage 3; Midfoot arthrodesis
. Stage 1; Intravenous antibiotics and surgical debridement

Correct Answer & Explanation

. Stage 1; Total contact casting and strict non-weight bearing

Explanation

This patient presents with acute Charcot arthropathy. The Eichenholtz classification describes Stage 1 (Development/Fragmentation) as characterized by joint edema, erythema, and radiographs showing fragmentation, debris, and subluxation. The treatment of choice is immobilization with total contact casting (TCC) to protect the foot and prevent progressive deformity while the acute inflammatory phase resolves.

Question 3025

Topic: 8. Foot and Ankle
A 60-year-old diabetic patient presents with a warm, swollen, and erythematous left foot. Radiographs show osseous fragmentation, joint subluxation, and periarticular debris at the midfoot. According to the Eichenholtz classification, what is the most appropriate initial management?
. Immediate open reduction and internal fixation
. Total contact casting and non-weight bearing
. Below-knee amputation
. Intravenous antibiotics for 6 weeks
. Custom orthotic shoe wear only

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation stage) of Charcot arthropathy, characterized by a warm, swollen foot with radiographic fragmentation and debris. The gold standard of treatment at this stage is strict immobilization and offloading, typically with a total contact cast (TCC), to prevent further deformity until the foot reaches the consolidation stage (Stage III).

Question 3026

Topic: 8. Foot and Ankle

A 14-year-old boy presents with frequent ankle sprains, peroneal spasticity, and a rigid flatfoot. Radiographs reveal a continuous 'C' sign on the lateral view. Which of the following is the most likely diagnosis?

. Calcaneonavicular coalition
. Talocalcaneal coalition
. Accessory navicular syndrome
. Vertical talus
. Os trigonum syndrome

Correct Answer & Explanation

. Talocalcaneal coalition

Explanation

The 'C' sign on a lateral radiograph is indicative of a talocalcaneal coalition (specifically involving the middle facet). It is formed by the continuous outline of the medial talar dome and the posteroinferior aspect of the sustentaculum tali. In contrast, a calcaneonavicular coalition is typically identified by the 'anteater nose' sign on an oblique radiograph.

Question 3027

Topic: 8. Foot and Ankle

A 22-year-old collegiate football player sustains an acute purely ligamentous Lisfranc injury of the midfoot with a 3 mm diastasis between the medial cuneiform and the base of the second metatarsal. He wishes to return to play as safely and definitively as possible. Based on recent Level I evidence, which surgical intervention provides the lowest rate of hardware removal and best long-term outcome for this purely ligamentous injury?

. Closed reduction and percutaneous K-wire fixation
. Open reduction and internal fixation with transarticular screws
. Open reduction and internal fixation with dorsal spanning plates
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Suture-button suspension arthroplasty

Correct Answer & Explanation

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

Explanation

Multiple studies, including a landmark prospective randomized trial by Ly and Coetzee, have demonstrated that primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) yields superior functional outcomes, a higher rate of return to pre-injury activity levels, and lower reoperation rates compared to ORIF for purely ligamentous Lisfranc injuries.

Question 3028

Topic: 8. Foot and Ankle

A 55-year-old male with long-standing poorly controlled diabetes mellitus presents with a red, hot, swollen, and painless right foot. He denies trauma or skin ulceration. His WBC count is normal, and ESR is mildly elevated at 25 mm/hr. Weight-bearing radiographs show fragmentation of the navicular, subluxation of the tarsometatarsal joints, and bony debris. What is the most appropriate initial management for this acute presentation?

. Immediate midfoot arthrodesis to stabilize the arch
. Intravenous antibiotics and emergent surgical debridement
. Total contact casting and strict non-weight-bearing
. Below-knee amputation
. Aspiration of the midfoot joint for crystal analysis and culture

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The clinical picture is classic for acute (Eichenholtz Stage 1) Charcot neuroarthropathy. The red, hot, swollen foot mimics infection, but the lack of an ulcer, normal WBC, and characteristic radiographic changes point to Charcot. The gold standard for initial management in the acute, active phase is offloading and immobilization, traditionally achieved with a total contact cast (TCC) to arrest the inflammatory destruction and prevent further deformity.

Question 3029

Topic: Midfoot & Hindfoot
A 32-year-old male sustains a Hawkins Type III talar neck fracture. This injury involves subluxation or dislocation of which of the following articulations?
. Subtalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Tibiotalar and talonavicular joints
. Subtalar and talonavicular joints

Correct Answer & Explanation

. Subtalar, tibiotalar, and talonavicular joints

Explanation

The Hawkins classification for talar neck fractures: Type I is nondisplaced; Type II is displaced with subtalar subluxation/dislocation; Type III is displaced with both subtalar and tibiotalar dislocation; Type IV (added by Canale and Kelly) involves subtalar, tibiotalar, and talonavicular dislocation.

Question 3030

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a unilaterally swollen, erythematous, and warm midfoot for the past 3 weeks. Radiographs show fragmentation of the navicular and cuneiforms with periarticular debris and subluxation. There is no open ulcer. According to the modified Eichenholtz classification, what stage is this, and what is the preferred initial management?

. Stage 0; Intravenous antibiotics and I&D
. Stage 1; Total contact casting and non-weight-bearing
. Stage 2; Custom orthosis and weight-bearing as tolerated
. Stage 3; Arthrodesis of the midfoot
. Stage 1; Immediate open reduction and internal fixation

Correct Answer & Explanation

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

Explanation

The patient is in Eichenholtz Stage 1 (Development/Fragmentation stage), characterized by erythema, swelling, joint subluxation, bony fragmentation, and periarticular debris. The cornerstone of acute management for Charcot arthropathy without deep infection is strict immobilization and offloading, typically using a total contact cast (TCC). Surgery is generally contraindicated during the acute inflammatory stage.

Question 3031

Topic: 8. Foot and Ankle

The Lisfranc ligament is essential for the stability of the midfoot and is often implicated in tarsometatarsal fracture-dislocations. Which of the following accurately describes the anatomical attachments of the Lisfranc ligament?

. From the lateral aspect of the medial cuneiform to the medial base of the first metatarsal
. From the lateral aspect of the medial cuneiform to the medial base of the second metatarsal
. From the medial aspect of the middle cuneiform to the lateral base of the second metatarsal
. From the medial aspect of the lateral cuneiform to the base of the third metatarsal
. From the base of the first metatarsal to the base of the second metatarsal

Correct Answer & Explanation

. From the lateral aspect of the medial cuneiform to the medial 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. There is notably no direct intermetatarsal ligament between the bases of the first and second metatarsals, rendering this articulation susceptible to disruption.

Question 3032

Topic: Forefoot

A 60-year-old female presents with dorsal midfoot pain and stiffness in the first metatarsophalangeal (MTP) joint. Radiographs show advanced joint space narrowing, a large dorsal osteophyte, and flattening of the metatarsal head (Coughlin and Shurnas Grade 3 hallux rigidus). She has failed nonoperative management. What is the gold standard surgical treatment?

. Dorsal cheilectomy
. First MTP joint arthrodesis
. First MTP joint arthroplasty
. Keller resection arthroplasty
. Moberg osteotomy

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

For advanced (Grade 3 or 4) hallux rigidus with diffuse joint involvement and severe pain, the gold standard surgical treatment is a first MTP joint arthrodesis. It provides reliable and durable pain relief and restores walking ability. Dorsal cheilectomy is indicated for early stages (Grades 1 and 2) where the plantar joint space is preserved.

Question 3033

Topic: 8. Foot and Ankle

During open reduction and internal fixation of a tarsometatarsal fracture-dislocation, the surgeon must restore the anatomical integrity of the Lisfranc ligament. Which of the following accurately describes the anatomy of the Lisfranc ligament?

. The dorsal ligament connecting the medial cuneiform to the second metatarsal base
. The plantar ligament connecting the medial cuneiform to the second metatarsal base
. The interosseous ligament connecting the medial cuneiform to the second metatarsal base
. The ligament connecting the first and second metatarsal bases
. The plantar ligament connecting the navicular to the medial cuneiform

Correct Answer & Explanation

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

Explanation

The Lisfranc ligament is the strong, stout 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 ligamentous connection between the bases of the first and second metatarsals, making this interval mechanically vulnerable.

Question 3034

Topic: 8. Foot and Ankle

A 55-year-old patient with poorly controlled diabetes mellitus presents with a red, hot, and swollen foot. Radiographs demonstrate fragmentation of the midfoot bones, subchondral cysts, and early joint subluxation. There are no skin ulcerations. Which of the following is the most appropriate initial management?

. Immediate open reduction and internal fixation of the midfoot
. Intravenous antibiotics and urgent bone biopsy
. Total contact casting and non-weight bearing
. Custom orthotics and physical therapy
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The patient is presenting with acute Stage I (Development/Fragmentation stage) Charcot arthropathy, characterized by a red, hot, swollen foot with radiographic evidence of osteopenia, fragmentation, and joint subluxation. In the absence of an open ulcer or signs of systemic infection, the standard of care for acute Charcot neuroarthropathy is immobilization and offloading, typically achieved via a total contact cast (TCC), to halt the progression of deformity until the active inflammatory stage resolves.

Question 3035

Topic: 8. Foot and Ankle

During the Ponseti method for correction of idiopathic clubfoot, what is the critical first manipulative step performed before applying the initial cast?

. Abduction of the forefoot against counter-pressure on the calcaneus
. Supination of the forefoot and elevation of the first metatarsal to align it with the hindfoot
. Pronation of the forefoot to correct the varus deformity
. Direct stretching of the Achilles tendon to correct equinus
. Forced eversion of the calcaneus

Correct Answer & Explanation

. Supination of the forefoot and elevation of the first metatarsal to align it with the hindfoot

Explanation

The Ponseti method corrects the deformities of clubfoot in a specific sequence (CAVE: Cavus, Adductus, Varus, Equinus). The very first step is to correct the cavus deformity. This is achieved by supinating the forefoot and elevating the first ray (first metatarsal), which aligns the forefoot with the hindfoot. Pronating the forefoot is a common error that worsens the cavus.

Question 3036

Topic: Midfoot & Hindfoot

In adult acquired flatfoot deformity (posterior tibial tendon dysfunction), what is the primary static stabilizing ligament of the medial longitudinal arch that classically attenuates and fails?

. Deltoid ligament
. Bifurcate ligament
. Long plantar ligament
. Plantar calcaneonavicular (spring) ligament
. Plantar aponeurosis

Correct Answer & Explanation

. Plantar calcaneonavicular (spring) ligament

Explanation

While the posterior tibial tendon provides dynamic support to the medial longitudinal arch, the primary static stabilizer is the plantar calcaneonavicular ligament, commonly known as the spring ligament. In adult acquired flatfoot deformity, the posterior tibial tendon fails, leading to increased stress on the static stabilizers. Attenuation and ultimate failure of the spring ligament leads to severe talonavicular subluxation (peritalar subluxation) characteristic of Stage 2b/3 disease.

Question 3037

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a swollen, warm, and erythematous right foot. Radiographs show periarticular debris, fragmentation of the navicular, and early subluxation of the talonavicular joint. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent?

. Stage 0 (Inflammation)
. Stage 1 (Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Consolidation/Remodeling)
. Stage 4 (Ulceration)

Correct Answer & Explanation

. Stage 1 (Fragmentation)

Explanation

The Eichenholtz classification describes the natural history of Charcot arthropathy. Stage 0 is inflammation with normal radiographs. Stage 1 is the Developmental/Fragmentation stage characterized by periarticular debris, fragmentation, and subluxation. Stage 2 is Coalescence (absorption of debris, early fusion). Stage 3 is Consolidation (remodeling and rounded bone edges).

Question 3038

Topic: Midfoot & Hindfoot
A 45-year-old female presents with painful, progressive flattening of her left foot. Clinical examination reveals a 'too many toes' sign and inability to perform a single-leg heel raise. Radiographs demonstrate significant talonavicular uncoverage (>40%) without evidence of osteoarthritis. According to the Johnson and Strom classification, what is the stage and the most appropriate surgical treatment?
. Stage I; Tenosynovectomy of the tibialis posterior
. Stage IIA; Medial displacement calcaneal osteotomy and FDL transfer
. Stage IIB; Lateral column lengthening, FDL transfer, and medial displacement calcaneal osteotomy
. Stage III; Subtalar arthrodesis
. Stage IV; Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

. Stage IIB; Lateral column lengthening, FDL transfer, and medial displacement calcaneal osteotomy

Explanation

The inability to perform a single-leg heel raise with flexible deformity indicates Stage II adult acquired flatfoot deformity. The presence of significant forefoot abduction (talonavicular uncoverage >30-40%) sub-classifies it as Stage IIB, which necessitates a lateral column lengthening (Evans osteotomy) in addition to soft tissue transfers and medial displacement calcaneal osteotomy.

Question 3039

Topic: 8. Foot and Ankle

The primary Lisfranc ligament, critical for the stability of the midfoot, connects which two osseous structures?

. Medial cuneiform to the first metatarsal base
. Medial cuneiform to the second metatarsal base
. Intermediate cuneiform to the second metatarsal base
. Lateral cuneiform to the third metatarsal base
. Cuboid to the fourth metatarsal base

Correct Answer & Explanation

. Medial cuneiform to the second metatarsal base

Explanation

The Lisfranc ligament is an oblique, stout interosseous ligament that runs from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. There is no direct ligamentous connection between the first and second metatarsal bases, making this ligament vital for stabilizing the keystone of the midfoot.

Question 3040

Topic: 8. Foot and Ankle

During the Ponseti casting technique for the treatment of idiopathic clubfoot, the initial step of manipulation involves correcting the cavus deformity by elevating the first ray. In the subsequent stages of casting to correct the adductus and varus deformities, which bony structure acts as the essential fulcrum for lateral abduction of the foot?

. Calcaneus
. Navicular
. Cuboid
. Head of the talus
. Base of the fifth metatarsal

Correct Answer & Explanation

. Head of the talus

Explanation

In the Ponseti method, after correcting the cavus by supinating the forefoot to align it with the hindfoot, the entire foot is abducted around the lateral aspect of the head of the talus, which serves as the fulcrum. Direct pressure should never be applied to the calcaneus or the cuboid, as this blocks normal subtalar kinematics and can cause a midfoot break.

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