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8. Foot and Ankle MCQs

Practice Set 155 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 3081

Topic: 8. Foot and Ankle

When comparing operative versus non-operative management of acute Achilles tendon ruptures utilizing modern early functional rehabilitation protocols, which of the following statements is most accurate regarding clinical outcomes?

. Non-operative management has a significantly higher re-rupture rate than operative management.
. Operative management has a higher risk of deep vein thrombosis.
. Both groups demonstrate similar re-rupture rates when early functional weight-bearing is employed.
. Operative management leads to significantly superior objective plantarflexion strength at 5 years.
. Non-operative management results in a higher rate of sural nerve injury.

Correct Answer & Explanation

. Both groups demonstrate similar re-rupture rates when early functional weight-bearing is employed.

Explanation

Recent high-quality studies (e.g., Willits et al.) have demonstrated that when an early functional rehabilitation protocol (early weight-bearing and range of motion in an orthosis) is used, the re-rupture rates between operative and non-operative management of acute Achilles tendon ruptures are statistically similar. Operative management has a higher risk of wound complications and sural nerve injury (if percutaneous/minimally invasive).

Question 3082

Topic: Midfoot & Hindfoot

A 24-year-old professional athlete sustains a purely ligamentous Lisfranc injury. Based on prospective randomized trials comparing open reduction internal fixation (ORIF) to primary arthrodesis for purely ligamentous Lisfranc injuries, primary arthrodesis is associated with:

. Higher rates of hardware failure and implant breakage
. Decreased ability to return to the previous level of sports
. Better short- and medium-term functional outcomes and lower rates of secondary surgeries
. Increased risk of complex regional pain syndrome (CRPS)
. A higher rate of nonunion requiring massive bone grafting

Correct Answer & Explanation

. Better short- and medium-term functional outcomes and lower rates of secondary surgeries

Explanation

Studies (such as Ly and Coetzee, JBJS 2006) demonstrate that for purely ligamentous Lisfranc injuries, primary arthrodesis of the medial 2 or 3 rays yields better functional outcomes and avoids the frequent need for secondary fusion due to post-traumatic arthritis or hardware removal associated with ORIF.

Question 3083

Topic: 8. Foot and Ankle

A 24-year-old male sustains a traumatic knee dislocation. Following closed reduction, the knee is splinted. His ankle-brachial index (ABI) is measured at 0.85. Palpable distal pulses are present. What is the most appropriate next step in management?

. Discharge with close outpatient follow-up
. Immediate surgical exploration of the popliteal artery
. Perform a CT angiogram of the lower extremity
. Observation and repeat ABI in 4 hours
. Apply a bridging external fixator immediately

Correct Answer & Explanation

. Perform a CT angiogram of the lower extremity

Explanation

In the setting of a knee dislocation, an ABI less than 0.9 is a strong indicator of a potential vascular injury, even if pulses are palpable. A CT angiogram is the gold standard next step to evaluate the popliteal artery and determine if surgical intervention is necessary.

Question 3084

Topic: Midfoot & Hindfoot
A 55-year-old overweight female presents with progressive flattening of her left foot, medial pain, and inability to perform a single-leg heel rise. Examination shows a flexible hindfoot with significant forefoot abduction (>40% uncoverage of the talonavicular joint). What is the most appropriate surgical management for this Stage IIb adult-acquired flatfoot?
. Gastrocnemius recession and flexor digitorum longus (FDL) transfer alone
. FDL transfer, medial displacement calcaneal osteotomy (MDCO), and lateral column lengthening
. Subtalar arthrodesis and FDL transfer
. Triple arthrodesis
. Talonavicular arthrodesis alone

Correct Answer & Explanation

. FDL transfer, medial displacement calcaneal osteotomy (MDCO), and lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction (adult-acquired flatfoot) is characterized by a flexible deformity with profound forefoot abduction. Surgical correction requires addressing both columns: a medializing calcaneal osteotomy (for hindfoot valgus), lateral column lengthening (e.g., Evans osteotomy for forefoot abduction), and soft tissue reconstruction (FDL transfer).

Question 3085

Topic: Midfoot & Hindfoot
A 30-year-old man falls from a height and sustains a Hawkins Type III fracture of the talar neck. Which of the following best describes the anatomical disruption associated with a Hawkins Type III fracture?
. Undisplaced fracture of the talar neck
. Fracture of the talar neck with subluxation of the subtalar joint only
. Fracture of the talar neck with dislocation of both the subtalar and tibiotalar joints
. Fracture of the talar neck with dislocation of the subtalar, tibiotalar, and talonavicular joints
. Comminuted fracture of the talar body with extrusion

Correct Answer & Explanation

. Fracture of the talar neck with dislocation of the subtalar, tibiotalar, and talonavicular joints

Explanation

The Hawkins classification describes talar neck fractures: Type I is non-displaced. Type II involves subluxation or dislocation of the subtalar joint. Type III involves dislocation of both the subtalar and tibiotalar (ankle) joints. Type IV involves dislocation of the subtalar, tibiotalar, and talonavicular joints.

Question 3086

Topic: Midfoot & Hindfoot

A 20-year-old collegiate football player sustains a severe midfoot injury. Radiographs and MRI confirm a purely ligamentous Lisfranc injury with lateral displacement of the second through fifth metatarsals. Based on high-level prospective evidence comparing primary arthrodesis versus open reduction and internal fixation (ORIF) for purely ligamentous Lisfranc injuries, primary arthrodesis of which specific joints is recommended to yield superior long-term clinical outcomes?

. 1st, 2nd, and 3rd tarsometatarsal (TMT) joints
. 4th and 5th tarsometatarsal (TMT) joints
. Naviculocuneiform joints
. Talonavicular joint
. Calcaneocuboid joint

Correct Answer & Explanation

. 1st, 2nd, and 3rd tarsometatarsal (TMT) joints

Explanation

In purely ligamentous Lisfranc injuries, prospective randomized studies (such as those by Ly and Coetzee) have demonstrated that primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) leads to significantly better functional outcomes, less need for hardware removal, and a lower rate of subsequent procedures compared to ORIF. The 4th and 5th TMT joints are highly mobile and are generally pinned with K-wires rather than fused, to preserve their necessary sagittal motion.

Question 3087

Topic: 8. Foot and Ankle

A 14-year-old male presents with recurrent ankle sprains and rigid, flat feet. Radiographs reveal a continuous 'C-sign' on the lateral radiograph of the ankle. Which of the following physical examination findings is most likely to be present?

. A flexible hindfoot valgus that corrects with single-leg heel rise
. A rigid hindfoot valgus with restricted subtalar motion
. A prominent bony lump on the dorsal aspect of the midfoot
. Tenderness over the medial aspect of the navicular tuberosity
. Hyperextension of the first metatarsophalangeal joint during weight bearing

Correct Answer & Explanation

. A rigid hindfoot valgus with restricted subtalar motion

Explanation

The 'C-sign' on a lateral ankle radiograph is highly indicative of a talocalcaneal (subtalar) coalition, formed by the continuous bony outline of the medial talar dome and the sustentaculum tali. Patients typically present with a rigid (peroneal spastic) flatfoot, characterized by a hindfoot valgus that does NOT correct (invert) during the single-leg heel rise test, and markedly restricted subtalar inversion and eversion.

Question 3088

Topic: 8. Foot and Ankle

A 22-year-old collegiate football player sustains an axial load to a plantarflexed foot. Weight-bearing radiographs reveal a 2.5 mm diastasis between the bases of the first and second metatarsals ('fleck sign'). The primary ligamentous disruption in this injury normally connects which two osseous structures?

. First metatarsal base to the second metatarsal base
. Medial cuneiform to the base of the second metatarsal
. Medial cuneiform to the middle cuneiform
. Navicular to the medial cuneiform
. Second metatarsal base to the third metatarsal base

Correct Answer & Explanation

. 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 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 3089

Topic: Midfoot & Hindfoot

A 55-year-old male with poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm right foot. Radiographs demonstrate periarticular osteopenia, prominent bony fragmentation, and multiple subluxations at the Lisfranc joint complex. According to the Eichenholtz classification of Charcot arthropathy, this presentation represents which stage?

. Stage 0 (Prodromal)
. Stage 1 (Developmental/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Reconstruction/Consolidation)
. Stage 4 (Ulceration)

Correct Answer & Explanation

. Stage 1 (Developmental/Fragmentation)

Explanation

Eichenholtz Stage 1 (Developmental/Fragmentation stage) is characterized clinically by the acute red, hot, swollen foot, and radiographically by periarticular fragmentation, debris formation, joint subluxation/dislocation, and osteopenia. Stage 2 (Coalescence) shows absorption of debris and early fusion, while Stage 3 (Reconstruction) shows rounding of bone ends and decreased sclerosis.

Question 3090

Topic: 8. Foot and Ankle
A 58-year-old patient with poorly controlled type 2 diabetes presents with a red, hot, swollen left foot. Plain radiographs reveal fragmentation of the navicular and cuneiforms with early collapse of the longitudinal arch. There are no skin ulcerations. WBC count, ESR, and CRP are within normal limits. What is the most appropriate initial management?
. Intravenous antibiotics for suspected osteomyelitis
. Total contact casting and non-weight-bearing
. Open reduction and internal fixation of the midfoot
. Midfoot arthrodesis with a beaming technique
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

The clinical presentation and normal inflammatory markers in a diabetic patient strongly suggest acute Charcot neuroarthropathy (Eichenholtz Stage I - Fragmentation). In the absence of an ulcer, infection is much less likely. The gold standard for initial management is strict immobilization and offloading, typically achieved with a total contact cast (TCC), until the acute inflammatory phase resolves and the bones begin to consolidate (Eichenholtz Stage III).

Question 3091

Topic: 8. Foot and Ankle

A 45-year-old female undergoes a proximal crescentic osteotomy and distal soft tissue reconstruction for severe hallux valgus. Six months postoperatively, she complains of transfer metatarsalgia under the second metatarsal head. What is the most likely technical error during the primary procedure?

. Under-correction of the intermetatarsal angle
. Excessive plantarflexion of the first metatarsal head
. Dorsal elevation of the first metatarsal head
. Over-tightening of the medial capsule
. Failure to release the adductor hallucis

Correct Answer & Explanation

. Dorsal elevation of the first metatarsal head

Explanation

Dorsal elevation (dorsiflexion) of the first metatarsal is a well-recognized complication of proximal first metatarsal osteotomies, particularly if fixation is inadequate. This dorsal malunion leads to a functionally shortened and elevated first ray, removing its weight-bearing capacity. The mechanical load is subsequently transferred to the lesser metatarsal heads, classically causing second metatarsal overload and transfer metatarsalgia.

Question 3092

Topic: Midfoot & Hindfoot

A 55-year-old patient with long-standing, poorly controlled diabetes presents with a swollen, warm, and erythematous right foot. There is no open ulceration. Radiographs reveal marked osteopenia, periarticular bony debris, fragmentation, and dorsal subluxation at the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent?

. Stage 0 (Prodromal)
. Stage 1 (Developmental/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Consolidation/Remodeling)
. Stage 4 (Chronic)

Correct Answer & Explanation

. Stage 1 (Developmental/Fragmentation)

Explanation

Eichenholtz Stage 1 (Developmental) is characterized clinically by a red, hot, swollen foot and radiographically by active bone destruction, fragmentation, periarticular debris, and joint subluxation/dislocation. Stage 0 lacks radiographic changes. Stage 2 involves absorption of fine debris and early fusion. Stage 3 is characterized by remodeling and consolidation of the deformity.

Question 3093

Topic: Midfoot & Hindfoot
A 28-year-old male presents with severe foot pain after a high-energy motor vehicle accident. Radiographs reveal a Hawkins Type III fracture of the talar neck. Which of the following precisely describes this injury pattern?
. Undisplaced talar neck fracture
. Talar neck fracture with subluxation or dislocation of the subtalar joint
. Talar neck fracture with dislocation of both the subtalar and tibiotalar joints
. Talar neck fracture with dislocation of the subtalar, tibiotalar, and talonavicular joints
. Talar head fracture with talonavicular joint dislocation

Correct Answer & Explanation

. Talar neck fracture with dislocation of both the subtalar and tibiotalar joints

Explanation

The Hawkins classification describes talar neck fractures: Type I is an undisplaced fracture; Type II involves subtalar subluxation or dislocation; Type III involves dislocation of both the subtalar and tibiotalar joints (the talar body is often extruded posteromedially); Type IV (added later by Canale and Kelly) includes subluxation or dislocation of the subtalar, tibiotalar, and talonavicular joints.

Question 3094

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs demonstrate a Hallux Valgus Angle (HVA) of 35 degrees, an Intermetatarsal Angle (IMA) of 16 degrees, and a Distal Metatarsal Articular Angle (DMAA) of 22 degrees. To achieve a congruent joint and prevent early recurrence, the surgical plan MUST incorporate which of the following?

. A simple proximal crescentic osteotomy
. An isolated modified McBride soft tissue release
. An arthrodesis of the first tarsometatarsal joint (Lapidus) only
. A biplanar osteotomy (e.g., a distally based closing wedge) to specifically correct the articular orientation
. A resection arthroplasty of the first metatarsophalangeal joint (Keller procedure)

Correct Answer & Explanation

. A biplanar osteotomy (e.g., a distally based closing wedge) to specifically correct the articular orientation

Explanation

A normal Distal Metatarsal Articular Angle (DMAA) is less than 10 degrees. An abnormally high DMAA (22 degrees in this case) indicates significant lateral deviation of the distal metatarsal articular surface. Procedures that correct only the IMA (like a standard proximal osteotomy or Lapidus) without addressing the DMAA will leave the MTP joint incongruent, leading to stiffness, pain, and high recurrence risk. A biplanar or double osteotomy (often including a distal medial closing wedge like a Reverdin) is necessary to reorient the articular surface.

Question 3095

Topic: 8. Foot and Ankle

A 58-year-old patient with long-standing, poorly controlled diabetes mellitus presents with a swollen, warm, and erythematous right foot. There is no open ulceration. The skin temperature on the affected foot is 4 degrees Celsius warmer than the contralateral foot. Elevation of the limb for 10 minutes results in significant reduction of the erythema. Radiographs show soft tissue swelling and early periarticular fragmentation at the tarsometatarsal joints. What is the most appropriate initial management?

. Urgent surgical debridement and intravenous antibiotics
. Total contact casting and strict non-weight-bearing
. Oral antibiotics and weight-bearing as tolerated
. Arthrodesis of the tarsometatarsal joints
. Corticosteroid injection into the affected joints

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

This patient presents with an acute Eichenholtz Stage I Charcot arthropathy. The key clinical distractor is ruling out infection; in acute Charcot, erythema typically resolves with elevation, whereas in cellulitis/infection, it does not. Furthermore, there is no open ulcer. The mainstay of treatment for acute Charcot arthropathy is immobilization and offloading. Total contact casting with strict non-weight-bearing is the gold standard to prevent further architectural collapse during the active fragmentation stage.

Question 3096

Topic: 8. Foot and Ankle

A 22-year-old football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs reveal a 3 mm diastasis between the bases of the first and second metatarsals. What is the primary stabilizing ligament of this articulation?

. Plantar calcaneonavicular ligament
. Dorsal tarsometatarsal ligament
. Plantar ligament from medial cuneiform to base of second metatarsal
. Interosseous ligament between the first and second metatarsals
. Spring ligament

Correct Answer & Explanation

. Plantar ligament from medial cuneiform to base of second metatarsal

Explanation

The Lisfranc ligament is an interosseous/plantar ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is the thickest, strongest, and primary stabilizer of the Lisfranc joint complex.

Question 3097

Topic: 8. Foot and Ankle

A 42-year-old 'weekend warrior' sustains an acute Achilles tendon rupture. He opts for non-operative management. What is the most critical component of the early functional rehabilitation protocol to minimize the re-rupture rate?

. Strict immobilization in a cast for 8 weeks
. Immediate full weight-bearing in neutral dorsiflexion
. Early weight-bearing in a functional brace with a heel lift and early active range of motion
. Delayed weight-bearing until ultrasound confirms bridging scar
. Immediate passive stretching into dorsiflexion

Correct Answer & Explanation

. Early weight-bearing in a functional brace with a heel lift and early active range of motion

Explanation

Modern non-operative management of Achilles tendon ruptures heavily relies on functional rehabilitation. This includes early weight-bearing in plantarflexion (using functional braces with heel wedges) and early controlled active range of motion. This active approach produces re-rupture rates comparable to operative management.

Question 3098

Topic: 8. Foot and Ankle
A 55-year-old diabetic male presents with a heavily swollen, erythematous, but relatively painless right foot. He denies trauma. Radiographs show early fragmentation, debris, and subluxation at the tarsometatarsal (Lisfranc) joints. What is the most appropriate initial management for this presentation?
. Immediate open reduction and internal fixation of the midfoot
. Primary arthrodesis of the tarsometatarsal joints
. Total contact casting and strict non-weight bearing
. Intravenous antibiotics and emergent surgical debridement
. Custom accommodative shoe wear and weight bearing as tolerated

Correct Answer & Explanation

. Total contact casting and strict non-weight bearing

Explanation

This patient presents with acute Eichenholtz stage I (fragmentation phase) Charcot neuroarthropathy. The gold standard for initial management of an acute, active Charcot foot is total contact casting and offloading to halt the destructive process and prevent further deformity until the acute inflammation subsides and the bones coalesce (Stage II/III).

Question 3099

Topic: Midfoot & Hindfoot
A 55-year-old male with poorly controlled diabetes presents with a swollen, warm, and erythematous left foot without any open ulcers. Radiographs demonstrate extensive subchondral fragmentation, joint subluxation, and intra-articular loose debris without significant osteosclerosis. According to the Eichenholtz classification of Charcot arthropathy, what stage does this clinical and radiographic picture represent?
. Stage 0 (Inflammatory)
. Stage I (Developmental/Fragmentation)
. Stage II (Coalescence)
. Stage III (Reconstruction/Consolidation)
. Stage IV (Ulceration)

Correct Answer & Explanation

. Stage I (Developmental/Fragmentation)

Explanation

Eichenholtz Stage I is the developmental or fragmentation stage, characterized radiographically by osteochondral fragmentation, joint subluxation, and debris formation. Stage 0 is clinically warm and swollen but with normal radiographs. Stage II (coalescence) features absorption of fine debris and early sclerosis. Stage III (reconstruction) shows rounding of bone ends and solid consolidation.

Question 3100

Topic: Midfoot & Hindfoot
A 50-year-old female presents with stage IIb adult-acquired flatfoot deformity, characterized by a flexible deformity with significant forefoot abduction (>40% uncovering of the talonavicular joint on AP weight-bearing radiographs). Which surgical combination is most appropriate to correct this multi-planar deformity?
. Gastrocnemius recession, FDL transfer to the navicular, and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer to the navicular, MDCO, and lateral column lengthening
. Triple arthrodesis
. Talonavicular arthrodesis and FDL transfer
. Subtalar arthrodesis and medializing calcaneal osteotomy

Correct Answer & Explanation

. FDL transfer to the navicular, MDCO, and lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction indicates a flexible flatfoot with significant forefoot abduction. While an FDL transfer and MDCO correct the valgus hindfoot, the forefoot abduction requires a lateral column lengthening (e.g., Evans osteotomy) to restore the talonavicular coverage and correct the transverse plane deformity. Stage III (rigid) requires a triple arthrodesis.

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