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8. Foot and Ankle MCQs

Practice Set 156 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 3101

Topic: 8. Foot and Ankle

A 25-year-old athlete sustains a hyper-plantarflexion injury to the midfoot. Radiographs show a 'fleck sign' at the base of the second metatarsal. The primary ligament disrupted in this injury normally connects which two osseous structures?

. Medial cuneiform to the base of the 1st metatarsal
. Medial cuneiform to the base of the 2nd metatarsal
. Middle cuneiform to the base of the 2nd metatarsal
. Lateral cuneiform to the base of the 3rd metatarsal
. Cuboid to the base of the 4th metatarsal

Correct Answer & Explanation

. Medial cuneiform to the base of the 2nd metatarsal

Explanation

The 'fleck sign' represents an avulsion fracture of the base of the second metatarsal at the attachment of the Lisfranc ligament. The Lisfranc ligament is an interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is critical for the stability of the midfoot.

Question 3102

Topic: 8. Foot and Ankle

During the operative fixation of a primarily ligamentous Lisfranc injury involving the entire tarsometatarsal joint complex, which of the following represents the correct anatomical order and trajectory for the primary 'Lisfranc screw'?

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

Correct Answer & Explanation

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

Explanation

The primary Lisfranc ligament is an intra-articular ligament that connects the medial cuneiform to the base of the second metatarsal. The anatomical and biomechanically optimal trajectory for the classic 'Lisfranc screw' mimics this ligament, starting from the medial cuneiform and directed laterally and distally into the base of the second metatarsal.

Question 3103

Topic: 8. Foot and Ankle

A 25-year-old athlete sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs demonstrate a 2 mm widening between the first and second metatarsal bases along with a subtle 'fleck sign'. The fleck sign represents a bony avulsion of the Lisfranc ligament from which specific anatomical structure?

. Base of the first metatarsal
. Base of the second metatarsal
. Medial cuneiform
. Middle cuneiform
. Navicular

Correct Answer & Explanation

. Base of the second metatarsal

Explanation

The Lisfranc ligament is a strong interosseous ligament connecting the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. A 'fleck sign' on a radiograph represents an avulsion fracture of this ligament, almost exclusively pulling off from the base of the second metatarsal.

Question 3104

Topic: Midfoot & Hindfoot
A 55-year-old patient with long-standing poorly controlled diabetes presents with a unilaterally swollen, erythematous, and warm foot without skin ulceration. Radiographs demonstrate extensive periarticular debris, bony fragmentation, and early subluxation of the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, this presentation corresponds to:
. Stage 0
. Stage I
. Stage II
. Stage III
. Stage IV

Correct Answer & Explanation

. Stage I

Explanation

The Eichenholtz classification of Charcot arthropathy includes: Stage 0 (high-risk foot, swelling, warmth, normal x-rays); Stage I (Developmental/Fragmentation: hyperemic, fragmentation, debris, subluxation); Stage II (Coalescence: decreased swelling/warmth, absorption of fine debris, early fusion); Stage III (Consolidation: remodeling, stable deformity). The clinical and radiographic findings match Stage I.

Question 3105

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled type 2 diabetes presents with a unilaterally swollen, erythematous, and warm foot without open ulcerations. Radiographs show periarticular fragmentation, subluxation, and bony debris at the tarsometatarsal joints. According to the Eichenholtz classification, what is the stage of this disease process and the standard initial management?

. Stage 0; rigid internal fixation
. Stage 1; total contact casting and non-weight bearing
. Stage 2; immediate midfoot arthrodesis
. Stage 3; custom accommodative shoe wear
. Stage 1; urgent surgical debridement and intravenous antibiotics

Correct Answer & Explanation

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

Explanation

The patient has Stage 1 (Developmental/Fragmentation stage) Charcot arthropathy, characterized by erythema, swelling, warmth, and radiographic evidence of fragmentation and subluxation. The standard of care for acute Stage 1 Charcot is immediate offloading, most effectively achieved with total contact casting (TCC) and non-weight bearing to prevent further collapse.

Question 3106

Topic: 8. Foot and Ankle

Recent high-level evidence and meta-analyses comparing operative versus non-operative management of acute Achilles tendon ruptures highlight specific complication profiles. When modern functional rehabilitation protocols (early weight-bearing and motion) are utilized for both groups, which of the following is true?

. Operative treatment demonstrates significantly greater long-term plantarflexion power
. Non-operative treatment has a statistically higher rate of deep venous thrombosis
. Operative treatment eliminates the risk of sural nerve injury
. There is no clinically significant difference in re-rupture rates between the two groups
. Non-operative treatment has a zero percent re-rupture rate

Correct Answer & Explanation

. There is no clinically significant difference in re-rupture rates between the two groups

Explanation

Historically, non-operative management of Achilles tendon ruptures (involving prolonged rigid immobilization) was associated with higher re-rupture rates. However, recent randomized controlled trials and meta-analyses demonstrate that when modern functional rehabilitation (early motion and weight-bearing in a boot) is employed, there is no significant difference in re-rupture rates between operative and non-operative groups, though operative management carries higher risks of infection and nerve injury.

Question 3107

Topic: Midfoot & Hindfoot

A 25-year-old athlete sustains a purely ligamentous Lisfranc injury. Current evidence comparing primary arthrodesis versus open reduction and internal fixation (ORIF) for purely ligamentous Lisfranc injuries suggests which of the following regarding primary arthrodesis?

. It results in a lower rate of return to competitive sports.
. It provides inferior midfoot functional scores at 2 years.
. It is associated with a lower rate of hardware removal and subsequent surgical procedures.
. It has a higher rate of nonunion than bony Lisfranc injuries.
. It requires a longer period of non-weight-bearing postoperatively compared to ORIF.

Correct Answer & Explanation

. It is associated with a lower rate of hardware removal and subsequent surgical procedures.

Explanation

Multiple prospective studies (e.g., Ly and Coetzee) have demonstrated that primary arthrodesis for purely ligamentous Lisfranc injuries provides comparable or superior functional outcomes and significantly lower rates of subsequent surgeries, such as hardware removal or conversion to salvage arthrodesis, compared to ORIF. ORIF in purely ligamentous injuries often leads to progressive arch collapse and post-traumatic arthritis.

Question 3108

Topic: 8. Foot and Ankle

A 55-year-old male with poorly controlled diabetes presents with a swollen, erythematous, and warm left foot. Radiographs reveal periarticular debris, fragmentation, and subluxation of the tarsometatarsal joints. According to the Eichenholtz classification, what is the appropriate stage and recommended initial treatment?

. Stage 0; immediate primary arthrodesis
. Stage 1; total contact casting and non-weight bearing
. Stage 2; custom orthotics and weight-bearing as tolerated
. Stage 3; open reduction and internal fixation
. Stage 1; intravenous antibiotics and surgical debridement

Correct Answer & Explanation

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

Explanation

The patient's clinical presentation and radiographic findings (debris, fragmentation, subluxation) are pathognomonic for Eichenholtz Stage 1 (developmental/fragmentation stage) of Charcot neuroarthropathy. The gold standard initial treatment during this active inflammatory stage is rigid immobilization and offloading, typically achieved with a total contact cast (TCC) and non-weight bearing, to prevent further deformity. Reconstructive surgery is contraindicated in the acute phase.

Question 3109

Topic: Midfoot & Hindfoot
A 55-year-old poorly controlled diabetic patient presents with a swollen, warm, and erythematous right foot. There is no open ulceration. Radiographs reveal focal osteopenia, joint subluxation, debris, and fragmentation around the tarsometatarsal joints. Which of the following corresponds to the correct Eichenholtz stage and the standard of care initial management?
. Stage 0; rigid internal fixation
. Stage I; total contact casting
. Stage II; total contact casting
. Stage III; custom orthotic footwear
. Stage I; immediate midfoot arthrodesis

Correct Answer & Explanation

. Stage II; total contact casting

Explanation

The clinical and radiographic presentation describes Eichenholtz Stage I (Development/Fragmentation stage) of Charcot arthropathy, characterized by swelling, warmth, joint debris, subluxation, and fragmentation. The gold standard initial management is immobilization and offloading with a total contact cast (TCC).

Question 3110

Topic: Midfoot & Hindfoot
A 52-year-old female presents with medial ankle pain and a progressively flattening arch. Examination shows a flexible pes planovalgus, inability to perform a single-limb heel rise, and a positive "too many toes" sign. Radiographs show significant talonavicular uncoverage (>40%). Which of the following is the most appropriate surgical reconstruction for this specific stage of adult-acquired flatfoot deformity (Stage IIB)?
. Isolated flexor digitorum longus (FDL) transfer to the navicular
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Isolated subtalar arthrodesis
. Triple arthrodesis
. Gastrocnemius recession alone

Correct Answer & Explanation

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

Explanation

The patient has Stage IIB Posterior Tibial Tendon Dysfunction (flexible flatfoot with severe forefoot abduction, indicated by >40% talonavicular uncoverage). Stage IIB requires an FDL transfer to reconstruct the posterior tibial tendon, a medial displacement calcaneal osteotomy to correct the hindfoot valgus, and a lateral column lengthening (e.g., Evans osteotomy) to adequately correct the severe forefoot abduction.

Question 3111

Topic: 8. Foot and Ankle

A 25-year-old athlete presents with midfoot pain after sustaining a twisting injury to his foot while playing football. Weight-bearing radiographs reveal a subtle widening between the first and second metatarsal bases, and a 'fleck sign' is visible. The injured ligament responsible for this pathognomonic finding typically originates and inserts on which of the following structures?

. Base of the 1st metatarsal to the base of the 2nd metatarsal
. Medial cuneiform to the base of the 2nd metatarsal
. Medial cuneiform to the base of the 1st metatarsal
. Intermediate cuneiform to the base of the 2nd metatarsal
. Lateral cuneiform to the cuboid

Correct Answer & Explanation

. Medial cuneiform to the base of the 2nd metatarsal

Explanation

The 'fleck sign' is pathognomonic for a Lisfranc injury and represents a bony avulsion of the Lisfranc ligament. The Lisfranc ligament is a strong interosseous ligament that originates from the lateral aspect of the medial cuneiform and inserts onto 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.

Question 3112

Topic: Midfoot & Hindfoot

A 55-year-old man with a 15-year history of poorly controlled type 2 diabetes mellitus presents with a swollen, warm, and erythematous left foot. He denies fevers, chills, or any open wounds. His inflammatory markers are normal. Radiographs demonstrate periarticular osteopenia, osseous debris, and fragmentation of the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, what is the most appropriate initial management for this patient?

. Urgent surgical debridement and intravenous antibiotics
. Open reduction and rigid internal fixation of the midfoot
. Total contact casting and strict non-weight-bearing
. Prescribing custom accommodative footwear and allowing full weight-bearing
. Intravenous bisphosphonates and immediate physical therapy

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The patient's clinical presentation and radiographic findings (fragmentation, debris, periarticular osteopenia) correspond to Eichenholtz Stage 1 (Development/Fragmentation stage) of Charcot arthropathy. In this acute inflammatory stage, the primary treatment is strict immobilization and offloading to prevent further structural collapse. The gold standard is total contact casting (TCC) and non-weight-bearing. Surgery is generally contraindicated during the acute inflammatory phase due to poor bone quality and high risk of failure, unless there is an unstable deformity causing imminent skin breakdown.

Question 3113

Topic: 8. Foot and Ankle
A 28-year-old male presents after a high-speed motor vehicle accident with a Hawkins type III fracture of the talar neck. What is the approximate rate of avascular necrosis (AVN) associated with this specific injury pattern?
. 0-10%
. 20-50%
. 70-100%
. Always occurs
. 15-20%

Correct Answer & Explanation

. 70-100%

Explanation

Hawkins type III fractures involve the talar neck with dislocation of the subtalar and tibiotalar joints. Because the three main sources of blood supply (artery of the tarsal canal, artery of the sinus tarsi, and deltoid branches) are typically disrupted in this displacement pattern, the rate of AVN is reported to be near 70-100%.

Question 3114

Topic: Midfoot & Hindfoot
A 50-year-old female presents with medial ankle pain, a progressively flattening arch, and an inability to perform a single-leg heel rise. Examination reveals a flexible pes planovalgus deformity. Radiographs show no degenerative changes in the subtalar or talonavicular joints. What is the standard surgical treatment if non-operative management fails?
. Isolated talonavicular fusion
. Subtalar fusion
. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Ankle arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy

Explanation

The patient has Stage II posterior tibial tendon dysfunction (PTTD), defined by a flexible flatfoot deformity and loss of PTT function. Standard joint-sparing surgical treatment consists of an FDL tendon transfer to replace the dysfunctional PTT, combined with a medializing calcaneal osteotomy to correct the valgus heel alignment and protect the transfer. Triple arthrodesis is indicated for Stage III, where the deformity becomes rigid with arthritic changes.

Question 3115

Topic: 8. Foot and Ankle

A 30-year-old equestrian sustains an axial load to a plantarflexed foot. On anteroposterior (AP) and oblique radiographs, which specific alignment is the most reliable indicator of an intact, normal Lisfranc joint complex?

. The medial border of the second metatarsal aligns with the medial border of the middle cuneiform on the AP view
. The medial border of the third metatarsal aligns with the medial border of the lateral cuneiform on the AP view
. The medial border of the fourth metatarsal aligns with the medial border of the cuboid on the oblique view
. The lateral border of the first metatarsal aligns with the lateral border of the medial cuneiform on the oblique view
. The medial border of the fifth metatarsal aligns with the medial border of the cuboid on the lateral view

Correct Answer & Explanation

. The medial border of the second metatarsal aligns with the medial border of the middle cuneiform on the AP view

Explanation

To rule out a subtle Lisfranc injury, critical radiographic alignments must be confirmed. On the AP view, the medial border of the base of the 2nd metatarsal must align continuously with the medial border of the middle cuneiform. On the 30-degree internal oblique view, the medial border of the 3rd metatarsal aligns with the medial border of the lateral cuneiform, and the medial border of the 4th metatarsal aligns with the medial border of the cuboid.

Question 3116

Topic: 8. Foot and Ankle

A 28-year-old woman presents with a symptomatic cavovarus foot deformity secondary to Charcot-Marie-Tooth disease. A Coleman block test is performed, and her hindfoot varus corrects completely to neutral. Which of the following procedures is most appropriate to address the skeletal driver of her deformity?

. Subtalar arthrodesis
. Triple arthrodesis
. Lateralizing calcaneal osteotomy
. Dorsiflexion osteotomy of the first metatarsal
. Closing wedge osteotomy of the cuboid

Correct Answer & Explanation

. Dorsiflexion osteotomy of the first metatarsal

Explanation

The Coleman block test distinguishes a flexible hindfoot varus from a rigid hindfoot varus. If the hindfoot varus corrects to neutral when the first ray is allowed to drop off the block, the varus is flexible and primarily driven by a rigid, plantarflexed first ray (forefoot driven). The appropriate skeletal treatment is a dorsiflexion osteotomy of the 1st metatarsal, usually accompanied by soft tissue balancing (e.g., plantar fascia release, peroneus longus to brevis transfer).

Question 3117

Topic: Ankle Trauma & Sports
In the Lauge-Hansen classification of ankle fractures, a Supination-External Rotation (SER) injury follows a specific, sequential pattern of structural failure. Which of the following accurately represents Stage III of an SER injury?
. Rupture of the anterior inferior tibiofibular ligament
. Spiral fracture of the distal fibula at the level of the syndesmosis
. Rupture of the posterior inferior tibiofibular ligament or fracture of the posterior malleolus
. Transverse fracture of the medial malleolus
. Rupture of the deltoid ligament only

Correct Answer & Explanation

. Rupture of the posterior inferior tibiofibular ligament or fracture of the posterior malleolus

Explanation

The Lauge-Hansen SER sequence is: Stage I - Anterior inferior tibiofibular ligament (AITFL) rupture; Stage II - Spiral/oblique fracture of the lateral malleolus; Stage III - Posterior inferior tibiofibular ligament (PITFL) rupture or posterior malleolus fracture; Stage IV - Medial malleolus transverse fracture or deltoid ligament rupture.

Question 3118

Topic: 8. Foot and Ankle

When treating congenital talipes equinovarus (clubfoot) using the Ponseti method, what is the correct anatomical sequence for correcting the deformity?

. Equinus, Varus, Adductus, Cavus
. Cavus, Adductus, Varus, Equinus
. Adductus, Varus, Cavus, Equinus
. Varus, Cavus, Adductus, Equinus
. Cavus, Varus, Adductus, Equinus

Correct Answer & Explanation

. Cavus, Adductus, Varus, Equinus

Explanation

The Ponseti method dictates a specific sequence of correction remembered by the mnemonic CAVE: Cavus, Adductus, Varus, and Equinus. The cavus deformity is corrected first by elevating the first metatarsal (supinating the forefoot). This unlocks the transverse tarsal joint, allowing subsequent correction of adductus and varus by abducting the foot around the fixed talar head. Equinus is corrected last, typically requiring a percutaneous Achilles tenotomy.

Question 3119

Topic: Midfoot & Hindfoot

A 55-year-old female presents with stage IIB adult acquired flatfoot deformity (posterior tibial tendon dysfunction). Clinical and radiographic examination reveals a flexible flatfoot with significant forefoot abduction (talonavicular uncoverage of 45%). What surgical intervention is most appropriate to specifically address the excessive forefoot abduction?

. Subtalar arthrodesis
. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer to navicular and medial displacement calcaneal osteotomy (MDCO) only
. FDL transfer, MDCO, and lateral column lengthening (e.g., Evans osteotomy)
. Isolated Spring ligament repair

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening (e.g., Evans osteotomy)

Explanation

Stage II posterior tibial tendon dysfunction indicates a flexible flatfoot deformity. Stage IIA has no significant forefoot abduction and is typically treated with an FDL transfer and MDCO. Stage IIB is defined by significant forefoot abduction (typically >30-40% talonavicular uncoverage). To correct this, a lateral column lengthening (such as an Evans calcaneal osteotomy) must be added to the FDL transfer and MDCO.

Question 3120

Topic: 8. Foot and Ankle

A 24-year-old football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs demonstrate a 3 mm widening of the interval between the bases of the first and second metatarsals. Which of the following ligaments is primarily disrupted in this classic injury pattern?

. Plantar ligament connecting the first cuneiform to the second metatarsal base
. Dorsal ligament connecting the second cuneiform to the first metatarsal base
. Plantar ligament connecting the first cuneiform to the first metatarsal base
. Interosseous ligament connecting the first and second metatarsal bases
. Spring ligament

Correct Answer & Explanation

. Plantar ligament connecting the first cuneiform to the second metatarsal base

Explanation

The Lisfranc ligament is an oblique interosseous ligament that connects the lateral aspect of the medial (first) cuneiform to the medial base of the second metatarsal. It is the strongest and most critical ligament for the stability of the tarsometatarsal joint complex. There is no direct transverse ligamentous connection between the bases of the first and second metatarsals.

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