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8. Foot and Ankle MCQs

Practice Set 157 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 3121

Topic: Midfoot & Hindfoot

A 55-year-old male with poorly controlled type 2 diabetes presents with a swollen, warm, and erythematous right foot. There are no open ulcers, and his systemic inflammatory markers are normal. Radiographs reveal fragmentation and early subluxation of the talonavicular and calcaneocuboid joints. According to the Eichenholtz classification, what stage of Charcot arthropathy is this patient currently in, and what is the mainstay of treatment?

. Stage 0; immediate arthrodesis
. Stage 1; total contact casting and non-weight-bearing
. Stage 2; custom orthotics and modified shoe wear
. Stage 3; total contact casting and non-weight-bearing
. Stage 1; intravenous antibiotics and surgical debridement

Correct Answer & Explanation

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

Explanation

The patient is in Eichenholtz Stage 1 (Developmental/Fragmentation), characterized by erythema, warmth, swelling, and radiographic evidence of bone debris, fragmentation, and joint subluxation. The mainstay of treatment in the acute fragmentation phase is strict offloading, typically achieved with total contact casting (TCC) to prevent further deformity until the active inflammatory phase resolves.

Question 3122

Topic: 8. Foot and Ankle

A 55-year-old female presents with progressive flattening of her left foot, pain along the medial ankle, and inability to perform a single-leg heel raise. Clinical examination reveals a positive 'too many toes' sign. Which tendon is primarily dysfunctional in the early stages of this condition?

. Flexor hallucis longus
. Peroneus brevis
. Tibialis anterior
. Tibialis posterior
. Flexor digitorum longus

Correct Answer & Explanation

. Tibialis posterior

Explanation

The clinical scenario describes Adult Acquired Flatfoot Deformity (AAFD), most commonly caused by posterior tibial tendon dysfunction (PTTD). The tibialis posterior is the primary dynamic stabilizer of the medial longitudinal arch; its failure leads to hindfoot valgus, midfoot abduction (positive 'too many toes' sign), and forefoot supination.

Question 3123

Topic: 8. Foot and Ankle

A 24-year-old football player presents with midfoot pain after a hyper-plantarflexion injury. Radiographs reveal widening of the space between the bases of the first and second metatarsals, raising suspicion for a Lisfranc injury. What is the true anatomical path of the intact Lisfranc ligament?

. Connects the medial cuneiform to the base of the first metatarsal
. Connects the medial cuneiform to the base of the second metatarsal
. Connects the intermediate cuneiform to the base of the second metatarsal
. Connects the lateral cuneiform to the cuboid
. Connects the navicular to the medial cuneiform

Correct Answer & Explanation

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

Explanation

The Lisfranc ligament is a strong 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 midfoot stability because there is no direct intermetatarsal ligament connecting the first and second metatarsal bases.

Question 3124

Topic: 8. Foot and Ankle

In the evaluation of a suspected Lisfranc injury, which radiographic finding is considered the most reliable indicator of instability on a weight-bearing AP view of the foot?

. Medial border of the second metatarsal not aligning with the medial border of the middle cuneiform
. Lateral border of the first metatarsal not aligning with the lateral border of the medial cuneiform
. Distance greater than 1 mm between the third and fourth metatarsals
. Plantar gapping of the calcaneocuboid joint
. Avulsion fracture of the navicular tuberosity

Correct Answer & Explanation

. Medial border of the second metatarsal not aligning with the medial border of the middle cuneiform

Explanation

The hallmark radiographic sign of a Lisfranc injury on a weight-bearing AP radiograph is a step-off or widening between the medial border of the second metatarsal base and the medial border of the middle cuneiform. A gap of >2mm between the bases of the 1st and 2nd metatarsals is also highly indicative.

Question 3125

Topic: 8. Foot and Ankle

A 55-year-old male presents with painful, limited dorsiflexion of the great toe. Radiographs show dorsal osteophytes at the first metatarsophalangeal joint with preserved joint space on the plantar aspect. What is the most appropriate initial surgical management if non-operative measures fail?

. Cheilectomy
. First MTP joint arthrodesis
. Keller resection arthroplasty
. Total joint arthroplasty of the first MTP
. Weil osteotomy of the first metatarsal

Correct Answer & Explanation

. Cheilectomy

Explanation

The patient has Coughlin and Shurnas Grade 1 or 2 hallux rigidus (preserved plantar joint space with dorsal osteophytes causing mechanical block). A cheilectomy (excision of the dorsal osteophytes and the dorsal third of the metatarsal head) is the procedure of choice. Arthrodesis is reserved for advanced (Grade 3 or 4) disease.

Question 3126

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic male presents with a swollen, erythematous, and warm left foot. Radiographs show periarticular debris, fragmentation of the tarsometatarsal joints, and early subluxation. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent and what is the key histological hallmark?

. Stage 1; presence of osseous debris and active bone resorption.
. Stage 2; absorption of fine debris and early fusion.
. Stage 3; remodeling of bone ends and decreased sclerosis.
. Stage 0; normal radiographs with diffuse marrow edema on MRI.
. Stage 4; fixed deformity with chronic plantar ulceration.

Correct Answer & Explanation

. Stage 1; presence of osseous debris and active bone resorption.

Explanation

The Eichenholtz classification divides Charcot arthropathy into three main radiographic stages (0 was added later). Stage 1 (Development/Fragmentation) is characterized by joint effusion, soft tissue swelling, osteopenia, periarticular fragmentation, debris formation, and subluxation. Stage 2 (Coalescence) shows absorption of fine debris, early sclerosis, and fusion. Stage 3 (Consolidation) shows remodeling and rounding of bone ends.

Question 3127

Topic: 8. Foot and Ankle

According to the Ponseti method for the treatment of idiopathic clubfoot, the sequence of deformity correction follows the acronym CAVE. What is the precise maneuver required to correct the first component of the deformity (Cavus)?

. Pronation of the forefoot with counter-pressure on the lateral aspect of the talus.
. Supination of the forefoot with elevation of the first metatarsal.
. Dorsiflexion of the ankle with tension on the Achilles tendon.
. Abduction of the forefoot with counter-pressure on the calcaneus.
. Plantarflexion of the first metatarsal to align with the hindfoot.

Correct Answer & Explanation

. Supination of the forefoot with elevation of the first metatarsal.

Explanation

The components of clubfoot are corrected in the order of CAVE: Cavus, Adductus, Varus, Equinus. The cavus deformity is driven by a relatively plantarflexed first ray. To correct it, the forefoot must be supinated (by elevating the first metatarsal) to align the forefoot with the hindfoot, which is already in varus and supination.

Question 3128

Topic: 8. Foot and Ankle

A 45-year-old female undergoes surgical evaluation for a symptomatic hallux valgus deformity. Preoperative radiographs reveal an Intermetatarsal Angle (IMA) of 14 degrees, a Hallux Valgus Angle (HVA) of 32 degrees, and a Distal Metatarsal Articular Angle (DMAA) of 25 degrees. Which of the following procedures is most appropriate to specifically address her elevated DMAA?

. Proximal crescentic osteotomy.
. Lapidus procedure (first tarsometatarsal arthrodesis).
. Biplanar (Reverdin) distal metatarsal osteotomy.
. Akin osteotomy of the proximal phalanx.
. Scarf osteotomy with pure lateral translation.

Correct Answer & Explanation

. Biplanar (Reverdin) distal metatarsal osteotomy.

Explanation

The DMAA measures the relationship of the articular surface of the first metatarsal head to the longitudinal axis of the metatarsal shaft. A normal DMAA is less than 10-15 degrees. An abnormally high DMAA indicates lateral deviation of the articular cartilage. To correct this, an intra-articular or distal biplanar osteotomy (such as a Reverdin or biplanar Chevron osteotomy) is required to rotate the articular surface medially. Proximal procedures like a Lapidus or crescentic osteotomy will correct the IMA but cannot alter the distal articular surface angle (DMAA).

Question 3129

Topic: 8. Foot and Ankle
A 32-year-old male sustains a Hawkins Type III talar neck fracture following a high-energy motor vehicle collision. Which of the following blood vessels provides the majority of the blood supply to the talar body, making it most vulnerable to disruption in this specific injury pattern?
. Artery of the tarsal canal
. Artery of the tarsal sinus
. Dorsalis pedis artery
. Deltoid branch of the posterior tibial 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) supplies the majority of the talar body. A Hawkins Type III fracture involves the talar neck with subluxation or dislocation of both the subtalar and tibiotalar joints. This disrupts the artery of the tarsal canal, the artery of the tarsal sinus, and often the deltoid branches, leading to a risk of avascular necrosis (AVN) that approaches 100%.

Question 3130

Topic: 8. Foot and Ankle

Which of the following specific ligamentous attachments correctly defines the anatomy of the Lisfranc ligament?

. 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 medial cuneiform

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is a robust, oblique interosseous ligament that runs from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is a critical stabilizer of the tarsometatarsal joint complex, compensating for the lack of a direct intermetatarsal ligamentous connection between the bases of the first and second metatarsals.

Question 3131

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a swollen, warm, and erythematous foot without open ulceration. Radiographs reveal periarticular fragmentation, subluxation, and bony debris at the midfoot joints. According to the Eichenholtz classification of Charcot arthropathy, what is the most appropriate initial treatment?

. Immediate open reduction and internal fixation of the midfoot
. Total contact casting and non-weight bearing
. Below-knee amputation
. Intravenous antibiotics for 6 weeks followed by arthrodesis
. Custom orthotic shoe wear and unrestricted weight bearing

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation stage), which is characterized clinically by a red, hot, swollen foot and radiographically by fragmentation, subluxation, and joint debris. The gold standard for treatment during this acute, active stage is rigid immobilization and offloading, typically via a total contact cast (TCC) and strict non-weight bearing until the disease progresses to the coalescent stage (Stage II).

Question 3132

Topic: Midfoot & Hindfoot
A 55-year-old poorly controlled diabetic patient presents with a swollen, erythematous, and warm left foot. There are no open ulcers, and inflammatory markers are only mildly elevated. Radiographs reveal extensive periarticular fragmentation, bony debris, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what is the current stage of this Charcot neuroarthropathy and the most appropriate initial management?
. Stage 0; Immobilization in a total contact cast
. Stage I; Immobilization in a total contact cast and non-weight bearing
. Stage II; Transition to a custom orthotic shoe
. Stage III; Operative midfoot arthrodesis
. Stage I; Immediate surgical debridement and application of external fixation

Correct Answer & Explanation

. Stage I; Immobilization in a total contact cast and non-weight bearing

Explanation

The clinical and radiographic presentation is classic for Eichenholtz Stage I (Developmental/Fragmentation stage) Charcot arthropathy, characterized by acute inflammation, periarticular fragmentation, debris, and joint subluxation/dislocation. The mainstay of treatment in the acute fragmentation phase is strict immobilization (usually a total contact cast) and offloading to prevent further structural collapse. Surgery is generally avoided in the acute inflammatory stage unless severe deformity prevents casting or there is an associated deep infection.

Question 3133

Topic: 8. Foot and Ankle

A patient sustains a high-energy midfoot injury. An AP radiograph of the foot reveals the 'Fleck sign' in the first intermetatarsal space. This pathognomonic finding represents a bony avulsion of the Lisfranc ligament from its attachment at the:

. Medial aspect of the base of the second metatarsal
. Lateral aspect of the medial cuneiform
. Plantar aspect of the intermediate cuneiform
. Lateral aspect of the base of the first metatarsal
. Dorsal aspect of the cuboid

Correct Answer & Explanation

. Medial aspect of the base of the second metatarsal

Explanation

The Lisfranc ligament is a strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. While avulsions can occur at either end, the classic 'Fleck sign' represents an avulsion fragment in the first intermetatarsal space that most commonly pulls off from the medial base of the second metatarsal.

Question 3134

Topic: 8. Foot and Ankle
A 25-year-old man sustains a severe pelvic crush injury resulting in a U-shaped sacral fracture (spinopelvic dissociation). Which of the following neurological deficits is most characteristic of this specific injury pattern?
. Weakness in hip flexion and knee extension
. Foot drop and weakness in great toe extension
. Weakness in plantar flexion and absent Achilles reflex
. Bowel and bladder incontinence with saddle anesthesia
. Loss of sensation over the anterior thigh

Correct Answer & Explanation

. Bowel and bladder incontinence with saddle anesthesia

Explanation

A U-shaped sacral fracture is a complex Denis Zone III injury resulting in spinopelvic dissociation. Because the fracture lines cross the central sacral canal transversely, there is a very high incidence of damage to the lower sacral nerve roots (S2-S4), classically resulting in sphincter dysfunction (bowel/bladder incontinence) and saddle anesthesia.

Question 3135

Topic: Forefoot

A 45-year-old woman presents with severe bunion pain. Radiographs demonstrate a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 20 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate to address her pathology?

. Distal chevron osteotomy
. Scarf osteotomy
. Lapidus procedure (1st TMT arthrodesis)
. Akin osteotomy
. Keller resection arthroplasty

Correct Answer & Explanation

. Lapidus procedure (1st TMT arthrodesis)

Explanation

The Lapidus procedure (first tarsometatarsal joint arthrodesis) is indicated for severe hallux valgus deformities (HVA > 40 degrees, IMA > 15-20 degrees), particularly when there is associated hypermobility of the first TMT joint. Distal or diaphyseal osteotomies (Chevron, Scarf) are insufficient for severe deformities with TMT hypermobility.

Question 3136

Topic: 8. Foot and Ankle

A 10-year-old boy presents with an established idiopathic right clubfoot that is being treated with the Ponseti method. According to the Ponseti principles of serial casting, which of the following describes the correct initial maneuver to correct the cavus deformity?

. Pronation of the forefoot with depression of the first metatarsal
. Supination of the forefoot with elevation of the first metatarsal
. Abduction of the forefoot against counter-pressure on the calcaneocuboid joint
. Direct dorsiflexion of the midfoot through the transverse tarsal joint
. Plantarflexion of the first metatarsal combined with varus pressure on the heel

Correct Answer & Explanation

. Supination of the forefoot with elevation of the first metatarsal

Explanation

In the Ponseti method, the first step in correcting a clubfoot deformity is addressing the cavus. The cavus is primarily caused by plantarflexion of the first ray relative to the hindfoot. To correct this, the forefoot must be supinated (to match the hindfoot supination) by elevating the first metatarsal. Once the cavus is corrected and the forefoot is aligned with the hindfoot, the entire foot can be gradually abducted around the talus to correct the adductus and varus.

Question 3137

Topic: 8. Foot and Ankle

The primary stabilizing ligament of the tarsometatarsal articulation, commonly referred to as the Lisfranc ligament, connects which of the following specific osseous structures?

. Medial aspect of the medial cuneiform to the medial aspect of the second metatarsal base
. Lateral aspect of the medial cuneiform to the medial aspect of the second metatarsal base
. Medial aspect of the intermediate cuneiform to the lateral aspect of the first metatarsal base
. Lateral aspect of the intermediate cuneiform to the medial aspect of the second metatarsal base
. Anterior aspect of the navicular to the dorsal aspect of the second metatarsal base

Correct Answer & Explanation

. Lateral aspect of the medial cuneiform to the medial aspect of the second metatarsal base

Explanation

The Lisfranc ligament is an intra-articular interosseous ligament that serves as the primary restraint to dorsal and lateral displacement of the second metatarsal base. Anatomically, it originates from the lateral surface of the medial cuneiform and inserts onto the medial aspect of the base of the second metatarsal. It lacks a true dorsal component and is thickest on its plantar aspect.

Question 3138

Topic: Midfoot & Hindfoot

A 58-year-old male with poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm left foot. Radiographs reveal marked osteopenia, periarticular fragmentation, and joint subluxation at the midfoot. According to the Eichenholtz classification for Charcot arthropathy, which stage does this represent and what is the standard of care?

. Stage 0; Intravenous antibiotics and surgical debridement
. 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 4; Below knee amputation

Correct Answer & Explanation

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

Explanation

The patient's clinical and radiographic presentation is consistent with Stage 1 (Developmental/Fragmentation stage) of the Eichenholtz classification for Charcot arthropathy. Radiographically, this is characterized by osteopenia, bony fragmentation, joint subluxation/dislocation, and debris. Stage 2 is Coalescence (absorption of fine debris, early sclerosis). Stage 3 is Consolidation (remodeling, rounding of bone ends, solid fusion). The gold standard treatment for Stage 1 acute Charcot is offloading, most effectively achieved with a total contact cast (TCC).

Question 3139

Topic: 8. Foot and Ankle

An Evans osteotomy is frequently utilized in the surgical correction of adult acquired flatfoot deformity (Stage IIb) to address severe forefoot abduction. At which precise anatomical location is this lateral column lengthening osteotomy performed?

. Through the cuboid, 1 cm distal to the calcaneocuboid joint
. Through the calcaneus, 1.5 cm proximal to the calcaneocuboid joint
. Through the talar neck
. Through the medial cuneiform
. Through the calcaneus, horizontally beneath the posterior facet

Correct Answer & Explanation

. Through the calcaneus, 1.5 cm proximal to the calcaneocuboid joint

Explanation

The Evans osteotomy is a lateral column lengthening procedure performed through the anterior calcaneus, typically 1 to 1.5 cm proximal to the calcaneocuboid joint. A bone graft is inserted to lengthen the lateral column and correct forefoot abduction.

Question 3140

Topic: 8. Foot and Ankle

A 30-year-old sustains a Hawkins Type II talar neck fracture. Which of the following arteries provides the predominant blood supply to the body of the talus, placing it at risk in this injury?

. Artery of the tarsal canal
. Artery of the tarsal sinus
. Deltoid branch of the posterior tibial artery
. 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, is the most important blood supply to the body of the talus. Talar neck fractures (especially displaced ones like Hawkins II-IV) often disrupt this vessel, leading to high rates of avascular necrosis.

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