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8. Foot and Ankle MCQs

Practice Set 159 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 3161

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic presents with a swollen, erythematous, and warm foot with a rocker-bottom deformity. Radiographs demonstrate significant periarticular debris, fragmentation of the midfoot bones, and joint subluxation without evidence of consolidation. Pulses are palpable and skin is intact. According to the Eichenholtz classification, what is the most appropriate initial management?

. Immediate midfoot arthrodesis with robust internal fixation
. Total contact casting and strict non-weight-bearing
. Charcot Restraint Orthotic Walker (CROW) with weight-bearing as tolerated
. Surgical excision of the bony fragments to prevent ulceration
. Intravenous antibiotics for 6 weeks for presumed osteomyelitis

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation phase) of Charcot arthropathy, characterized by warmth, swelling, erythema, and radiographic fragmentation and debris. The standard of care in this acute, active phase is rigid immobilization, typically with a total contact cast (TCC), and non-weight-bearing to prevent further deformity. Surgical reconstruction is generally contraindicated in the acute phase due to high failure rates and soft tissue compromise. CROW boots are used later in the consolidation/coalescence phases.

Question 3162

Topic: 8. Foot and Ankle

A 55-year-old male with poorly controlled diabetes presents with a swollen, erythematous foot. Radiographs reveal fragmentation of the navicular and cuneiforms with joint subluxation, but no consolidation. According to the Eichenholtz classification, what stage is this, and what is the primary pathophysiological driver according to the neurovascular theory?

. Stage 0; microvascular thrombosis
. Stage 1; autonomic neuropathy leading to hyperemic bone resorption
. Stage 2; loss of protective sensation leading to repetitive microtrauma
. Stage 3; peripheral arterial disease leading to osteonecrosis
. Stage 4; active infection driving osteomyelitis

Correct Answer & Explanation

. Stage 1; autonomic neuropathy leading to hyperemic bone resorption

Explanation

The patient is in Eichenholtz Stage 1 (Fragmentation), characterized by acute inflammation, subluxation, and bony fragmentation. The French/neurovascular theory states that autonomic neuropathy causes arteriovenous shunting and local hyperemia, which increases osteoclastic activity leading to bone resorption and structural collapse.

Question 3163

Topic: 8. Foot and Ankle

Which of the following radiographic findings is considered pathognomonic for a Lisfranc injury?

. A bony avulsion fragment in the space between the bases of the first and second metatarsals
. Widening of the syndesmosis between the distal tibia and fibula
. Plantar subluxation of the cuboid relative to the calcaneus
. Dorsal displacement of the navicular relative to the talar head
. An intra-articular fracture of the base of the fifth metatarsal

Correct Answer & Explanation

. A bony avulsion fragment in the space between the bases of the first and second metatarsals

Explanation

The 'fleck sign' is a small bony avulsion fragment seen in the intermetatarsal space between the medial cuneiform and the base of the second metatarsal. It represents an avulsion of the Lisfranc ligament and is pathognomonic for a Lisfranc joint complex disruption.

Question 3164

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm right foot. Radiographs of the foot are completely normal. An MRI is obtained, demonstrating diffuse bone marrow edema across the midfoot without cortical disruption, subchondral cysts, or fragmentation. Which Eichenholtz stage of Charcot arthropathy does this represent?

. Stage 0 (Active inflammatory)
. Stage 1 (Developmental)
. Stage 2 (Coalescent)
. Stage 3 (Reconstructive)
. Stage 4 (Chronic non-active)

Correct Answer & Explanation

. Stage 0 (Active inflammatory)

Explanation

Eichenholtz Stage 0 (often added to the original 3-stage classification by Shibata et al.) represents the earliest, pre-radiographic phase of Charcot arthropathy. It is characterized by clinical inflammation (warmth, swelling, erythema) and normal radiographs. MRI will show early changes such as bone marrow edema and microfractures before gross structural collapse occurs.

Question 3165

Topic: 8. Foot and Ankle

Which of the following radiographic parameters best evaluates the integrity of the distal tibiofibular syndesmosis on a standard AP view of the ankle?

. Tibiofibular clear space greater than 6 mm measured 1 cm proximal to the plafond.
. Tibiofibular overlap less than 10 mm.
. Talar tilt greater than 5 degrees.
. Medial clear space greater than 4 mm.
. Tibiofibular clear space less than 6 mm measured 1 cm proximal to the plafond.

Correct Answer & Explanation

. Tibiofibular clear space greater than 6 mm measured 1 cm proximal to the plafond.

Explanation

On standard AP and mortise radiographs of the ankle, the tibiofibular clear space should be less than 6 mm when measured 1 cm proximal to the tibial plafond. A measurement of 6 mm or greater indicates a high likelihood of syndesmotic injury. Tibiofibular overlap should be >6 mm on the AP view and >1 mm on the mortise view.

Question 3166

Topic: Midfoot & Hindfoot

The spring ligament complex is a critical static stabilizer of the medial longitudinal arch. Which of its components is most frequently degenerated or torn in adult acquired flatfoot deformity associated with posterior tibial tendon dysfunction?

. Superomedial calcaneonavicular ligament
. Inferior calcaneonavicular ligament
. Medioplantar oblique ligament
. Plantar fascia
. Cervical ligament

Correct Answer & Explanation

. Superomedial calcaneonavicular ligament

Explanation

The superomedial calcaneonavicular ligament is the most robust portion of the spring ligament complex and serves as a critical sling for the talar head. It is the most commonly torn or attenuated component in adult acquired flatfoot deformity associated with posterior tibial tendon dysfunction (PTTD).

Question 3167

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic patient presents with a swollen, erythematous, and warm right foot. Radiographs show fragmentation, debris, and subluxation of the midfoot joints. Pulses are bounding. According to the Eichenholtz classification, this is Stage 1 Charcot arthropathy. What is the most appropriate initial management?

. Immediate primary arthrodesis of the midfoot
. Exostectomy of prominent bone
. Total contact casting and non-weight bearing
. Below-knee amputation
. Open reduction and internal fixation of acute fractures

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

Eichenholtz Stage 1 (development/fragmentation) of Charcot neuroarthropathy presents with active inflammation (red, hot, swollen foot) and radiographic evidence of osteopenia, fragmentation, and joint subluxation. The gold standard of treatment during this acute, active phase is strict offloading and immobilization, typically achieved with a Total Contact Cast (TCC). Surgery in Stage 1 is generally avoided due to profound hyperemia, severe osteopenia, and high failure rates.

Question 3168

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled diabetes presents with a red, hot, swollen right foot. Radiographs reveal periarticular osteopenia, osseous fragmentation, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, what stage is this, and what is the primary pathophysiologic process occurring?

. Stage 0; Inflammation and joint effusion
. Stage 1; Development and fragmentation
. Stage 2; Coalescence and absorption of fine debris
. Stage 3; Consolidation and remodeling
. Stage 4; Late deformity and ulceration

Correct Answer & Explanation

. Stage 1; Development and fragmentation

Explanation

Eichenholtz Stage 1 is the 'development' or 'fragmentation' stage, characterized clinically by a red, hot, swollen foot and radiographically by bony debris at articular margins, fragmentation, joint subluxation/dislocation, and loss of joint space. Stage 2 is coalescence, and Stage 3 is consolidation/remodeling.

Question 3169

Topic: 8. Foot and Ankle

A 60-year-old patient with poorly controlled type 2 diabetes presents with a swollen, erythematous, and warm painless right foot. Radiographs demonstrate extensive periarticular bony debris, fragmentation of the navicular, and subluxation of the talonavicular joint. What is the Eichenholtz stage and the most appropriate initial management?

. Stage 0; Magnetic resonance imaging (MRI) of the foot
. Stage 1; Total contact casting and strict non-weight bearing
. Stage 2; Custom orthotic footwear and partial weight bearing
. Stage 3; Major hindfoot arthrodesis
. Stage 1; Immediate surgical debridement and arthrodesis

Correct Answer & Explanation

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

Explanation

The patient is presenting with acute Charcot neuroarthropathy. The Eichenholtz classification is used to stage Charcot feet: Stage 0 is clinically suspected (warm, red, swollen) but radiographically normal; Stage 1 is development/fragmentation (bony debris, fragmentation, subluxation); Stage 2 is coalescence (absorption of debris, early fusion); Stage 3 is remodeling. The patient is in Stage 1. The gold standard initial treatment is offloading via total contact casting (TCC) to halt progression and prevent further deformity.

Question 3170

Topic: Midfoot & Hindfoot
A 55-year-old female presents with severe, progressive flattening of her left foot. Examination demonstrates a rigid hindfoot valgus deformity and a completely absent ability to perform a single-limb heel rise. Radiographs confirm subtalar and talonavicular osteoarthritis. What is the appropriate classification stage of her posterior tibial tendon dysfunction (PTTD) and the most definitive surgical treatment?
. Stage I; Tenosynovectomy and orthotics
. Stage II; Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Stage III; Triple or double hindfoot arthrodesis
. Stage IV; Tibiotalocalcaneal (TTC) arthrodesis
. Stage II; Subtalar arthrodesis

Correct Answer & Explanation

. Stage III; Triple or double hindfoot arthrodesis

Explanation

Posterior tibial tendon dysfunction (PTTD) is classified into four stages. Stage I: tendon pathology without deformity. Stage II: flexible flatfoot deformity. Stage III: fixed/rigid flatfoot deformity with degenerative joint changes in the hindfoot (subtalar/talonavicular). Stage IV: progression to involve the ankle joint (valgus talar tilt). Because this patient has a rigid hindfoot valgus with osteoarthritis, she is Stage III. The standard surgical treatment for Stage III is a corrective hindfoot arthrodesis (such as a triple or double arthrodesis).

Question 3171

Topic: Midfoot & Hindfoot
A 50-year-old diabetic male presents with an erythematous, swollen, and warm foot with no open wounds. Radiographs show fragmentation of the navicular, periarticular osseous debris, and subluxation of the midfoot joints. According to the Eichenholtz classification of Charcot arthropathy, what is the current stage and best initial management?
. Stage 0; MRI evaluation and custom orthotics
. Stage I; Total contact casting and strict non-weight bearing
. Stage II; Rigid shoe wear and partial weight bearing
. Stage III; Midfoot arthrodesis
. Stage IV; Below-knee amputation

Correct Answer & Explanation

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

Explanation

Eichenholtz Stage I is the developmental (or fragmentation) stage, characterized clinically by a red, hot, swollen foot and radiographically by bone debris, fragmentation, and joint subluxation. The gold standard treatment during this active phase is offloading with a total contact cast (TCC) to prevent further deformity until the acute inflammatory process subsides (Stage II - coalescence).

Question 3172

Topic: 8. Foot and Ankle

The Lisfranc ligament is critical for transverse stability of the midfoot. Which of the following accurately describes the precise origin and insertion of the main bundle of the Lisfranc ligament?

. Originates on the lateral aspect of the medial cuneiform and inserts on the medial aspect of the base of the second metatarsal
. Originates on the medial cuneiform and inserts on the base of the first metatarsal
. Originates on the middle cuneiform and inserts on the base of the second metatarsal
. Originates on the navicular and inserts on the base of the second metatarsal
. Originates on the lateral cuneiform and inserts on the cuboid

Correct Answer & Explanation

. Originates on the lateral aspect of the medial cuneiform and inserts on the medial aspect of the base of the second metatarsal

Explanation

The Lisfranc ligament is the strongest of the tarsometatarsal interosseous ligaments. It spans obliquely from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. There is no ligamentous connection directly between the bases of the first and second metatarsals, making the Lisfranc ligament essential for tying the midfoot to the forefoot.

Question 3173

Topic: 8. Foot and Ankle

A 55-year-old male with severe insertional Achilles tendinopathy and a prominent Haglund's deformity undergoes surgical debridement and exostectomy. Intraoperatively, it is determined that to adequately resect the calcaneal spur and debride the tendon, 60% of the Achilles tendon footprint must be detached. What is the most appropriate next step in the procedure?

. Primary repair with heavy non-absorbable sutures to the remaining footprint
. V-Y tendon advancement to relieve tension
. Flexor hallucis longus (FHL) tendon transfer
. Peroneus brevis tendon transfer
. Gastrocnemius recession alone

Correct Answer & Explanation

. Flexor hallucis longus (FHL) tendon transfer

Explanation

In the surgical management of insertional Achilles tendinopathy, if more than 50% of the Achilles tendon insertion is detached during debridement and ostectomy, primary repair alone carries a high risk of failure and weakness. Augmentation with a tendon transfer, most commonly the Flexor Hallucis Longus (FHL), is indicated to provide mechanical strength and a robust vascular supply to the healing area.

Question 3174

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a swollen, erythematous, and warm left foot. Radiographs reveal diffuse osteopenia, periarticular fragmentation, and early joint subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what stage of Charcot arthropathy does this represent, and what is the primary pathophysiological driver?

. Stage 0; autonomic neuropathy leading to vasospasm
. Stage 1; autonomic neuropathy leading to hyperemia and active bone resorption
. Stage 2; somatic neuropathy leading to repetitive microtrauma and coalescence
. Stage 3; motor neuropathy leading to muscle imbalance and remodeling
. Stage 4; advanced sensory neuropathy leading to ulceration

Correct Answer & Explanation

. Stage 1; autonomic neuropathy leading to hyperemia and active bone resorption

Explanation

The patient is in Eichenholtz Stage 1 (Development/Fragmentation stage), characterized clinically by a red, hot, swollen foot and radiographically by osteopenia, fragmentation, and joint subluxation/dislocation. The underlying pathophysiology involves autonomic neuropathy causing loss of sympathetic tone, arteriovenous shunting, hyperemia, and consequently increased osteoclastic bone resorption.

Question 3175

Topic: Midfoot & Hindfoot

A 30-year-old construction worker sustains a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal joints. Based on prospective randomized trials comparing primary arthrodesis versus open reduction and internal fixation (ORIF) for purely ligamentous Lisfranc injuries, which of the following statements is most accurate regarding primary arthrodesis?

. It is associated with a significantly higher rate of hardware failure
. It results in decreased functional outcomes at 2-year follow-up
. It eliminates the need for hardware removal and reduces the rate of secondary procedures
. It relies solely on temporary K-wire fixation for 6 weeks
. It carries a higher risk of developing symptomatic adjacent joint arthritis

Correct Answer & Explanation

. It results in decreased functional outcomes at 2-year follow-up

Explanation

Level I randomized controlled trials (e.g., Ly and Coetzee, 2006) comparing ORIF to primary arthrodesis for purely ligamentous Lisfranc injuries have shown that primary arthrodesis yields better functional outcomes and a lower rate of secondary surgeries. ORIF of purely ligamentous injuries often results in progressive arch collapse or arthritis, and typically requires a planned secondary surgery for hardware removal, whereas primary arthrodesis provides a definitive, stable construct.

Question 3176

Topic: 8. Foot and Ankle

An infant with a severe idiopathic clubfoot is being treated with serial casting according to the Ponseti method. After four casts, the cavus, adductus, and varus deformities have been fully corrected. The foot remains in 15 degrees of equinus. What is the most appropriate next step in management?

. Continue weekly serial casting until equinus is passively correctable to 15 degrees of dorsiflexion
. Perform a percutaneous Achilles tenotomy followed by a final cast for 3 weeks
. Perform a comprehensive posteromedial release
. Prescribe an ankle-foot orthosis (AFO) to stretch the Achilles tendon
. Perform a transfer of the tibialis anterior to the lateral cuneiform

Correct Answer & Explanation

. Perform a percutaneous Achilles tenotomy followed by a final cast for 3 weeks

Explanation

In the Ponseti method for clubfoot, the deformities are corrected in a specific sequence: Cavus, Adductus, Varus, then Equinus (CAVE). Equinus is the final deformity addressed. In approximately 80-90% of cases, the Achilles tendon is too tight to be corrected by casting alone without causing a rocker-bottom deformity. The standard of care is a percutaneous Achilles tenotomy followed by a final cast in maximal dorsiflexion and abduction for 3 weeks.

Question 3177

Topic: Midfoot & Hindfoot

A 30-year-old male sustains a midfoot injury after falling from a height. Radiographs show a widening between the bases of the 1st and 2nd metatarsals. What is the primary stabilizing structure of the affected joint complex?

. Dorsal Lisfranc ligament
. Interosseous Lisfranc ligament
. Plantar Lisfranc ligament
. Spring ligament
. Long plantar ligament

Correct Answer & Explanation

. Interosseous Lisfranc ligament

Explanation

The patient has a Lisfranc injury. The Lisfranc ligament complex consists of dorsal, interosseous, and plantar ligaments. The interosseous Lisfranc ligament is the strongest and primary stabilizer of the Lisfranc complex, connecting the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. The plantar ligament is the second strongest, and the dorsal ligament is the weakest, which is why most dislocations occur dorsally.

Question 3178

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled diabetes presents with a warm, swollen, erythematous left foot. Radiographs show midfoot joint subluxation, osteopenia, and periarticular bony fragmentation/debris. 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 (Reconstruction/Consolidation)
. Stage 4 (Resolution)

Correct Answer & Explanation

. Stage 1 (Developmental/Fragmentation)

Explanation

Eichenholtz Stage 1 (Fragmentation) is the acute developmental phase characterized by clinical inflammation (erythema, warmth, swelling) and radiographic findings of osteopenia, joint subluxation/dislocation, bony fragmentation, and debris. Stage 2 (Coalescence) shows absorption of fine debris and early fusion/sclerosis. Stage 3 (Consolidation) shows remodeling and stable deformity. Stage 0 is the inflammatory prodrome with normal radiographs.

Question 3179

Topic: Midfoot & Hindfoot
A 55-year-old diabetic patient presents with a swollen, erythematous, right foot. Radiographs reveal extensive periarticular fragmentation, bony debris, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, this represents:
. 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 (Developmental/Fragmentation) is characterized clinically by a red, hot, swollen foot, and radiographically by bony fragmentation, debris formation, subluxation, and dislocation. Stage II (Coalescence) involves absorption of fine debris and early fusion. Stage III (Reconstruction) shows rounding of bone ends and decreased sclerosis.

Question 3180

Topic: 8. Foot and Ankle

In a severe midfoot injury, radiographs reveal a 'Fleck sign' in the first intermetatarsal space, pathognomonic for a Lisfranc ligament avulsion. The Lisfranc ligament structurally connects which two bones?

. Medial cuneiform to the base of the first metatarsal
. Middle cuneiform to the base of the second metatarsal
. Medial cuneiform to the base of the second metatarsal
. Lateral cuneiform to the base of the third metatarsal
. Navicular to the base of the second metatarsal

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is a strong interosseous ligament that runs obliquely from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the primary stabilizer of the second tarsometatarsal joint; there is no direct ligamentous connection between the first and second metatarsal bases.

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