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8. Foot and Ankle MCQs

Practice Set 16 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 301

Topic: 8. Foot and Ankle

A 30-year-old athlete sustains a hyperplantarflexion injury to his midfoot. Radiographs show a widening between the first and second metatarsal bases. Anatomically, the critical Lisfranc ligament connects which two osseous structures?

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

Correct Answer & Explanation

. Medial cuneiform to the second metatarsal base

Explanation

The Lisfranc ligament is a strong interosseous ligament bridging the plantar-lateral aspect of the medial cuneiform to the plantar-medial aspect of the second metatarsal base. Its disruption causes midfoot instability.

Question 302

Topic: 8. Foot and Ankle

A 24-year-old male sustains a midfoot injury during a football game. Radiographs reveal a small bony avulsion fragment in the space between the base of the first and second metatarsals (the "fleck sign"). This fragment typically originates from which of the following structures?

. The lateral aspect of the navicular bone
. The plantar aspect of the cuboid
. The base of the second metatarsal or lateral medial cuneiform
. The dorsal aspect of the first metatarsal
. The anterior process of the calcaneus

Correct Answer & Explanation

. The base of the second metatarsal or lateral medial cuneiform

Explanation

The "fleck sign" is pathognomonic for a Lisfranc injury. It represents a bony avulsion of the Lisfranc ligament, which connects the medial cuneiform to the base of the second metatarsal.

Question 303

Topic: 8. Foot and Ankle

A 28-year-old male sustains a crush injury to his foot. Radiographs reveal a 'fleck sign' in the first intermetatarsal space. This radiographic sign represents an avulsion of the Lisfranc ligament from its attachment on which of the following bones?

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

Correct Answer & Explanation

. Base of the second metatarsal

Explanation

The 'fleck sign' is highly indicative of a Lisfranc injury. It represents a bony avulsion of the Lisfranc ligament from its distal attachment at the base of the second metatarsal.

Question 304

Topic: 8. Foot and Ankle

A 35-year-old man feels a sudden "pop" in his posterior ankle while playing basketball. He has a positive Thompson test on examination. Which specific clinical finding constitutes a positive Thompson test?

. Absence of ankle plantarflexion upon squeezing the calf muscle
. Increased passive dorsiflexion compared to the contralateral side
. Weakness in resisted plantarflexion
. Palpable gap in the Achilles tendon
. Inability to perform a single-leg heel raise

Correct Answer & Explanation

. Absence of ankle plantarflexion upon squeezing the calf muscle

Explanation

The Thompson test evaluates the integrity of the Achilles tendon. Squeezing the calf muscle in a prone patient should normally cause passive ankle plantarflexion; an absence of this movement is a positive test, indicating a complete rupture.

Question 305

Topic: 8. Foot and Ankle

A 35-year-old construction worker falls from a height and sustains a closed, highly comminuted, intra-articular calcaneus fracture. On examination in the ED, he has massive swelling and severe fracture blisters over the lateral hindfoot. What is the most appropriate initial management?

. Immediate Open Reduction Internal Fixation (ORIF) via an extensile lateral approach.
. Immediate primary subtalar arthrodesis.
. Elevation and immobilization, delaying definitive surgical fixation until the soft tissues recover.
. Fasciotomies of the foot compartments followed by immediate internal fixation.

Correct Answer & Explanation

. Elevation and immobilization, delaying definitive surgical fixation until the soft tissues recover.

Explanation

In the presence of massive swelling and fracture blisters, definitive ORIF through an extensile lateral approach should be delayed until the soft tissues have healed and the "wrinkle sign" is present. Premature incision carries an unacceptably high risk of wound necrosis and deep infection.

Question 306

Topic: 8. Foot and Ankle

A 22-year-old football player sustains a high-energy midfoot injury. Radiographs show widening between the 1st and 2nd metatarsal bases.

Which ligamentous connection is anatomically disrupted in a classic Lisfranc injury?

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

Correct Answer & Explanation

. Medial cuneiform to second metatarsal base

Explanation

The primary Lisfranc ligament connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. There is no direct ligamentous connection between the first and second metatarsal bases.

Question 307

Topic: 8. Foot and Ankle

A 24-year-old football player sustains a hyperplantarflexion injury to his midfoot. Radiographs show widening between the base of the first and second metatarsals. The injured Lisfranc ligament normally connects which two structures?

. Medial cuneiform and base of the second metatarsal
. Intermediate cuneiform and base of the second metatarsal
. Medial cuneiform and base of the first metatarsal
. Navicular and medial cuneiform
. Cuboid and base of the fourth metatarsal

Correct Answer & Explanation

. Medial cuneiform and 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 base of the second metatarsal. It provides critical stability to the tarsometatarsal joint complex.

Question 308

Topic: Forefoot

In comparing the clinical efficacy of intra-articular sodium hyaluronate injections vs triamcinolone injections for the treatment of hallux rigidus, which factor showed significantly better improvement in the sodium hyaluronate group:

. Gait pain
. Pain at rest
. Pain with passive mobilization
. Use of analgesics
. Pain with palpation

Correct Answer & Explanation

. Gait pain

Explanation

In a prospective randomized study comparing sodium hyaluronate vs cortisone injections for hallux rigidus, gait pain and AOFAS scores were significantly better in the sodium hyaluronate-treated group. There was no significant difference between the two treatment groups with regard to rest pain, pain with mobilization, pain with palpation, and use of analgesics.

Question 309

Topic: 8. Foot and Ankle

A 39-year-old man has a forced dorsiflexion injury while skiing. Radiographs taken in the emergency department show a small avulsion flake off the lateral surface of the fibula distally on the mortise view. This patient most likely has:

. A lateral process of the talus fracture
. An osteochondral fracture of the talus
. An anterior process of the calcaneus fracture
. A peroneal tendon dislocation
. A syndesmotic sprain

Correct Answer & Explanation

. A peroneal tendon dislocation

Explanation

A forced dorsiflexion injury, especially with skiing, is a common mechanism described for peroneal tendon dislocation. All of the diagnoses listed are potential injuries that can initially be mistaken for an ankle sprain. The flake avulsion off of the lateral border of the distal fibula is almost pathognomonic of a peroneal tendon dislocation injury.

Question 310

Topic: 8. Foot and Ankle

Which of the following is not considered to be a risk factor for peroneal tendon tears:

. Shallow retromalleolar groove
. Gastrocnemius-soleus contracture
. Ligamentous laxity
. Varus hindfoot alignment
. Recurrent lateral ankle ligament instability

Correct Answer & Explanation

. Shallow retromalleolar groove

Explanation

A shallow retrofibular groove and ligamentous laxity predispose to subluxation of the peroneal tendons causing attritional tears over the posterolateral fibular ridge. Varus hindfoot alignment places patients at risk for inversion sprains, which may cause trauma to the peroneal tendons when they are put on stretch. Heel chord contracture has not been implicated in the development of peroneal tendon tears.

Question 311

Topic: 8. Foot and Ankle

A 24-year-old athlete sustains a hyperplantarflexion injury to the midfoot. Radiographs show no obvious fractures, but weight-bearing films reveal a 3 mm diastasis between the base of the first and second metatarsals. What is the most appropriate definitive management?

. Non-weight bearing in a short leg cast for 6 weeks
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation (ORIF)
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Cam boot mobilization with immediate weight-bearing

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF)

Explanation

A Lisfranc ligament injury with >2 mm diastasis indicates instability and requires surgical stabilization. In a young athlete without extensive articular comminution or preexisting arthritis, ORIF is generally preferred over primary arthrodesis.

Question 312

Topic: 8. Foot and Ankle

A 40-year-old male undergoes operative repair of an acute Achilles tendon rupture using a minimally invasive technique. Sural nerve injury is a known complication. At what level relative to the lateral malleolus does the sural nerve typically cross the lateral border of the Achilles tendon?

. 2-3 cm proximal
. 5-7 cm proximal
. 9-12 cm proximal
. 15-18 cm proximal
. At the level of the insertion

Correct Answer & Explanation

. 9-12 cm proximal

Explanation

The sural nerve typically crosses the lateral border of the Achilles tendon approximately 9-12 cm proximal to the calcaneal insertion. Minimally invasive or percutaneous repairs in this proximal zone place the nerve at significant risk.

Question 313

Topic: 8. Foot and Ankle

A 40-year-old male sustains an acute Achilles tendon rupture. When discussing non-operative management utilizing an early functional rehabilitation protocol versus surgical repair, what outcome is most accurate regarding non-operative management?

. Significantly higher re-rupture rate
. Significantly higher risk of deep vein thrombosis
. Equivalent re-rupture rate with higher risk of wound complications
. Equivalent re-rupture rate with a decreased risk of wound complications
. Significantly better long-term plantarflexion power

Correct Answer & Explanation

. Equivalent re-rupture rate with a decreased risk of wound complications

Explanation

Modern randomized controlled trials show that when functional, early weight-bearing rehabilitation is utilized, non-operative management has an equivalent re-rupture rate to surgical repair. It avoids the surgical wound complications associated with operative management.

Question 314

Topic: 8. Foot and Ankle

In the evaluation of a suspected Lisfranc injury, the primary stabilizing ligament of the tarsometatarsal joint complex originates from which structure and inserts onto which structure?

. Lateral aspect of the medial cuneiform to the medial aspect of the second metatarsal base
. Medial aspect of the medial cuneiform to the first metatarsal base
. Middle cuneiform to the second metatarsal base
. Cuboid to the fourth metatarsal base
. Navicular to the medial cuneiform

Correct Answer & Explanation

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

Explanation

The Lisfranc ligament is an interosseous ligament that originates from the lateral aspect of the medial cuneiform and inserts onto the medial base of the second metatarsal, providing critical stability to the midfoot.

Question 315

Topic: 8. Foot and Ankle

Patients sustaining a crushing injury to the foot with midfoot tenderness but without any radiographic signs of fracture or dislocation:

. Should be managed with a postoperative shoe and early physical therapy until the tenderness resolves
. Should be splinted and kept non-weight bearing until nontender
. Should be protected in a cast boot with early weight bearing to tolerance
. Requires open reduction internal fixation to prevent long-term arthritis
. C an be discharged with no further follow-up

Correct Answer & Explanation

. Should be splinted and kept non-weight bearing until nontender

Explanation

Patients who sustain a foot injury and have clinical midfoot tenderness should be assumed to have a serious midfoot sprain until proven otherwise. These patients should be protected non-weight bearing until the tenderness is gone before weight-bearing and physical therapy begins.

Question 316

Topic: 8. Foot and Ankle

The calcaneal compartment of the foot contains all of the following structures except:

. Quadratus plantae muscle
. Posterior tibial nerve, artery, and vein
. Lateral plantar nerve, artery, and vein
. Interossei muscles
. 1st dorsal metatarsal artery

Correct Answer & Explanation

. Interossei muscles

Explanation

The four interossei muscles are contained in their respective interosseous compartments. The calcaneal compartment may also variably contain the medial plantar nerve. The remaining compartments of the foot are the adductor, medial, lateral, and superficial.

Question 317

Topic: 8. Foot and Ankle

Time to radiographic fusion following arthroscopic ankle arthrodesis is:

. Longer than following an open technique arthrodesis
. Shorter than following an open technique arthrodesis
. The same as open technique
. Is affected by whether external bone stimulation is utilized
. Is affected by whether two-screw or three-screw fixation is utilized

Correct Answer & Explanation

. Shorter than following an open technique arthrodesis

Explanation

Time to radiographic fusion following arthroscopic ankle arthrodesis is shorter than following open ankle arthrodesis. Theoretically, the decreased dissection and soft-tissue stripping contributes to greater vascular inflow to heal the fusion site.

Question 318

Topic: 8. Foot and Ankle

Neighboring joint arthritis following ankle arthrodesis has not been found in the:

. Knee joint
. Naviculocuneiform joint
. First metatarsophalangeal joint
. Subtalar joint
. Hindfoot joint

Correct Answer & Explanation

. Subtalar joint

Explanation

Long-term follow-up of ankle fusions show that nearly all patients develop arthritis in the hindfoot, midfoot, and 1st metatarsophalangeal joint. There is no evidence to show that the hip or knee is at greater risk for developing arthritis following ankle fusion.

Question 319

Topic: 8. Foot and Ankle

Range of motion following total ankle replacement is closely correlated with:

. Amount of osteophytes resected during surgery
. Meticulous ligament balancing
. Level of tibial and talar saw cuts
. Preoperative range of motion
. Size of implant

Correct Answer & Explanation

. Preoperative range of motion

Explanation

A radiographic study comparing preoperative to postoperative tibio-talar range of motion as measured by radiographs showed that the amount of motion that patients had following ankle replacement was most dependent upon the motion they had before surgery.

Question 320

Topic: 8. Foot and Ankle
Take-down of ankle arthrodesis and conversion to total ankle replacement:
. Is impossible if the fibula has been resected
. Is a dependable procedure with a rate of complications similar to primary ankle replacement
. Has a poor clinical success rate if there is no clear underlying cause of pain from the ankle fusion
. Results in minimal gains in ankle range of motion
. Requires custom made prosthetic implants

Correct Answer & Explanation

. Has a poor clinical success rate if there is no clear underlying cause of pain from the ankle fusion

Explanation

This article studied the success rates of revising previous ankle fusions to ankle replacement. The authors found that if the etiology of a patient's pain was unclear, the patients did poorly. Patients with prior fibula resection could still be revised to ankle replacement with allograft bone to support the lateral side of the implant. Range of motion following revision to arthroplasty was comparable to primary replacement.

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