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8. Foot and Ankle MCQs

Practice Set 161 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 3201

Topic: 8. Foot and Ankle

The Lisfranc joint complex is crucial for midfoot stability. The Lisfranc ligament itself is the strongest stabilizing structure in this region. Between which two osseous structures does the primary intra-articular component of the Lisfranc ligament course?

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

Correct Answer & Explanation

. Medial cuneiform and the base of the second metatarsal

Explanation

The Lisfranc ligament connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is a critical stabilizer of the midfoot because there is no transverse ligament connecting the bases of the first and second metatarsals.

Question 3202

Topic: 8. Foot and Ankle

A 40-year-old male undergoes a percutaneous repair of an acute Achilles tendon rupture. Post-operatively, he complains of numbness over the lateral aspect of his heel and foot. Which nerve was most likely injured, and what is its anatomic relationship to the Achilles tendon at the level of the repair?

. Sural nerve; it crosses the lateral border of the tendon from medial to lateral approximately 10 cm proximal to the insertion
. Sural nerve; it crosses from medial to lateral approximately 4 cm proximal to the insertion
. Superficial peroneal nerve; it runs along the lateral border of the tendon
. Tibial nerve; it lies directly anterior to the tendon
. Sural nerve; it crosses from lateral to medial approximately 10 cm proximal to the insertion

Correct Answer & Explanation

. Sural nerve; it crosses the lateral border of the tendon from medial to lateral approximately 10 cm proximal to the insertion

Explanation

The sural nerve is at high risk during percutaneous Achilles tendon repairs. It typically descends near the midline of the proximal calf and courses laterally, crossing the lateral border of the Achilles tendon from medial to lateral approximately 9.8 cm (roughly 10 cm) proximal to the calcaneal insertion.

Question 3203

Topic: 8. Foot and Ankle

A 55-year-old poorly controlled diabetic male presents with a red, hot, swollen right foot. He denies any penetrating trauma or fever. Radiographs reveal periarticular fragmentation, subluxation at the tarsometatarsal joints, and debris, but no osteomyelitis. Laboratory markers (WBC, CRP) are normal to minimally elevated. According to the Eichenholtz classification, what is his current stage and the most appropriate initial treatment?

. Stage 0; prescribe customized accommodative footwear
. Stage 1; apply a total contact cast and strict non-weight-bearing
. Stage 2; schedule for primary arthrodesis of the midfoot
. Stage 3; apply a Charcot Restraint Orthotic Walker (CROW)
. Stage 1; initiate intravenous antibiotics and plan for surgical debridement

Correct Answer & Explanation

. Stage 1; apply a total contact cast and strict non-weight-bearing

Explanation

The patient is in Eichenholtz Stage 1 (Fragmentation/Development stage), characterized by a red, hot, swollen foot, joint laxity, subluxation, and bony fragmentation on radiographs. The mainstay of initial treatment is immediate immobilization and offloading. The gold standard is a total contact cast (TCC) to prevent further deformity until the acute inflammatory phase resolves and the foot enters Stage 2 (Coalescence).

Question 3204

Topic: 8. Foot and Ankle

A 28-year-old female sustains a twisting injury to her midfoot. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the first and second metatarsals, with no obvious fractures (purely ligamentous Lisfranc injury). Which of the following treatments provides the best long-term functional outcome and lowest reoperation rate for this specific injury pattern?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation (ORIF) with transarticular screws
. Primary arthrodesis of the medial 2 or 3 tarsometatarsal joints
. Conservative management in a non-weight-bearing cast for 8 weeks
. Application of a spanning external fixator

Correct Answer & Explanation

. Primary arthrodesis of the medial 2 or 3 tarsometatarsal joints

Explanation

Multiple studies (including the landmark paper by Ly and Coetzee, 2006) have demonstrated that primary arthrodesis of the medial columns (1st, 2nd, and sometimes 3rd TMT joints) yields better long-term functional outcomes and significantly lower rates of reoperation and subsequent arthritis compared to ORIF in cases ofpurely ligamentousLisfranc injuries.

Question 3205

Topic: Midfoot & Hindfoot

A 52-year-old diabetic patient presents with a swollen, erythematous, and warm foot. Radiographs demonstrate fragmentation of the tarsometatarsal joints, periarticular debris, and joint subluxation. There are no skin ulcerations. What is the most appropriate initial management?

. Arthrodesis of the midfoot
. Total contact casting and non-weight-bearing
. Intravenous antibiotics
. Exostectomy of prominent bone
. Open reduction and internal fixation

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation) of Charcot arthropathy. The mainstay of initial treatment for acute, active Charcot arthropathy is strict immobilization and offloading, most effectively achieved with a total contact cast (TCC), until the extremity progresses to the coalescence phase.

Question 3206

Topic: Midfoot & Hindfoot
A 28-year-old man sustains a talar neck fracture following a fall from a height. Radiographs reveal a displaced fracture of the talar neck with subluxation of the subtalar joint, but the tibiotalar and talonavicular joints remain perfectly congruent. According to the Hawkins classification, what is the approximate historical risk of developing avascular necrosis (AVN) of the talar body?
. 0-10%
. 20-50%
. 75-90%
. 100%
. AVN does not occur in this specific pattern

Correct Answer & Explanation

. 20-50%

Explanation

The patient has a Hawkins Type II talar neck fracture (subtalar subluxation/dislocation with intact ankle and talonavicular joints). The historical risk of AVN for a Hawkins II fracture is approximately 20-50% (commonly cited as 42%). Hawkins I (nondisplaced) is 0-10%; Hawkins III (subtalar + tibiotalar dislocation) is 50-100% (often ~90%); Hawkins IV (all 3 joints dislocated) is near 100%.

Question 3207

Topic: Forefoot

A 45-year-old female presents with symptomatic hallux valgus that has failed non-operative management. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 42 degrees and an Intermetatarsal Angle (IMA) of 18 degrees. Based on these parameters, which of the following is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Proximal metatarsal osteotomy
. Akin osteotomy alone
. Keller resection arthroplasty
. Silver procedure (simple bunionectomy)

Correct Answer & Explanation

. Proximal metatarsal osteotomy

Explanation

An Intermetatarsal Angle (IMA) > 15 degrees and a Hallux Valgus Angle (HVA) > 40 degrees constitute a severe hallux valgus deformity. A distal osteotomy (like a chevron) is insufficient to translate the metatarsal head enough to correct this large IMA. A proximal metatarsal osteotomy (or a Lapidus procedure) is required to achieve adequate correction.

Question 3208

Topic: 8. Foot and Ankle
A 55-year-old diabetic patient presents with a warm, swollen, erythematous foot. Radiographs reveal fragmentation of the midfoot, periarticular debris, and subluxation of the tarsometatarsal joints. According to the Eichenholtz classification, what stage is this patient in?
. 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 clinically by a red, hot, swollen foot and radiographically by bony debris, fragmentation, and joint subluxation. Stage II shows absorption of debris and early coalescence, while Stage III shows remodeling.

Question 3209

Topic: Midfoot & Hindfoot
A 60-year-old man presents with a painful, severe, and rigid flatfoot deformity. Examination reveals an inability to perform a single-leg heel raise, and the heel remains in fixed valgus on double-leg heel raise. Weight-bearing radiographs demonstrate profound osteoarthritis of the subtalar, talonavicular, and calcaneocuboid joints. What is the most appropriate definitive surgical intervention?
. Medial displacement calcaneal osteotomy and flexor digitorum longus transfer
. Lateral column lengthening (Evans osteotomy)
. Isolated subtalar arthrodesis
. Triple arthrodesis
. Talonavicular arthrodesis with spring ligament repair

Correct Answer & Explanation

. Triple arthrodesis

Explanation

This patient has a Stage III posterior tibial tendon dysfunction (PTTD), which is characterized by a fixed, rigid flatfoot deformity and degenerative joint disease (osteoarthritis) of the hindfoot complex. The gold standard surgical treatment for Stage III PTTD with advanced degenerative changes in the subtalar, talonavicular, and calcaneocuboid joints is a triple arthrodesis.

Question 3210

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a progressive painful flatfoot deformity. Examination shows she is unable to perform a single-leg heel rise. Radiographs demonstrate collapse of the medial longitudinal arch, talonavicular unroofing of 40%, and significant forefoot abduction. What is the most appropriate surgical intervention?

. Gastrocnemius recession and medial displacement calcaneal osteotomy
. Flexor digitorum longus (FDL) transfer to the navicular alone
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Subtalar arthrodesis alone
. Triple arthrodesis

Correct Answer & Explanation

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

Explanation

The patient has Stage IIb adult-acquired flatfoot deformity (posterior tibial tendon dysfunction), characterized by flexible flatfoot with significant forefoot abduction (>30% talonavicular unroofing). Stage IIb requires addressing the medial column (FDL transfer) as well as correcting both the hindfoot valgus (medial displacement calcaneal osteotomy) and forefoot abduction (lateral column lengthening).

Question 3211

Topic: Ankle Trauma & Sports

According to the Lauge-Hansen classification, what is the sequence of injury in a Supination-External Rotation (SER) ankle fracture?

. Anterior inferior tibiofibular ligament -> short oblique fibula fracture -> posterior inferior tibiofibular ligament -> medial malleolus/deltoid ligament
. Medial malleolus -> anterior inferior tibiofibular ligament -> high fibula fracture -> posterior inferior tibiofibular ligament
. Medial malleolus -> transverse fibula fracture
. Anterior inferior tibiofibular ligament -> posterior inferior tibiofibular ligament -> high fibula fracture
. Deltoid ligament -> short oblique fibula fracture -> syndesmosis rupture

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament -> short oblique fibula fracture -> posterior inferior tibiofibular ligament -> medial malleolus/deltoid ligament

Explanation

The Lauge-Hansen SER sequence is: Stage 1) Anterior inferior tibiofibular ligament (AITFL) rupture; Stage 2) Spiral/short oblique fracture of the lateral malleolus; Stage 3) Posterior inferior tibiofibular ligament (PITFL) tear or posterior malleolus fracture; Stage 4) Medial malleolus fracture or deltoid ligament tear.

Question 3212

Topic: 8. Foot and Ankle

In the anatomic stabilization of the tarsometatarsal articulation, which of the following ligaments provides the primary stabilization to the Lisfranc joint complex?

. Dorsal ligament from the medial cuneiform to the second metatarsal base
. Plantar ligament from the medial cuneiform to the second metatarsal base
. Interosseous ligament from the medial cuneiform to the second metatarsal base
. Plantar ligament from the intermediate cuneiform to the second metatarsal base
. Interosseous ligament from the medial cuneiform to the first metatarsal base

Correct Answer & Explanation

. Interosseous ligament from the medial cuneiform to the second metatarsal base

Explanation

The Lisfranc ligament is an interosseous ligament that runs from 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 tarsometatarsal articulation. There is no transverse intermetatarsal ligament between the 1st and 2nd metatarsals.

Question 3213

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with progressive, painful flatfoot deformity. She has inability to perform a single-limb heel rise, and the deformity is passively correctable. MRI shows a complete rupture of the posterior tibial tendon. Which of the following surgical interventions is most appropriate?

. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Talonavicular arthrodesis
. Anterior tibial tendon transfer
. Gastrocnemius recession alone

Correct Answer & Explanation

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

Explanation

This patient has a Stage II adult acquired flatfoot deformity (passively correctable, unable to perform single heel rise). Standard treatment involves reconstruction, typically with an FDL tendon transfer to substitute for the PTT, combined with a medializing calcaneal osteotomy to correct the valgus hindfoot and protect the transfer.

Question 3214

Topic: 8. Foot and Ankle

A 54-year-old poorly controlled diabetic male presents with a swollen, erythematous, and warm right foot without open ulcers. Pulses are bounding. Radiographs demonstrate periarticular fragmentation, debris, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what is the most appropriate initial management?

. Immediate midfoot arthrodesis with rigid internal fixation
. Total contact casting and non-weight-bearing
. Intravenous antibiotics and MRI to rule out osteomyelitis
. Below-knee amputation
. Surgical debridement of the tarsometatarsal joints

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

This patient presents with Stage 1 (Developmental/Fragmentation) Charcot neuroarthropathy, characterized by warmth, erythema, bounding pulses, and radiographic fragmentation/debris. The standard of care for acute, active (Stage 1) Charcot is immobilization and offloading, typically utilizing a total contact cast (TCC). Surgery in Stage 1 carries a very high failure rate and is generally avoided unless there is severe, unstable deformity threatening the soft tissue envelope.

Question 3215

Topic: Midfoot & Hindfoot
A 60-year-old obese female presents with a painful, progressive flatfoot deformity. Examination reveals she is unable to perform a single-leg heel rise on the affected side. The deformity is flexible and passively correctable to neutral. What is the most appropriate surgical intervention for this stage of posterior tibial tendon dysfunction (PTTD)?
. Isolated primary repair of the posterior tibial tendon
. Flexor digitorum longus (FDL) transfer to the navicular and a medial displacement calcaneal osteotomy
. Subtalar arthrodesis with Achilles tendon lengthening
. Triple arthrodesis (subtalar, talonavicular, and calcaneocuboid)
. Talonavicular arthrodesis alone

Correct Answer & Explanation

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

Explanation

This patient has Stage II PTTD (flexible flatfoot, inability to perform a single-leg heel rise). Stage I is tenosynovitis without deformity; Stage III is a rigid/fixed deformity; Stage IV involves ankle joint arthritis/tilt. The gold standard surgical treatment for Stage II PTTD is an extra-articular bony correction (Medial Displacement Calcaneal Osteotomy) combined with a soft tissue reconstruction (FDL tendon transfer to substitute for the incompetent PTT). Triple arthrodesis is reserved for Stage III (rigid) deformity.

Question 3216

Topic: 8. Foot and Ankle

A 55-year-old woman with a 15-year history of poorly controlled type 2 diabetes mellitus presents with a swollen, warm, and erythematous right foot. She denies any specific trauma. She has no fevers or chills, and laboratory markers for infection (WBC, CRP, ESR) are within normal limits. Radiographs demonstrate fragmentation of the tarsometatarsal joints, joint subluxation, and soft tissue swelling. What is the gold standard initial management for this condition?

. Intravenous antibiotics for 6 weeks
. Open reduction and internal fixation of the midfoot
. Arthrodesis of the tarsometatarsal joints
. Total contact casting and strict non-weight-bearing
. Immediate below-knee amputation

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The clinical and radiographic presentation is classic for acute (Eichenholtz stage I) Charcot neuroarthropathy. The initial management of acute Charcot arthropathy involves arresting the inflammatory process and preventing further skeletal deformity. This is most effectively achieved with total contact casting (TCC) to offload and immobilize the foot until the acute inflammatory phase (warmth, erythema, edema) completely resolves, which often takes several months.

Question 3217

Topic: 8. Foot and Ankle

A 42-year-old man sustains an acute Achilles tendon rupture while playing basketball. He elects for nonoperative management utilizing a functional rehabilitation protocol. Compared to traditional surgical repair, current evidence suggests nonoperative functional rehabilitation is associated with:

. A significantly higher rerupture rate
. A higher rate of deep vein thrombosis
. Significantly greater plantar flexion strength at 2 years
. A similar rerupture rate but lower risk of soft-tissue complications
. A longer required period of strict non-weight bearing

Correct Answer & Explanation

. A similar rerupture rate but lower risk of soft-tissue complications

Explanation

Recent high-quality randomized controlled trials and meta-analyses comparing functional rehabilitation (early weight-bearing and early range of motion) to surgical repair for acute Achilles tendon ruptures have shown similar rerupture rates between the two groups. However, nonoperative management avoids the surgical risks of infection, wound healing issues, and sural nerve injury.

Question 3218

Topic: Midfoot & Hindfoot
A 28-year-old male sustains a high-energy motor vehicle collision resulting in a Hawkins type III fracture of the talar neck. Which of the following accurately describes the fracture pattern and the associated risk of avascular necrosis (AVN)?
. Nondisplaced fracture; 0-10% risk of AVN
. Displaced fracture with subtalar subluxation; 20-50% risk of AVN
. Displaced fracture with subtalar and tibiotalar dislocation; nearly 100% risk of AVN
. Displaced fracture with subtalar, tibiotalar, and talonavicular dislocation; 100% risk of AVN
. Talar body fracture with extrusion; 50% risk of AVN

Correct Answer & Explanation

. Displaced fracture with subtalar and tibiotalar dislocation; nearly 100% risk of AVN

Explanation

The Hawkins classification is used for talar neck fractures. Type I is a nondisplaced fracture (AVN risk ~0-10%). Type II is displaced with subtalar subluxation or dislocation (AVN risk ~20-50%). Type III is displaced with both subtalar and tibiotalar dislocations, and the AVN risk approaches 100%. Type IV involves displacement of the subtalar, tibiotalar, and talonavicular joints. Therefore, Type III corresponds to subtalar and tibiotalar dislocation with a near 100% risk of AVN.

Question 3219

Topic: 8. Foot and Ankle

A 55-year-old patient with long-standing poorly controlled diabetes presents with a swollen, erythematous, and warm left foot. Radiographs reveal fragmentation and periarticular debris at the tarsometatarsal joints. Which of the following is the most appropriate initial management for this acute condition?

. Immediate open reduction and internal fixation of the midfoot
. Intravenous antibiotics and irrigation and debridement
. Total contact casting and non-weight bearing
. Custom orthotics and physical therapy
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

This patient is presenting with acute Charcot neuroarthropathy (Eichenholtz stage 1), characterized by a red, hot, swollen foot with radiographic evidence of fragmentation. The gold standard for acute Charcot arthropathy is immediate immobilization and offloading, typically achieved with total contact casting (TCC) and non-weight bearing. Surgery is generally contraindicated in the acute inflammatory phase due to severe osteopenia and high risk of hardware failure.

Question 3220

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled type 2 diabetes and peripheral neuropathy presents with a warm, swollen, and erythematous right foot. Radiographs demonstrate periarticular bony fragmentation, debris, and midfoot subluxation. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?

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

Correct Answer & Explanation

. Stage 1 (Developmental/Fragmentation)

Explanation

The patient is in Eichenholtz Stage 1 (Developmental/Fragmentation phase). This stage is characterized clinically by a red, hot, swollen foot and radiographically by osteopenia, periarticular fragmentation, subluxation/dislocation, and bony debris. Stage 0 is the inflammatory phase with a normal radiograph (except possible osteopenia) but positive MRI findings. Stage 2 (Coalescence) involves the absorption of fine debris and early fusion. Stage 3 (Consolidation) shows remodeling and rounding of bone ends.

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