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8. Foot and Ankle MCQs

Practice Set 166 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 3301

Topic: 8. Foot and Ankle

A 55-year-old male with long-standing, poorly controlled diabetes presents with a swollen, erythematous, and warm left foot. Radiographs reveal fragmentation and subluxation of the tarsometatarsal joints, but no obvious gas or focal osteomyelitis. What is the most appropriate initial management?

. Urgent irrigation and debridement
. Total contact casting and strict non-weight-bearing
. Intravenous antibiotics and surgical arthrodesis
. Open reduction and internal fixation of the midfoot
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The patient is presenting with acute Stage 0 or 1 Charcot arthropathy. The gold standard for initial treatment is immobilization with a total contact cast and non-weight-bearing to prevent further deformity and allow the acute inflammatory phase to subside.

Question 3302

Topic: 8. Foot and Ankle

A 16-year-old male with Charcot-Marie-Tooth disease presents with bilateral cavovarus foot deformities. On examination, a Coleman block test completely corrects his hindfoot varus. What does this physical examination finding indicate?

. The hindfoot varus is rigid and requires a subtalar fusion.
. The deformity is driven by a plantarflexed first ray, and the hindfoot is flexible.
. The deformity is primarily driven by a tight Achilles tendon.
. The anterior tibial tendon is overactive.
. A triple arthrodesis is the only surgical option.

Correct Answer & Explanation

. The deformity is driven by a plantarflexed first ray, and the hindfoot is flexible.

Explanation

The Coleman block test nullifies the effect of a plantarflexed first ray. If the hindfoot varus corrects when the first ray drops off the block, the hindfoot is flexible, meaning surgical correction should focus on the forefoot (e.g., dorsiflexion osteotomy of the first metatarsal).

Question 3303

Topic: 8. Foot and Ankle

A 68-year-old male is considering surgical options for end-stage primary ankle osteoarthritis. Which of the following is considered an absolute contraindication for a total ankle arthroplasty (TAA)?

. Age greater than 65 years
. Mild varus deformity of 5 degrees
. Previous anterior ankle arthroscopy
. Severe peripheral neuropathy with absence of protective sensation
. Body mass index (BMI) of 28

Correct Answer & Explanation

. Severe peripheral neuropathy with absence of protective sensation

Explanation

Severe peripheral neuropathy, lack of protective sensation, and active infection are absolute contraindications to total ankle arthroplasty. These conditions significantly increase the risk of implant failure, Charcot arthropathy, and soft tissue complications.

Question 3304

Topic: Midfoot & Hindfoot

A 55-year-old female presents with medial ankle pain and a progressively flattening arch. She is unable to perform a single-limb heel rise, but her hindfoot is passively correctable. Which of the following is the most standard surgical intervention for this stage of disease?

. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy
. Subtalar arthrodesis only
. Primary repair of the posterior tibial tendon without osseous procedure
. Gastrocnemius recession only

Correct Answer & Explanation

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

Explanation

The patient has Stage II adult-acquired flatfoot deformity (posterior tibial tendon dysfunction) characterized by a flexible deformity. Standard surgical treatment involves a joint-sparing procedure, combining a tendon transfer (FDL) with an osseous realignment (e.g., MDCO).

Question 3305

Topic: 8. Foot and Ankle

A 50-year-old male presents with chronic Achilles tendon rupture diagnosed 4 months after the initial injury. Intraoperatively, after debridement of the necrotic tendon ends, there is a 6-cm gap with the ankle in neutral. What is the most appropriate reconstructive option?

. End-to-end primary repair using heavy nonabsorbable suture
. Gastrocsoleus fascial turndown flap alone
. Conservative management in a specialized boot
. V-Y advancement of the gastrocnemius aponeurosis augmented with a flexor hallucis longus (FHL) tendon transfer
. Free tissue transfer

Correct Answer & Explanation

. V-Y advancement of the gastrocnemius aponeurosis augmented with a flexor hallucis longus (FHL) tendon transfer

Explanation

Chronic Achilles ruptures with gaps greater than 5 cm typically require combined procedures for adequate tensioning and strength. A V-Y tendon advancement provides length, while an FHL transfer provides vascularity and mechanical augmentation.

Question 3306

Topic: 8. Foot and Ankle

A 22-year-old competitive skier presents with recurrent lateral ankle pain and a snapping sensation behind the lateral malleolus. MRI confirms a tear of the superior peroneal retinaculum (SPR) with subluxation of the peroneal tendons. What is the most appropriate surgical treatment?

. Excision of the peroneal brevis tendon
. Tenodesis of the peroneus longus to the peroneus brevis
. Deepening of the fibular retromalleolar groove and repair of the SPR
. Lateral collateral ligament reconstruction with a split peroneus brevis graft
. Calcaneal osteotomy

Correct Answer & Explanation

. Deepening of the fibular retromalleolar groove and repair of the SPR

Explanation

Symptomatic recurrent peroneal tendon subluxation is treated by deepening the fibular groove and repairing or tightening the superior peroneal retinaculum. This restores the anatomic tunnel and prevents further subluxation.

Question 3307

Topic: Ankle Trauma & Sports

An ankle fracture characterized by a vertical fracture of the medial malleolus and a transverse fracture of the fibula below the level of the syndesmosis most likely corresponds to which Lauge-Hansen classification pattern?

. Supination-Adduction (SAD)
. Supination-External Rotation (SER)
. Pronation-Abduction (PAB)
. Pronation-External Rotation (PER)
. Pronation-Adduction (PAD)

Correct Answer & Explanation

. Supination-Adduction (SAD)

Explanation

The Supination-Adduction (SAD) mechanism causes tension on the lateral side (transverse fibular fracture or lateral ligament tear) and compression on the medial side, resulting in a vertical shear fracture of the medial malleolus.

Question 3308

Topic: 8. Foot and Ankle

During the standard lateral extensile approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, the surgical flap must be raised as a full-thickness subperiosteal layer. Which artery is the primary blood supply to this flap?

. Dorsalis pedis artery
. Medial plantar artery
. Sural artery
. Anterior tibial artery
. Lateral calcaneal artery

Correct Answer & Explanation

. Lateral calcaneal artery

Explanation

The lateral calcaneal artery, a branch of the peroneal artery, provides the primary vascular supply to the lateral flap in a calcaneus approach. Raising a full-thickness subperiosteal flap protects this delicate blood supply and minimizes the risk of wound edge necrosis.

Question 3309

Topic: 8. Foot and Ankle

A 55-year-old male runner presents with chronic posterior heel pain. Imaging shows a prominent retrocalcaneal exostosis (Haglund's deformity) and calcification within the Achilles tendon insertion. After 6 months of failed conservative management, surgical intervention is planned. This typically involves which of the following?

. Percutaneous Achilles tendon lengthening
. Debridement of the diseased tendon, excision of the exostosis, and reattachment of the tendon using suture anchors
. Complete excision of the Achilles tendon and isolated FDL transfer
. Endoscopic retrocalcaneal bursectomy only
. Medial displacement calcaneal osteotomy

Correct Answer & Explanation

. Debridement of the diseased tendon, excision of the exostosis, and reattachment of the tendon using suture anchors

Explanation

Insertional Achilles tendinopathy with a Haglund's deformity requires excision of the bony prominence and diseased tendon. If significant tendon detachment is required for adequate debridement (often >50%), suture anchor reattachment is necessary.

Question 3310

Topic: 8. Foot and Ankle

A 32-year-old male sustains an inversion ankle injury. Clinical examination reveals pain over the anterior inferior tibiofibular ligament and a positive external rotation stress test. Initial non-weight-bearing radiographs are normal. What is the most appropriate next step to diagnose a subtle syndesmotic injury?

. Diagnostic ankle arthroscopy
. Bone scan
. Ultrasound of the lateral ankle ligaments
. Casting and re-evaluation in 4 weeks
. Weight-bearing ankle radiographs or MRI

Correct Answer & Explanation

. Weight-bearing ankle radiographs or MRI

Explanation

Subtle, purely ligamentous syndesmosis injuries can be easily missed on static non-weight-bearing radiographs. Weight-bearing radiographs or MRI are essential for detecting hidden diastasis or confirming the ligamentous tear.

Question 3311

Topic: 8. Foot and Ankle

A 35-year-old man sustains a pronation-external rotation ankle fracture. Intraoperatively, after fibular fixation, syndesmotic instability is noted along with a posterior malleolus fracture involving 15% of the articular surface. What is the biomechanically optimal management to stabilize the syndesmosis?

. One 3.5mm trans-syndesmotic screw
. Two 4.5mm trans-syndesmotic screws
. Flexible suture-button device
. Open reduction and internal fixation of the posterior malleolus
. Conservative management with a non-weight-bearing cast

Correct Answer & Explanation

. Open reduction and internal fixation of the posterior malleolus

Explanation

ORIF of the posterior malleolus restores the posterior incisura and the posterior inferior tibiofibular ligament (PITFL). This provides superior biomechanical stability to the syndesmosis compared to trans-syndesmotic screws.

Question 3312

Topic: 8. Foot and Ankle

A 65-year-old man with end-stage post-traumatic ankle osteoarthritis presents for evaluation. He requests a total ankle arthroplasty (TAA). Which of the following is considered an absolute contraindication to TAA in this patient?

. Prior ankle open reduction internal fixation
. Charcot neuroarthropathy with complete loss of protective sensation
. Age greater than 60 years
. Body Mass Index of 32 kg/m2
. Coronal plane deformity of 5 degrees

Correct Answer & Explanation

. Charcot neuroarthropathy with complete loss of protective sensation

Explanation

Absolute contraindications to total ankle arthroplasty include active infection, Charcot neuroarthropathy with loss of protective sensation, severe avascular necrosis of the talus, and inadequate vascular supply.

Question 3313

Topic: 8. Foot and Ankle

A 58-year-old man presents with a 3-month history of Achilles area pain and weakness following a "pop" felt during tennis. Clinical exam reveals a palpable gap and a positive Thompson test. MRI confirms a chronic Achilles tendon rupture with a 6 cm defect after simulated debridement. Which of the following is the most appropriate surgical management?

. Direct end-to-end repair using non-absorbable sutures
. Gastrocnemius recession and conservative casting
. Flexor hallucis longus (FHL) tendon transfer to the calcaneus
. Plantaris autograft augmentation only
. Extensor digitorum brevis transfer

Correct Answer & Explanation

. Flexor hallucis longus (FHL) tendon transfer to the calcaneus

Explanation

For chronic Achilles tendon ruptures (>4 weeks) with a defect larger than 5 cm, direct repair is usually impossible due to retraction and poor tissue quality. Flexor hallucis longus (FHL) transfer is the gold standard as it provides excellent vascularity, length, and in-phase contractile plantarflexion strength.

Question 3314

Topic: 8. Foot and Ankle

A 52-year-old woman complains of progressive posterior heel pain that worsens with tight-fitting shoes. Examination reveals a prominence at the posterosuperior calcaneal tuberosity. MRI demonstrates insertional Achilles tendinosis with calcification involving 60% of the tendon insertion. She has failed 6 months of physical therapy. What is the most appropriate surgical intervention?

. Endoscopic retrocalcaneal bursectomy only
. Gastrocnemius recession
. Debridement of the Achilles tendon, excision of the Haglund's deformity, and reattachment with an anchor
. Debridement, excision of Haglund's deformity, Achilles reattachment, and FHL transfer
. Calcaneal closing wedge osteotomy (Keck and Kelly)

Correct Answer & Explanation

. Debridement, excision of Haglund's deformity, Achilles reattachment, and FHL transfer

Explanation

In severe insertional Achilles tendinopathy where greater than 50% of the tendon must be detached or debrided to remove calcifications and the Haglund's prominence, tendon reattachment should be augmented with a Flexor Hallucis Longus (FHL) transfer to provide adequate strength.

Question 3315

Topic: 8. Foot and Ankle

A 45-year-old male undergoes ORIF for a Weber C ankle fracture. Intraoperative external rotation stress testing reveals widening of the medial clear space, and a syndesmotic screw is subsequently placed. Postoperative CT scan is utilized to assess reduction. What is the most common long-term consequence of unrecognized syndesmosis malreduction?

. Early-onset post-traumatic ankle osteoarthritis
. Nonunion of the fibular fracture
. Tibialis posterior tendon dysfunction
. Deep infection and hardware failure
. Avascular necrosis of the talus

Correct Answer & Explanation

. Early-onset post-traumatic ankle osteoarthritis

Explanation

Malreduction of the syndesmosis alters ankle joint contact mechanics, leading to significantly elevated articular contact pressures. This biomechanical mismatch is the most common cause of early-onset post-traumatic osteoarthritis after a syndesmotic injury.

Question 3316

Topic: 8. Foot and Ankle

A 38-year-old recreational athlete sustains an acute Achilles tendon rupture and elects for nonoperative management. Which of the following rehabilitation protocols has been shown in recent literature to yield re-rupture rates comparable to operative management?

. Cast immobilization in fixed equinus for 8 weeks followed by progressive weight-bearing
. Immediate full weight-bearing in a neutral walking boot without heel wedges
. Functional rehabilitation utilizing early weight-bearing and range of motion in an orthosis with heel wedges
. Cast immobilization in a neutral ankle position for 6 weeks
. Strict non-weight-bearing in a resting splint for 4 weeks, followed by unbraced physical therapy

Correct Answer & Explanation

. Functional rehabilitation utilizing early weight-bearing and range of motion in an orthosis with heel wedges

Explanation

Functional rehabilitation utilizing early weight-bearing and early ROM in a structured orthosis with heel wedges has been shown to produce re-rupture rates similar to surgical repair. This approach successfully mitigates the risk of re-rupture while avoiding typical surgical complications such as wound breakdown and infection.

Question 3317

Topic: 8. Foot and Ankle

A 55-year-old male presents with a 4-month history of profound weakness in plantar flexion and an altered gait. Clinical examination reveals a palpable gap in the Achilles tendon 5 cm proximal to the insertion. Intraoperatively, following debridement of necrotic tissue, a 6 cm tendon defect is measured. What is the most appropriate surgical management?

. Direct end-to-end repair with heavy nonabsorbable suture
. V-Y tendon advancement of the proximal gastrocnemius aponeurosis alone
. Flexor hallucis longus (FHL) tendon transfer to the calcaneus
. Achilles tendon allograft wrapped with a biologic patch
. Isolated gastrocnemius recession

Correct Answer & Explanation

. Flexor hallucis longus (FHL) tendon transfer to the calcaneus

Explanation

For chronic Achilles tendon ruptures with defects greater than 5 cm after debridement, a tendon transfer (most commonly the flexor hallucis longus) is indicated. FHL transfer effectively restores plantar flexion strength, bridges the defect, and provides excellent vascularity to the compromised region.

Question 3318

Topic: 8. Foot and Ankle

A 48-year-old male runner complains of chronic, posterior heel pain that is worse after exercise. Radiographs show a prominent Haglund deformity and extensive intratendinous calcification at the Achilles insertion. Conservative measures have failed. If surgical debridement requires detachment of 60% of the Achilles tendon insertion, what is the recommended subsequent step?

. Simple reattachment of the remaining tendon using dual suture anchors
. Reattachment with suture anchors and augmentation with a flexor hallucis longus (FHL) transfer
. Achilles lengthening via an open Z-plasty
. A corrective calcaneal closing wedge (Keck and Kelly) osteotomy
. Resection of the distal 2 cm of the tendon and synthetic ligament reconstruction

Correct Answer & Explanation

. Reattachment with suture anchors and augmentation with a flexor hallucis longus (FHL) transfer

Explanation

When debridement of insertional Achilles tendinopathy requires detachment of more than 50% of the tendon footprint, simple reattachment carries a high risk of failure. Augmentation with an FHL transfer is recommended to provide mechanical strength, relieve tension on the repair, and bring healthy vascularized tissue to the area.

Question 3319

Topic: Midfoot & Hindfoot

A 55-year-old female presents with medial ankle pain, a flexible pes planovalgus deformity, and an inability to perform a single-leg heel raise. The deformity completely corrects when she stands on her toes. If 6 months of conservative management with a custom orthosis fails, which of the following is the most appropriate initial surgical intervention?

. Triple arthrodesis
. Subtalar arthrodesis
. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy
. Tibiotalocalcaneal arthrodesis with a retrograde nail
. Isolated spring ligament reconstruction

Correct Answer & Explanation

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

Explanation

This patient has Stage II posterior tibial tendon dysfunction characterized by a flexible planovalgus deformity. The gold standard surgical treatment involves a joint-sparing procedure utilizing an FDL transfer to replace the posterior tibial tendon, combined with a medializing calcaneal osteotomy to correct the valgus hindfoot axis.

Question 3320

Topic: Midfoot & Hindfoot
A 62-year-old female with a long history of a pes planovalgus deformity now presents with a rigid hindfoot and significant pain in the lateral hindfoot due to subfibular impingement. A trial of a custom Arizona brace was unsuccessful in relieving her symptoms. Which surgical procedure is most indicated?
. FDL transfer and lateral column lengthening (Evans osteotomy)
. Medial displacement calcaneal osteotomy and gastrocnemius recession
. Double (subtalar and talonavicular) or triple arthrodesis
. Isolated talonavicular arthrodesis
. Ankle arthrodesis

Correct Answer & Explanation

. Double (subtalar and talonavicular) or triple arthrodesis

Explanation

Stage III PTTD is characterized by a rigid, fixed planovalgus deformity, subtalar arthritis, and often lateral subfibular impingement. A joint-sacrificing procedure, such as a double or triple arthrodesis, is required to achieve coronal plane correction, stabilize the hindfoot, and relieve pain.

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