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8. Foot and Ankle MCQs

Practice Set 167 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 3321

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with a painful, flexible flatfoot deformity. Standing radiographs reveal greater than 40% talonavicular uncoverage on the AP view. She is diagnosed with Stage IIb posterior tibial tendon dysfunction. What is the most appropriate surgical management?

. FDL transfer and medial displacement calcaneal osteotomy
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis
. Isolated subtalar arthrodesis
. Gastrocnemius recession and FDL transfer alone

Correct Answer & Explanation

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

Explanation

Stage IIb posterior tibial tendon dysfunction is characterized by a flexible deformity with forefoot abduction (>40% talonavicular uncoverage). A lateral column lengthening must be added to the FDL transfer and calcaneal osteotomy to correct the abduction.

Question 3322

Topic: 8. Foot and Ankle

A 22-year-old collegiate running back sustains a purely ligamentous Lisfranc injury. There are no fractures identified on CT scan, but weight-bearing radiographs demonstrate 4 mm of diastasis between the medial and middle cuneiforms. What is the most appropriate definitive treatment?

. Non-weight-bearing cast for 6 weeks
. Open reduction and internal fixation with transarticular screws
. Primary arthrodesis of the 1st, 2nd, and 3rd tarsometatarsal joints
. Closed reduction and percutaneous pinning
. Suture-button fixation of the 2nd metatarsal base to the medial cuneiform

Correct Answer & Explanation

. Primary arthrodesis of the 1st, 2nd, and 3rd tarsometatarsal joints

Explanation

Primary arthrodesis of the medial column (1st-3rd TMT joints) is recommended for purely ligamentous Lisfranc injuries. This approach yields better functional outcomes and lower reoperation rates compared to ORIF in ligamentous variants.

Question 3323

Topic: 8. Foot and Ankle

A 30-year-old male is involved in a high-speed motor vehicle collision and sustains a Hawkins II talar neck fracture.

Which of the following blood vessels provides the primary blood supply to the talar body and is at greatest risk in this injury?

. Artery of the tarsal sinus
. Deltoid branches of the posterior tibial artery
. Dorsalis pedis artery branches
. Artery of the tarsal canal
. Peroneal artery branches

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, provides the majority of the blood supply to the talar body. It enters inferiorly and is highly susceptible to disruption in displaced talar neck fractures.

Question 3324

Topic: 8. Foot and Ankle

When comparing operative repair to nonoperative management utilizing early functional bracing for acute Achilles tendon ruptures, which of the following statements is supported by current literature?

. Operative treatment has significantly higher rerupture rates.
. Nonoperative management with functional bracing has similar rerupture rates but fewer wound complications.
. Nonoperative management with traditional casting yields better plantarflexion strength than operative repair.
. Operative repair eliminates the risk of sural nerve injury.
. Early functional bracing requires a longer duration of non-weight-bearing than surgical repair.

Correct Answer & Explanation

. Nonoperative management with functional bracing has similar rerupture rates but fewer wound complications.

Explanation

Recent randomized controlled trials show that nonoperative management using early functional rehabilitation protocols has rerupture rates comparable to surgical repair. Furthermore, nonoperative management avoids surgical wound complications and infections.

Question 3325

Topic: Forefoot

A 45-year-old female presents with severe bunion pain. Radiographs reveal a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and clinical hypermobility of the 1st tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Scarf osteotomy
. 1st TMT joint arthrodesis (Lapidus procedure)
. 1st MTP joint arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. 1st TMT joint arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (1st TMT arthrodesis) is indicated for severe hallux valgus (IMA >15 degrees) combined with 1st TMT hypermobility. It provides powerful correction of the intermetatarsal angle and stabilizes the medial column.

Question 3326

Topic: 8. Foot and Ankle

A 40-year-old male is evaluated for persistent lateral hindfoot pain 8 months after nonoperative management of a joint-depressed calcaneus fracture. Examination reveals tenderness inferior to the lateral malleolus and pain with active eversion against resistance. What is the most likely etiology of his pain?

. Subtalar post-traumatic arthritis
. Sural nerve neuroma
. Peroneal tendon impingement from lateral wall blowout
. Calcaneocuboid arthritis
. Posterior tibial tendon dysfunction

Correct Answer & Explanation

. Peroneal tendon impingement from lateral wall blowout

Explanation

Lateral wall blowout is a classic complication of nonoperative management in displaced calcaneus fractures. This leads to subfibular impingement of the peroneal tendons, causing lateral hindfoot pain and pain with resisted eversion.

Question 3327

Topic: Midfoot & Hindfoot

A 60-year-old patient with long-standing, poorly controlled diabetes presents with a unilaterally warm, swollen, and erythematous foot without ulceration. Radiographs show periarticular debris, fragmentation, and joint subluxation at the midfoot. What is the most appropriate initial management?

. Intravenous antibiotics and bone biopsy
. Total contact casting
. Primary arthrodesis of the midfoot
. Open reduction and internal fixation
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting

Explanation

This presentation is classic for Eichenholtz Stage I (fragmentation stage) acute Charcot arthropathy. The gold standard for initial treatment is immobilization and offloading via a total contact cast until the acute inflammatory phase resolves.

Question 3328

Topic: Forefoot

A patient undergoes excision of a symptomatic mass in the 3rd intermetatarsal space after failing shoe modifications and injections. A Mulder's click was present preoperatively. What histopathologic finding is expected in the excised specimen?

. Malignant peripheral nerve sheath cells
. Perineural fibrosis and axonal degeneration
. Multinucleated giant cells and hemosiderin deposition
. Proliferation of disorganized nerve fascicles (true neuroma)
. Synovial cell hyperplasia

Correct Answer & Explanation

. Perineural fibrosis and axonal degeneration

Explanation

Morton's neuroma is not a true neoplastic neuroma but rather a compressive neuropathy. Histology classically shows perineural fibrosis, endoneurial edema, and axonal degeneration of the common digital nerve.

Question 3329

Topic: 8. Foot and Ankle

A 65-year-old male with end-stage post-traumatic ankle arthritis is undergoing an isolated tibiotalar arthrodesis. To optimize postoperative gait, what is the ideal position for ankle fusion?

. Neutral dorsiflexion, 0-5 degrees valgus, 5-10 degrees external rotation
. 5 degrees plantarflexion, neutral coronal alignment, 15 degrees external rotation
. 5 degrees dorsiflexion, 5 degrees varus, neutral rotation
. Neutral dorsiflexion, 5 degrees varus, 5-10 degrees external rotation
. 10 degrees plantarflexion, 0-5 degrees valgus, neutral rotation

Correct Answer & Explanation

. Neutral dorsiflexion, 0-5 degrees valgus, 5-10 degrees external rotation

Explanation

Optimal position for ankle arthrodesis is neutral dorsiflexion (0 degrees), 0 to 5 degrees of hindfoot valgus, and external rotation equal to the contralateral limb (typically 5 to 10 degrees). This alignment minimizes adjacent joint stress.

Question 3330

Topic: 8. Foot and Ankle

A 21-year-old collegiate track athlete complains of vague, chronic midfoot pain. CT scan reveals a non-displaced stress fracture of the tarsal navicular. Why is this specific fracture at high risk for delayed union or nonunion?

. Excessive pull of the anterior tibial tendon
. Relative avascularity of the central third of the navicular
. Constant compressive forces from the talus head
. Disruption of the plantar fascia insertion
. High incidence of concomitant subtalar coalition

Correct Answer & Explanation

. Relative avascularity of the central third of the navicular

Explanation

The central third of the tarsal navicular is a vascular watershed zone. Stress fractures typically occur in this avascular region, making them prone to delayed union and nonunion, often requiring strict non-weight-bearing cast immobilization or surgical fixation.

Question 3331

Topic: Midfoot & Hindfoot

A 14-year-old boy presents with frequent ankle sprains and a rigid, painful flatfoot. Lateral radiographs demonstrate a prominent 'C-sign.'

This finding is most indicative of which pathology?

. Calcaneonavicular coalition
. Talocalcaneal coalition
. Talonavicular coalition
. Posterior tibial tendon avulsion
. Accessory navicular syndrome

Correct Answer & Explanation

. Talocalcaneal coalition

Explanation

The 'C-sign' on a lateral radiograph represents a continuous outline formed by the medial border of the talar dome and the posterior border of the sustentaculum tali. It is highly indicative of a talocalcaneal coalition.

Question 3332

Topic: 8. Foot and Ankle

During surgical treatment for insertional Achilles tendinopathy and a prominent Haglund deformity, severe tendon degeneration requires detachment of 60% of the Achilles insertion to adequately debride the calcification and retrocalcaneal bursa. What is the recommended next step in managing the tendon?

. Allow the tendon to heal secondarily without reattachment
. Primary end-to-end repair to the remaining tendon
. Reattachment to the calcaneus using suture anchors
. Gastrocnemius recession only
. Immediate total ankle arthroplasty

Correct Answer & Explanation

. Reattachment to the calcaneus using suture anchors

Explanation

If 50% or more of the Achilles tendon insertion is detached during debridement for insertional tendinopathy, it must be formally reattached to the calcaneal footprint using suture anchors to prevent postoperative rupture and weakness.

Question 3333

Topic: Forefoot

A 58-year-old male presents with dorsal foot pain and inability to wear dress shoes. Examination shows less than 10 degrees of 1st MTP dorsiflexion and pain throughout the midrange of motion. Radiographs show severe joint space narrowing and large dorsal osteophytes (Grade 3 hallux rigidus). What is the most reliable definitive treatment?

. Cheilectomy
. 1st MTP joint arthrodesis
. Moberg osteotomy
. Resection arthroplasty (Keller procedure)
. Silicone joint replacement

Correct Answer & Explanation

. 1st MTP joint arthrodesis

Explanation

For advanced (Grade 3 or 4) hallux rigidus with pain in the midrange of motion and diffuse joint space loss, 1st MTP arthrodesis provides the most reliable pain relief and functional improvement. Cheilectomy is reserved for earlier stages with pain only at terminal dorsiflexion.

Question 3334

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with medial ankle pain, a progressive flatfoot deformity, and the inability to perform a single-leg heel raise. Radiographs demonstrate >40% talonavicular uncoverage and significant forefoot abduction. Which of the following surgical interventions is most appropriate for this stage of deformity?
. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Isolated subtalar arthrodesis
. Triple arthrodesis
. Gastrocnemius recession and conservative shoe wear

Correct Answer & Explanation

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

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction, characterized by forefoot abduction (>40% talonavicular uncoverage). Treatment requires FDL transfer and medial calcaneal osteotomy, plus a lateral column lengthening to correct the significant abduction.

Question 3335

Topic: 8. Foot and Ankle

In a patient with Charcot-Marie-Tooth disease presenting with a classic cavovarus foot deformity, the plantarflexed first ray is primarily driven by the relative overpull of which of the following muscles?

. Tibialis anterior overpowering the peroneus longus
. Peroneus longus overpowering the tibialis anterior
. Tibialis posterior overpowering the peroneus brevis
. Extensor hallucis longus overpowering the flexor hallucis longus
. Gastrocnemius overpowering the soleus

Correct Answer & Explanation

. Peroneus longus overpowering the tibialis anterior

Explanation

In Charcot-Marie-Tooth, the peroneus longus retains its strength longer than the tibialis anterior, leading to a strong plantarflexing force on the first ray. This creates a forefoot-driven cavovarus deformity.

Question 3336

Topic: 8. Foot and Ankle
The major blood supply to the talar body, which is most at risk in a Hawkins Type III talar neck fracture, originates from which of the following arteries?
. Anterior tibial artery
. Peroneal artery
. Dorsalis pedis artery
. Artery of the tarsal canal
. Artery of the sinus tarsi

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, provides the dominant blood supply to the talar body. It is highly susceptible to injury in displaced talar neck fractures.

Question 3337

Topic: 8. Foot and Ankle

The Lisfranc ligament is best described as a stout band that originates on the medial cuneiform and inserts on the base of the second metatarsal. On which aspect of these bones does this ligament primarily attach?

. Dorsal aspect
. Plantar aspect
. Interosseous/plantar aspect
. Direct medial aspect
. Direct lateral aspect

Correct Answer & Explanation

. Interosseous/plantar aspect

Explanation

The Lisfranc ligament is an interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal, primarily providing plantar and interosseous stability.

Question 3338

Topic: Forefoot

A 42-year-old female presents with severe bunion pain. Weight-bearing radiographs reveal a hallux valgus angle of 45 degrees, an intermetatarsal angle of 18 degrees, and obvious widening and hypermobility of the first tarsometatarsal (TMT) joint. Which of the following is the most appropriate surgical treatment?

. Distal soft-tissue reconstruction with medial eminence resection
. Distal metatarsal chevron osteotomy
. Proximal metatarsal opening wedge osteotomy
. First TMT arthrodesis (Lapidus procedure)
. First metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure)

Explanation

First tarsometatarsal (TMT) arthrodesis, or the Lapidus procedure, is indicated for severe hallux valgus with an intermetatarsal angle >15 degrees and associated first TMT hypermobility.

Question 3339

Topic: 8. Foot and Ankle

During an extensile lateral approach to the calcaneus for open reduction and internal fixation of a highly comminuted intra-articular fracture, careful placement of the horizontal limb of the incision is required to protect which of the following structures?

. Deep peroneal nerve
. Superficial peroneal nerve
. Sural nerve
. Saphenous nerve
. Medial plantar nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve crosses the lateral aspect of the hindfoot and is at highest risk of injury during the horizontal limb incision of the extensile lateral approach to the calcaneus.

Question 3340

Topic: 8. Foot and Ankle
A 30-year-old male sustains a high-energy motor vehicle collision resulting in a displaced talar neck fracture with both subtalar and tibiotalar dislocation (Hawkins Type III). Which of the following best represents his risk of developing avascular necrosis (AVN) of the talar body?
. 0 to 10%
. 15 to 30%
. 40 to 50%
. Greater than 80%
. Equal to the risk of subtalar arthritis

Correct Answer & Explanation

. Greater than 80%

Explanation

Hawkins Type III fractures involve dislocation of the subtalar and ankle joints, disrupting all three major blood supplies to the talar body. This results in a historical AVN risk exceeding 80%, though modern prompt reduction may marginally lower this.

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