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8. Foot and Ankle MCQs

Practice Set 170 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 3381

Topic: Midfoot & Hindfoot
A 65-year-old woman presents with severe, chronic medial and lateral foot pain. On exam, she has a rigid, non-reducible hindfoot valgus deformity and fixed forefoot supination. She cannot perform a single-limb heel rise. Radiographs demonstrate advanced degenerative changes of the subtalar and talonavicular joints. What is the most appropriate surgical treatment?
. FDL transfer and medial displacement calcaneal osteotomy
. Lateral column lengthening and medial column arthrodesis
. Isolated subtalar arthrodesis
. Triple arthrodesis
. Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

. Triple arthrodesis

Explanation

Stage III PTTD involves a rigid hindfoot valgus deformity and degenerative changes in the subtalar and/or transverse tarsal joints. A triple arthrodesis (subtalar, talonavicular, and calcaneocuboid) is the gold standard for rigid, arthritic deformity correction in this setting.

Question 3382

Topic: 8. Foot and Ankle

According to the Lauge-Hansen classification, what is the initial structure injured in a supination-external rotation (SER) ankle fracture?

. Posterior inferior tibiofibular ligament
. Anterior inferior tibiofibular ligament
. Short oblique fracture of the fibula
. Superficial deltoid ligament
. Deep deltoid ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament

Explanation

The SER mechanism progresses sequentially in four stages. Stage 1 is the rupture of the anterior inferior tibiofibular ligament (AITFL), followed by a short oblique fibula fracture (Stage 2), rupture of the posterior inferior tibiofibular ligament (Stage 3), and finally, deltoid ligament failure or a medial malleolus fracture (Stage 4).

Question 3383

Topic: Forefoot

A 50-year-old woman presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle of 45 degrees, an intermetatarsal angle of 18 degrees, and plantar gapping at the 1st tarsometatarsal (TMT) joint consistent with hypermobility. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. First TMT joint arthrodesis (Lapidus)
. Ludloff osteotomy
. First MTP joint arthrodesis

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus)

Explanation

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

Question 3384

Topic: Forefoot

A 45-year-old woman presents with a painful bunion. Radiographs reveal a hallux valgus angle of 42 degrees, an intermetatarsal angle of 18 degrees, and obvious hypermobility of the first tarsometatarsal joint on clinical exam. What is the most appropriate surgical treatment?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue release
. First tarsometatarsal joint arthrodesis with distal soft tissue release
. Akin osteotomy
. Keller resection arthroplasty

Correct Answer & Explanation

. First tarsometatarsal joint arthrodesis with distal soft tissue release

Explanation

The Lapidus procedure (first tarsometatarsal joint arthrodesis) is indicated for severe hallux valgus (IMA > 15 degrees) accompanied by first ray hypermobility. It stabilizes the medial column and prevents recurrence.

Question 3385

Topic: Midfoot & Hindfoot

A 50-year-old woman presents with medial ankle pain and a progressively flattening arch. She has pain and inability to perform a single-leg heel raise. The hindfoot valgus is flexible and corrects to neutral when she stands on her toes. Radiographs show uncovering of the talonavicular joint but no arthritis. What is the most appropriate surgical intervention?

. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Subtalar arthrodesis
. Isolated FDL transfer
. Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

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

Explanation

This patient has Stage II posterior tibial tendon dysfunction (flexible deformity, no arthritis). The gold standard surgical treatment is an FDL transfer to the navicular combined with a medial displacement calcaneal osteotomy.

Question 3386

Topic: 8. Foot and Ankle

In a supination-external rotation (SER) ankle fracture, what is the first structure injured according to the Lauge-Hansen classification?

. Posterior inferior tibiofibular ligament
. Anterior inferior tibiofibular ligament
. Interosseous membrane
. Deltoid ligament
. Fibula

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament

Explanation

In the Lauge-Hansen supination-external rotation mechanism, the anterior inferior tibiofibular ligament (AITFL) is the first structure to fail (Stage I). This is followed by a spiral fracture of the fibula (Stage II).

Question 3387

Topic: 8. Foot and Ankle

A patient develops a progressive iatrogenic hallux varus deformity after a bunionectomy. Operative notes describe aggressive lateral soft tissue release and excision of the fibular sesamoid. Resection of which structure most significantly contributed to this complication?

. Medial eminence
. Adductor hallucis tendon
. Deep transverse metatarsal ligament
. Lateral head of the flexor hallucis brevis
. Extensor hallucis brevis

Correct Answer & Explanation

. Lateral head of the flexor hallucis brevis

Explanation

Excision of the fibular sesamoid often involves resection of the lateral head of the flexor hallucis brevis. This severely imbalances the dynamic stabilizers of the MTP joint, heavily predisposing the patient to a hallux varus deformity.

Question 3388

Topic: Midfoot & Hindfoot
A 62-year-old man presents with a painful, rigid flatfoot deformity. Examination reveals a fixed hindfoot valgus and an inability to perform a single-leg heel raise. Radiographs demonstrate advanced degenerative changes at the subtalar and talonavicular joints. What is the recommended surgical management?
. Calcaneal lengthening osteotomy
. FDL transfer and medial displacement calcaneal osteotomy
. Subtalar arthroereisis
. Triple arthrodesis
. Ankle arthrodesis

Correct Answer & Explanation

. Triple arthrodesis

Explanation

A rigid flatfoot deformity with subtalar and talonavicular arthritis defines Stage III posterior tibial tendon dysfunction. The definitive treatment for a fixed, arthritic hindfoot is a triple arthrodesis.

Question 3389

Topic: Forefoot

A 22-year-old woman has a painful bunion. Radiographs reveal a hallux valgus angle of 35 degrees, an intermetatarsal angle of 12 degrees, and a distal metatarsal articular angle (DMAA) of 20 degrees. The first MTP joint is congruous. Which of the following procedures is most appropriate?

. Lapidus procedure
. Distal chevron osteotomy with medial closing wedge
. Proximal opening wedge osteotomy
. First MTP joint arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. Distal chevron osteotomy with medial closing wedge

Explanation

An abnormally high DMAA (>15 degrees) indicates that the distal articular surface is laterally deviated. A biplanar distal chevron osteotomy (incorporating a medial closing wedge) corrects both the intermetatarsal angle and the articular orientation.

Question 3390

Topic: Midfoot & Hindfoot

During surgical reconstruction for flexible adult acquired flatfoot deformity (Stage II PTTD), the surgeon explores the medial soft tissues. Which ligamentous structure is most commonly attenuated and requires imbrication or repair along with the FDL transfer?

. Deltoid ligament
. Bifurcate ligament
. Plantar calcaneonavicular (Spring) ligament
. Long plantar ligament
. Interosseous talocalcaneal ligament

Correct Answer & Explanation

. Plantar calcaneonavicular (Spring) ligament

Explanation

The plantar calcaneonavicular (spring) ligament is the primary static stabilizer of the talonavicular joint. It is frequently stretched or torn in Stage II PTTD and often requires repair or reconstruction during FDL transfer.

Question 3391

Topic: 8. Foot and Ankle

During a distal chevron osteotomy for hallux valgus, the surgeon must be careful to avoid avascular necrosis of the first metatarsal head. This risk is minimized by carefully preserving which of the following?

. Dorsomedial cutaneous nerve
. Plantar-lateral capsular attachments
. Extensor hallucis longus tendon sheath
. Medial collateral ligament of the MTP joint
. Deep transverse metatarsal ligament

Correct Answer & Explanation

. Plantar-lateral capsular attachments

Explanation

The primary blood supply to the first metatarsal head enters via the capsular arterial network, primarily at the plantar-lateral aspect. Preserving the plantar-lateral soft tissue attachments during osteotomy and lateral release minimizes the risk of AVN.

Question 3392

Topic: 8. Foot and Ankle
A 70-year-old woman with a longstanding flatfoot deformity now reports deep, aching medial ankle pain. Standing radiographs demonstrate severe hindfoot valgus, talonavicular subluxation, and talar tilt within the ankle mortise with narrowing of the lateral tibiotalar joint space. What stage of posterior tibial tendon dysfunction does this represent?
. Stage I
. Stage IIa
. Stage IIb
. Stage III
. Stage IV

Correct Answer & Explanation

. Stage IV

Explanation

Stage IV posterior tibial tendon dysfunction is characterized by deltoid ligament insufficiency leading to valgus tilting of the talus in the ankle mortise, often accompanied by lateral ankle impingement and arthritis.

Question 3393

Topic: Ankle Trauma & Sports
An ankle fracture characterized by a transverse fracture of the medial malleolus, rupture of the syndesmosis, and a short oblique or comminuted fracture of the fibula at or above the level of the syndesmosis represents which Lauge-Hansen mechanism?
. Supination-External Rotation III
. Supination-Adduction II
. Pronation-Abduction III
. Pronation-External Rotation IV
. Supination-External Rotation IV

Correct Answer & Explanation

. Pronation-Abduction III

Explanation

A transverse medial malleolar fracture indicates a pronation injury (tension medially). A bending force laterally causes a short oblique or comminuted fibular fracture at the syndesmosis, classic for the Pronation-Abduction mechanism.

Question 3394

Topic: Forefoot

A patient undergoes a bunionectomy with a distal chevron osteotomy. Intraoperatively, the intermetatarsal and hallux valgus angles are completely corrected, but the great toe remains deviated laterally at the interphalangeal joint. What is the most appropriate next step?

. Lateral capsular release
. Medial closing wedge osteotomy of the proximal phalanx
. Adductor hallucis tenotomy
. Revision of the metatarsal osteotomy
. First MTP joint arthrodesis

Correct Answer & Explanation

. Medial closing wedge osteotomy of the proximal phalanx

Explanation

Residual valgus deformity of the hallux at the interphalangeal joint, despite a corrected MTP joint, is termed hallux interphalangeus. It is effectively treated with a medial closing wedge osteotomy of the proximal phalanx (Akin procedure).

Question 3395

Topic: Midfoot & Hindfoot

In a patient with Stage IIb posterior tibial tendon dysfunction, a flexor digitorum longus transfer and lateral column lengthening are performed. Intraoperatively, the foot is noted to have persistent forefoot supinatus with the hindfoot held in neutral. Which of the following procedures should be added?

. Medial displacement calcaneal osteotomy
. First tarsometatarsal arthrodesis or medial cuneiform osteotomy
. Subtalar arthrodesis
. Kidner procedure
. Spring ligament reconstruction alone

Correct Answer & Explanation

. First tarsometatarsal arthrodesis or medial cuneiform osteotomy

Explanation

Persistent forefoot supinatus after hindfoot correction in flatfoot reconstruction requires medial column stabilization. This is typically achieved with an opening wedge medial cuneiform osteotomy (Cotton) or first TMT arthrodesis to plantarflex the first ray.

Question 3396

Topic: Forefoot

A 60-year-old woman with advanced rheumatoid arthritis presents with severe bilateral bunions, lesser toe deformities, and subluxation of the first MTP joints. Radiographs of the first MTP joint show complete loss of cartilage and erosion. What is the gold standard surgical treatment for her first ray?

. Proximal crescentic osteotomy
. Distal soft tissue reconstruction
. First MTP joint arthrodesis
. Keller resection arthroplasty
. Silicone replacement arthroplasty

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

First MTP joint arthrodesis is the procedure of choice for severe, arthritic hallux valgus in rheumatoid patients. It provides definitive, long-lasting relief and creates a stable medial column to assist in lesser toe reconstruction.

Question 3397

Topic: 8. Foot and Ankle

A 55-year-old woman presents with pain and difficulty wearing shoes 1 year after a modified McBride bunionectomy. Clinical examination reveals a rigid hallux varus deformity with severe degenerative joint disease of the first metatarsophalangeal (MTP) joint on radiographs. What is the most appropriate definitive treatment?

. Extensor hallucis longus (EHL) transfer to the metatarsal neck.
. Abductor hallucis tendon release and medial capsulotomy.
. Reverse distal chevron osteotomy.
. First MTP joint arthrodesis.
. Excision of the medial eminence.

Correct Answer & Explanation

. First MTP joint arthrodesis.

Explanation

In a patient with a symptomatic, rigid hallux varus deformity accompanied by severe degenerative changes of the first MTP joint, arthrodesis is the most reliable and definitive treatment to relieve pain and correct alignment.

Question 3398

Topic: Midfoot & Hindfoot

A 62-year-old woman presents with a flexible, acquired flatfoot deformity (Stage II PTTD). She has a positive single-leg heel rise test. Radiographs show uncovering of the talonavicular joint and a talonavicular sag. Conservative measures have failed. Which surgical combination is most appropriate?

. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy.
. Posterior tibial tendon debridement alone.
. Subtalar arthrodesis.
. Triple arthrodesis.
. Tibiotalocalcaneal arthrodesis.

Correct Answer & Explanation

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

Explanation

Stage II PTTD features a flexible flatfoot. The gold standard surgical management includes a soft-tissue reconstruction (FDL transfer) combined with a bony procedure (medial displacement calcaneal osteotomy or lateral column lengthening) to restore the arch and correct hindfoot valgus.

Question 3399

Topic: Midfoot & Hindfoot
A 70-year-old man presents with a painful, rigid flatfoot deformity and is unable to perform a single-leg heel rise. Examination shows fixed hindfoot valgus and forefoot abduction. Radiographs reveal advanced osteoarthritis of the subtalar and talonavicular joints, with no ankle joint arthritis. What is the most appropriate surgical treatment?
. FDL transfer and lateral column lengthening.
. Isolated subtalar arthrodesis.
. Triple arthrodesis.
. Pantalar arthrodesis.
. Medial displacement calcaneal osteotomy.

Correct Answer & Explanation

. Triple arthrodesis.

Explanation

Stage III PTTD is characterized by a rigid deformity and arthritic changes in the hindfoot joints. A triple arthrodesis (subtalar, talonavicular, and calcaneocuboid) is the most appropriate treatment to correct the rigid deformity and relieve pain.

Question 3400

Topic: Forefoot

A 48-year-old woman has a severe hallux valgus deformity with a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 20 degrees, and hypermobility of the first tarsometatarsal (TMT) joint. What is the surgical procedure of choice?

. Distal chevron osteotomy.
. Proximal crescentic osteotomy.
. Lapidus procedure (first TMT arthrodesis).
. Akin osteotomy.
. Keller resection arthroplasty.

Correct Answer & Explanation

. Lapidus procedure (first TMT arthrodesis).

Explanation

For severe hallux valgus (IMA >15 degrees) associated with first TMT joint hypermobility, a Lapidus procedure (first TMT arthrodesis) provides reliable correction and stabilizes the medial column to prevent recurrence.

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