Menu

8. Foot and Ankle MCQs

Practice Set 171 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 3401

Topic: 8. Foot and Ankle

A 65-year-old man with poorly controlled type 2 diabetes mellitus and profound peripheral neuropathy sustains an acute, closed, displaced bimalleolar ankle fracture. What modification to the standard surgical approach is most appropriate?

. Delay surgery indefinitely and cast the leg.
. Use of standard fixation followed by immediate weight-bearing.
. Use of augmented fixation (e.g., multiple syndesmotic screws) and a prolonged non-weight-bearing period.
. Primary tibiotalar arthrodesis.
. External fixation as definitive treatment.

Correct Answer & Explanation

. Use of augmented fixation (e.g., multiple syndesmotic screws) and a prolonged non-weight-bearing period.

Explanation

Diabetic patients with neuropathy are at a high risk for hardware failure and Charcot arthropathy following ankle fractures. Augmented fixation and an extended period of non-weight-bearing are recommended to ensure successful union and minimize complications.

Question 3402

Topic: 8. Foot and Ankle

A 14-year-old girl with open physes presents with a symptomatic hallux valgus deformity (HVA 30 degrees, IMA 14 degrees). What is the most important factor to address surgically to prevent recurrence in this juvenile patient?

. Performing a simple bunionectomy (Silver procedure).
. Waiting until skeletal maturity to perform osteotomies.
. Choosing an isolated distal soft-tissue procedure.
. Addressing an abnormal distal metatarsal articular angle (DMAA).
. Fusing the first MTP joint.

Correct Answer & Explanation

. Addressing an abnormal distal metatarsal articular angle (DMAA).

Explanation

Juvenile hallux valgus is frequently associated with an increased distal metatarsal articular angle (DMAA). Failure to address an abnormal DMAA with a double osteotomy often leads to high recurrence rates in adolescent patients.

Question 3403

Topic: Forefoot

A 45-year-old woman presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 40 degrees and an intermetatarsal angle (IMA) of 17 degrees. There is no evidence of first tarsometatarsal (TMT) joint hypermobility or degenerative changes at the first metatarsophalangeal (MTP) joint. Which of the following is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Proximal metatarsal osteotomy with a distal soft-tissue procedure
. First MTP joint arthrodesis
. Lapidus procedure
. Akin osteotomy

Correct Answer & Explanation

. Proximal metatarsal osteotomy with a distal soft-tissue procedure

Explanation

An IMA greater than 13-15 degrees with a large HVA requires a proximal metatarsal osteotomy or Lapidus procedure to achieve adequate correction. Since there is no TMT hypermobility, a proximal osteotomy with distal soft-tissue realignment is appropriate.

Question 3404

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with a progressive flatfoot deformity. She is unable to perform a single-leg heel rise. Examination shows a flexible hindfoot valgus. Weight-bearing radiographs show uncovering of the talonavicular joint of 40%. Which of the following surgical procedures is most appropriate?

. Flexor digitorum longus (FDL) transfer and medializing calcaneal osteotomy
. FDL transfer, medializing calcaneal osteotomy, and lateral column lengthening
. Isolated subtalar arthrodesis
. Triple arthrodesis
. Gastrocnemius recession alone

Correct Answer & Explanation

. FDL transfer, medializing calcaneal osteotomy, and lateral column lengthening

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by significant forefoot abduction (>30% talonavicular uncoverage). This requires a lateral column lengthening in addition to FDL transfer and medializing calcaneal osteotomy.

Question 3405

Topic: 8. Foot and Ankle
During open reduction and internal fixation of a Weber B fibula fracture, the static mortise radiograph appears normal. Which of the following intraoperative tests is most reliable for diagnosing latent syndesmotic instability?
. Anterior drawer test of the ankle
. Squeeze test of the proximal calf
. External rotation stress test under fluoroscopy
. Silfverskiรถld test
. Measurement of the tibiofibular overlap on a standard AP view

Correct Answer & Explanation

. External rotation stress test under fluoroscopy

Explanation

Intraoperative assessment using an external rotation stress test or a lateral pull test (Cotton test) under fluoroscopy is the most reliable method to detect latent syndesmotic instability.

Question 3406

Topic: Forefoot

A 48-year-old woman presents with a painful bunion. Clinical examination demonstrates significant hypermobility of the first tarsometatarsal (TMT) joint in the sagittal plane. Radiographs show an intermetatarsal angle (IMA) of 18 degrees and a hallux valgus angle (HVA) of 42 degrees. What is the most appropriate definitive procedure?

. Distal chevron osteotomy
. Ludloff osteotomy
. First tarsometatarsal arthrodesis (Lapidus procedure)
. First metatarsophalangeal arthrodesis
. Scarf osteotomy

Correct Answer & Explanation

. First tarsometatarsal arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (first TMT arthrodesis) is specifically indicated for patients with moderate to severe hallux valgus accompanied by first TMT joint hypermobility.

Question 3407

Topic: Midfoot & Hindfoot
A 62-year-old man presents with a painful, severe flatfoot deformity. On examination, the hindfoot is in a fixed valgus position and cannot be passively inverted to neutral. Radiographs reveal degenerative changes in the subtalar and talonavicular joints. What is the most appropriate surgical treatment?
. FDL transfer and medializing calcaneal osteotomy
. Lateral column lengthening and FDL transfer
. Medializing calcaneal osteotomy and spring ligament repair
. Triple arthrodesis
. Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

. Triple arthrodesis

Explanation

A fixed, rigid flatfoot deformity with degenerative changes in the subtalar and talonavicular joints represents Stage III PTTD, which is best treated with a triple arthrodesis.

Question 3408

Topic: Forefoot

A 45-year-old woman presents with pain and medial deviation of her great toe 6 months after undergoing a distal chevron osteotomy and lateral soft tissue release for hallux valgus. Standing radiographs reveal an intermetatarsal angle (IMA) of 6 degrees and a hallux valgus angle (HVA) of -15 degrees. What intraoperative technical error is the most likely cause of this complication?

. Failure to release the adductor hallucis
. Over-resection of the medial eminence (staking the metatarsal head)
. Under-correction of the intermetatarsal angle
. Dorsiflexion malunion of the capital fragment
. Failure to perform an Akin osteotomy

Correct Answer & Explanation

. Over-resection of the medial eminence (staking the metatarsal head)

Explanation

Hallux varus is a known complication of bunion surgery. It is most commonly caused by over-resection of the medial eminence (staking the head), over-tightening of the medial capsule, over-release of the lateral structures, or excision of the fibular sesamoid.

Question 3409

Topic: 8. Foot and Ankle

A 55-year-old woman presents with a painful, flexible flatfoot deformity. She is unable to perform a single-leg heel rise on the affected side. Standing radiographs demonstrate 45% uncovering of the talonavicular joint and a talonavicular uncoverage angle of 40 degrees. According to the Johnson and Strom classification (modified by Myerson), what is the most appropriate surgical management?

. Medial displacement calcaneal osteotomy and FDL transfer
. Lateral column lengthening (Evans), medial displacement calcaneal osteotomy, and FDL transfer
. Isolated talonavicular arthrodesis
. Triple arthrodesis
. Ankle-foot orthosis and physical therapy only

Correct Answer & Explanation

. Lateral column lengthening (Evans), medial displacement calcaneal osteotomy, and FDL transfer

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction, characterized by a flexible flatfoot with significant forefoot abduction (>30-40% talonavicular uncoverage). Management requires FDL transfer and medializing calcaneal osteotomy, plus a lateral column lengthening to correct the severe forefoot abduction.

Question 3410

Topic: 8. Foot and Ankle

During a distal chevron osteotomy for hallux valgus, care must be taken to avoid avascular necrosis of the first metatarsal head. Which of the following vessels provides the primary blood supply to the first metatarsal head?

. First dorsal metatarsal artery
. First plantar metatarsal artery
. Medial plantar artery
. Deep plantar artery
. Dorsalis pedis artery

Correct Answer & Explanation

. First plantar metatarsal artery

Explanation

The primary blood supply to the first metatarsal head arises from the first plantar metatarsal artery, which gives off capsular branches entering the head at the plantar-lateral aspect. Extensive lateral soft tissue release combined with a distal osteotomy can jeopardize this blood supply.

Question 3411

Topic: Midfoot & Hindfoot
A 68-year-old man presents with a long-standing flatfoot deformity. On examination, the hindfoot is in severe valgus and is completely rigid on attempted manual correction. He has significant pain over the lateral aspect of the subtalar joint. Radiographs reveal bone-on-bone arthritis of the subtalar and talonavicular joints. What is the most appropriate surgical treatment?
. FDL transfer to the navicular
. Medial displacement calcaneal osteotomy with spring ligament repair
. Subtalar arthrodesis with FHL transfer
. Triple arthrodesis
. Tibiotalocalcaneal (TTC) arthrodesis

Correct Answer & Explanation

. Triple arthrodesis

Explanation

This is Stage III posterior tibial tendon dysfunction, characterized by a rigid, non-correctable hindfoot deformity with subtalar/talonavicular arthritis. The gold standard surgical treatment for Stage III PTTD is a triple arthrodesis.

Question 3412

Topic: Forefoot

A 35-year-old woman presents with a painful bunion. Clinical examination demonstrates significant hypermobility of the first tarsometatarsal (TMT) joint, with dorsal elevation of the first ray on weight-bearing. Standing radiographs show a hallux valgus angle of 35 degrees and an intermetatarsal angle of 18 degrees. Which of the following is the most appropriate surgical procedure?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. First tarsometatarsal arthrodesis (Lapidus procedure)
. First metatarsophalangeal arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. First tarsometatarsal arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for moderate to severe hallux valgus associated with first ray hypermobility or TMT joint arthritis. It definitively addresses the apex of the deformity and stabilizes the medial column.

Question 3413

Topic: Midfoot & Hindfoot

In the pathogenesis of posterior tibial tendon dysfunction (PTTD), the spring ligament complex frequently attenuates. Which specific band of the spring ligament is the primary static stabilizer of the talonavicular joint and is most commonly torn?

. Inferomedial calcaneonavicular ligament
. Superomedial calcaneonavicular ligament
. Plantar calcaneonavicular ligament
. Dorsal talonavicular ligament
. Bifurcate ligament

Correct Answer & Explanation

. Superomedial calcaneonavicular ligament

Explanation

The superomedial calcaneonavicular ligament is the thickest and most critical component of the spring ligament complex. It acts as the primary static sling supporting the talar head, and its failure is a hallmark of progressive PTTD.

Question 3414

Topic: 8. Foot and Ankle

A 24-year-old man sustains an SER-IV equivalent ankle injury with a ruptured deltoid ligament and a fibula fracture above the level of the syndesmosis. After rigid internal fixation of the fibula, how is the integrity of the syndesmosis best evaluated intraoperatively?

. Anterior drawer test of the ankle
. Talar tilt test under direct visualization
. Cotton test (lateral traction on the fibula using a bone hook) under fluoroscopy
. Squeezing the calf while palpating the medial malleolus
. Measuring the medial clear space without applying any stress

Correct Answer & Explanation

. Cotton test (lateral traction on the fibula using a bone hook) under fluoroscopy

Explanation

The Cotton test is performed by applying a lateral traction force to the fibula with a bone hook while observing the syndesmosis under fluoroscopy. Widening of the tibiofibular clear space indicates syndesmotic instability requiring fixation.

Question 3415

Topic: Forefoot

A patient undergoes a proximal crescentic osteotomy and distal soft tissue release for severe hallux valgus. Postoperative radiographs show the intermetatarsal angle is corrected to 7 degrees, but the great toe still deviates laterally at the interphalangeal joint with a Hallux Valgus Interphalangeus (HVI) angle of 18 degrees. What is the best next step to achieve full clinical correction?

. Revision of the proximal metatarsal osteotomy
. Medial closing wedge osteotomy of the proximal phalanx (Akin osteotomy)
. Repeat lateral soft tissue release
. Extensor hallucis longus lengthening
. First metatarsophalangeal arthrodesis

Correct Answer & Explanation

. Medial closing wedge osteotomy of the proximal phalanx (Akin osteotomy)

Explanation

An Akin osteotomy (medial closing wedge of the proximal phalanx) is indicated to correct hallux valgus interphalangeus. It does not correct the intermetatarsal angle but straightens the toe when the primary MTP deformity has been addressed.

Question 3416

Topic: Midfoot & Hindfoot

When performing a tendon transfer for Stage II posterior tibial tendon dysfunction, the Flexor Digitorum Longus (FDL) is typically preferred over the Flexor Hallucis Longus (FHL). What is the primary functional reason for avoiding routine FHL harvest in this setting?

. FHL is weaker than the FDL and insufficient to support the arch
. FHL harvest leads to significant loss of great toe push-off strength during the terminal stance phase
. FHL has an inadequate excursion length compared to the FDL
. FHL tendon is located too far laterally to reach the navicular tuberosity
. FHL transfer is associated with a high rate of severe hallux varus

Correct Answer & Explanation

. FHL harvest leads to significant loss of great toe push-off strength during the terminal stance phase

Explanation

While the FHL is stronger than the FDL, harvesting the FHL can lead to a significant functional deficit in great toe push-off during gait. The FDL provides sufficient strength for the transfer with highly acceptable donor site morbidity.

Question 3417

Topic: 8. Foot and Ankle

A 40-year-old woman sustains a trimalleolar ankle fracture. CT scan reveals the posterior malleolar fragment involves 35% of the articular surface and is displaced 3 mm proximally, with posterior subluxation of the talus. What is the most appropriate management of the posterior malleolus?

. Non-operative management in a cast
. Open reduction and internal fixation to restore articular congruity and the incisura fibularis
. Excision of the posterior fragment and repair of the posterior capsule
. Syndesmotic screw fixation only, relying on ligamentotaxis
. Primary tibiotalar arthrodesis

Correct Answer & Explanation

. Open reduction and internal fixation to restore articular congruity and the incisura fibularis

Explanation

Posterior malleolar fractures involving >25-30% of the articular surface, exhibiting >2 mm displacement, or associated with posterior talar subluxation require ORIF. Anatomic reduction restores the joint surface and the posterior tibiofibular syndesmotic stability.

Question 3418

Topic: 8. Foot and Ankle

A 16-year-old female presents with juvenile hallux valgus. Radiographs demonstrate an intermetatarsal angle of 14 degrees and a Distal Metatarsal Articular Angle (DMAA) of 25 degrees. If a standard proximal metatarsal osteotomy is performed alone without addressing the DMAA, which of the following is the most likely outcome?

. A perfectly congruent joint with excellent long-term alignment
. An incongruent joint resulting in medial subluxation of the MTP joint and lateral impingement
. Immediate severe hallux varus
. Avascular necrosis of the metatarsal head
. Spontaneous correction of the DMAA over time

Correct Answer & Explanation

. An incongruent joint resulting in medial subluxation of the MTP joint and lateral impingement

Explanation

An abnormally high DMAA implies the articular surface of the metatarsal head is laterally deviated. Correcting the IMA alone without a distal procedure (like a biplanar chevron or distal closing wedge) forces the phalanx medially against a laterally directed articular surface, causing incongruency and risk of recurrence.

Question 3419

Topic: 8. Foot and Ankle
A 72-year-old woman presents with severe, long-standing flatfoot. Radiographs show rigid hindfoot valgus, severe subtalar arthritis, and a valgus tilt of the talus within the ankle mortise. What is her posterior tibial tendon dysfunction stage and the most appropriate surgical treatment?
. Stage II - FDL transfer and calcaneal osteotomy
. Stage III - Triple arthrodesis
. Stage IV - Tibiotalocalcaneal (TTC) arthrodesis
. Stage IV - Isolated deltoid ligament reconstruction
. Stage III - Total ankle arthroplasty

Correct Answer & Explanation

. Stage IV - Tibiotalocalcaneal (TTC) arthrodesis

Explanation

Valgus tilt of the talus within the ankle mortise indicates deltoid ligament failure, defining Stage IV PTTD. In the presence of a rigid hindfoot and subtalar arthritis, a tibiotalocalcaneal (TTC) arthrodesis is the most reliable treatment to correct the deformity and relieve pain.

Question 3420

Topic: 8. Foot and Ankle

A 28-year-old man twists his ankle. Initial non-weight-bearing radiographs show an isolated Weber B lateral malleolus fracture with a symmetric medial clear space. Clinical examination reveals exquisite tenderness over the deltoid ligament. What is the most appropriate next step to determine the need for operative fixation?

. Immediate ORIF of the fibula
. Gravity stress radiograph or external rotation stress view of the ankle
. MRI of the ankle to evaluate the deltoid ligament
. Application of a short leg cast and weight-bearing as tolerated
. Diagnostic ankle arthroscopy

Correct Answer & Explanation

. Gravity stress radiograph or external rotation stress view of the ankle

Explanation

A Weber B fracture with medial tenderness suggests a potential bimalleolar equivalent injury (deltoid rupture). A gravity stress or external rotation stress radiograph is necessary to assess medial clear space widening; if widening occurs (>4-5 mm), surgical fixation is indicated.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page