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8. Foot and Ankle MCQs

Practice Set 172 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 3421

Topic: 8. Foot and Ankle

A 55-year-old woman complains of progressive medial ankle pain and loss of the arch of her foot over the past year. On examination, she has a flexible flatfoot deformity and cannot perform a single-limb heel rise on the affected side. Radiographs show a talonavicular coverage angle of 15 degrees. What is the most appropriate surgical management?

. Orthotic management only
. Subtalar arthrodesis
. FDL transfer to the navicular and medializing calcaneal osteotomy
. Triple arthrodesis
. Ankle and hindfoot arthrodesis

Correct Answer & Explanation

. FDL transfer to the navicular and medializing calcaneal osteotomy

Explanation

Stage II posterior tibial tendon dysfunction (PTTD) is characterized by a flexible flatfoot deformity. Joint-sparing procedures such as an FDL transfer combined with a medializing calcaneal osteotomy are the most appropriate surgical indicated treatment.

Question 3422

Topic: Midfoot & Hindfoot
A 62-year-old woman presents with severe flatfoot deformity. Examination reveals a rigid hindfoot in valgus and pain in the sinus tarsi. She is unable to invert her heel on double-limb heel rise. Radiographs demonstrate advanced degenerative changes in the subtalar and talonavicular joints. What is the most appropriate surgical treatment?
. Tenosynovectomy of the posterior tibial tendon
. FDL transfer and medializing calcaneal osteotomy
. Subtalar arthrodesis only
. Triple arthrodesis
. Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

. Triple arthrodesis

Explanation

Stage III PTTD involves a rigid deformity with associated hindfoot arthritis. It is best treated with a triple arthrodesis to correct the deformity and reliably alleviate arthritic pain.

Question 3423

Topic: Forefoot

A 40-year-old woman has a painful bunion. Weight-bearing radiographs show a hallux valgus angle (HVA) of 42 degrees and an intermetatarsal angle (IMA) of 18 degrees. The first TMT joint is stable with no evidence of hypermobility or arthritis. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Proximal first metatarsal osteotomy with distal soft-tissue release
. First TMT arthrodesis (Lapidus)
. First MTP arthrodesis
. Akin osteotomy

Correct Answer & Explanation

. Proximal first metatarsal osteotomy with distal soft-tissue release

Explanation

For a severe hallux valgus deformity (IMA >15 degrees, HVA >40 degrees) without first TMT hypermobility or midfoot arthritis, a proximal osteotomy with distal soft-tissue release provides the necessary powerful correction.

Question 3424

Topic: Forefoot

A 45-year-old woman complains of a painful bunion. Radiographs reveal an HVA of 38 degrees and an IMA of 16 degrees. Clinical examination reveals significant sagittal plane hypermobility of the first tarsometatarsal (TMT) joint. What is the best surgical option?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. First TMT arthrodesis (Lapidus)
. Keller arthroplasty
. First MTP arthrodesis

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus)

Explanation

The Lapidus procedure (first TMT arthrodesis) is specifically indicated for moderate to severe hallux valgus when associated with clinical first TMT hypermobility to prevent recurrence.

Question 3425

Topic: Ankle Trauma & Sports

A 28-year-old man sustains a twisting injury to his ankle. Non-weight-bearing radiographs show a spiral fracture of the distal fibula at the level of the syndesmosis, with an intact medial malleolus and normal medial clear space. A subsequent external rotation stress radiograph reveals a medial clear space of 6 mm. What is the appropriate management?

. Short leg cast for 6 weeks
. CAM boot with immediate weight-bearing
. Open reduction and internal fixation of the fibula only
. Open reduction and internal fixation of the fibula and stabilization of the syndesmosis
. Deltoid ligament repair only

Correct Answer & Explanation

. Open reduction and internal fixation of the fibula and stabilization of the syndesmosis

Explanation

A positive external rotation stress test with widening of the medial clear space indicates a syndesmotic or deep deltoid injury (bimalleolar equivalent fracture). This requires ORIF of the lateral malleolus and evaluation with potential stabilization of the syndesmosis.

Question 3426

Topic: 8. Foot and Ankle

In a Lauge-Hansen Supination-External Rotation (SER) stage IV ankle fracture, what is the correct sequential order of structural failure?

. AITFL, medial malleolus, PITFL, fibula
. Deltoid ligament, AITFL, fibula, PITFL
. AITFL, spiral fibula fracture, PITFL, medial malleolus/deltoid ligament
. Medial malleolus, anterior medial capsule, fibula, lateral collateral ligaments
. PITFL, fibula, AITFL, deltoid ligament

Correct Answer & Explanation

. AITFL, spiral fibula fracture, PITFL, medial malleolus/deltoid ligament

Explanation

The SER sequence classically progresses from anterolateral to posteromedial: 1) AITFL, 2) short oblique/spiral distal fibula fracture, 3) PITFL or posterior malleolus, and 4) Deltoid ligament or medial malleolus.

Question 3427

Topic: 8. Foot and Ankle

A 35-year-old woman develops hallux varus 6 months following a bunionectomy. On examination, the deformity is flexible and she has pain with wearing shoes. Which of the following surgical steps during her index procedure most likely contributed to this complication?

. Medial displacement of the metatarsal head by 2 mm
. Failure to release the adductor hallucis tendon
. Incomplete resection of the medial eminence
. Over-resection of the medial eminence (staking the head) and fibular sesamoidectomy
. Dorsiflexion of the first metatarsal head

Correct Answer & Explanation

. Over-resection of the medial eminence (staking the head) and fibular sesamoidectomy

Explanation

Hallux varus is an iatrogenic complication of overcorrection. Major risk factors include excessive medial eminence resection (staking the metatarsal head), over-release of the lateral soft tissues, and excision of the fibular sesamoid.

Question 3428

Topic: 8. Foot and Ankle

A patient with an ankle fracture has a large posterior malleolar fragment involving 35% of the articular surface. Posterior subluxation of the talus is evident on the lateral radiograph. What is the primary biomechanical advantage of open reduction and internal fixation of this posterior malleolar fragment?

. It restores the anterior inferior tibiofibular ligament length
. It provides superior stability to the syndesmosis compared to trans-syndesmotic screws alone
. It eliminates the need to fix the medial malleolus
. It allows for immediate weight-bearing
. It prevents the development of subtalar arthritis

Correct Answer & Explanation

. It provides superior stability to the syndesmosis compared to trans-syndesmotic screws alone

Explanation

Anatomical fixation of a significant posterior malleolus fragment (>25% or with subluxation) directly restores the PITFL insertion. This offers superior biomechanical stability to the syndesmosis compared to isolated syndesmotic screws.

Question 3429

Topic: Midfoot & Hindfoot

Which of the following structures is the primary static stabilizer of the talonavicular joint and is most commonly attenuated or torn in conjunction with posterior tibial tendon dysfunction?

. Plantar fascia
. Long plantar ligament
. Superomedial calcaneonavicular (spring) ligament
. Deltoid ligament
. Bifurcate ligament

Correct Answer & Explanation

. Superomedial calcaneonavicular (spring) ligament

Explanation

The superomedial calcaneonavicular (spring) ligament is the primary static restraint to talar head plantarflexion. It is frequently attenuated or torn as PTTD progresses.

Question 3430

Topic: 8. Foot and Ankle
A 22-year-old woman presents with bilateral foot pain due to juvenile hallux valgus. Radiographs show an HVA of 30 degrees, an IMA of 12 degrees, and a distal metatarsal articular angle (DMAA) of 25 degrees (normal <10). What surgical procedure is critical to achieve a congruent first MTP joint in this patient?
. Simple distal chevron osteotomy
. Lapidus procedure
. Proximal crescentic osteotomy alone
. Biplanar distal osteotomy or double first metatarsal osteotomy to correct the DMAA
. Keller arthroplasty

Correct Answer & Explanation

. Biplanar distal osteotomy or double first metatarsal osteotomy to correct the DMAA

Explanation

Juvenile hallux valgus is frequently associated with an increased DMAA. Failure to correct the DMAA using a biplanar or double osteotomy will result in an incongruent joint and a very high rate of recurrence.

Question 3431

Topic: 8. Foot and Ankle

A 50-year-old female undergoes a distal chevron osteotomy for a mild hallux valgus deformity. During the procedure, the lateral soft tissues are aggressively released intra-articularly to correct sesamoid subluxation. What is the most significant risk associated with this specific combination of maneuvers?

. Nonunion of the osteotomy
. Avascular necrosis of the first metatarsal head
. Deep peroneal nerve injury
. Hallux rigidus
. Transfer metatarsalgia

Correct Answer & Explanation

. Avascular necrosis of the first metatarsal head

Explanation

The primary blood supply to the first metatarsal head is the first plantar metatarsal artery. Combining a distal osteotomy with an extensive intra-articular lateral soft-tissue release disrupts the capsular blood supply, significantly increasing the risk of avascular necrosis.

Question 3432

Topic: 8. Foot and Ankle
Which clinical sign on physical examination is most specific for diagnosing a severe, rigid Stage III posterior tibial tendon dysfunction compared to a flexible Stage II?
. Too many toes sign
. Inability to perform a single-leg heel rise
. Lack of inversion of the calcaneus during heel rise
. Inability to passively correct the hindfoot valgus to neutral
. Tenderness along the course of the posterior tibial tendon

Correct Answer & Explanation

. Inability to passively correct the hindfoot valgus to neutral

Explanation

Stage III PTTD is clinically differentiated from Stage II by the presence of a fixed, rigid hindfoot valgus deformity that cannot be passively reduced to a neutral alignment.

Question 3433

Topic: 8. Foot and Ankle

A 30-year-old female presents with a hallux valgus deformity and a symptomatic hallux valgus interphalangeus (HVI) angle of 20 degrees. Following a first metatarsal osteotomy, the IMA and HVA are corrected, but the big toe still abuts the second toe due to the HVI. What is the most appropriate next step?

. First MTP arthrodesis
. Proximal phalanx medial closing wedge osteotomy (Akin osteotomy)
. Revision first metatarsal osteotomy
. Second toe amputation
. Flexor hallucis longus transfer

Correct Answer & Explanation

. Proximal phalanx medial closing wedge osteotomy (Akin osteotomy)

Explanation

The Akin osteotomy (a medial closing wedge osteotomy of the proximal phalanx) is indicated specifically to correct hallux valgus interphalangeus after the primary IMA and joint congruency have been addressed.

Question 3434

Topic: 8. Foot and Ankle

A 24-year-old athlete reports midfoot pain after a twisting injury. Radiographs show a "fleck sign" in the first intermetatarsal space. Which of the following anatomical structures is primarily injured?

. Plantar ligament between the 1st and 2nd metatarsal bases
. Interosseous ligament between the medial cuneiform and 2nd metatarsal base
. Dorsal ligament between the medial cuneiform and 1st metatarsal
. Spring ligament
. Bifurcate ligament

Correct Answer & Explanation

. Interosseous ligament between the medial cuneiform and 2nd metatarsal base

Explanation

The "fleck sign" represents an avulsion fracture of the Lisfranc ligament. The Lisfranc ligament is an interosseous ligament connecting the lateral aspect of the medial cuneiform to the medial base of the second metatarsal.

Question 3435

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with flexible flatfoot, inability to perform a single-leg heel raise, and >40% uncovering of the talonavicular joint on an AP weight-bearing radiograph. What is the most appropriate surgical management for this stage of posterior tibial tendon dysfunction?
. Posterior tibial tendon debridement alone
. Flexor digitorum longus (FDL) transfer with medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and lateral column lengthening
. Triple arthrodesis
. Isolated talonavicular arthrodesis

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

This patient has Stage IIb adult-acquired flatfoot deformity, characterized by significant forefoot abduction (talonavicular uncovering >30-40%). Appropriate treatment includes an FDL transfer, a medializing calcaneal osteotomy (MDCO), and a lateral column lengthening to correct the abduction.

Question 3436

Topic: 8. Foot and Ankle

During an extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, which of the following structures is at greatest risk of iatrogenic injury at the proximal extent of the vertical incision?

. Superficial peroneal nerve
. Sural nerve
. Peroneal artery
. Tibial nerve
. Flexor hallucis longus tendon

Correct Answer & Explanation

. Sural nerve

Explanation

The extensile lateral approach to the calcaneus involves a full-thickness flap. The vertical limb is placed just anterior to the Achilles tendon, placing the sural nerve at high risk of injury, especially at the proximal aspect of the incision.

Question 3437

Topic: 8. Foot and Ankle

A 22-year-old collegiate basketball player sustains an acute fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal. Intramedullary screw fixation is planned. The high rate of nonunion in this area is primarily due to a watershed blood supply involving which vessels?

. Nutrient artery and metaphyseal arteries
. Nutrient artery and periosteal arteries
. Dorsal metatarsal artery and plantar metatarsal artery
. Medial plantar artery and lateral plantar artery
. Arcuate artery and deep plantar artery

Correct Answer & Explanation

. Nutrient artery and metaphyseal arteries

Explanation

A Jones fracture occurs at the metaphyseal-diaphyseal junction of the fifth metatarsal (Zone 2). This region is a vascular watershed area between the intraosseous nutrient artery supplying the diaphysis and the metaphyseal arteries supplying the base.

Question 3438

Topic: 8. Foot and Ankle

A 40-year-old man undergoes minimally invasive (percutaneous) repair of an acute Achilles tendon rupture. Postoperatively, he complains of numbness along the lateral aspect of his foot. Which structure was most likely injured during the procedure?

. Tibial nerve
. Superficial peroneal nerve
. Sural nerve
. Saphenous nerve
. Lateral plantar nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve crosses from medial to lateral near the Achilles tendon, typically 10-12 cm proximal to the calcaneal insertion. It is at significant risk of entrapment or iatrogenic injury during percutaneous or minimally invasive Achilles tendon repairs.

Question 3439

Topic: Forefoot

A 45-year-old woman presents with a symptomatic bunion. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 42 degrees and an intermetatarsal angle (IMA) of 18 degrees. There is clinical hypermobility at the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Proximal opening wedge osteotomy
. Modified McBride procedure
. First TMT joint arthrodesis (Lapidus)
. First metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus)

Explanation

Severe hallux valgus (HVA >40, IMA >15) with first TMT joint hypermobility is best treated with a first TMT joint arthrodesis (Lapidus procedure). This provides powerful correction of the intermetatarsal angle and stabilizes the incompetent medial column.

Question 3440

Topic: 8. Foot and Ankle

A 14-year-old boy presents with a history of recurrent ankle sprains and rigid, painful flatfeet. Radiographs reveal an elongated anterior process of the calcaneus (anteater sign). Which radiographic view best visualizes this specific pathology?

. AP weight-bearing view of the foot
. Harris axial view of the heel
. 45-degree internal oblique view of the foot
. Lateral weight-bearing view of the ankle
. Mortise view of the ankle

Correct Answer & Explanation

. 45-degree internal oblique view of the foot

Explanation

The clinical presentation and "anteater sign" indicate a calcaneonavicular coalition. The 45-degree internal oblique radiograph of the foot is the optimal view to visualize the calcaneonavicular interval and confirm the diagnosis.

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