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8. Foot and Ankle MCQs

Practice Set 173 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 3441

Topic: Forefoot

A professional football player sustains a hyperextension injury to his first metatarsophalangeal (MTP) joint. MRI confirms a complete tear of the plantar plate with proximal retraction of the sesamoids. If left untreated, what is the most likely long-term complication?

. Hallux varus
. Hallux rigidus
. Cock-up deformity of the hallux
. Hammer toe deformity
. Transfer metatarsalgia

Correct Answer & Explanation

. Hallux rigidus

Explanation

A complete plantar plate tear (Grade 3 turf toe) causes severe instability and altered kinematics of the first MTP joint. Without surgical repair to restore the anatomical alignment, progressive joint degeneration inevitably leads to hallux rigidus.

Question 3442

Topic: Midfoot & Hindfoot

A 58-year-old man with poorly controlled diabetes presents with a warm, swollen, and erythematous left foot. He denies trauma. Radiographs show periarticular fragmentation and subluxation at the midtarsal joint. There are no open wounds. What is the most appropriate initial management?

. Intravenous antibiotics and urgent surgical debridement
. Total contact casting and non-weight-bearing
. Midfoot arthrodesis
. Below-knee amputation
. Custom orthotic shoe wear

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

This patient presents with acute (Eichenholtz Stage 1) Charcot arthropathy. The mainstay of initial treatment is immobilization and offloading with a total contact cast (TCC) to prevent further deformity until the acute inflammatory phase resolves.

Question 3443

Topic: Midfoot & Hindfoot

A 30-year-old patient presents with a purely ligamentous Lisfranc injury with 4 mm of diastasis on weight-bearing radiographs. According to recent literature, what is the most significant advantage of primary arthrodesis over open reduction and internal fixation (ORIF) for this specific injury pattern?

. Lower rate of hardware removal and secondary salvage procedures
. Faster return to competitive sports and activities
. Better preservation of midfoot physiologic motion
. Lower risk of neurovascular injury during the surgical approach
. Decreased rate of adjacent segment arthritis in the midfoot

Correct Answer & Explanation

. Lower rate of hardware removal and secondary salvage procedures

Explanation

Primary arthrodesis for purely ligamentous Lisfranc injuries yields similar functional outcomes to ORIF but significantly decreases the need for subsequent hardware removal and secondary salvage arthrodesis.

Question 3444

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with medial foot pain and a progressive flatfoot deformity. She has a flexible hindfoot valgus and is unable to perform a single-leg heel rise. According to the Johnson and Strom classification modified by Myerson, what stage of posterior tibial tendon dysfunction does this patient have, and what is the most appropriate surgical management if conservative treatment fails?
. Stage I; Tenosynovectomy
. Stage II; FDL transfer and medial displacement calcaneal osteotomy
. Stage III; Subtalar arthrodesis
. Stage IV; Tibiotalocalcaneal arthrodesis
. Stage II; Triple arthrodesis

Correct Answer & Explanation

. Stage II; FDL transfer and medial displacement calcaneal osteotomy

Explanation

Stage II PTTD is characterized by a flexible flatfoot deformity and the inability to perform a single heel rise. Surgical management typically involves an FDL tendon transfer to the navicular and a medial displacement calcaneal osteotomy (MDCO) to correct the hindfoot valgus.

Question 3445

Topic: 8. Foot and Ankle

A 22-year-old man with a history of frequent ankle sprains presents with bilateral cavovarus feet. A Coleman block test demonstrates that the hindfoot varus corrects to neutral when the first metatarsal is allowed to plantarflex off the block. What does this test result indicate regarding the primary driver of this patient's deformity?

. Rigid hindfoot driven by an overpull of the tibialis anterior
. Flexible hindfoot driven by a rigidly plantarflexed first ray due to peroneus longus overpull
. Rigid forefoot driven by an overpull of the peroneus brevis
. Flexible hindfoot driven by a severe Achilles tendon contracture
. Rigid hindfoot driven by severe weakness of the tibialis posterior

Correct Answer & Explanation

. Flexible hindfoot driven by a rigidly plantarflexed first ray due to peroneus longus overpull

Explanation

A flexible hindfoot that corrects on the Coleman block test indicates the varus is driven by a rigidly plantarflexed first ray. In conditions like Charcot-Marie-Tooth disease, this is typically due to the overpull of the peroneus longus relative to the weak tibialis anterior.

Question 3446

Topic: Midfoot & Hindfoot
A 60-year-old man with poorly controlled diabetes mellitus presents with a swollen, red, warm, and painless right foot. Radiographs show periarticular fragmentation and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what stage does this represent, and what is the most appropriate initial management?
. Stage 0; Surgical arthrodesis of the midfoot
. Stage I (Fragmentation); Total contact casting and non-weight-bearing
. Stage II (Coalescence); Custom orthotic shoe wear
. Stage III (Reconstruction); Medial exostectomy
. Stage I (Fragmentation); Immediate open reduction and internal fixation

Correct Answer & Explanation

. Stage I (Fragmentation); Total contact casting and non-weight-bearing

Explanation

Stage I (Fragmentation) of Charcot arthropathy is characterized by acute inflammation, osteopenia, fragmentation, and joint subluxation. The gold standard for initial management is strict immobilization and offloading, typically with a total contact cast.

Question 3447

Topic: 8. Foot and Ankle

A 38-year-old recreational basketball player sustains an acute Achilles tendon rupture. Based on current literature comparing functional bracing with early mobilization to surgical repair, which of the following statements is true?

. Surgical repair has a significantly higher re-rupture rate.
. Non-operative management with early functional rehabilitation has similar re-rupture rates to surgical repair.
. Surgical repair is associated with a much lower rate of wound complications.
. Non-operative management results in a 50% decrease in plantarflexion strength at 2 years.
. Surgical repair is strictly indicated for all patients under 50 years old regardless of activity level.

Correct Answer & Explanation

. Non-operative management with early functional rehabilitation has similar re-rupture rates to surgical repair.

Explanation

Recent high-level evidence demonstrates that non-operative management utilizing functional bracing and early mobilization yields equivalent functional outcomes and similar re-rupture rates compared to surgical repair, while avoiding surgical wound complications.

Question 3448

Topic: Forefoot

A 45-year-old woman presents with a painful bunion. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue realignment
. First TMT arthrodesis (Lapidus procedure)
. Metatarsophalangeal (MTP) joint arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure)

Explanation

A severe hallux valgus deformity (HVA > 40°, IMA > 15°) associated with first TMT joint hypermobility is best treated with a first TMT arthrodesis (Lapidus procedure). This provides stable long-term correction and directly addresses the hypermobile segment.

Question 3449

Topic: 8. Foot and Ankle

A 35-year-old construction worker falls from a height and sustains a closed, displaced intra-articular calcaneus fracture. CT reveals a Sanders Type IV fracture pattern. What is the most appropriate definitive surgical management?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation via an extensile lateral approach
. Primary subtalar arthrodesis
. Excision of the fractured fragments and Achilles advancement
. Nonoperative management with early range of motion

Correct Answer & Explanation

. Primary subtalar arthrodesis

Explanation

Sanders Type IV calcaneus fractures are highly comminuted with four or more articular fragments. Primary subtalar arthrodesis is recommended for these injuries due to the high failure rate and poor functional outcomes associated with open reduction and internal fixation (ORIF).

Question 3450

Topic: 8. Foot and Ankle

A 24-year-old collegiate football player sustains a purely ligamentous Lisfranc injury. Stress radiographs show 3 mm of widening between the base of the first and second metatarsals. What is the most appropriate management?

. Non-weight-bearing cast for 6 weeks
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Open reduction and internal fixation with screws
. Percutaneous Kirschner wire fixation
. Carbon fiber orthotic and immediate weight-bearing as tolerated

Correct Answer & Explanation

. Primary arthrodesis of the first, second, and third tarsometatarsal joints

Explanation

Primary arthrodesis is preferred over ORIF for purely ligamentous Lisfranc injuries. It yields lower rates of hardware failure and reoperation, while providing superior functional outcomes compared to joint-preserving fixation.

Question 3451

Topic: Forefoot

A 50-year-old woman presents with severe bunion deformity. Examination reveals a hypermobile first tarsometatarsal (TMT) joint. Radiographs show a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue release
. First TMT arthrodesis (Lapidus procedure)
. First metatarsophalangeal (MTP) joint arthrodesis
. Keller arthroplasty

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure)

Explanation

A Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus deformities (IMA >15 degrees) accompanied by first ray hypermobility. It effectively stabilizes the medial column and reliably corrects large intermetatarsal angles.

Question 3452

Topic: 8. Foot and Ankle

The blood supply to the body of the talus is primarily provided by the artery of the tarsal canal. From which of the following parent vessels does this artery arise?

. Anterior tibial artery
. Posterior tibial artery
. Peroneal artery
. Dorsalis pedis artery
. Medial plantar artery

Correct Answer & Explanation

. Posterior tibial artery

Explanation

The artery of the tarsal canal is a branch of the posterior tibial artery and provides the dominant blood supply to the body of the talus. It anastomoses with the artery of the sinus tarsi to form a crucial vascular sling under the talar neck.

Question 3453

Topic: 8. Foot and Ankle

A 45-year-old female presents with progressive flattening of her left foot and medial ankle pain. Examination shows she is unable to perform a single-leg heel raise. Hindfoot valgus is correctable, but there is marked forefoot abduction. What is the most appropriate surgical intervention for this Stage IIB adult-acquired flatfoot deformity?

. Isolated flexor digitorum longus (FDL) transfer to the navicular
. FDL transfer and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and lateral column lengthening
. Subtalar arthrodesis
. Triple arthrodesis

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

Stage IIB posterior tibial tendon dysfunction involves a flexible hindfoot with significant forefoot abduction (>40% talonavicular uncoverage). Treatment requires FDL transfer, MDCO for hindfoot valgus, and lateral column lengthening (e.g., Evans osteotomy) to adequately correct the forefoot abduction.

Question 3454

Topic: 8. Foot and Ankle

A 22-year-old man with Charcot-Marie-Tooth disease presents with a rigid cavovarus deformity. The Coleman block test demonstrates that the hindfoot varus is fully correctable when the first ray drops off the block. What is the primary anatomic driver of this patient's hindfoot deformity?

. Plantarflexed first ray
. Contracted Achilles tendon
. Weakness of the peroneus longus
. Overactivity of the tibialis anterior
. Rigid subtalar joint arthritis

Correct Answer & Explanation

. Plantarflexed first ray

Explanation

In a cavovarus foot, a correctable Coleman block test indicates that a plantarflexed first ray is the primary driver displacing the hindfoot into varus during weight-bearing. Surgical correction must include a dorsiflexion osteotomy of the first metatarsal to address this primary pathology.

Question 3455

Topic: 8. Foot and Ankle

During surgical repair of an acute Achilles tendon rupture, the surgeon dissects through the paratenon. The sural nerve is at greatest risk of injury in which location relative to the Achilles tendon insertion?

. 2 cm proximal to the insertion, crossing from medial to lateral
. 5 cm proximal to the insertion, crossing from lateral to medial
. 9.8 cm proximal to the insertion, crossing from medial to lateral
. 15 cm proximal to the insertion, crossing from lateral to medial
. The sural nerve does not cross the Achilles tendon

Correct Answer & Explanation

. 9.8 cm proximal to the insertion, crossing from medial to lateral

Explanation

The sural nerve crosses the lateral border of the Achilles tendon on average 9.8 cm proximal to its calcaneal insertion. Care must be taken during proximal dissection, particularly in percutaneous or minimally invasive repairs, to avoid iatrogenic injury.

Question 3456

Topic: 8. Foot and Ankle

A 55-year-old diabetic male presents with an acutely swollen, red, and warm right foot without open wounds. Pulses are bounding. Radiographs show normal bone architecture with no fractures or dislocations. Laboratory markers for infection are normal. What is the most appropriate initial management?

. Intravenous antibiotics
. Incision and drainage
. Total contact casting
. Surgical arthrodesis of the midfoot
. Corticosteroid injection

Correct Answer & Explanation

. Total contact casting

Explanation

The presentation is classic for acute Eichenholtz Stage 0 Charcot arthropathy. Immediate total contact casting is the standard of care to offload the foot, prevent skeletal fragmentation, and allow the acute inflammatory process to subside.

Question 3457

Topic: 8. Foot and Ankle

A 60-year-old male with symptomatic end-stage ankle osteoarthritis fails conservative management. He is considering an ankle arthrodesis. What is the optimal position for ankle fusion to maximize functional gait?

. 10 degrees of plantarflexion, 5 degrees of varus, internal rotation
. Neutral dorsiflexion, 5 degrees of valgus, 5-10 degrees of external rotation
. 5 degrees of dorsiflexion, neutral hindfoot, 15 degrees of external rotation
. Neutral dorsiflexion, 5 degrees of varus, 15 degrees of internal rotation
. 15 degrees of plantarflexion, neutral hindfoot, neutral rotation

Correct Answer & Explanation

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

Explanation

The optimal position for an ankle arthrodesis is neutral dorsiflexion, approximately 5 degrees of valgus, and 5 to 10 degrees of external rotation (or matching the contralateral side). This alignment maximizes compensatory motion in the transverse tarsal joints and optimizes the patient's gait cycle.

Question 3458

Topic: 8. Foot and Ankle

A 24-year-old football player sustains a hyperplantarflexion injury to his right foot. Weight-bearing radiographs show a 3 mm diastasis between the base of the first and second metatarsals. What is the primary stabilizing structure commonly injured in this scenario?

. Dorsal tarsometatarsal ligament
. Interosseous ligament between the medial cuneiform and second metatarsal base
. Plantar fascia
. Spring ligament
. Intermetatarsal ligament between the first and second metatarsals

Correct Answer & Explanation

. Interosseous ligament between the medial cuneiform and second metatarsal base

Explanation

The Lisfranc ligament is a strong interosseous ligament connecting the medial cuneiform to the base of the second metatarsal. It is the primary stabilizer of the tarsometatarsal joint complex.

Question 3459

Topic: Midfoot & Hindfoot
A 30-year-old male is involved in a high-speed motor vehicle collision and sustains a Hawkins Type III talar neck fracture. What is the approximate risk of developing avascular necrosis (AVN) of the talar body?
. 0-10%
. 15-30%
. 40-50%
. 75-100%
. 100% in all cases

Correct Answer & Explanation

. 75-100%

Explanation

Hawkins Type III fractures involve subluxation or dislocation of both the subtalar and tibiotalar joints. The risk of AVN is historically reported between 75-100% due to disruption of the major blood supplies to the talar body.

Question 3460

Topic: Forefoot

A 55-year-old female presents with a painful bunion. Weight-bearing radiographs show a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. There is hypermobility of the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Proximal closing wedge osteotomy
. First TMT arthrodesis (Lapidus procedure)
. Metatarsophalangeal (MTP) joint arthrodesis
. Keller arthroplasty

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA > 15 degrees) especially in the presence of first ray hypermobility. It provides powerful correction and stabilizes the medial column.

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