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8. Foot and Ankle MCQs

Practice Set 179 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 3561

Topic: 8. Foot and Ankle

A 25-year-old athlete sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs demonstrate a 3 mm diastasis between the base of the first and second metatarsals. What is the primary anatomic structure disrupted in this injury?

. The transverse metatarsal ligament connecting the first and second metatarsal bases
. The interosseous ligament connecting the medial cuneiform to the second metatarsal base
. The distal interosseous membrane
. The medial band of the plantar fascia
. The plantar calcaneonavicular (spring) ligament

Correct Answer & Explanation

. The interosseous ligament connecting the medial cuneiform to the second metatarsal base

Explanation

The Lisfranc ligament is an interosseous ligament that connects the medial cuneiform to the base of the second metatarsal. There is no direct ligamentous connection between the bases of the first and second metatarsals, making the Lisfranc ligament the critical stabilizer of this complex.

Question 3562

Topic: 8. Foot and Ankle

A 40-year-old male is scheduled for open reduction and internal fixation of a displaced intra-articular calcaneus fracture via an extensile lateral approach. Which of the following structures is most at risk during the initial surgical dissection of the full-thickness flap?

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

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve is at significant risk during the extensile lateral approach to the calcaneus, particularly at the proximal and distal limbs of the incision. A full-thickness subperiosteal flap must be carefully elevated to protect the nerve and the delicate vascular supply to the skin.

Question 3563

Topic: 8. Foot and Ankle

A 22-year-old male sustains a high-energy knee dislocation. Following emergent closed reduction, his foot is well-perfused, but his Ankle-Brachial Index (ABI) is measured at 0.8. What is the next most appropriate step in management?

. Immediate surgical exploration
. CT angiography of the lower extremity
. Serial physical examinations every 4 hours
. Duplex ultrasonography
. Application of a long leg cast

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

An ABI less than 0.9 following a knee dislocation strongly suggests an underlying arterial injury, even in the presence of palpable pulses or a well-perfused foot. CT angiography is indicated to accurately evaluate the popliteal artery and plan necessary surgical intervention.

Question 3564

Topic: Midfoot & Hindfoot
A 30-year-old man sustains a Hawkins Type III talar neck fracture. What does this classification indicate regarding the specific fracture pattern and its associated risk of avascular necrosis (AVN)?
. Undisplaced fracture, 0-10% AVN risk
. Displaced fracture with subtalar subluxation, 20-50% AVN risk
. Displaced fracture with subtalar and tibiotalar dislocation, nearly 100% AVN risk
. Displaced fracture with talonavicular dislocation, 10-20% AVN risk
. Fracture of the talar body, 50% AVN risk

Correct Answer & Explanation

. Displaced fracture with subtalar and tibiotalar dislocation, nearly 100% AVN risk

Explanation

A Hawkins Type III fracture involves a displaced talar neck fracture with dislocation of both the subtalar and tibiotalar joints. This severe injury disrupts the major blood supply to the talar body, leading to a very high rate of avascular necrosis, often approaching 100%.

Question 3565

Topic: 8. Foot and Ankle

Which of the following parameters measured on a standard anteroposterior (AP) or mortise radiograph is considered the most reliable indicator of syndesmotic widening?

. Tibiofibular overlap less than 10 mm on the AP view
. Medial clear space greater than 4 mm on the mortise view
. Tibiofibular clear space greater than 5 mm measured 1 cm above the joint line
. Talar tilt greater than 2 degrees
. Shenton's line of the ankle disruption

Correct Answer & Explanation

. Tibiofibular clear space greater than 5 mm measured 1 cm above the joint line

Explanation

The tibiofibular clear space, measured 1 cm above the joint line on an AP or mortise radiograph, should be less than 6 mm. It is the most reliable radiographic parameter for assessing syndesmotic integrity, as it is unaffected by tibial rotation.

Question 3566

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with a painful, flexible flatfoot deformity and an inability to perform a single-leg heel raise.

Clinical examination reveals severe forefoot abduction with 'too many toes' sign. Which of the following procedures is most appropriate to specifically address the forefoot abduction component of her deformity?

. Medial displacement calcaneal osteotomy
. Lateral column lengthening (Evans osteotomy)
. First tarsometatarsal arthrodesis
. Kidner procedure
. Subtalar arthrodesis

Correct Answer & Explanation

. Lateral column lengthening (Evans osteotomy)

Explanation

Lateral column lengthening (Evans osteotomy) effectively corrects the forefoot abduction associated with Stage IIb adult acquired flatfoot deformity. A medial displacement calcaneal osteotomy primarily addresses hindfoot valgus but does not reliably correct severe forefoot abduction.

Question 3567

Topic: 8. Foot and Ankle

A 24-year-old man presents with a symptomatic cavovarus foot deformity. A Coleman block test is performed, during which the first ray is allowed to drop off the block, and the hindfoot corrects to a neutral alignment. This finding indicates that the hindfoot varus is primarily driven by which of the following?

. A rigid subtalar joint
. A rigidly plantarflexed first ray
. A contracted Achilles tendon
. Weakness of the peroneus brevis
. Spasticity of the posterior tibial tendon

Correct Answer & Explanation

. A rigidly plantarflexed first ray

Explanation

The Coleman block test distinguishes between rigid and flexible hindfoot varus. If the hindfoot corrects to neutral when the first ray is allowed to drop, the deformity is flexible and driven by a rigidly plantarflexed first ray.

Question 3568

Topic: 8. Foot and Ankle

A 14-year-old boy presents with frequent ankle sprains and a rigid, flat foot. CT imaging confirms a middle facet talocalcaneal coalition. If nonoperative management fails, what is the generally accepted threshold of joint involvement above which a subtalar or triple arthrodesis is recommended over surgical resection?

. 10%
. 25%
. 50%
. 75%
. 90%

Correct Answer & Explanation

. 50%

Explanation

Resection of a talocalcaneal coalition is generally contraindicated if the coalition involves more than 50% of the posterior facet area or if there are advanced degenerative changes. In these cases, arthrodesis is the preferred surgical treatment.

Question 3569

Topic: 8. Foot and Ankle

According to the Lauge-Hansen classification, which of the following represents the correct sequential order of structural injury in a Supination-External Rotation (SER) ankle fracture?

. Anterior inferior tibiofibular ligament -> Lateral malleolus -> Posterior inferior tibiofibular ligament -> Medial malleolus/Deltoid
. Medial malleolus -> Anterior inferior tibiofibular ligament -> Lateral malleolus -> Posterior inferior tibiofibular ligament
. Anterior inferior tibiofibular ligament -> Posterior inferior tibiofibular ligament -> Lateral malleolus -> Medial malleolus
. Lateral malleolus -> Anterior inferior tibiofibular ligament -> Posterior inferior tibiofibular ligament -> Medial malleolus
. Deltoid ligament -> Anterior inferior tibiofibular ligament -> Fibula -> Posterior inferior tibiofibular ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament -> Lateral malleolus -> Posterior inferior tibiofibular ligament -> Medial malleolus/Deltoid

Explanation

In the SER pattern, the force creates sequential injury starting anterolaterally: AITFL (Stage 1), spiral fracture of the fibula (Stage 2), PITFL or posterior malleolus (Stage 3), and finally the medial malleolus or deltoid ligament (Stage 4).

Question 3570

Topic: Ankle Trauma & Sports

During open reduction and internal fixation of a Weber C ankle fracture, the surgeon needs to evaluate the syndesmosis. Which intraoperative method is considered the most reliable indicator of syndesmotic instability requiring fixation?

. Direct visualization of an intact anterior inferior tibiofibular ligament
. Positive intraoperative fluoroscopic Cotton test
. Measurement of the medial clear space as exactly 3mm
. Observation of tibiofibular overlap greater than 15mm
. Preoperative MRI showing isolated deltoid sprain

Correct Answer & Explanation

. Positive intraoperative fluoroscopic Cotton test

Explanation

The intraoperative fluoroscopic Cotton test (lateral pull on the fibula using a bone hook) is the most reliable clinical test to assess dynamic syndesmotic instability. Widening of the tibiofibular clear space under stress dictates the need for syndesmotic fixation.

Question 3571

Topic: 8. Foot and Ankle

A 65-year-old patient with long-standing, poorly controlled diabetes mellitus and severe peripheral neuropathy presents with a displaced bimalleolar ankle fracture. To minimize the high risk of complications, which modification to standard operative management is most appropriate?

. Immediate weight-bearing to prevent disuse osteopenia
. Standard single-screw syndesmotic fixation
. Utilization of augmented fixation such as multiple syndesmotic screws and prolonged non-weight-bearing
. Use of bioabsorbable plates and screws
. Nonoperative management with a soft compressive dressing

Correct Answer & Explanation

. Utilization of augmented fixation such as multiple syndesmotic screws and prolonged non-weight-bearing

Explanation

Diabetic patients with severe neuropathy are at high risk for fixation failure and Charcot arthropathy. Enhanced fixation techniques, such as multiple trans-syndesmotic screws or stronger locking constructs, combined with prolonged non-weight-bearing, are recommended.

Question 3572

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with a painful, unilateral flatfoot deformity. She is unable to perform a single-leg heel rise, but manual testing reveals that her subtalar joint remains mobile and reducible. What is the most appropriate surgical treatment?

. In situ subtalar arthrodesis
. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Tibiotalocalcaneal arthrodesis
. Isolated gastrocnemius recession

Correct Answer & Explanation

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

Explanation

This patient has a Stage II adult acquired flatfoot deformity (flexible flatfoot). The gold standard surgical management for a flexible deformity involves an FDL transfer to replace the diseased posterior tibial tendon, combined with a medial displacement calcaneal osteotomy.

Question 3573

Topic: 8. Foot and Ankle

In a patient with Charcot-Marie-Tooth disease who presents with a progressive, flexible cavovarus foot deformity, the plantarflexed first ray is primarily driven by the relative overpull of which specific muscle?

. Tibialis posterior
. Peroneus brevis
. Peroneus longus
. Extensor hallucis longus
. Flexor hallucis longus

Correct Answer & Explanation

. Peroneus longus

Explanation

In Charcot-Marie-Tooth disease, muscle imbalances lead to the classic cavovarus deformity. The peroneus longus remains strong and overpulls the weak tibialis anterior, driving the first metatarsal into rigid plantarflexion.

Question 3574

Topic: 8. Foot and Ankle

A 40-year-old man presents with severe lateral hindfoot pain 2 years after nonoperative management of a displaced intra-articular calcaneus fracture. Examination reveals subtalar stiffness and subfibular impingement. Radiographs show a healed calcaneal malunion with loss of Bohler's angle and advanced subtalar arthritis. What is the best surgical option?

. Lateral wall exostectomy alone
. Subtalar arthrodesis with lateral wall exostectomy
. Isolated corrective calcaneal osteotomy
. Triple arthrodesis
. Ankle arthrodesis

Correct Answer & Explanation

. Subtalar arthrodesis with lateral wall exostectomy

Explanation

For a painful calcaneal malunion with subtalar arthritis and subfibular impingement, an in situ subtalar arthrodesis combined with a lateral wall exostectomy reliably relieves pain and restores lateral hindfoot anatomy.

Question 3575

Topic: 8. Foot and Ankle

According to the Lauge-Hansen classification, what is the correct sequential order of tissue injury in a supination-external rotation (SER) ankle fracture?

. Deltoid ligament, fibula, posterior inferior tibiofibular ligament (PITFL), anterior inferior tibiofibular ligament (AITFL)
. AITFL, fibula, PITFL, deltoid ligament or medial malleolus
. Fibula, AITFL, deltoid ligament, PITFL
. PITFL, fibula, AITFL, deltoid ligament
. AITFL, deltoid ligament, fibula, PITFL

Correct Answer & Explanation

. AITFL, fibula, PITFL, deltoid ligament or medial malleolus

Explanation

The SER injury progresses in four stages: Stage 1 is the AITFL; Stage 2 is the short oblique/spiral fracture of the fibula; Stage 3 is the PITFL or posterior malleolus; Stage 4 is the deltoid ligament or medial malleolus.

Question 3576

Topic: 8. Foot and Ankle

A 14-year-old boy presents with a rigid flatfoot and a history of recurrent ankle sprains. Clinical suspicion is high for a calcaneonavicular coalition. Which radiographic view is most sensitive and specific for demonstrating this specific coalition?

. Standard anteroposterior (AP) ankle
. Lateral weight-bearing foot
. 45-degree internal oblique view of the foot
. Harris axial view of the calcaneus
. Mortise view of the ankle

Correct Answer & Explanation

. 45-degree internal oblique view of the foot

Explanation

The 45-degree internal oblique view of the foot elongates the calcaneonavicular interval, making it the best standard radiograph to diagnose a calcaneonavicular coalition. The Harris axial view is best for talocalcaneal coalitions.

Question 3577

Topic: Midfoot & Hindfoot

A 15-year-old girl is evaluated for a painful, rigid flatfoot. A lateral weight-bearing radiograph demonstrates a continuous, dense osseous outline extending from the talar dome down to the sustentaculum tali (the "C-sign"). This radiographic finding strongly suggests which underlying condition?

. Calcaneonavicular coalition
. Talonavicular coalition
. Talocalcaneal coalition
. Naviculocuneiform coalition
. Symptomatic accessory navicular

Correct Answer & Explanation

. Talocalcaneal coalition

Explanation

The "C-sign" on a lateral radiograph represents a continuous bony bridge between the talar dome and the sustentaculum tali. It is a highly reliable indicator of a talocalcaneal coalition, particularly involving the middle facet.

Question 3578

Topic: 8. Foot and Ankle

A 22-year-old woman is being evaluated for a symptomatic cavovarus foot deformity. A Coleman block test is performed by having the patient stand with her lateral heel and foot on a wooden block, allowing the first metatarsal to hang freely. During this maneuver, her hindfoot varus completely corrects to neutral. What does this indicate?

. The hindfoot varus deformity is rigid and requires a primary calcaneal osteotomy.
. The deformity is flexible and primarily driven by a plantarflexed first ray.
. The tibialis posterior tendon is ruptured or incompetent.
. The peroneus brevis muscle is spastic.
. Triple arthrodesis is required due to multiple rigid joint deformities.

Correct Answer & Explanation

. The deformity is flexible and primarily driven by a plantarflexed first ray.

Explanation

The Coleman block test evaluates hindfoot flexibility. If the hindfoot varus corrects to neutral when the first metatarsal is allowed to drop, the hindfoot is flexible, and the deformity is primarily driven by the rigid, plantarflexed first ray.

Question 3579

Topic: 8. Foot and Ankle
A 62-year-old woman has severe, long-standing, medial and lateral ankle pain with a progressive flatfoot deformity. Examination shows a fixed, rigid planovalgus deformity, and radiographs demonstrate significant joint space narrowing and subchondral sclerosis in the subtalar and talonavicular joints. What is the most definitive surgical intervention?
. Gastrocnemius recession and custom orthotics
. Medial displacement calcaneal osteotomy with FDL tendon transfer
. Isolated in situ subtalar arthrodesis
. Triple arthrodesis
. Total ankle arthroplasty

Correct Answer & Explanation

. Triple arthrodesis

Explanation

This patient has a Stage III adult acquired flatfoot deformity, characterized by a rigid deformity and established hindfoot/midfoot arthritis. The standard definitive surgical treatment is a triple arthrodesis to realign and fuse the painful, arthritic joints.

Question 3580

Topic: Ankle Trauma & Sports

A 40-year-old patient presents with a severe ankle injury. Radiographs show a transverse fracture of the medial malleolus and a comminuted, bending-type fracture of the fibula located above the level of the syndesmosis. Which Lauge-Hansen classification does this pattern most accurately fit?

. Supination-Adduction
. Supination-External Rotation
. Pronation-External Rotation
. Pronation-Abduction
. Supination-Plantarflexion

Correct Answer & Explanation

. Pronation-Abduction

Explanation

The Pronation-Abduction injury pattern begins with tension medially (transverse medial malleolus fracture or deltoid rupture), followed by syndesmotic rupture, and concludes with a comminuted bending fracture of the fibula above the joint level.

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