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8. Foot and Ankle MCQs

Practice Set 18 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 341

Topic: 8. Foot and Ankle

Which modality for the treatment of chronic insertional Achilles tendinopathy was shown to have the best clinical outcome:

. C oncentric Achilles tendon stretching
. Eccentric Achilles tendon stretching
. Short-term immobilization of the ankle in equinus
. Low-energy shockwave therapy
. Topical anesthetic

Correct Answer & Explanation

. Low-energy shockwave therapy

Explanation

A randomized controlled trial compared recalcitrant insertional Achilles tendinopathy treated with eccentric heel cord stretching versus low-energy shockwave therapy. At 4 months, 28% of the stretching group and 64% of the shockwave therapy group reported complete relief of symptoms or greatly improved symptoms. All outcome measures showed favorable results with shockwave therapy.

Question 342

Topic: Forefoot
A tailor's bunion is an abnormal prominence of the lateral aspect of the 5th metatarsal head. Similar to hallux valgus deformities, tailor's bunions can be due to a widened intermetatarsal angle between the 4th and 5th metatarsal shafts. The normal 4-5 intermetatarsal angle is:
. Less than 8°-9°
. Less than 12°
. Less than 15°
. Less than 20°
. Less than 25°

Correct Answer & Explanation

. Less than 8°-9°

Explanation

4-5 intermetatarsal angle in normal feet averages 6.2 degrees. Different authors believe an abnormally wide 4-5 intermetatarsal angle to be anything greater than 8°-9°.

Question 343

Topic: 8. Foot and Ankle
A 54-year-old woman with a 10-year history of type II diabetes mellitus develops a Wagner grade 2 ulceration under the first metatarsal head, which has not healed for 3 months. There is no gross cellulitis or drainage. A tagged white blood cell scan shows no signs of osteomyelitis, and noninvasive vascular studies reveal normal hemodynamics. She has failed wet-to-dry normal saline dressings and bacitracin ointment local wound care. The next step in treating this patient's chronic ulcer is:
. Application of hydro-colloid gel dressings
. Use of a custom-made pressure off-loading plastizote insole
. Application of a total contact cast by a qualified physician or cast technician
. Regular debridement of the ulcer
. Amoxicillin/clavulanate potassium 875 mg twice daily

Correct Answer & Explanation

. Application of a total contact cast by a qualified physician or cast technician

Explanation

The description of the ulcer indicates that it is not grossly infected and that there is no underlying bony involvement. According to evidence-based medicine, the only treatments that are likely to be effective in the healing of diabetic foot ulcerations are topical growth factors, total contact casting, and for severely infected ulcers, hyperbaric oxygen.

Question 344

Topic: 8. Foot and Ankle

Which is the best match in surface topography when performing an osteochondral autograft transplantation procedure from the distal femur to the talar dome for an osteochondral lesion of the talus:

. From the superior-medial femoral condyle to the antero-medial talar dome
. From the inferior-medial femoral condyle to the postero-medial talar dome
. From the superior-lateral femoral condyle to any position on the medial talar dome
. From the inferior-medial femoral condyle to the centro-medial talar dome
. From the inferior-lateral femoral condyle to the antero-medial talar dome

Correct Answer & Explanation

. From the superior-lateral femoral condyle to any position on the medial talar dome

Explanation

In a magnetic resonance imaging topography study looking for the best corresponding shape of the articular surface between the non-weightbearing femoral condyle and the medial talar dome, plugs from the supero-lateral femoral condyle had the best fit with osteochondral lesions of the medial talus in the anterior, central, and posterior zones.

Question 345

Topic: 8. Foot and Ankle

The most frequent location for osteochondral lesions of the talar dome is:

. Anterolateral talar dome (Raikin zone 3)
. Posteromedial talar dome (Raikin zone 7)
. Lateral talar dome, mid-body (Raikin zone 6)
. Medial talar dome, mid-body (Raikin zone 4)
. Anteromedial talar dome (Raikin zone 1)

Correct Answer & Explanation

. Medial talar dome, mid-body (Raikin zone 4)

Explanation

A survey of 428 osteochondral lesions of the talus was undertaken using a nine zone anatomical grid system to determine the most frequent location in which these lesions occur. Results showed that 62% of lesions occurred in the medial talar dome and 34% over the lateral talar dome. The most frequent location along the medial dome was the mid-body of the talus. Medial lesions were larger in surface area as well as deeper than lateral lesions.

Question 346

Topic: 8. Foot and Ankle

Which gait parameters are significantly improved following first metatarsophalangeal arthrodesis for symptomatic hallux rigidus:

. Maximal ankle push off power
. Stride length
. Walking velocity
. C adence
. Foot progression angle

Correct Answer & Explanation

. Maximal ankle push off power

Explanation

A prospective gait study was performed measuring various gait parameters 1 week prior to and 1 year following first metatarsophalangeal joint arthrodesis. The three significant changes in gait were increased maximal ankle push off power, increased single limb support time on the affected limb, and decreased step width. Stride length, walking velocity, and cadence were not significantly different after fusion.

Question 347

Topic: 8. Foot and Ankle

Which clinical or radiographic finding is not commonly associated with moderate or severe hallux valgus deformity in adults:

. Positive family history
. Presence of bilateral bunion deformity
. Oval or curved metatarsophalangeal joint on radiographs
. Longer 1st metatarsal than 2nd metatarsal
. Achilles tendon contracture

Correct Answer & Explanation

. Positive family history

Explanation

A clinical series of 122 bunions was evaluated for demographic, etiologic, and radiographic findings associated with moderate to severe hallux valgus deformity. The following findings were reported: 83% of patients had a positive family history of bunions 84% of patients had bilateral bunion deformities 71% of patients had curved or oval-shaped metatarsophalangeal joints 71% of patients had a longer 1st metatarsal compared to the 2nd metatarsal by an average of 2.4 mm 11% of bunions were associated with an Achilles tendon contracture

Question 348

Topic: 8. Foot and Ankle
A 58-year-old runner has symptoms of chronic noninsertional Achilles tendinopathy for 8 months. Rest, ice, anti-inflammatory medications, and heel wedges have not helped. Which of the following treatments may help alleviate this patient's symptoms:
. Concentric Achilles tendon stretching
. Topical lidocaine patches
. Intratendinous cortisone injection
. Topical glyceryl trinitrate
. Oral fluoroquinolone therapy

Correct Answer & Explanation

. Topical glyceryl trinitrate

Explanation

Noninsertional Achilles tendinosis is a noninflammatory degenerative condition that is common in middle-aged athletes. In a 3-year follow-up study examining the use of topical glyceryl trinitrate for Achilles tendinosis, patients were noted to have significantly less tendon tenderness and improved clinical scores compared to the placebo group. At 3 years, 88% of treated patients were asymptomatic. Novel nonoperative measures include sclerosing injections into the Achilles tendon with polidocanol and shock-wave therapy to the Achilles tendon.

Question 349

Topic: 8. Foot and Ankle
The Brostrom lateral ligament reconstruction is a reliable technique for primary stabilization of ankle instability. The Gould modification of this technique uses which structure to reinforce the repair:
. One half of the peroneus brevis
. One half of the peroneus longus
. The calcaneofibular ligament
. The inferior extensor retinaculum
. The posterior inferior tibiofibular ligament

Correct Answer & Explanation

. The inferior extensor retinaculum

Explanation

The initial description of the Gould modification of the Brostrom procedure recommended 'suturing what one finds (there is always some ligament present) and reinforcing the anterior talofibular ligament repair with overlap of the nearby lateral talocalcaneal ligament plus the marginal ankle retinaculum'.

Question 350

Topic: 8. Foot and Ankle

Following ankle injury, which radiographic parameter is indicative of syndesmotic instability:

. Medial clear space greater than 2 mm
. Syndesmotic clear space greater than 5 mm measured 2 cm above the ankle joint on the anteroposterior (AP) view
. Syndesmotic overlap of less than 1 mm measured 1 cm above the ankle joint on the mortise view
. Syndesmotic clear space greater than 5 mm measured 1 cm above the ankle joint on the mortise view
. Syndesmotic overlap of less than 1 mm measured 1 cm above the ankle joint on the AP view

Correct Answer & Explanation

. Syndesmotic overlap of less than 1 mm measured 1 cm above the ankle joint on the AP view

Explanation

The normal radiographic findings of the syndesmosis on plain radiographs of the ankle are: Medial clear space less than or equal to 4 mm Syndesmotic clear space less than 5 mm measured 1 cm above the ankle joint on the AP view of the ankle Syndesmotic overlap greater than 1 mm measured 1 cm above the ankle joint on the mortise view of the ankle

Question 351

Topic: 8. Foot and Ankle

In a purely ligamentous Lisfranc injury, which anatomical structure is considered the primary stabilizer of the second tarsometatarsal joint?

. Dorsal tarso-metatarsal ligament
. Plantar ligament from the medial cuneiform to the second metatarsal
. Interosseous ligament from the medial cuneiform to the second metatarsal base
. Plantar calcaneocuboid ligament
. Spring ligament

Correct Answer & Explanation

. Interosseous ligament from the medial cuneiform to the second metatarsal base

Explanation

The Lisfranc ligament is an interosseous ligament connecting the medial cuneiform to the base of the second metatarsal. It is the strongest and most critical primary stabilizer of the tarsometatarsal complex.

Question 352

Topic: 8. Foot and Ankle

A 24-year-old athlete sustains a plantar flexion injury to the midfoot. Weight-bearing radiographs show a 2mm diastasis between the base of the first and second metatarsals. What is the primary stabilizing ligament disrupted in this injury?

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

Correct Answer & Explanation

. Interosseous ligament from medial cuneiform to second metatarsal base

Explanation

The Lisfranc ligament is an interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the second metatarsal base. It is the primary stabilizer of the second tarsometatarsal joint.

Question 353

Topic: 8. Foot and Ankle

Which of the following blood vessels provides the primary vascular supply to the watershed area of the Achilles tendon (2 to 6 cm proximal to its insertion)?

. Posterior tibial artery
. Peroneal artery
. Anterior tibial artery
. Sural artery
. Dorsalis pedis artery

Correct Answer & Explanation

. Peroneal artery

Explanation

The Achilles tendon receives its blood supply primarily from the posterior tibial and peroneal arteries. The peroneal artery provides the main vascularization to the critical watershed area 2-6 cm proximal to the calcaneal insertion.

Question 354

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a painful, flexible flatfoot deformity. She is unable to perform a single-leg heel rise. MRI confirms a complete rupture of the posterior tibial tendon. What is the most appropriate surgical intervention?

. Isolated posterior tibial tendon repair
. Flexor digitorum longus (FDL) transfer with a medial displacement calcaneal osteotomy
. Subtalar arthrodesis only
. Triple arthrodesis
. Gastrocnemius recession and orthotics

Correct Answer & Explanation

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

Explanation

For a Stage II (flexible) adult-acquired flatfoot deformity due to posterior tibial tendon insufficiency, joint-sparing surgery is indicated. FDL transfer combined with a medial displacement calcaneal osteotomy addresses both the tendon pathology and the mechanical malalignment.

Question 355

Topic: 8. Foot and Ankle

A 24-year-old athlete sustains a hyperplantarflexion injury to the midfoot. Weight-bearing radiographs demonstrate a 2.5 mm diastasis between the base of the first and second metatarsals. What is the primary stabilizing structure of this articulation?

. Plantar interosseous ligament between the medial cuneiform and second metatarsal base
. Dorsal ligament between the medial cuneiform and second metatarsal base
. Interosseous ligament between the first and second metatarsal bases
. Plantar fascia
. Spring ligament

Correct Answer & Explanation

. Plantar interosseous ligament between the medial cuneiform and second metatarsal base

Explanation

The Lisfranc ligament is an interosseous plantar ligament connecting the lateral aspect of the medial cuneiform to the medial aspect of the second metatarsal base. It is the primary stabilizer of the second tarsometatarsal joint; there is no direct ligamentous connection between the first and second metatarsal bases.

Question 356

Topic: Midfoot & Hindfoot
A 55-year-old female presents with progressive flattening of her left foot and medial arch pain. On examination, she has a flexible flatfoot deformity and cannot perform a single-limb heel rise. Radiographs show no degenerative changes in the subtalar or talonavicular joints. What is the correct stage of her posterior tibial tendon dysfunction (PTTD) and the most appropriate surgical management if conservative treatment fails?
. Stage I; tenosynovectomy
. Stage II; flexor digitorum longus transfer and medial displacement calcaneal osteotomy
. Stage III; triple arthrodesis
. Stage IV; tibiotalocalcaneal arthrodesis
. Stage II; isolated subtalar arthrodesis

Correct Answer & Explanation

. Stage II; flexor digitorum longus transfer and medial displacement calcaneal osteotomy

Explanation

Stage II PTTD is characterized by a flexible planovalgus deformity, inability to perform a single heel rise, and absent degenerative joint changes. Surgical management typically involves joint-sparing procedures such as an FDL tendon transfer coupled with a medial displacement calcaneal osteotomy.

Question 357

Topic: 8. Foot and Ankle

Which of the following is the most reliable way to determine that a deltoid ligament injury is associated with a Weber B level lateral malleolus fracture:

. The presence of medial tenderness on clinical examination
. The presence of medial ecchymosis on clinical examination
. The presence of significant medial swelling on clinical examination
. Evidence of medial clear space widening on stress radiographs
. The presence of lateral malleolus tenderness

Correct Answer & Explanation

. Evidence of medial clear space widening on stress radiographs

Explanation

Weber B supination, external rotation ankle fractures were evaluated to determine the reliability of medial tenderness, ecchymosis, and swelling in predicting deltoid incompetence. These clinical signs were poorly predictive, and stress radiographs were recommended for an accurate diagnosis of instability.

Question 358

Topic: 8. Foot and Ankle

Following calcaneus fracture, risk factors for later need for subtalar arthrodesis due to painful posttraumatic arthritis include all of the following except:

. Bohlers angle <0°
. Sanders type IV fractures
. Workers compensation
. Initial nonoperative care
. Female gender

Correct Answer & Explanation

. Female gender

Explanation

Buckley conducted a series of large prospective studies following calcaneus fracture outcomes in Canada. All of the above factors were associated with the need for later subtalar fusion except female gender. In his other studies, it was demonstrated that male gender was a risk factor for not having a significantly better clinical outcome with surgery versus nonsurgical treatment.

Question 359

Topic: 8. Foot and Ankle

The distinguishing factor in a Hawkins type 4 talar neck fracture is:

. The presence of an incongruent ankle joint
. Incongruity of the ankle and/or subtalar joint with the presence of a talonavicular dislocation.
. The presence of an incongruent subtalar joint
. The presence of an associated talar body fracture
. The presence of a posterior process of the talus fracture

Correct Answer & Explanation

. Incongruity of the ankle and/or subtalar joint with the presence of a talonavicular dislocation.

Explanation

Hawkins type 1 fractures are nondisplaced. Hawkins type 2 fractures have an incongruent subtalar joint. Hawkins type 3 fractures have an incongruent ankle and subtalar joint. Hawkins type 4 fractures have the above injuries and incongruent talo-navicular joint.

Question 360

Topic: 8. Foot and Ankle

Triple arthrodesis is associated with:

. Long-term clinical stability with respect to pain relief
. High rates of nonunion
. Worse patient satisfaction when ankle arthritis is present
. Development of ankle arthritis over time
. No increased risk for ankle arthritis

Correct Answer & Explanation

. Development of ankle arthritis over time

Explanation

Saltzman and colleagues followed 67 patients who underwent triple arthrodesis at 44-year follow-up. Nearly all patients had ankle arthritis at final follow-up. C linical relief of pain deteriorated over time between intermediate 25-year follow-up and 44-year follow-up in the same group of patients.

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