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8. Foot and Ankle MCQs

Practice Set 180 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 3581

Topic: 8. Foot and Ankle

When counseling a patient on the choice between operative and nonoperative management for an acute Achilles tendon rupture using modern, early-functional rehabilitation protocols, operative treatment is statistically associated with a higher risk of which of the following?

. Overall rate of tendon re-rupture
. Long-term plantarflexion weakness
. Wound complications and superficial infection
. Deep vein thrombosis
. Sural nerve entrapment in the calf

Correct Answer & Explanation

. Wound complications and superficial infection

Explanation

Modern randomized controlled trials show that early functional rehabilitation protocols make the re-rupture rates between operative and nonoperative management statistically similar. However, operative management consistently carries a higher risk of wound complications and infection.

Question 3582

Topic: 8. Foot and Ankle

A 28-year-old woman reports persistent lateral foot pain 4 weeks after an inversion injury initially diagnosed as an ankle sprain. She has maximal point tenderness about 2 cm anterior and inferior to the lateral malleolus. Radiographs reveal a minimally displaced fracture of the anterior process of the calcaneus. This fracture usually occurs via avulsion of which ligament?

. Anterior talofibular ligament
. Calcaneofibular ligament
. Bifurcate ligament
. Cervical ligament
. Interosseous talocalcaneal ligament

Correct Answer & Explanation

. Bifurcate ligament

Explanation

Fractures of the anterior process of the calcaneus are often misdiagnosed as simple lateral ankle sprains. They typically result from an avulsion of the bifurcate ligament (calcaneocuboid and calcaneonavicular bands) during forceful plantarflexion and inversion.

Question 3583

Topic: 8. Foot and Ankle

A 35-year-old man sustains an ankle fracture. Radiographs show a posterior malleolar fragment involving 30% of the articular surface with posterior subluxation of the talus. What is the most appropriate surgical approach for direct visualization and isolated fixation of this fragment?

. Anterior approach
. Medial approach
. Direct lateral approach
. Posteromedial approach
. Posterolateral approach

Correct Answer & Explanation

. Posterolateral approach

Explanation

The posterolateral approach allows direct visualization and stable fixation of the posterior malleolus, which is indicated for large fragments (>25%) with posterior subluxation. It provides excellent access while avoiding the posteromedial neurovascular bundle.

Question 3584

Topic: 8. Foot and Ankle

A 55-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. She has a flexible hindfoot valgus and is unable to perform a single-leg heel raise. Nonoperative management has failed. What is the most appropriate surgical intervention?

. Ankle arthrodesis
. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Subtalar arthrodesis
. Tibialis anterior tendon transfer

Correct Answer & Explanation

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

Explanation

The patient has Stage II posterior tibial tendon dysfunction (flexible deformity). The gold standard surgical treatment involves FDL transfer to the navicular and a medializing calcaneal osteotomy to restore the medial arch and correct hindfoot valgus.

Question 3585

Topic: Midfoot & Hindfoot
A 62-year-old female presents with severe, rigid planovalgus deformity and lateral hindfoot pain secondary to subfibular impingement. Radiographs show significant subtalar and talonavicular arthritis. What is the most appropriate definitive treatment?
. Lateral column lengthening
. FDL transfer and calcaneal osteotomy
. Triple arthrodesis
. Ankle arthrodesis
. Gastrocnemius recession alone

Correct Answer & Explanation

. Triple arthrodesis

Explanation

Stage III adult acquired flatfoot deformity is characterized by a rigid deformity with associated hindfoot arthritis. Triple arthrodesis (subtalar, talonavicular, and calcaneocuboid) provides deformity correction, stability, and definitive pain relief.

Question 3586

Topic: Ankle Trauma & Sports

During open reduction and internal fixation of a Weber C ankle fracture, the surgeon suspects a syndesmotic injury. Which of the following intraoperative tests is considered the most reliable for evaluating syndesmotic instability?

. Cotton test
. Silfverskiold test
. Anterior drawer test
. Talar tilt test
. Coleman block test

Correct Answer & Explanation

. Cotton test

Explanation

The Cotton test involves placing a bone hook around the fibula and applying a lateral force to assess for diastasis of the syndesmosis. It is highly reliable for intraoperative evaluation of syndesmotic integrity.

Question 3587

Topic: 8. Foot and Ankle

A patient with a history of a conservatively managed calcaneus fracture presents 1 year later with persistent lateral midfoot pain exacerbated by walking on uneven ground. Examination reveals tenderness localized to the lateral column. Which joint is most likely responsible for these symptoms?

. Subtalar joint
. Talonavicular joint
. Calcaneocuboid joint
. Tibiotalar joint
. Naviculocuneiform joint

Correct Answer & Explanation

. Calcaneocuboid joint

Explanation

The calcaneocuboid joint can be involved in intra-articular calcaneus fractures or affected by altered biomechanics. Post-traumatic arthritis of this joint typically presents with lateral column pain exacerbated by uneven terrain.

Question 3588

Topic: 8. Foot and Ankle

A 16-year-old boy presents with progressive bilateral cavovarus foot deformities. Neurological examination reveals weakness in foot dorsiflexion and eversion. In Charcot-Marie-Tooth disease, which muscle imbalance is the primary driver of this forefoot-driven hindfoot varus deformity?

. Overpull of the peroneus brevis against a weak tibialis posterior
. Overpull of the peroneus longus against a weak tibialis anterior
. Overpull of the tibialis anterior against a weak Achilles tendon
. Weakness of the flexor hallucis longus
. Spasticity of the gastrocnemius-soleus complex

Correct Answer & Explanation

. Overpull of the peroneus longus against a weak tibialis anterior

Explanation

In Charcot-Marie-Tooth disease, the overpull of a strong peroneus longus against a weak tibialis anterior forces the first ray into plantarflexion. This creates a rigidly plantarflexed first ray, which drives the hindfoot into a secondary varus alignment.

Question 3589

Topic: 8. Foot and Ankle

A patient presents with a severe cavovarus deformity. A Coleman block test is performed, and the hindfoot completely corrects to a neutral alignment when the first metatarsal is allowed to drop off the block. What does this indicate about the deformity?

. The hindfoot deformity is rigid and requires a subtalar arthrodesis
. The deformity is driven by a rigidly plantarflexed forefoot and the hindfoot is flexible
. The Achilles tendon is contracted and requires surgical lengthening
. There is an isolated structural abnormality of the calcaneus
. The subtalar joint is fused

Correct Answer & Explanation

. The deformity is driven by a rigidly plantarflexed forefoot and the hindfoot is flexible

Explanation

The Coleman block test assesses hindfoot flexibility in a cavovarus foot. If the hindfoot varus corrects when the plantarflexed first ray is allowed to drop, it confirms that the hindfoot is flexible and the deformity is primarily forefoot-driven.

Question 3590

Topic: 8. Foot and Ankle

A 45-year-old female presents with an isolated lateral malleolus fracture and medial joint line tenderness. A gravity stress radiograph demonstrates 6 mm of medial clear space widening. Which of the following statements regarding the medial injury is most accurate?

. Routine primary repair of the deltoid ligament is strictly required
. The deep deltoid ligament provides the primary resistance to lateral talar shift
. The superficial deltoid ligament originates primarily from the posterior malleolus
. Fixation of the fibula alone is insufficient to restore ankle joint stability
. The medial clear space widening is physiological for this age group

Correct Answer & Explanation

. The deep deltoid ligament provides the primary resistance to lateral talar shift

Explanation

The deep deltoid ligament is the primary medial stabilizer against lateral talar shift. In a bimalleolar equivalent fracture, anatomic fixation of the fibula and syndesmosis restores stability; routine repair of the deltoid ligament is generally not necessary.

Question 3591

Topic: 8. Foot and Ankle

A 12-year-old boy presents with frequent ankle sprains and a rigid flatfoot. Radiographs show a "C sign", and CT confirms a middle facet talocalcaneal coalition. If nonoperative management fails and there is no significant arthritis, what is the best surgical option?

. Resection of the coalition with interposition of the extensor digitorum brevis
. Triple arthrodesis
. Calcaneal sliding osteotomy
. Resection of the coalition with interposition of fat or FHL tendon
. Subtalar arthrodesis

Correct Answer & Explanation

. Resection of the coalition with interposition of fat or FHL tendon

Explanation

For symptomatic talocalcaneal coalitions without degenerative changes, resection with interposition of a fat graft or FHL tendon is indicated to prevent recurrence. Extensor digitorum brevis interposition is typically utilized for calcaneonavicular coalitions.

Question 3592

Topic: 8. Foot and Ankle

A 25-year-old athlete sustains a lateral subtalar dislocation. Closed reduction in the emergency department is unsuccessful. Which of the following anatomic structures is most commonly interposed and blocking reduction in this specific injury pattern?

. Extensor digitorum brevis
. Posterior tibial tendon
. Peroneal tendons
. Flexor hallucis longus
. Tibialis anterior tendon

Correct Answer & Explanation

. Posterior tibial tendon

Explanation

In a lateral subtalar dislocation, the posterior tibial tendon (PTT) frequently becomes entrapped between the talus and the navicular, blocking closed reduction and necessitating surgical intervention.

Question 3593

Topic: 8. Foot and Ankle

A 45-year-old man undergoes ORIF for a Weber C ankle fracture with syndesmotic instability. Two cortical screws are placed across four cortices. Regarding syndesmotic screw fixation, what does the current orthopedic literature recommend?

. Routine removal at 6 weeks prior to weight-bearing
. Placement in maximum dorsiflexion is mandatory to prevent stiffness
. There is no significant difference in functional outcomes between retained and removed screws
. Screw retention is definitively associated with worse clinical outcomes

Correct Answer & Explanation

. There is no significant difference in functional outcomes between retained and removed screws

Explanation

Current evidence shows no significant functional difference between retained and removed syndesmotic screws. Furthermore, retained screws that eventually break do not negatively impact long-term patient outcomes, making routine removal unnecessary.

Question 3594

Topic: 8. Foot and Ankle

When treating a trimalleolar ankle fracture, which of the following is the strongest absolute indication for operative fixation of the posterior malleolus?

. Fragment involving >10% of the articular surface
. Persistent posterior subluxation of the talus after fixing the lateral and medial malleoli
. Presence of an associated syndesmotic injury
. Any fragment size in a patient over 65 years old

Correct Answer & Explanation

. Persistent posterior subluxation of the talus after fixing the lateral and medial malleoli

Explanation

While indications for posterior malleolus fixation have evolved to include smaller fragments if they contribute to syndesmotic instability, the absolute strongest indication remains persistent posterior subluxation of the talus. Restoring joint congruity and stability is paramount.

Question 3595

Topic: 8. Foot and Ankle

A 65-year-old poorly controlled diabetic patient with peripheral neuropathy sustains a bimalleolar equivalent ankle fracture. What modification to the standard surgical protocol is most strongly recommended?

. Use of bioabsorbable implants to reduce infection risk
. Single rather than double syndesmotic screws
. Enhanced fixation constructs (e.g., TTC nailing or multiple syndesmotic screws) and prolonged non-weight-bearing
. Early weight-bearing at 2 weeks to prevent osteopenia

Correct Answer & Explanation

. Enhanced fixation constructs (e.g., TTC nailing or multiple syndesmotic screws) and prolonged non-weight-bearing

Explanation

Diabetic patients with neuropathy have a substantially higher risk of Charcot arthropathy, hardware failure, and nonunion. Enhanced rigid fixation (such as locking plates or TTC nails) and a prolonged non-weight-bearing period (often double the normal duration) are strongly recommended.

Question 3596

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with a flexible flatfoot deformity, unable to perform a single-leg heel raise. She has pain along the medial hindfoot. Imaging shows uncovering of the talonavicular joint but no arthritis. Conservative management has failed. Which of the following surgical procedures is most appropriate?

. Triple arthrodesis
. Isolated talonavicular fusion
. Flexor digitorum longus (FDL) transfer to the navicular and medializing calcaneal osteotomy
. Tibialis anterior tendon transfer

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer to the navicular and medializing calcaneal osteotomy

Explanation

Stage II posterior tibial tendon dysfunction (PTTD) presents as a flexible deformity without arthritis. It is typically treated with joint-sparing procedures such as an FDL transfer combined with a medializing calcaneal osteotomy to correct the mechanical axis.

Question 3597

Topic: 8. Foot and Ankle

A 24-year-old man with Charcot-Marie-Tooth disease presents with a rigid bilateral cavovarus foot deformity and recurrent lateral ankle sprains. The Coleman block test demonstrates a flexible hindfoot that corrects to neutral when the first ray is off the block. What is the primary driver of his hindfoot varus deformity?

. Overactive tibialis anterior
. Plantarflexed first ray
. Weakness of the posterior tibial tendon
. Contracted Achilles tendon

Correct Answer & Explanation

. Plantarflexed first ray

Explanation

In Charcot-Marie-Tooth disease, the primary deforming force is typically a plantarflexed first ray driven by an overactive peroneus longus outpulling a weak tibialis anterior. The Coleman block test proves the hindfoot varus is flexible and secondary to this forefoot pronation.

Question 3598

Topic: 8. Foot and Ankle
A 38-year-old construction worker falls from a ladder, sustaining an intra-articular calcaneus fracture. Radiographs reveal a decreased Bรถhler's angle and an increased angle of Gissane. What is the primary anatomic goal of open reduction and internal fixation in this setting?
. Restoration of the calcaneocuboid joint to prevent midfoot arthritis
. Restoration of hindfoot height, width, and posterior facet congruity
. Excision of the posterior tuberosity
. Primary subtalar arthrodesis in all displaced cases

Correct Answer & Explanation

. Restoration of hindfoot height, width, and posterior facet congruity

Explanation

The primary goals of ORIF for displaced intra-articular calcaneus fractures are the restoration of the posterior facet congruity, restoration of calcaneal height, and reduction of calcaneal width to decompress the subfibular space.

Question 3599

Topic: 8. Foot and Ankle

A 45-year-old man is 2 years status-post nonoperative management of a displaced intra-articular calcaneus fracture. He now presents with lateral hindfoot pain and difficulty walking on uneven ground. Physical examination reveals impingement of the fibula against the lateral calcaneal wall. What is the most appropriate definitive surgical intervention?

. Subtalar arthrodesis with in situ bone grafting
. Lateral calcaneal wall exostectomy and peroneal tenolysis
. Subtalar distraction arthrodesis combined with lateral calcaneal wall exostectomy
. Triple arthrodesis

Correct Answer & Explanation

. Subtalar distraction arthrodesis combined with lateral calcaneal wall exostectomy

Explanation

Late complications of nonoperatively managed calcaneus fractures often include subtalar arthritis and lateral impingement due to widening of the calcaneus. The standard treatment for this combined pathology is a subtalar distraction arthrodesis coupled with a lateral wall exostectomy.

Question 3600

Topic: 8. Foot and Ankle

A 45-year-old man sustains a bimalleolar equivalent ankle fracture. Radiographs show a posterior malleolus fragment involving 15% of the articular surface. Intraoperatively, after fixing the lateral malleolus, the syndesmosis remains unstable. What is the most appropriate next step in management?

. Place a single trans-syndesmotic screw
. Perform an open reduction and internal fixation of the posterior malleolus
. Apply a spanning external fixator
. Reconstruct the anterior inferior tibiofibular ligament using allograft
. Accept the reduction and place the patient in a non-weight-bearing cast

Correct Answer & Explanation

. Perform an open reduction and internal fixation of the posterior malleolus

Explanation

Recent literature indicates that ORIF of the posterior malleolus, even for smaller fragments, restores syndesmotic stability better than trans-syndesmotic screws. Anatomic reduction of the posterior malleolus reconstructs the posterior inferior tibiofibular ligament (PITFL) footprint.

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