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8. Foot and Ankle MCQs

Practice Set 181 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 3601

Topic: 8. Foot and Ankle

A 32-year-old male presents to the emergency department after a twisting injury to his ankle. The ankle is grossly deformed and irreducible in the trauma bay under procedural sedation. Radiographs demonstrate a fracture-dislocation. What is the most likely anatomic block to reduction in a classic Bosworth injury?

. Interposition of the posterior tibial tendon
. Entrapment of the flexor hallucis longus
. The proximal fibular fragment locked behind the posterolateral tibial tubercle
. Osteochondral fragment from the talar dome
. Deltoid ligament interposition in the medial clear space

Correct Answer & Explanation

. The proximal fibular fragment locked behind the posterolateral tibial tubercle

Explanation

A Bosworth fracture-dislocation involves the proximal fragment of the fibula becoming locked behind the posterolateral tubercle of the tibia. This classically results in an irreducible deformity requiring urgent open reduction.

Question 3602

Topic: 8. Foot and Ankle

A 60-year-old female with long-standing, poorly controlled type 2 diabetes mellitus and profound peripheral neuropathy sustains a displaced bimalleolar ankle fracture. Which of the following surgical strategies is most appropriate to minimize the risk of post-operative failure?

. Standard rigid fixation with immediate weight-bearing
. Augmented fixation including multiple syndesmotic screws and prolonged non-weight-bearing
. Primary tibiotalocalcaneal arthrodesis with a retrograde nail
. Closed reduction and casting to avoid surgical wound complications
. Standard rigid fixation and routine syndesmotic screw removal at 6 weeks

Correct Answer & Explanation

. Augmented fixation including multiple syndesmotic screws and prolonged non-weight-bearing

Explanation

Diabetic patients with neuropathy are at high risk for Charcot arthropathy and hardware failure following ankle fractures. Maximized rigid fixation, often including augmented syndesmotic fixation and prolonged non-weight-bearing (double the standard time), is recommended.

Question 3603

Topic: 8. Foot and Ankle

A 24-year-old man with Charcot-Marie-Tooth disease presents with a progressive, bilateral cavovarus foot deformity. The Coleman block test demonstrates that the hindfoot varus corrects to neutral when the first ray is allowed to plantarflex off the block. What is the primary muscle imbalance driving this patient's forefoot deformity?

. Weak peroneus longus and strong tibialis anterior
. Strong peroneus longus overpowering a weak tibialis anterior
. Weak tibialis posterior and strong peroneus brevis
. Strong gastrocnemius overpowering a weak tibialis anterior
. Weak extensor digitorum longus and strong flexor digitorum longus

Correct Answer & Explanation

. Strong peroneus longus overpowering a weak tibialis anterior

Explanation

In Charcot-Marie-Tooth disease, a strong peroneus longus overpowers a weak tibialis anterior, causing plantarflexion of the first ray and a forefoot-driven cavovarus deformity. The hindfoot varus is initially flexible (corrects on Coleman block test) but can become rigid over time.

Question 3604

Topic: 8. Foot and Ankle
A 55-year-old woman presents with severe medial ankle pain and a progressively flattening arch. On examination, she is unable to perform a single-leg heel rise. Radiographs demonstrate >40% uncoverage of the talonavicular joint and a flexible hindfoot valgus deformity. What is the most appropriate surgical management?
. Flexor digitorum longus transfer and medializing calcaneal osteotomy only
. Flexor digitorum longus transfer, medializing calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis
. Isolated talonavicular arthrodesis
. Gastrocnemius recession and anterior tibialis tendon transfer

Correct Answer & Explanation

. Flexor digitorum longus transfer, medializing calcaneal osteotomy, and lateral column lengthening

Explanation

This patient has a Stage IIb adult-acquired flatfoot deformity, characterized by a flexible deformity with significant forefoot abduction (>40% TN uncoverage). Treatment requires a soft tissue reconstruction (FDL transfer) combined with a medial osteotomy and lateral column lengthening to correct the forefoot abduction.

Question 3605

Topic: 8. Foot and Ankle

A 14-year-old boy presents with frequent ankle sprains and rigid, flat arches. Examination reveals significant restriction of subtalar motion. Lateral radiographs demonstrate a continuous osseous connection between the talus and calcaneus forming a "C-sign". Which facet of the subtalar joint is most commonly involved in this condition?

. Anterior facet
. Middle facet
. Posterior facet
. Lateral facet
. Medial facet

Correct Answer & Explanation

. Middle facet

Explanation

The "C-sign" on a lateral radiograph is indicative of a talocalcaneal coalition. This coalition most commonly occurs at the middle facet of the subtalar joint.

Question 3606

Topic: 8. Foot and Ankle

A 28-year-old male sustains a pronation-external rotation (PER) ankle fracture. Operative fixation of the fibula and medial malleolus is performed. Intraoperative stress testing reveals widening of the medial clear space, and a syndesmotic screw is planned. At what distance above the tibial plafond should the syndesmotic screw ideally be placed to biomechanically optimize stabilization without violating the joint capsule?

. 1 to 1.5 cm
. 2 to 3 cm
. 4 to 5 cm
. 6 to 7 cm
. 8 to 9 cm

Correct Answer & Explanation

. 2 to 3 cm

Explanation

Syndesmotic screws are typically placed 2 to 3 cm proximal to the tibial plafond. This level avoids the distal tibiofibular joint capsule while providing optimal biomechanical stability to the healing syndesmosis.

Question 3607

Topic: Midfoot & Hindfoot
A 55-year-old female presents with Stage IIB posterior tibial tendon dysfunction (flexible pes planovalgus with >30% uncoverage of the talar head). She has failed conservative management. Surgical reconstruction is planned, including a flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO). What additional procedure is most critical to correct the forefoot abduction deformity?
. Subtalar arthrodesis
. Lateral column lengthening
. First tarsometatarsal arthrodesis
. Spring ligament reconstruction
. Evans osteotomy of the cuboid

Correct Answer & Explanation

. Lateral column lengthening

Explanation

In Stage IIB PTTD with significant forefoot abduction (indicated by talar head uncoverage), a medial displacement calcaneal osteotomy alone is insufficient. A lateral column lengthening (e.g., Evans osteotomy of the calcaneus) is required to restore talonavicular joint alignment and correct the abduction.

Question 3608

Topic: 8. Foot and Ankle

A 35-year-old male sustains an acute ankle injury after a fall. Radiographs demonstrate a displaced distal fibula fracture with fixed posterior subluxation of the talus. Closed reduction in the emergency department under conscious sedation is unsuccessful. What anatomic structure is most likely impeding the reduction of the fibula?

. Peroneal tendons
. Posterior tibiofibular ligament
. Anterior edge of the posterior tibial tubercle (Volkmann's incisura)
. Medial malleolus
. Flexor hallucis longus tendon

Correct Answer & Explanation

. Anterior edge of the posterior tibial tubercle (Volkmann's incisura)

Explanation

A Bosworth fracture-dislocation involves the proximal fibular fragment becoming locked behind the posterior tubercle of the distal tibia (Volkmann's incisura). Closed reduction is typically impossible, necessitating urgent open reduction and internal fixation to prevent skin necrosis.

Question 3609

Topic: 8. Foot and Ankle

A 24-year-old male with Charcot-Marie-Tooth disease presents with a progressive bilateral cavovarus foot deformity. The Coleman block test demonstrates that the hindfoot varus is flexible and completely corrects when the first metatarsal is allowed to drop off the block. What is the primary driving force for the hindfoot varus in this patient?

. Weakness of the tibialis posterior
. Plantarflexed first ray driven by peroneus longus overpull
. Contracture of the Achilles tendon
. Overactivity of the tibialis anterior
. Rigid subtalar joint arthritis

Correct Answer & Explanation

. Plantarflexed first ray driven by peroneus longus overpull

Explanation

In CMT-associated cavovarus foot, the relatively spared peroneus longus overpowers the weak tibialis anterior, leading to a plantarflexed first ray. This rigid plantarflexed first ray acts as a 'kickstand,' forcing the flexible hindfoot into a compensatory varus alignment during stance.

Question 3610

Topic: 8. Foot and Ankle

A 42-year-old man presents with chronic lateral hindfoot pain and difficulty walking on uneven ground, 18 months after nonoperative treatment of a displaced intra-articular calcaneus fracture. Examination reveals restricted subtalar motion and subfibular impingement. Radiographs show a healed calcaneus with loss of Bohler's angle, lateral wall blow-out, and subtalar arthritis. What is the most appropriate surgical management?

. Subtalar arthrodesis alone
. Subtalar arthrodesis with lateral wall exostectomy (in situ)
. Distraction bone block subtalar arthrodesis with lateral wall exostectomy
. Triple arthrodesis
. Calcaneal osteotomy without arthrodesis

Correct Answer & Explanation

. Distraction bone block subtalar arthrodesis with lateral wall exostectomy

Explanation

A calcaneal malunion typically presents with loss of height, lateral wall exostosis causing subfibular impingement, and subtalar arthritis. Distraction bone block subtalar arthrodesis restores calcaneal height and talar declination, while lateral wall exostectomy relieves the subfibular peroneal impingement.

Question 3611

Topic: 8. Foot and Ankle

A 45-year-old female presents with severe insertional Achilles tendinopathy that has failed 6 months of conservative management. During surgical debridement of the tendon and excision of the Haglund's deformity, it is determined that 60% of the Achilles insertion must be detached. Which of the following is the most appropriate next step in management?

. Reattachment of the Achilles tendon with suture anchors alone
. Flexor hallucis longus (FHL) tendon transfer
. Peroneus brevis tendon transfer
. Gastrocnemius recession
. V-Y tendon lengthening

Correct Answer & Explanation

. Flexor hallucis longus (FHL) tendon transfer

Explanation

When more than 50% of the Achilles tendon insertion is compromised or detached during debridement, augmentation with a tendon transfer is indicated. The flexor hallucis longus (FHL) is the preferred transfer due to its strength, axis of pull, and proximity.

Question 3612

Topic: 8. Foot and Ankle

A 14-year-old boy with Charcot-Marie-Tooth (CMT) disease presents with a progressive bilateral cavovarus foot deformity. Which of the following muscle imbalances is the primary driver of the hindfoot varus deformity in this patient?

. Tibialis anterior overpowering peroneus longus
. Tibialis posterior overpowering peroneus brevis
. Extensor hallucis longus overpowering flexor hallucis longus
. Gastrocnemius overpowering the intrinsic foot muscles
. Peroneus brevis overpowering tibialis posterior

Correct Answer & Explanation

. Tibialis posterior overpowering peroneus brevis

Explanation

In CMT, the hindfoot varus is primarily driven by a strong tibialis posterior overpowering a weak peroneus brevis. The forefoot cavus (plantarflexed first ray) is caused by a strong peroneus longus overpowering a weak tibialis anterior.

Question 3613

Topic: 8. Foot and Ankle

A 24-year-old snowboarder presents with lateral ankle pain and swelling after a hard landing. Radiographs are negative for an acute lateral malleolus fracture, but a CT scan reveals a displaced fracture of the lateral process of the talus. Which of the following is the most appropriate management for a lateral process fracture displaced by 4 mm?

. Non-weight-bearing cast for 6 weeks
. Weight-bearing in a controlled ankle motion (CAM) boot for 4 weeks
. Open reduction and internal fixation (ORIF)
. Primary subtalar arthrodesis
. Excision of the fracture fragment

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF)

Explanation

Fractures of the lateral process of the talus (snowboarder's fracture) that are displaced >2 mm or involve a significant articular step-off should be treated with ORIF. Nonoperative management of displaced fractures can lead to subtalar arthritis and chronic pain.

Question 3614

Topic: Midfoot & Hindfoot

A 22-year-old collegiate football player sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial and middle cuneiforms. He undergoes operative intervention. According to recent literature, which of the following outcomes is associated with primary arthrodesis compared to open reduction and internal fixation (ORIF) for this specific injury pattern?

. Higher rate of hardware failure
. Lower rate of return to sport
. Decreased incidence of secondary procedures
. Increased incidence of midfoot arthritis
. Inferior midfoot clinical outcome scores at 2 years

Correct Answer & Explanation

. Decreased incidence of secondary procedures

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis has been shown to result in a decreased incidence of secondary procedures (such as hardware removal or salvage fusion) compared to ORIF. Short- and mid-term functional scores are generally similar or slightly favor primary arthrodesis in purely ligamentous patterns.

Question 3615

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with progressive flattening of her left arch and medial ankle pain. Examination reveals a flexible hindfoot valgus, inability to perform a single-leg heel raise, and forefoot abduction of 30 degrees (positive 'too many toes' sign). Radiographs confirm Stage IIb posterior tibial tendon dysfunction. Which surgical intervention is most appropriate?

. Primary talonavicular arthrodesis
. FDL transfer to the navicular and medial displacement calcaneal osteotomy alone
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis
. Gastrocnemius recession alone

Correct Answer & Explanation

. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening

Explanation

Stage IIb adult acquired flatfoot deformity involves a flexible hindfoot with significant forefoot abduction (often >30-40% uncoverage of the talar head). Management typically requires FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening (Evans osteotomy or calcaneocuboid distraction arthrodesis) to correct the abduction.

Question 3616

Topic: 8. Foot and Ankle
A 30-year-old man sustains a Hawkins Type III talar neck fracture following a motor vehicle collision. Which of the following represents the primary blood supply to the talar body that is most commonly disrupted in this injury?
. Artery of the tarsal sinus
. Artery of the tarsal canal
. Dorsalis pedis artery branches
. Deltoid branch of the posterior tibial artery
. Peroneal artery perforators

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, provides the dominant blood supply to the talar body. In a Hawkins Type III fracture (talar neck fracture with subtalar and ankle joint dislocation), this blood supply is reliably disrupted, leading to high rates of avascular necrosis.

Question 3617

Topic: Forefoot

A 60-year-old male complains of progressive dorsal foot pain and stiffness of his great toe. Radiographs show severe joint space narrowing, dorsal osteophytes, and subchondral sclerosis at the first metatarsophalangeal (MTP) joint. Clinical exam demonstrates less than 10 degrees of dorsiflexion. What is the most reliable surgical treatment for long-term pain relief in this patient?

. Cheilectomy
. Moberg osteotomy
. First MTP joint arthrodesis
. Keller resection arthroplasty
. Silicone implant arthroplasty

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

This patient has severe (Coughlin Grade 3 or 4) hallux rigidus. First MTP joint arthrodesis is the gold standard and most reliable surgical treatment for end-stage hallux rigidus, providing predictable pain relief and functional restoration.

Question 3618

Topic: 8. Foot and Ankle

Which of the following is true regarding the nonoperative management of acute Achilles tendon ruptures when utilizing an early functional rehabilitation protocol?

. The re-rupture rate is significantly higher than with operative management.
. The risk of sural nerve injury is higher than with operative management.
. The re-rupture rate is statistically similar to operative management.
. Patients have significantly decreased plantarflexion strength at 2 years compared to traditional cast immobilization.
. Early functional rehabilitation requires strict non-weight-bearing for the first 6 weeks.

Correct Answer & Explanation

. The re-rupture rate is statistically similar to operative management.

Explanation

Recent high-quality evidence shows that when early functional rehabilitation (early weight-bearing and ROM in a boot) is utilized, the re-rupture rates between nonoperative and operative management of Achilles tendon ruptures are statistically similar. Operative management does, however, carry a higher risk of complications such as infection and sural nerve injury.

Question 3619

Topic: 8. Foot and Ankle

During the operative fixation of a severely displaced intra-articular calcaneus fracture, the surgeon must identify the 'constant fragment' to aid in the reduction of the remaining fracture pieces. Which of the following anatomical structures defines the constant fragment?

. The lateral wall attached to the calcaneofibular ligament
. The posterior tuberosity attached to the Achilles tendon
. The anteromedial fragment encompassing the sustentaculum tali
. The anterior process articulating with the cuboid
. The posterolateral fragment articulating with the fibula

Correct Answer & Explanation

. The anteromedial fragment encompassing the sustentaculum tali

Explanation

The anteromedial fragment, which includes the sustentaculum tali, remains firmly attached to the talus via the strong interosseous talocalcaneal and deltoid ligaments. This is known as the 'constant fragment' and serves as the foundation to which the rest of the calcaneus is reduced.

Question 3620

Topic: 8. Foot and Ankle

A 12-year-old boy presents with rigid flatfeet and recurrent ankle sprains. Radiographs are suspicious for a tarsal coalition. Which imaging view is most appropriate to clearly identify a talocalcaneal coalition involving the middle facet?

. Anteroposterior view of the foot
. Lateral view of the ankle
. Harris axial view of the heel
. Oblique view of the foot
. Canale view

Correct Answer & Explanation

. Harris axial view of the heel

Explanation

The Harris axial view (calcaneal axial view) is specifically utilized to visualize the posterior and middle facets of the subtalar joint. It is the best plain radiographic view to diagnose a talocalcaneal coalition.

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