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8. Foot and Ankle MCQs

Practice Set 197 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 3921

Topic: 8. Foot and Ankle

A 60-year-old man with long-standing poorly controlled diabetes presents with a unilaterally swollen, red, and warm right foot. He denies trauma. Pedal pulses are bounding. Radiographs demonstrate mild osteopenia but no fractures or dislocations. What is the most appropriate initial management?

. Intravenous antibiotics and emergent surgical debridement
. Prescription for a rocker-bottom shoe
. Application of a total contact cast (TCC)
. Immediate open reduction and internal fixation of the midfoot
. Recommendation to apply ice and elevate the foot at home

Correct Answer & Explanation

. Intravenous antibiotics and emergent surgical debridement

Explanation

The clinical presentation is classic for Eichenholtz Stage 0 Charcot arthropathy (inflammation without radiographic destruction). Prompt offloading with a total contact cast is required to prevent progression to bone destruction and deformity.

Question 3922

Topic: 8. Foot and Ankle

A 48-year-old man complains of pain localized to the dorsal aspect of his right first metatarsophalangeal (MTP) joint, particularly during the push-off phase of walking. Radiographs demonstrate a prominent dorsal osteophyte on the first metatarsal head, but the joint space remains well-preserved. What is the best initial surgical option if non-operative management fails?

. Cheilectomy
. First MTP arthrodesis
. First MTP total joint arthroplasty
. Keller resection arthroplasty
. Proximal phalanx osteotomy (Akin)

Correct Answer & Explanation

. Cheilectomy

Explanation

In early-stage hallux rigidus (Coughlin and Shurnas Grade 1 or 2) where the joint space is preserved but dorsal osteophytes limit dorsiflexion, a cheilectomy (removal of the dorsal bone spur and dorsal 30% of the metatarsal head) is the procedure of choice.

Question 3923

Topic: 8. Foot and Ankle

A 26-year-old man sustains an external rotation injury to his right ankle. Radiographs show a proximal third fibula fracture (Maisonneuve fracture) and widening of the medial clear space on the AP ankle view. For this specific injury pattern to occur, which of the following structures MUST be disrupted?

. Calcaneofibular ligament
. Spring ligament
. Interosseous membrane
. Anterior process of the calcaneus
. Bifurcate ligament

Correct Answer & Explanation

. Calcaneofibular ligament

Explanation

A Maisonneuve fracture involves a proximal fibular fracture associated with a syndesmotic injury. The force transmission tears the deltoid ligament (or medial malleolus), the anterior inferior tibiofibular ligament, and the interosseous membrane up to the level of the fibular fracture.

Question 3924

Topic: 8. Foot and Ankle

A 67-year-old woman with end-stage post-traumatic ankle osteoarthritis is considering surgical options. She asks about a total ankle arthroplasty (TAA). Which of the following conditions is an absolute contraindication to performing a TAA?

. Age greater than 65 years
. Body mass index of 28
. Mild to moderate obesity
. Presence of hardware from a previous fracture
. Severe peripheral neuropathy with loss of protective sensation

Correct Answer & Explanation

. Age greater than 65 years

Explanation

Severe peripheral neuropathy (often associated with diabetes or Charcot arthropathy), active infection, and extensive avascular necrosis of the talus are absolute contraindications for total ankle arthroplasty.

Question 3925

Topic: 8. Foot and Ankle

A 35-year-old weekend warrior undergoes minimally invasive surgical repair for an acute midsubstance Achilles tendon rupture. Postoperatively, he reports numbness along the lateral aspect of his foot. Which nerve was most likely injured during the procedure?

. Superficial peroneal nerve
. Sural nerve
. Tibial nerve
. Deep peroneal nerve
. Saphenous nerve

Correct Answer & Explanation

. Superficial peroneal nerve

Explanation

The sural nerve crosses from medial to lateral over the Achilles tendon approximately 10 cm proximal to its insertion. It is the structure most at risk during percutaneous or minimally invasive Achilles repairs.

Question 3926

Topic: 8. Foot and Ankle

A 50-year-old man is undergoing operative intervention for severe, recalcitrant insertional Achilles tendinopathy with a prominent Haglund's deformity. The surgeon plans a retrocalcaneal exostectomy and debridement of the diseased tendon. Up to what percentage of the Achilles tendon insertion can typically be detached and primarily repaired without requiring an augmentation transfer (e.g., FHL)?

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

Correct Answer & Explanation

. 10%

Explanation

Most literature supports that up to 50% of the Achilles tendon insertion can be safely detached and repaired using suture anchors. If more than 50% is compromised, a flexor hallucis longus (FHL) transfer is typically recommended to augment the repair.

Question 3927

Topic: 8. Foot and Ankle

A 16-year-old girl presents with a 3-month history of insidious forefoot pain, localized to the second metatarsophalangeal joint. Radiographs show flattening, sclerosis, and fragmentation of the second metatarsal head. What is the most likely diagnosis?

. Sever's disease
. Freiberg's infraction
. Kohler's disease
. Morton's neuroma
. Stress fracture of the metatarsal shaft

Correct Answer & Explanation

. Sever's disease

Explanation

Freiberg's infraction is avascular necrosis of a metatarsal head, most commonly affecting the second metatarsal in adolescent females. Radiographs classically show flattening and subchondral sclerosis of the metatarsal head.

Question 3928

Topic: 8. Foot and Ankle

A 30-year-old construction worker sustains a severe crush injury to his foot. The foot is tensely swollen, and he has excruciating pain with passive toe extension. If a foot compartment syndrome is missed and left untreated, what is the classic late clinical deformity that develops?

. Equinovarus deformity
. Pes planovalgus deformity
. Hallux valgus
. Claw toe deformity
. Drop foot

Correct Answer & Explanation

. Equinovarus deformity

Explanation

Unrecognized compartment syndrome of the foot leads to ischemic contracture of the intrinsic foot musculature. The classic late sequela is severe, rigid claw toe deformities.

Question 3929

Topic: 8. Foot and Ankle

A 24-year-old football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs show a 3 mm diastasis between the base of the first and second metatarsals without associated fractures.

What is the most appropriate management for this purely ligamentous injury?

. Rigid CAM boot for 6 weeks
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with trans-articular screws
. Primary partial midfoot arthrodesis
. Primary total midfoot arthrodesis

Correct Answer & Explanation

. Rigid CAM boot for 6 weeks

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the first, second, and third tarsometatarsal joints provides better long-term functional outcomes and lower revision rates compared to ORIF. ORIF is generally preferred for bony Lisfranc fracture-dislocations.

Question 3930

Topic: 8. Foot and Ankle

A 45-year-old man undergoes percutaneous repair of an acute Achilles tendon rupture. Postoperatively, he notes numbness along the lateral aspect of his foot. At what location relative to the calcaneal insertion was the injured nerve most likely compromised during the percutaneous approach?

. 2 to 4 cm proximal to the insertion
. 5 to 7 cm proximal to the insertion
. 9 to 12 cm proximal to the insertion
. 15 to 18 cm proximal to the insertion
. At the musculotendinous junction

Correct Answer & Explanation

. 2 to 4 cm proximal to the insertion

Explanation

The sural nerve is at greatest risk during percutaneous Achilles repair. It crosses the lateral border of the Achilles tendon from lateral to medial at an average of 9.8 cm (range, 7-13 cm) proximal to the calcaneal insertion.

Question 3931

Topic: 8. Foot and Ankle

A 30-year-old motorcyclist sustains a high-energy trauma resulting in a severe foot and ankle injury. Radiographs reveal a talar neck fracture with complete dislocation of the talar body from both the subtalar and tibiotalar joints.

According to the Hawkins classification, what is the estimated rate of avascular necrosis (AVN) of the talar body?

. 0-10%
. 20-30%
. 40-50%
. 80-100%
. AVN rate in this pattern is independent of displacement

Correct Answer & Explanation

. 0-10%

Explanation

This is a Hawkins type III talar neck fracture, characterized by displacement of the talar body from the subtalar and tibiotalar joints. The disruption of all three major blood supplies leads to an AVN rate approaching 80-100%.

Question 3932

Topic: 8. Foot and Ankle

A 42-year-old woman sustains a trimalleolar equivalent ankle fracture with a large posterior malleolus fragment involving 35% of the articular surface. During operative fixation, which of the following interventions provides the greatest biomechanical stability to the distal tibiofibular syndesmosis?

. Single tricortical trans-syndesmotic screw
. Double quadricortical trans-syndesmotic screws
. Trans-syndesmotic suture-button construct
. Anatomical internal fixation of the posterior malleolus
. Direct repair of the anterior inferior tibiofibular ligament

Correct Answer & Explanation

. Single tricortical trans-syndesmotic screw

Explanation

The posterior inferior tibiofibular ligament (PITFL) provides the majority of syndesmotic stability. Anatomical fixation of a posterior malleolus fragment restores the PITFL tension, providing greater syndesmotic stiffness than trans-syndesmotic screws alone.

Question 3933

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled diabetes mellitus presents with a red, hot, swollen, and painless left foot.

Radiographs demonstrate acute periarticular fragmentation and debris around the midfoot, with no clinical signs of an open ulcer or osteomyelitis. Which of the following is the most appropriate initial management?

. Intravenous antibiotics and surgical debridement
. Total contact casting and non-weight bearing
. Open reduction and rigid internal fixation
. Primary midfoot arthrodesis
. Below-knee amputation

Correct Answer & Explanation

. Intravenous antibiotics and surgical debridement

Explanation

This patient has acute Eichenholtz Stage I Charcot arthropathy. The gold standard for initial management is strict immobilization and offloading, typically achieved with a total contact cast (TCC).

Question 3934

Topic: Forefoot

A 60-year-old man presents with severe pain and stiffness in his first metatarsophalangeal (MTP) joint. Radiographs show joint space obliteration, a large dorsal osteophyte, and subchondral sclerosis. He has pain throughout the entire arc of motion. What is the most reliable surgical treatment for long-term pain relief?

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

Correct Answer & Explanation

. Cheilectomy

Explanation

The patient has advanced (Grade 3/4) hallux rigidus with pain through the entire range of motion. Arthrodesis of the first MTP joint is the gold standard, providing the most reliable long-term pain relief and functional improvement.

Question 3935

Topic: 8. Foot and Ankle

A 30-year-old equestrian falls from a horse, landing with her foot plantarflexed. She presents with midfoot pain, significant dorsal swelling, and plantar ecchymosis. Initial non-weight-bearing radiographs appear unremarkable.

What is the best initial diagnostic step to evaluate for a subtle Lisfranc injury?

. Non-weight-bearing MRI of the foot
. Non-weight-bearing CT scan of the foot
. Weight-bearing AP, lateral, and oblique radiographs of the foot
. Bone scan of the foot
. Diagnostic ultrasound of the tarsometatarsal joints

Correct Answer & Explanation

. Non-weight-bearing MRI of the foot

Explanation

Weight-bearing radiographs are essential for identifying subtle, dynamic Lisfranc instability, which is indicated by a gap greater than 2 mm between the bases of the first and second metatarsals or subtle dorsal displacement on the lateral view.

Question 3936

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with a painful, progressive flatfoot deformity. Clinical examination reveals a "too-many-toes" sign, flexible hindfoot valgus, and more than 30% uncovering of the talonavicular joint with forefoot abduction. She is unable to perform a single-limb heel rise. What is the most appropriate surgical management if conservative treatment fails?

. Isolated medial displacement calcaneal osteotomy
. Flexor digitorum longus (FDL) transfer with lateral column lengthening
. Subtalar arthrodesis
. Triple arthrodesis
. Gastrocnemius recession alone

Correct Answer & Explanation

. Isolated medial displacement calcaneal osteotomy

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction (flexible flatfoot with significant forefoot abduction). Lateral column lengthening, combined with an FDL transfer, is required to correct the severe forefoot abduction.

Question 3937

Topic: Forefoot

A 50-year-old man presents with pain in his right big toe that is worse during the toe-off phase of gait. Examination shows a palpable dorsal prominence and limited, painful dorsiflexion. Radiographs reveal dorsal osteophytes with preservation of the plantar joint space. What is the most appropriate initial surgical treatment if orthotics fail?

. First MTP arthrodesis
. Dorsal cheilectomy
. Keller resection arthroplasty
. Silicone implant arthroplasty
. Metatarsal osteotomy (Weil)

Correct Answer & Explanation

. First MTP arthrodesis

Explanation

This describes Coughlin and Shurnas Grade 2 hallux rigidus. Symptomatic Grade 1 and 2 hallux rigidus with preserved plantar articular cartilage is appropriately treated with dorsal cheilectomy to remove impinging bone and improve dorsiflexion.

Question 3938

Topic: 8. Foot and Ankle

A 60-year-old man with poorly controlled diabetes presents with a unilaterally red, hot, swollen, and painless foot. Pulses are bounding. Initial radiographs show soft tissue swelling but no acute fracture or dislocation. What is the most appropriate immediate management?

. Immediate open reduction and internal fixation
. Intravenous antibiotics and bone biopsy
. Incision and drainage
. Total contact casting and strict non-weight-bearing
. Arthrodesis of the midfoot

Correct Answer & Explanation

. Immediate open reduction and internal fixation

Explanation

This is a classic presentation of acute, Stage 0 Charcot arthropathy. The immediate priority is mechanical offloading with a total contact cast to prevent catastrophic structural collapse during the active inflammatory phase.

Question 3939

Topic: 8. Foot and Ankle

Recent meta-analyses comparing operative versus non-operative management of acute Achilles tendon ruptures using early functional rehabilitation bracing protocols have demonstrated which of the following outcomes?

. Operative management has a significantly lower re-rupture rate
. Non-operative management has a significantly lower re-rupture rate
. Re-rupture rates are similar, but operative management has a higher risk of wound complications
. Non-operative management leads to significantly greater plantarflexion strength
. Operative management has a shorter time to return to walking without a boot

Correct Answer & Explanation

. Operative management has a significantly lower re-rupture rate

Explanation

When early functional rehabilitation protocols are utilized, the re-rupture rates between operative and non-operative management are nearly identical. However, operative management carries an inherently higher risk of wound complications and infection.

Question 3940

Topic: 8. Foot and Ankle

A 25-year-old man complains of persistent lateral ankle pain 6 months after a severe inversion sprain. MRI demonstrates an osteochondral lesion of the talar dome. Which of the following best describes the typical characteristics of an anterolateral talar osteochondral lesion?

. Shallow, wafer-shaped, and strongly associated with a history of trauma
. Deep, cup-shaped, and strongly associated with a history of trauma
. Shallow, wafer-shaped, and primarily idiopathic
. Deep, cup-shaped, and rarely associated with trauma
. Cystic, expanding, and exclusively posterior in location

Correct Answer & Explanation

. Shallow, wafer-shaped, and strongly associated with a history of trauma

Explanation

Anterolateral osteochondral lesions of the talus are classically shallow, wafer-like, and nearly always associated with a prior traumatic event (inversion and dorsiflexion). Posteromedial lesions are typically deep, cup-shaped, and less consistently tied to acute trauma.

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