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8. Foot and Ankle MCQs

Practice Set 199 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 3961

Topic: 8. Foot and Ankle

A 35-year-old female sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial cuneiform and 2nd metatarsal. Based on recent prospective randomized trials, what is the recommended surgical management for optimal functional outcomes?

. Open reduction and internal fixation with transarticular screws
. Primary arthrodesis of the 1st, 2nd, and 3rd tarsometatarsal joints
. Closed reduction and percutaneous pinning
. Dorsal bridge plating without joint preparation
. Non-operative management in a rigid cast for 8 weeks

Correct Answer & Explanation

. Open reduction and internal fixation with transarticular screws

Explanation

Prospective randomized trials have demonstrated that primary arthrodesis for purely ligamentous Lisfranc injuries yields superior functional outcomes and significantly lower reoperation rates compared to ORIF.

Question 3962

Topic: 8. Foot and Ankle

A 19-year-old athlete complains of severe midfoot pain after an axial load was applied to his plantarflexed foot. Non-weight-bearing radiographs in the emergency department are normal. What is the most appropriate next step in diagnosis?

. Weight-bearing radiographs of the foot
. Computed tomography (CT) of the ankle
. Diagnostic ultrasound of the plantar fascia
. Bone scintigraphy
. Discharge with a diagnosis of midfoot sprain

Correct Answer & Explanation

. Weight-bearing radiographs of the foot

Explanation

The initial step in evaluating a suspected subtle Lisfranc injury with normal non-weight-bearing radiographs is obtaining weight-bearing AP, lateral, and oblique views. These stress the midfoot and may reveal dynamic diastasis or arch collapse.

Question 3963

Topic: 8. Foot and Ankle

During open reduction and internal fixation of a severe, multi-column Lisfranc fracture-dislocation, what is the universally accepted correct sequence of reduction and fixation?

. 1st TMT joint, followed by 2nd TMT, then lateral columns
. Lateral columns (4th/5th TMT), followed by the medial column
. 2nd TMT joint, followed by the 1st TMT, then 3rd TMT
. 3rd TMT joint, followed by 2nd TMT, then 1st TMT
. Simultaneous temporary pinning of all columns before screw fixation

Correct Answer & Explanation

. 1st TMT joint, followed by 2nd TMT, then lateral columns

Explanation

The base of the 2nd metatarsal acts as the 'keystone' of the midfoot arch. Surgical reconstruction must begin with the anatomic reduction and stabilization of the 2nd TMT joint to the medial cuneiform, followed by the 1st TMT, 3rd TMT, and finally the lateral columns if needed.

Question 3964

Topic: 8. Foot and Ankle

A 55-year-old male presents with severe midfoot pain and a progressive planovalgus deformity. He was diagnosed with a 'foot sprain' 1 year ago. Radiographs demonstrate advanced degenerative changes at the tarsometatarsal joints with lateral subluxation. What is the most appropriate surgical treatment?

. Midfoot arthrodesis with realignment
. Open reduction and internal fixation with joint preservation
. Tendon transfer of the tibialis posterior to the dorsum of the foot
. Subtalar arthrodesis
. Excision of the proximal metatarsal bases

Correct Answer & Explanation

. Midfoot arthrodesis with realignment

Explanation

Late or missed Lisfranc injuries that present with post-traumatic arthritis and fixed midfoot deformity are best managed with realignment midfoot arthrodesis to relieve pain and restore a plantigrade foot.

Question 3965

Topic: Midfoot & Hindfoot

A 58-year-old male with long-standing, poorly controlled diabetes presents with a red, hot, swollen foot. He has bounding pedal pulses and intact skin. Radiographs show early fragmentation and subluxation of the midfoot. What is the most appropriate initial management?

. Intravenous antibiotics and surgical debridement
. Total contact casting and non-weight-bearing
. Immediate midfoot arthrodesis with robust hardware
. Incision and drainage
. Prescription of custom accommodative orthotics and weight-bearing as tolerated

Correct Answer & Explanation

. Intravenous antibiotics and surgical debridement

Explanation

The clinical picture describes acute Eichenholtz Stage I Charcot arthropathy. The gold standard for initial management is immediate offloading with a total contact cast to arrest progression and prevent catastrophic deformity while the acute inflammation subsides.

Question 3966

Topic: 8. Foot and Ankle

A 62-year-old female with neuropathy presents with a chronic, uninfected plantar forefoot ulcer beneath the 3rd metatarsal head. It is classified as Wagner Grade 1. What intervention has the highest level of evidence for achieving ulcer healing?

. Total contact casting (TCC)
. Daily wet-to-dry dressings
. Surgical excision of the 3rd metatarsal head
. Hyperbaric oxygen therapy
. Topical negative pressure wound therapy (wound VAC)

Correct Answer & Explanation

. Total contact casting (TCC)

Explanation

Total contact casting (TCC) is considered the gold standard for offloading and healing uncomplicated, non-infected plantar diabetic foot ulcers, consistently demonstrating the highest healing rates in randomized controlled trials.

Question 3967

Topic: 8. Foot and Ankle

A diabetic patient is being evaluated for a minor forefoot amputation due to a non-healing distal ulcer. Which of the following non-invasive vascular parameters represents the minimum threshold predictive of reliable wound healing?

. Ankle-Brachial Index (ABI) of 0.3
. Transcutaneous oxygen tension (TcPO2) > 30 mm Hg
. Toe absolute pressure of 15 mm Hg
. Serum albumin of 2.1 g/dL
. Total lymphocyte count of 800/mm3

Correct Answer & Explanation

. Ankle-Brachial Index (ABI) of 0.3

Explanation

A transcutaneous oxygen tension (TcPO2) greater than 30 mm Hg, an ABI > 0.45, toe pressures > 40 mm Hg, albumin > 3.0 g/dL, and TLC > 1500 are standard thresholds that predict adequate perfusion and nutrition for surgical wound healing in diabetics.

Question 3968

Topic: 8. Foot and Ankle

A 65-year-old diabetic patient has a recurrent uninfected plantar ulcer beneath the 1st metatarsal head despite optimal orthotics. Examination demonstrates 5 degrees of ankle plantarflexion with the knee extended, but 15 degrees of dorsiflexion with the knee flexed. What is the most appropriate surgical adjunct to aid in offloading?

. First metatarsophalangeal joint arthrodesis
. Gastrocnemius recession
. Percutaneous Achilles tendon lengthening
. First tarsometatarsal arthrodesis
. Dorsiflexion osteotomy of the 1st metatarsal

Correct Answer & Explanation

. First metatarsophalangeal joint arthrodesis

Explanation

The Silfverskiöld test is positive for an isolated gastrocnemius contracture (equinus). This contracture increases forefoot plantar pressures. A gastrocnemius recession effectively decreases these pressures, facilitating ulcer healing.

Question 3969

Topic: 8. Foot and Ankle

A 52-year-old diabetic male has a stable, rigid midfoot Charcot deformity with a prominent plantar-medial bony bossing. He has developed 3 recurrent, non-infected ulcers over this specific prominence despite custom total contact orthotics. What is the most appropriate surgical management?

. Below-knee amputation
. Midfoot arthrodesis with internal fixation
. Exostectomy of the bony prominence
. Triple arthrodesis
. Application of a circular ring external fixator

Correct Answer & Explanation

. Below-knee amputation

Explanation

In a patient with a rigid, stable Charcot foot and localized recurrent ulceration due to a bony prominence, a simple exostectomy (shaving the prominent bone) is highly effective, carries low morbidity, and avoids the high complication rates of major reconstructive arthrodesis.

Question 3970

Topic: 8. Foot and Ankle

A 40-year-old female sustains a pronation-abduction (PAB) ankle fracture. According to the Lauge-Hansen classification system, what represents the first stage (Stage I) of this specific injury mechanism?

. Rupture of the anterior inferior tibiofibular ligament (AITFL)
. Transverse fracture of the medial malleolus or rupture of the deltoid ligament
. Spiral fracture of the distal fibula
. Fracture of the posterior malleolus
. Comminuted fracture of the distal tibial plafond

Correct Answer & Explanation

. Rupture of the anterior inferior tibiofibular ligament (AITFL)

Explanation

In the Lauge-Hansen Pronation-Abduction (PAB) sequence, the foot is pronated (tensioning medial structures). Stage I is a transverse medial malleolar fracture or deltoid rupture. Stage II is syndesmotic rupture, and Stage III is an oblique/transverse fibular fracture.

Question 3971

Topic: Midfoot & Hindfoot

Total contact casting (TCC) is considered the gold standard for offloading diabetic plantar foot ulcers. Which of the following is an absolute contraindication to the application of a TCC?

. Wagner Grade 1 forefoot ulcer
. Wagner Grade 2 midfoot ulcer
. Active deep space abscess or acute osteomyelitis
. Stable Charcot arthropathy (Eichenholtz Stage III)
. Loss of protective sensation (LOPS)

Correct Answer & Explanation

. Wagner Grade 1 forefoot ulcer

Explanation

Absolute contraindications to Total Contact Casting (TCC) include active deep infection (abscess, gangrene, acute osteomyelitis) and severe peripheral arterial disease, as enclosing an infected or profoundly ischemic limb can lead to rapid limb loss.

Question 3972

Topic: 8. Foot and Ankle

A subtle radiographic finding indicative of a Lisfranc injury is the "fleck sign". This sign represents a bony avulsion of the Lisfranc ligament from which of the following anatomic locations?

. Lateral aspect of the medial cuneiform
. Medial aspect of the second metatarsal base
. Medial aspect of the first metatarsal base
. Lateral aspect of the second metatarsal base
. Plantar aspect of the navicular

Correct Answer & Explanation

. Lateral aspect of the medial cuneiform

Explanation

The 'fleck sign' represents a bony avulsion of the Lisfranc ligament. While the ligament spans from the medial cuneiform to the second metatarsal, the avulsion fragment (fleck) most commonly originates from the medial aspect of the base of the second metatarsal.

Question 3973

Topic: 8. Foot and Ankle

A 62-year-old diabetic male has a recurrent, non-healing plantar ulcer under the first metatarsal head despite 12 weeks of total contact casting. Ankle dorsiflexion is -10 degrees with the knee extended and -10 degrees with the knee flexed. Which of the following is the most appropriate surgical treatment to facilitate ulcer healing?

. Achilles tendon lengthening
. Gastrocnemius recession
. First metatarsophalangeal arthrodesis
. First metatarsal head resection
. Transmetatarsal amputation

Correct Answer & Explanation

. Achilles tendon lengthening

Explanation

The patient has a fixed equinus contracture with the knee extended and flexed, indicating a combined gastro-soleus contracture. An Achilles tendon lengthening (TAL) is required to reduce forefoot plantar pressure and heal the ulcer.

Question 3974

Topic: 8. Foot and Ankle

In the surgical management of a trimalleolar ankle fracture, anatomic reduction and internal fixation of the posterior malleolus is most strongly indicated to achieve which of the following biomechanical goals?

. Restore articular congruity and maximize syndesmotic stability
. Prevent post-traumatic arthritis of the subtalar joint
. Avoid the need for concurrent medial malleolar fixation
. Increase maximum postoperative ankle dorsiflexion
. Prevent anterior subluxation of the talus

Correct Answer & Explanation

. Restore articular congruity and maximize syndesmotic stability

Explanation

Fixation of the posterior malleolus restores the incisura fibularis, which significantly enhances syndesmotic stability. It also reconstructs the articular surface and limits posterior, not anterior, talar subluxation.

Question 3975

Topic: Midfoot & Hindfoot

A 45-year-old construction worker sustains a purely ligamentous Lisfranc injury involving the 1st, 2nd, and 3rd tarsometatarsal (TMT) joints. What is the most appropriate definitive management?

. Cast immobilization for 8 weeks and non-weight bearing
. Open reduction and screw fixation of all involved joints
. Primary arthrodesis of the medial three TMT joints
. Closed reduction and percutaneous K-wire fixation
. Primary arthrodesis of all five TMT joints

Correct Answer & Explanation

. Cast immobilization for 8 weeks and non-weight bearing

Explanation

Purely ligamentous Lisfranc injuries have a higher rate of hardware failure and loss of reduction with ORIF compared to primary arthrodesis. Arthrodesis of the medial three TMT joints provides superior long-term functional outcomes in these specific injuries.

Question 3976

Topic: 8. Foot and Ankle

A 55-year-old female with poorly controlled type 2 diabetes presents with a red, hot, swollen left foot. Radiographs show soft tissue swelling and mild osteopenia but no fractures. MRI shows diffuse marrow edema without focal fluid collections. Her ESR and CRP are normal. What is the most appropriate initial management?

. Intravenous antibiotics and emergent surgical debridement
. Total contact casting and strict non-weight bearing
. Primary midfoot arthrodesis with rigid fixation
. Intra-articular corticosteroid injection
. Empiric oral antibiotics for 6 weeks

Correct Answer & Explanation

. Intravenous antibiotics and emergent surgical debridement

Explanation

This presentation is classic for Eichenholtz stage 0 (acute) Charcot neuroarthropathy. The mainstay of treatment is strict offloading, typically with a total contact cast, to prevent joint collapse and progressive deformity.

Question 3977

Topic: 8. Foot and Ankle

A 28-year-old male sustains a twisting injury to his foot. Radiographs demonstrate a small bony avulsion fragment in the space between the bases of the first and second metatarsals. This fragment represents an avulsion of a structure that originates from which of the following bones?

. First metatarsal
. Medial cuneiform
. Intermediate cuneiform
. Navicular
. Cuboid

Correct Answer & Explanation

. First metatarsal

Explanation

The 'fleck sign' represents an avulsion fracture of the Lisfranc ligament. The Lisfranc ligament originates on the lateral aspect of the medial cuneiform and inserts on the medial base of the second metatarsal.

Question 3978

Topic: 8. Foot and Ankle

According to the Lauge-Hansen classification, a Supination-Adduction stage II ankle fracture typically presents with which of the following distinct fracture patterns?

. A transverse fibula fracture below the syndesmosis and a nearly vertical medial malleolus fracture
. A spiral fibula fracture above the syndesmosis
. A posterior malleolus fracture and transverse medial malleolus fracture
. A proximal fibula fracture associated with a syndesmotic tear
. Rupture of the anterior inferior tibiofibular ligament and a short oblique fibula fracture

Correct Answer & Explanation

. A transverse fibula fracture below the syndesmosis and a nearly vertical medial malleolus fracture

Explanation

Supination-adduction injuries begin with tension on the lateral side causing a transverse fibular fracture at or below the joint line (Stage I). This is followed by impaction of the talus into the medial malleolus, causing a vertical medial malleolus fracture (Stage II).

Question 3979

Topic: 8. Foot and Ankle

A 65-year-old patient with severe peripheral neuropathy and diabetes sustains a bimalleolar ankle fracture. Which surgical strategy is most appropriate to minimize the risk of catastrophic fixation failure and secondary Charcot arthropathy?

. Early active range of motion and weight-bearing to stimulate bone healing
. Use of bioabsorbable screws to minimize soft tissue irritation
. Standard ORIF with cast immobilization for exactly 4 weeks
. Augmented fixation with multiple syndesmotic screws or TTC nailing followed by prolonged non-weight bearing
. Percutaneous pinning to avoid soft tissue stripping

Correct Answer & Explanation

. Early active range of motion and weight-bearing to stimulate bone healing

Explanation

Diabetic ankle fractures have an exponentially higher complication rate, including fixation failure and Charcot neuroarthropathy. They require rigid, often augmented, internal fixation and prolonged non-weight bearing (often double the normal duration).

Question 3980

Topic: 8. Foot and Ankle

A 32-year-old athlete complains of persistent midfoot pain after a fall. Non-weight bearing radiographs in the emergency department appear normal. What is the next best step to evaluate for a subtle Lisfranc injury?

. Three-phase Technetium-99m bone scan
. Weight-bearing radiographs of the bilateral feet
. Diagnostic ultrasound of the dorsal foot
. CT scan of the foot without weight bearing
. In-office fluoroscopy with stress inversion

Correct Answer & Explanation

. Three-phase Technetium-99m bone scan

Explanation

Weight-bearing radiographs are essential to uncover subtle Lisfranc instability that may reduce spontaneously when the foot is not loaded. Bilateral comparison is useful to assess the normal anatomic alignment for the individual patient.

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