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8. Foot and Ankle MCQs

Practice Set 20 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 381

Topic: 8. Foot and Ankle

Which of the following statements describes the subtalar joint during walking:

. Heel strike to toe-off: Internal rotation of the tibia
. Heel strike to toe-off: Unlocking if transverse tarsal joint
. Heel strike to toe-off: Eversion of the subtalar joint
. Heel rise to toe-off: Eversion of the subtalar joint
. Heel rise to toe-off: Locking of the transverse tarsal joint

Correct Answer & Explanation

. Heel rise to toe-off: Locking of the transverse tarsal joint

Explanation

Discussion Because gait cycle questions are common on examinations, remember these points: Stance phase: 62% of cycle Swing phase: 38% of cycle Muscle firing Electromyography findings during gait cycle: Muscle Activity Heel strike Anterior tibialis Gastroc-soleus Eccentric contraction Quiet Foot flat Anterior tibialis Gastroc-soleus Quiet Eccentric contraction Heel-off Gastroc-soleus C oncentric contraction Toe-off Gastroc-soleus C oncentric contraction Subtalar joint Heel strike to foot flat: Three important points Eversion of the subtalar joint Unlocking of the transverse tarsal joint Internal rotation of the tibia Heel rise to toe-off Inversion of the subtalar joint Locking of the transverse tarsal joint External rotation of the tibia

Question 382

Topic: Midfoot & Hindfoot

Which of the following tendons is the main inverter of the hind foot:

. Peroneus longus tendon
. Peroneus brevis tendon
. Flexor hallucis longus tendon
. Flexor digitorum longus tendon
. Posterior tibial tendon

Correct Answer & Explanation

. Posterior tibial tendon

Explanation

p class="subHeader"> Discussion The posterior tibial tendon is the main inverter of the hindfoot. To conduct a sensitive test for posterior tibial tendon function, ask a patient to perform a single leg rise and observe if the hindfoot inverts. Patients with no posterior tibial tendon function are unable to invert the hindfoot on single leg rise.

Question 383

Topic: 8. Foot and Ankle

Which of the following statements about plantar fasciitis is true:

. Occurs in men more often than in women
. Bilateral involvement is rare
. Normal thickness of the plantar fascia is 15 mm
. Plantar fascia supports the medial longitudinal arch
. Plantar fascia inserts at the base of the metatarsals

Correct Answer & Explanation

. Plantar fascia supports the medial longitudinal arch

Explanation

Discussion Plantar fasciitis: General features Most common cause of heel pain Frequently occurs in athletes Men and women affected equally Symptoms are bilateral in 10% of patients C linical findings Pain on the bottom of the heel Pain is worse with first steps in the morning Pain is worse with weight bearing after sitting Pain is worse with activities of daily living Tenderness over the plantar fascia Pain is worsened by dorsiflexion of the toes Plantar fascia Broad, thick structure that originates from the medial calcaneal tuberosity and inserts on the plantar plates of the metatarsalphalangeal joints and proximal phalanges Supports the medial longitudinal arch Although the etiology of plantar fasciitis is not known, one theory is excessive stress on the plantar fascia causes micro tears Biopsies show fibroblastic proliferation and chronic granulomatous tissue The fascia can be as thick as 15 mm (3 mm is normal)

Question 384

Topic: Midfoot & Hindfoot

Which of the following statements describes the results of extracorporeal shock wave therapy for chronic plantar fasciitis:

. No improvement in pain scores occurred at 4 or 12 weeks.
. No improvement in pain scores occurred at 4 weeks, but significant improvement occurred at 12 weeks.
. Pain scores significantly improved at 4 and 12 weeks.
. Pain scores improved, but function did not improve.
. Although pain scores improved, less than 50% of the patients were satisfied.

Correct Answer & Explanation

. Pain scores significantly improved at 4 and 12 weeks.

Explanation

Discussion In a recent study in Orthopaedics, Furia showed that a significant improvement in pain and function scores occurred in patients who had plantar fasciitis treated with extracorporeal shock wave therapy. Approximately 80% of the patients were satisfied with the treatment and would have the shock wave treatment again. Results Pain Visual Analog Scale (VAS) Pre-treatment VAS 9.2 standard deviation (SD) 0.7 Post-treatment VAS (4 weeks) 3.4 SD 1.9 (P<.05) Post-treatment VAS (12 weeks) 2.4 SD dev 1.8 (P<.05) RAND Score Physical functioning Pre-treatment 40.4 SD 1.3 Post-treatment (4 weeks) 91.5 SD 11.5 (P<.05) Post-treatment (12 weeks) 91.5 SD 10.6 (P<.05) RAND Score Pain Pre-treatment 3.3 SD dev 1.1 Post-treatment (4 weeks) 88.6 SD 16 (P<.05) Post-treatment (12 weeks) 90.0 SD 11.6 (P<.05) Patient satisfaction At 4 and 12 weeks post treatment, 49 (82%) patients were satisfied, and all patients would undergo the procedure again.

Question 385

Topic: 8. Foot and Ankle

Treatment of significant loss of height and posttraumatic arthritis following nonoperative treatment of calcaneus fractures should include:

. Subtalar distraction bone block arthrodesis
. Corrective osteotomy
. Tibiotalocalcaneal arthrodesis
. Custom Arizona ankle brace with heel lift
. Custom orthotics with lateral heel posting

Correct Answer & Explanation

. Subtalar distraction bone block arthrodesis

Explanation

Management of late loss of height following calcaneus fracture is best addressed by a distraction arthrodesis of the subtalar joint using a wedge- shaped structural bone graft.

Question 386

Topic: 8. Foot and Ankle

The joint contact area of the second tarsometatarsal joint after Lisfranc dislocation diminishes the greatest with:

. Dorsolateral subluxation of the second metatarsal
. Dorsal subluxation of the second metatarsal
. Lateral subluxation of the second metatarsal
. Medial subluxation of the second metatarsal
. Plantar subluxation of the second metatarsal

Correct Answer & Explanation

. Dorsolateral subluxation of the second metatarsal

Explanation

Minor degrees of displacement not apparent on plain radiographs lead to significant decrease in the contact area of the second tarsometatarsal joint. Dorsolateral subluxation of the second tarsometatarsal joint suffers a loss of contact area more severely than pure dorsal or lateral subluxation. Just 3 mm of dorsolateral subluxation causes a 38% loss of contact area.

Question 387

Topic: Midfoot & Hindfoot

A 30-year-old male sustains a Hawkins Type II fracture of the talar neck following a motor vehicle collision. Which of the following accurately describes the joint dislocation and the associated risk of avascular necrosis (AVN)?

. Tibiotalar joint dislocation; 0-10% AVN risk
. Subtalar joint dislocation; 20-50% AVN risk
. Subtalar joint dislocation; 90-100% AVN risk
. Talonavicular joint dislocation; 0-10% AVN risk
. Tibiotalar and subtalar joint dislocations; 90-100% AVN risk

Correct Answer & Explanation

. Subtalar joint dislocation; 20-50% AVN risk

Explanation

A Hawkins Type II fracture involves a talar neck fracture with subluxation or dislocation of the subtalar joint. The risk of AVN in Type II fractures is classically reported as 20% to 50%.

Question 388

Topic: 8. Foot and Ankle

During surgical reconstruction of a Lisfranc injury, the surgeon must identify and recreate the Lisfranc ligament complex. Which of the following describes the anatomical attachments of the primary Lisfranc ligament?

. Medial cuneiform to the base of the second metatarsal
. Lateral cuneiform to the base of the second metatarsal
. Medial cuneiform to the base of the first metatarsal
. Navicular to the base of the second metatarsal
. Cuboid to the base of the third metatarsal

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is an intra-articular ligament that runs from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal.

Question 389

Topic: 8. Foot and Ankle

A 60-year-old female complains of medial ankle pain and a progressively flattening arch. On examination, she is diagnosed with Stage II adult acquired flatfoot deformity (posterior tibial tendon dysfunction). Which clinical finding is characteristic of Stage II?

. Pain along the tendon with normal tendon length and no visible deformity
. Flexible hindfoot valgus and an inability to perform a single-leg heel rise
. Rigid, irreducible hindfoot valgus and an inability to perform a single-leg heel rise
. Rigid hindfoot valgus accompanied by tibiotalar joint arthritis
. Deltoid ligament rupture with significant talar tilt

Correct Answer & Explanation

. Flexible hindfoot valgus and an inability to perform a single-leg heel rise

Explanation

Stage II posterior tibial tendon dysfunction is characterized by a visible flatfoot deformity with a flexible hindfoot valgus, forefoot abduction, and the clinical inability to perform a single-leg heel rise.

Question 390

Topic: 8. Foot and Ankle

A 35-year-old male sustains a pronation-external rotation ankle fracture. Following ORIF of the fibula, the syndesmosis remains unstable. Which of the following is true regarding syndesmotic screw fixation?

. Screws must be removed prior to weight-bearing to prevent diastasis.
. Routine removal of syndesmotic screws improves functional outcomes and reduces pain.
. Retention of broken syndesmotic screws does not negatively affect clinical outcomes.
. Rigid stainless steel screws provide superior outcomes compared to flexible suture-button constructs.
. Fixation should only engage 3 cortices to allow physiological distal fibula motion.

Correct Answer & Explanation

. Retention of broken syndesmotic screws does not negatively affect clinical outcomes.

Explanation

Studies show no significant difference in clinical outcomes whether syndesmotic screws are removed, retained, or broken. Routine removal is not indicated unless the hardware is symptomatic. Flexible fixation has shown comparable or slightly better functional outcomes than rigid screws.

Question 391

Topic: 8. Foot and Ankle

A 25-year-old male sustains a twisting injury to his midfoot. Weight-bearing radiographs demonstrate a 3 mm diastasis between the base of the first and second metatarsals. What is the primary stabilizing structure of this interval?

. The intermetatarsal ligament between the 1st and 2nd metatarsal bases
. The dorsal ligament from the medial cuneiform to the 2nd metatarsal base
. The plantar ligament from the medial cuneiform to the 2nd metatarsal base
. The plantar fascia
. The peroneus longus tendon

Correct Answer & Explanation

. The plantar ligament from the medial cuneiform to the 2nd metatarsal base

Explanation

The Lisfranc ligament is the strongest restraint to lateral displacement of the lesser metatarsals. It originates from the lateral plantar aspect of the medial cuneiform and inserts onto the medial plantar aspect of the base of the second metatarsal. There is no direct intermetatarsal ligament between the 1st and 2nd metatarsal bases.

Question 392

Topic: 8. Foot and Ankle

Which of the following ligaments is most critical for the primary stability of the tarsometatarsal joint complex (Lisfranc joint), connecting two specific osseous structures?

. Plantar ligament connecting the medial cuneiform and 1st metatarsal base
. Interosseous ligament connecting the medial cuneiform and 2nd metatarsal base
. Dorsal ligament connecting the middle cuneiform and 2nd metatarsal base
. Interosseous ligament connecting the lateral cuneiform and 3rd metatarsal base
. Plantar ligament connecting the cuboid and 4th metatarsal base

Correct Answer & Explanation

. Interosseous ligament connecting the medial cuneiform and 2nd metatarsal base

Explanation

The Lisfranc ligament is a strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is the thickest and most critical stabilizing structure of the midfoot tarsometatarsal complex.

Question 393

Topic: Midfoot & Hindfoot
According to the Hawkins classification of talar neck fractures, a Type III fracture is characterized by which of the following dislocation patterns?
. Nondisplaced fracture with no dislocations
. Subtalar joint dislocation only
. Subtalar and tibiotalar joint dislocations
. Subtalar, tibiotalar, and talonavicular joint dislocations
. Isolated talonavicular joint dislocation

Correct Answer & Explanation

. Subtalar and tibiotalar joint dislocations

Explanation

A Hawkins Type III talar neck fracture involves a displaced fracture of the talar neck with subluxation or dislocation of both the subtalar and tibiotalar (ankle) joints. This pattern carries a very high risk of avascular necrosis.

Question 394

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a red, warm, and severely swollen foot. Radiographs reveal extensive periarticular bone fragmentation, joint subluxation, and intra-articular debris. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent?

. Stage 0 (Prodromal)
. Stage 1 (Developmental/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Reconstruction/Consolidation)
. Stage 4 (Ankylosis)

Correct Answer & Explanation

. Stage 1 (Developmental/Fragmentation)

Explanation

Eichenholtz Stage 1 (Developmental) is characterized clinically by an erythematous, edematous foot and radiographically by bone fragmentation, joint subluxation, and periarticular debris. Stage 2 involves coalescence with absorption of fine debris, while Stage 3 shows remodeling.

Question 395

Topic: Forefoot

When planning surgical correction for hallux valgus, a patient presents with a hallux valgus angle (HVA) of 38 degrees and an intermetatarsal angle (IMA) of 18 degrees. Which of the following procedures is most appropriate to predictably correct this deformity?

. Distal metatarsal chevron osteotomy
. Modified McBride bunionectomy alone
. Proximal metatarsal crescentic osteotomy or Lapidus procedure
. Keller resection arthroplasty
. Akin osteotomy alone

Correct Answer & Explanation

. Proximal metatarsal crescentic osteotomy or Lapidus procedure

Explanation

An intermetatarsal angle (IMA) greater than 13-15 degrees constitutes a severe deformity requiring a proximal metatarsal osteotomy (e.g., crescentic or Ludloff) or a first tarsometatarsal fusion (Lapidus procedure). Distal osteotomies are generally insufficient for an IMA of 18 degrees.

Question 396

Topic: 8. Foot and Ankle
A 60-year-old overweight female presents with medial foot pain and a progressive flatfoot deformity. Which of the following physical examination findings is most specific for stage II posterior tibial tendon insufficiency?
. Inability to perform a single-limb heel rise
. Rigid hindfoot valgus uncorrectable with passive manipulation
. Positive anterior drawer test of the ankle
. Severe pain with passive dorsiflexion of the first metatarsophalangeal joint
. Rigid midfoot adduction

Correct Answer & Explanation

. Inability to perform a single-limb heel rise

Explanation

In Stage II posterior tibial tendon dysfunction, the tendon is ruptured or incompetent, clinically manifesting as an inability to perform a single-limb heel rise. The deformity remains flexible in Stage II, whereas it becomes rigid in Stage III.

Question 397

Topic: 8. Foot and Ankle

Which of the following procedures is not indicated as part of the reconstruction of the cavovarus hindfoot:

. Anterior tibial tendon transfer to the middle cuneiform
. Peroneus longus tendon to peroneus brevis tendon transfer
. Posterior tibial tendon transfer to the lateral cuneiform
. Extensor hallucis tendon transfer to the first metatarsal
. Posterior tibial tendon transfer to the peroneus brevis tendon

Correct Answer & Explanation

. Anterior tibial tendon transfer to the middle cuneiform

Explanation

All of the above tendon transfers may be used as part of a reconstruction of the cavus foot except the anterior tibial tendon. The imbalance between the anterior tibial tendon and the peroneus longus tendons are responsible for the cavovarus deformity.

Question 398

Topic: 8. Foot and Ankle

Transfer of the extensor hallucis longus tendon to the first metatarsal and arthrodesis of the hallux interphalangeal joint is indicated for which of the following deformities:

. A 36-year-old patient with a cavus foot following a compartment syndrome
. A 20-year-old patient with a flexible cavovarus deformity
. C orrection of hallux varus deformity
. C orrection of a laceration of the extensor hallucis longus
. A 42-year-old patient with C harcot-Marie-Tooth disease and pes planovalgus deformity

Correct Answer & Explanation

. A 36-year-old patient with a cavus foot following a compartment syndrome

Explanation

Correction of the claw hallux and first metatarsal equinus deformity may be accomplished by transfer of the extensor hallucis longus tendon and arthrodesis of the hallux interphalangeal joint. Once the deformity of the forefoot is fixed (e.g., following a compartment syndrome), the extensor hallucis longus tendon can no longer dorsiflex the first metatarsal. Although C harcot-Marie- Tooth disease is often associated with a cavus foot, the transfer is not indicated when a planovalgus foot is present.

Question 399

Topic: 8. Foot and Ankle

The primary cause for the deformity shown (Slide) is:

. Malunion of the metatarsal osteotomy
. Overplication of the medial capsule of the hallucis metatarsophalangeal joint
. Laceration of the flexor hallucis brevis tendon
. Laceration of the flexor hallucis longus tendon
. Fibular sesamoidectomy

Correct Answer & Explanation

. Fibular sesamoidectomy

Explanation

Overplication of the medial capsule, overcorrection of the metatarsal osteotomy, and excessive lateral soft tissue release can lead to a hallux varus deformity. The most likely cause, however, is interference with the varus- valgus balance of the hallux as a result of a fibular sesamoidectomy.

Question 400

Topic: 8. Foot and Ankle

A 33-year-old recreational athlete presents for treatment of chronic ankle pain. He recalls multiple ankle sprains that occurred 10 years ago. He has not undergone any surgical treatment. On examination, his ankle is stable, there is no crepitus on range of motion, and pain is present to palpation of the posterior ankle. A computerized axial tomography is presented (Slide). The surgical procedure most consistent with a rapid recovery and predictable outcome is:

. Ankle arthrodesis
. Arthroscopy of the ankle with drilling of the osteochondral defect
. Osteoarticular autograft procedure
. C artilage cell harvest with staged debridement of the talus and cartilage cell implantation
. Osteoarticular allograft procedure

Correct Answer & Explanation

. Arthroscopy of the ankle with drilling of the osteochondral defect

Explanation

Ankle arthrodesis must be used as a salvage procedure for failed management of the osteochondral lesion of the talus. Although osteoarticular autograft is a popular procedure, the results are variable and unpredictable, particularly in posteromedial lesions. Ankle arthroscopy with transarticular drilling is the most predictable procedure with expected satisfactory results in approximately 80% of patients.

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