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8. Foot and Ankle MCQs

Practice Set 200 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 3981

Topic: 8. Foot and Ankle

A patient requires a Syme amputation for a severe diabetic forefoot infection. Which of the following technical steps is absolutely essential for a successful outcome and a durable, weight-bearing stump?

. Preserving the anterior tibial artery as the primary blood supply
. Resecting the fibula but leaving the distal tibia intact without trimming the malleoli
. Anchoring the plantar heel pad securely to the distal tibia
. Performing a primary tenodesis of the Achilles tendon to the fibula
. Leaving the articular cartilage of the tibial plafond intact

Correct Answer & Explanation

. Preserving the anterior tibial artery as the primary blood supply

Explanation

A Syme amputation involves disarticulation of the ankle and removal of the malleoli. Securely anchoring the plantar heel pad to the distal tibia via drill holes is critical to prevent posterior and medial migration of the pad during weight-bearing.

Question 3982

Topic: 8. Foot and Ankle

A 40-year-old sustains an ankle injury. Radiographs reveal a widened medial clear space and a short oblique fracture of the fibula 6 cm proximal to the joint line. According to Lauge-Hansen, what was the first structure injured in this sequence?

. Anterior inferior tibiofibular ligament
. Deltoid ligament or medial malleolus
. Posterior inferior tibiofibular ligament
. Interosseous membrane
. Lateral collateral ligaments

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament

Explanation

This describes a Pronation-External Rotation (PER) injury. The sequence begins medially with a transverse medial malleolus fracture or deltoid ligament rupture (Stage I), followed by the AITFL (II), a high fibula fracture (III), and the PITFL or posterior malleolus (IV).

Question 3983

Topic: 8. Foot and Ankle

The primary osseous stability of the midfoot is provided by the interlocking 'keystone' configuration of the tarsometatarsal joints. Which anatomical structure forms this critical keystone?

. Base of the first metatarsal
. Base of the second metatarsal recessed between the medial and lateral cuneiforms
. The articulation between the medial cuneiform and navicular
. The cuboid locking into the calcaneus
. The base of the third metatarsal and the lateral cuneiform

Correct Answer & Explanation

. Base of the first metatarsal

Explanation

The base of the second metatarsal is deeply recessed proximally between the medial and lateral cuneiforms. This interlocking 'keystone' configuration provides the primary osseous stability of the Lisfranc joint complex.

Question 3984

Topic: 8. Foot and Ankle

A 60-year-old diabetic patient presents with a chronic, rigid, 'rocker-bottom' foot deformity (Eichenholtz Stage III) and a recurrent midfoot plantar ulcer under the cuboid. Nonoperative management with a CROW boot has failed multiple times. What is the most appropriate surgical intervention?

. First metatarsophalangeal joint arthrodesis
. Primary below-knee amputation
. Exostectomy and/or midfoot realignment arthrodesis
. Gastrocnemius recession alone
. Split-thickness skin grafting of the ulcer

Correct Answer & Explanation

. First metatarsophalangeal joint arthrodesis

Explanation

In a chronic, rigid Charcot foot with a rocker-bottom deformity and recurrent ulceration that fails offloading, surgical exostectomy of the bony prominence and/or midfoot realignment arthrodesis with rigid fixation is indicated to restore a plantigrade foot.

Question 3985

Topic: 8. Foot and Ankle

The 'logsplitter' injury of the ankle is best described by which of the following pathomechanical processes?

. A vertical shear fracture of the medial malleolus from forced supination
. An axial load injury driving the talus superiorly into the tibial plafond causing severe syndesmotic disruption
. An isolated posterior malleolus fracture involving more than 50% of the joint surface
. A high spiral fracture of the fibula associated with an acute deltoid rupture
. A comminuted fracture of the lateral process of the talus

Correct Answer & Explanation

. A vertical shear fracture of the medial malleolus from forced supination

Explanation

A 'logsplitter' injury occurs from high-energy axial loading that drives the talus cranially into the tibial plafond. This acts as a wedge, separating the tibia and fibula and causing severe disruption of the syndesmosis.

Question 3986

Topic: Midfoot & Hindfoot

A 35-year-old male is 2 years out from an open reduction and internal fixation of a severe Lisfranc injury. He now complains of severe, localized midfoot pain with weight-bearing. Radiographs show advanced degenerative changes at the 2nd and 3rd TMT joints. Management should consist of:

. Intra-articular hyaluronic acid injections
. Midfoot arthrodesis of the affected TMT joints
. Total ankle arthroplasty
. Removal of hardware and anatomic ligament reconstruction
. Chopart amputation

Correct Answer & Explanation

. Intra-articular hyaluronic acid injections

Explanation

Post-traumatic arthritis is a frequent complication after severe or ORIF-treated Lisfranc injuries. When conservative measures fail, arthrodesis of the involved TMT joints is the standard of care and provides reliable pain relief.

Question 3987

Topic: 8. Foot and Ankle

A 50-year-old diabetic woman has severe flexible claw toe deformities and recurrent distal tip ulcerations on digits 2-4. She has palpable pulses and a normal ABI. What is the most appropriate prophylactic surgical procedure to heal the ulcers and prevent recurrence?

. Amputation of digits 2-4
. Metatarsal head resections
. Percutaneous flexor tenotomies
. Arthrodesis of the PIP joints
. Extensor tendon lengthenings

Correct Answer & Explanation

. Amputation of digits 2-4

Explanation

For flexible claw toe deformities in diabetics complicated by distal tip ulcerations, percutaneous flexor tenotomies are highly effective. They correct the deformity, reduce pressure on the toe tips, and allow the ulcers to heal rapidly.

Question 3988

Topic: 8. Foot and Ankle

Which of the following accurately describes the primary attachment sites of the Lisfranc ligament?

. Medial cuneiform to the base of the first metatarsal
. Medial cuneiform to the base of the second metatarsal
. Middle cuneiform to the base of the second metatarsal
. Navicular to the base of the second metatarsal
. Lateral cuneiform to the cuboid

Correct Answer & Explanation

. Medial cuneiform to the base of the first metatarsal

Explanation

The Lisfranc ligament is an interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is critical for the stability of the midfoot.

Question 3989

Topic: 8. Foot and Ankle

A 30-year-old male sustains a purely ligamentous Lisfranc injury. Weight-bearing radiographs demonstrate 4 mm of diastasis between the first and second metatarsal bases without fracture. Which of the following is the most appropriate definitive management?

. Hard-soled shoe and immediate weight-bearing
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Non-weight-bearing cast for 6 weeks

Correct Answer & Explanation

. Hard-soled shoe and immediate weight-bearing

Explanation

For purely ligamentous Lisfranc injuries, evidence supports primary arthrodesis of the medial column over ORIF. This approach yields lower rates of hardware failure and avoids symptomatic secondary osteoarthritis.

Question 3990

Topic: 8. Foot and Ankle

A 55-year-old diabetic patient presents with a swollen, erythematous, and warm right foot without an open ulcer. Radiographs show fragmentation and subluxation of the midfoot. ESR and WBC are normal. What is the most appropriate initial management?

. Intravenous antibiotics for 6 weeks
. Immediate surgical debridement and fusion
. Total contact casting and non-weight-bearing
. Magnetic resonance imaging with contrast
. Below-knee amputation

Correct Answer & Explanation

. Intravenous antibiotics for 6 weeks

Explanation

The clinical picture describes acute Charcot neuroarthropathy (Eichenholtz stage I). The gold standard initial treatment to prevent progressive deformity is immobilization in a total contact cast and strict non-weight-bearing.

Question 3991

Topic: 8. Foot and Ankle

A 60-year-old diabetic male has a recurrent neuropathic ulcer under the first metatarsal head. He has a rigid equinus deformity with limited ankle dorsiflexion. What is the best surgical intervention to prevent recurrence after ulcer healing?

. First metatarsophalangeal joint arthrodesis
. Achilles tendon lengthening
. Transmetatarsal amputation
. Tibiotalocalcaneal fusion
. Excision of the first metatarsal head

Correct Answer & Explanation

. First metatarsophalangeal joint arthrodesis

Explanation

A rigid equinus contracture increases forefoot peak plantar pressures, contributing to recurrent forefoot ulceration. Achilles tendon lengthening or gastrocnemius recession effectively reduces these pressures and promotes ulcer healing.

Question 3992

Topic: 8. Foot and Ankle

A 25-year-old male sustains an ankle injury. Radiographs reveal a fracture-dislocation of the ankle. During closed reduction in the emergency department, the ankle remains irreducible. What is the most likely anatomic block to reduction?

. Interposition of the posterior tibial tendon
. The proximal fibular fragment is trapped behind the posterior tubercle of the tibia
. Entrapment of the flexor hallucis longus
. Deltoid ligament interposition in the medial gutter
. Anterior tibial tendon subluxation

Correct Answer & Explanation

. Interposition of the posterior tibial tendon

Explanation

A Bosworth fracture-dislocation is characterized by the proximal segment of the fibula becoming incarcerated behind the posterior tubercle of the tibia. This typically makes closed reduction impossible, necessitating urgent open reduction.

Question 3993

Topic: 8. Foot and Ankle

During ORIF of a supination-external rotation type IV ankle fracture, the surgeon suspects a syndesmotic injury. After fixing the fibula, what intraoperative maneuver is best to test the integrity of the syndesmosis?

. Anterior drawer test
. Talar tilt test
. The Cotton test (lateral pull on the fibula)
. Squeeze test of the proximal calf
. Silfverskiöld test

Correct Answer & Explanation

. Anterior drawer test

Explanation

The Cotton test involves applying a lateral and posterior force to the distal fibula using a bone hook. Diastasis of the syndesmosis under fluoroscopy during this maneuver confirms instability requiring syndesmotic fixation.

Question 3994

Topic: 8. Foot and Ankle

A patient undergoes a transmetatarsal amputation (TMA) for a gangrenous diabetic foot infection. Post-operatively, the patient is at highest risk for developing which of the following foot deformities?

. Equinovarus
. Equinovalgus
. Calcaneovarus
. Calcaneovalgus
. Cavovarus

Correct Answer & Explanation

. Equinovarus

Explanation

Following a transmetatarsal amputation, the loss of the toe extensors and peroneus brevis/tertius often leads to a muscle imbalance. The overpowering Achilles tendon and tibialis anterior/posterior pull the remaining foot into an equinovarus deformity.

Question 3995

Topic: Midfoot & Hindfoot

Regarding lower extremity amputations in diabetic patients, which level of amputation requires the least increase in energy expenditure for ambulation compared to normal gait?

. Syme amputation
. Transmetatarsal amputation
. Below-knee amputation
. Above-knee amputation
. Chopart amputation

Correct Answer & Explanation

. Syme amputation

Explanation

The more distal the amputation, the lower the energy expenditure required for ambulation. A transmetatarsal amputation requires approximately a 10-15% increase in energy expenditure, which is less than a Syme (15-30%) or below-knee (40-50%) amputation.

Question 3996

Topic: 8. Foot and Ankle

A 35-year-old patient presents with chronic lateral ankle pain 2 years after nonoperative treatment of an ankle fracture. Radiographs reveal a malunion with lateral talar shift. Disruption of which radiographic line on the AP view is the most sensitive indicator of fibular shortening?

. Shenton's line of the hip
. Iliopectineal line
. The unbroken curve between the lateral talar articular surface and the fibular recess (dime break sign)
. Boehler's angle
. Gissane's angle

Correct Answer & Explanation

. Shenton's line of the hip

Explanation

The "dime break" sign is an unbroken curve extending from the lateral aspect of the talus to the recess in the distal fibula. Disruption of this curve on a mortise or AP view indicates fibular shortening.

Question 3997

Topic: 8. Foot and Ankle

A 35-year-old construction worker undergoes open reduction and internal fixation for a highly comminuted bimalleolar equivalent ankle fracture with syndesmotic disruption. Intraoperatively, the syndesmosis is reduced and stabilized with two trans-syndesmotic screws. What is the most accurate imaging modality to assess the accuracy of the syndesmotic reduction postoperatively?

. Anteroposterior (AP) radiograph of the ankle
. Mortise radiograph of the ankle
. Bilateral computed tomography (CT) scan
. Magnetic resonance imaging (MRI)
. Standard weight-bearing radiographs

Correct Answer & Explanation

. Anteroposterior (AP) radiograph of the ankle

Explanation

Standard radiographs are notoriously inaccurate for evaluating fine syndesmotic reduction. Bilateral CT scanning is considered the gold standard for accurately assessing the reduction of the syndesmosis postoperatively.

Question 3998

Topic: 8. Foot and Ankle

A 24-year-old collegiate football player presents with severe midfoot pain after an axial loading injury to a plantar-flexed foot. Non-weight-bearing radiographs in the emergency department show no fractures or malalignment. What is the most appropriate next step in diagnosis?

. Magnetic resonance imaging (MRI) without contrast
. Computed tomography (CT) scan of the foot
. Weight-bearing radiographs of the foot
. Technetium-99m bone scan
. Diagnostic ultrasound of the midfoot

Correct Answer & Explanation

. Magnetic resonance imaging (MRI) without contrast

Explanation

The initial step in evaluating a suspected Lisfranc injury when non-weight-bearing films are normal is to obtain weight-bearing radiographs to assess for dynamic instability. MRI or CT may be indicated if weight-bearing films are equivocal.

Question 3999

Topic: Ankle Trauma & Sports

Current orthopedic literature suggests that direct open reduction and internal fixation of a posterior malleolus fracture fragment, as opposed to percutaneous AP screw fixation or nonoperative management, offers which of the following distinct biomechanical advantages?

. Eliminates the need for concomitant lateral malleolar fixation
. Decreases the rates of postoperative deep vein thrombosis
. Restores the posterior incisura and provides superior syndesmotic stability
. Prevents anterior talar translation in the mortise
. Allows for earlier weight-bearing at 2 weeks postoperatively

Correct Answer & Explanation

. Eliminates the need for concomitant lateral malleolar fixation

Explanation

Direct fixation of the posterior malleolus anatomically restores the posterior incisura fibularis. This restores the intact posterior inferior tibiofibular ligament (PITFL), providing superior biomechanical stability to the syndesmosis compared to trans-syndesmotic screws alone.

Question 4000

Topic: Midfoot & Hindfoot

A 30-year-old recreational athlete sustains a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal (TMT) joints. What surgical intervention has been shown in recent prospective literature to yield the most favorable functional outcomes and lowest reoperation rate for this specific injury pattern?

. Closed reduction and percutaneous pinning (CRPP)
. Open reduction and internal fixation (ORIF) with transarticular screws
. Open reduction and internal fixation (ORIF) with dorsal bridge plating
. Primary arthrodesis of the medial three TMT joints
. Ligamentous reconstruction with an allograft tendon

Correct Answer & Explanation

. Closed reduction and percutaneous pinning (CRPP)

Explanation

Recent prospective randomized trials demonstrate that primary arthrodesis of the 1st, 2nd, and 3rd TMT joints yields superior functional outcomes and significantly lower reoperation rates than ORIF for purely ligamentous Lisfranc injuries.

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