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8. Foot and Ankle MCQs

Practice Set 201 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 4001

Topic: 8. Foot and Ankle

A 62-year-old diabetic patient is successfully treated for an infection associated with a Wagner Grade 3 plantar ulcer beneath the first metatarsal head. Clinical examination reveals a severe equinus contracture. Which of the following adjunctive surgical interventions will best prevent recurrence of the ulcer?

. First metatarsophalangeal joint arthrodesis
. Midfoot amputation
. Tendo-Achilles lengthening (TAL)
. Split-thickness skin grafting over the ulcer bed
. Extracorporeal shockwave therapy

Correct Answer & Explanation

. First metatarsophalangeal joint arthrodesis

Explanation

An equinus contracture secondary to a tight Achilles tendon causes drastically increased plantar forefoot pressures during the stance phase. Tendo-Achilles lengthening (TAL) relieves this pressure and is critical in promoting healing and preventing recurrence of forefoot ulcers.

Question 4002

Topic: 8. Foot and Ankle

During the surgical exposure and reduction of a Lisfranc fracture-dislocation, an understanding of the local anatomy is critical. The primary Lisfranc ligament connects which of the following two structures?

. Medial cuneiform to the base of the second metatarsal
. Lateral cuneiform to the base of the third metatarsal
. Navicular to the medial cuneiform
. Cuboid to the base of the fifth metatarsal
. Calcaneus to the navicular tuberosity

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is a robust interosseous ligament that originates on the lateral aspect of the medial cuneiform and inserts onto the medial aspect of the base of the second metatarsal, anchoring the midfoot.

Question 4003

Topic: 8. Foot and Ankle

A 58-year-old diabetic man requires a transmetatarsal amputation for a non-healing, gangrenous toe wound. Preoperative non-invasive vascular testing is ordered to predict wound healing. Which of the following parameters is generally accepted as the minimum threshold indicating adequate perfusion for healing of the amputation?

. Ankle-brachial index (ABI) > 0.3
. Absolute toe pressure > 40 mm Hg
. Transcutaneous oxygen tension (TcPO2) < 20 mm Hg
. Serum albumin < 2.5 g/dL
. Ankle pressure < 50 mm Hg

Correct Answer & Explanation

. Ankle-brachial index (ABI) > 0.3

Explanation

An absolute toe pressure greater than 40 mm Hg (or ABI > 0.45) indicates adequate perfusion for distal foot amputations to heal. Transcutaneous oxygen tension (TcPO2) > 30 mm Hg is also a reliable indicator of healing potential.

Question 4004

Topic: 8. Foot and Ankle

A 40-year-old male sustains an irreducible fracture-dislocation of the right ankle following a fall from a height. The injury is classified as a Bosworth fracture-dislocation. Which of the following anatomic blocks to reduction is the hallmark of this injury?

. Anterior inferior tibiofibular ligament interposition
. Deltoid ligament entrapment within the medial clear space
. Posterior tibial tendon subluxation into the syndesmosis
. Proximal fibular fragment entrapped behind the posterior tubercle of the tibia
. Talus incarcerated vertically within the syndesmosis

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament interposition

Explanation

A Bosworth fracture-dislocation is a rare, severe injury wherein the proximal fragment of the fractured fibula becomes trapped rigidly behind the posterior lateral tubercle of the distal tibia, making closed reduction impossible.

Question 4005

Topic: Midfoot & Hindfoot

A patient with long-standing diabetes presents with a markedly swollen, warm, and erythematous foot. Radiographs demonstrate severe periarticular debris, joint dislocation, and fragmentation of the midfoot bones.

According to the Eichenholtz classification of Charcot neuroarthropathy, this represents which stage?

. Stage 0 (Pre-Charcot)
. Stage I (Fragmentation)
. Stage II (Coalescence)
. Stage III (Consolidation)
. Stage IV (Remodeling)

Correct Answer & Explanation

. Stage 0 (Pre-Charcot)

Explanation

Eichenholtz Stage I is the developmental (acute) phase of Charcot arthropathy. It is characterized clinically by a red, hot, swollen foot and radiographically by bone fragmentation, joint dislocation, and osseous debris.

Question 4006

Topic: 8. Foot and Ankle

What is the most common mechanism of injury that results in a longitudinal Lisfranc fracture-dislocation in an athletic population?

. Direct crushing blow to the dorsum of the midfoot
. Axial loading applied to a plantar-flexed foot
. Severe hyperdorsiflexion of the midfoot joints
. Eversion and external rotation of the hindfoot
. Forced inversion of a supinated forefoot

Correct Answer & Explanation

. Direct crushing blow to the dorsum of the midfoot

Explanation

The most common indirect mechanism for a Lisfranc injury is an axial load applied to a plantar-flexed foot. This forces the metatarsals to displace dorsally relative to the tarsus.

Question 4007

Topic: 8. Foot and Ankle

A Total Contact Cast (TCC) is considered the gold standard for offloading plantar diabetic foot ulcers. What is its primary biomechanical mechanism of action in promoting ulcer healing?

. Creates a vacuum environment to increase local capillary blood flow
. Delivers continuous topical antibiotics to the wound bed
. Transfers weight-bearing forces from the plantar forefoot to the heel and lower leg
. Immobilizes the knee to completely prevent ambulation
. Directly compresses the ulcer bed to limit local tissue edema

Correct Answer & Explanation

. Creates a vacuum environment to increase local capillary blood flow

Explanation

A Total Contact Cast (TCC) primarily works by redistributing plantar pressures. By maintaining total contact with the lower extremity, it transfers weight-bearing loads away from the forefoot and midfoot and distributes them evenly across the heel and lower leg.

Question 4008

Topic: Ankle Trauma & Sports

According to the Lauge-Hansen classification system, what is the sequence of injury in a Pronation-Abduction (PA) Stage III ankle fracture?

. Deltoid rupture -> AITFL rupture -> Transverse/short oblique fibula fracture -> Posterior malleolus fracture
. AITFL rupture -> Spiral fibula fracture -> Posterior malleolus fracture -> Deltoid rupture
. Transverse medial malleolus fracture -> PITFL rupture -> Low transverse fibula fracture
. Deltoid rupture -> Anterior syndesmosis rupture -> Oblique fracture of the fibula at the joint level
. Deltoid rupture -> Syndesmosis rupture -> Bending fracture of the fibula above the syndesmosis

Correct Answer & Explanation

. Deltoid rupture -> AITFL rupture -> Transverse/short oblique fibula fracture -> Posterior malleolus fracture

Explanation

In the Pronation-Abduction sequence: Stage 1 is deltoid ligament rupture or transverse medial malleolar fracture; Stage 2 is rupture of the AITFL/syndesmosis; Stage 3 is a bending (transverse or comminuted) fracture of the fibula above the level of the syndesmosis.

Question 4009

Topic: 8. Foot and Ankle

A 24-year-old football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the first and second metatarsals. What is the most appropriate definitive management?

. Non-weight bearing in a short leg cast for 6 weeks
. Closed reduction and casting
. Open reduction and internal fixation (ORIF) or primary arthrodesis
. Carbon fiber shoe insert and immediate weight bearing
. Excision of the medial cuneiform

Correct Answer & Explanation

. Non-weight bearing in a short leg cast for 6 weeks

Explanation

Lisfranc injuries with >2 mm diastasis or any instability require operative intervention. ORIF or primary arthrodesis restores anatomic alignment and optimizes functional outcomes.

Question 4010

Topic: Forefoot

A 55-year-old woman complains of painful bunions. Examination reveals a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Akin osteotomy alone
. Proximal crescentic osteotomy
. First TMT joint arthrodesis (Lapidus procedure)
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

A Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (HVA >40, IMA >15) associated with first TMT joint hypermobility.

Question 4011

Topic: Midfoot & Hindfoot

A 30-year-old man falls from a height and sustains a Hawkins Type III talar neck fracture. This fracture pattern involves displacement of the talar neck with subluxation or dislocation of which joints?

. Subtalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Tibiotalar joint only
. Talonavicular joint only

Correct Answer & Explanation

. Subtalar joint only

Explanation

A Hawkins Type III talar neck fracture involves displacement of the talar body with dislocation of both the subtalar and tibiotalar joints. It carries a high risk of avascular necrosis.

Question 4012

Topic: Midfoot & Hindfoot

A 58-year-old patient with poorly controlled type 2 diabetes presents with a red, hot, swollen right foot. There is no history of trauma or open wounds. Radiographs show periarticular debris, joint subluxation, and fragmentation of the midfoot. What is the most appropriate initial management?

. Intravenous antibiotics and urgent surgical debridement
. Total contact casting and non-weight bearing
. Primary arthrodesis of the midfoot
. Injection of intra-articular corticosteroids
. Custom orthotics and physical therapy

Correct Answer & Explanation

. Intravenous antibiotics and urgent surgical debridement

Explanation

The clinical presentation is classic for acute Charcot arthropathy (Eichenholtz stage I). The standard initial treatment is offloading with a total contact cast to prevent further deformity.

Question 4013

Topic: 8. Foot and Ankle

A 40-year-old recreational tennis player feels a 'pop' in his posterior ankle. Examination shows a positive Thompson test. If he elects for non-operative management with early functional rehabilitation, he should be counseled that compared to surgical repair, he has a:

. Higher risk of deep vein thrombosis
. Higher risk of rerupture
. Higher risk of sural nerve injury
. Greater decrease in plantarflexion strength
. Longer hospital stay

Correct Answer & Explanation

. Higher risk of deep vein thrombosis

Explanation

Non-operative management of Achilles tendon ruptures has historically been associated with a slightly higher rerupture rate compared to surgical repair, though modern functional rehab protocols have narrowed this gap. Surgery carries higher wound complication risks.

Question 4014

Topic: 8. Foot and Ankle

A 24-year-old athlete sustains a midfoot injury after an axial load was applied to his plantarflexed foot. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the first and second metatarsals, alongside a "fleck sign". Which of the following is the most common mechanism for this specific injury pattern?

. Axial load to a plantarflexed foot
. Dorsiflexion and forced eversion
. Plantarflexion and forced inversion
. Direct crush injury to the dorsal midfoot
. External rotation with foot pronation

Correct Answer & Explanation

. Axial load to a plantarflexed foot

Explanation

The typical mechanism for a Lisfranc injury is an indirect axial load to a plantarflexed foot, causing hyperplantarflexion and rupture of the ligamentous complex. The "fleck sign" represents an avulsion of the Lisfranc ligament from the base of the second metatarsal.

Question 4015

Topic: 8. Foot and Ankle

When comparing functional rehabilitation protocols to open surgical repair for the management of an acute Achilles tendon rupture, recent randomized controlled trials demonstrate which of the following regarding functional non-operative management?

. Higher re-rupture rate and lower infection rate
. Lower re-rupture rate and higher infection rate
. Similar re-rupture rate but higher infection rate
. Similar re-rupture rate and lower wound complication rate
. Significantly higher rate of deep vein thrombosis

Correct Answer & Explanation

. Higher re-rupture rate and lower infection rate

Explanation

Recent studies support that early functional rehabilitation for non-operative management yields re-rupture rates equivalent to operative repair. Additionally, non-operative management avoids the wound healing complications associated with surgery.

Question 4016

Topic: Ankle Trauma & Sports

A 28-year-old football player sustains a high ankle sprain. A positive stress radiograph confirms a syndesmotic injury. During surgical repair, an understanding of the syndesmotic anatomy is critical. Which of the following ligaments provides the greatest structural strength and primary stabilization to the distal tibiofibular syndesmosis?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Interosseous ligament
. Deltoid ligament
. Calcaneofibular ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

The posterior inferior tibiofibular ligament (PITFL) is the strongest component of the syndesmotic complex, contributing approximately 40% to 45% of the total syndesmotic resistance to fibular displacement.

Question 4017

Topic: Midfoot & Hindfoot

A 35-year-old man sustains a Hawkins type II fracture of the talar neck after a motor vehicle collision. By definition, a Hawkins type II talar neck fracture is characterized by displacement and subluxation or dislocation at which of the following articulations?

. Subtalar joint
. Tibiotalar joint
. Talonavicular joint
. Calcaneocuboid joint
. Naviculocuneiform joint

Correct Answer & Explanation

. Subtalar joint

Explanation

A Hawkins II talar neck fracture involves a fracture of the talar neck with subluxation or dislocation of the subtalar joint. The tibiotalar joint remains anatomically aligned.

Question 4018

Topic: Forefoot

A 45-year-old woman presents with painful bilateral bunions. Examination reveals significant hypermobility of the first tarsometatarsal (TMT) joint. Weight-bearing radiographs show a hallux valgus angle (HVA) of 38 degrees and an intermetatarsal angle (IMA) of 16 degrees. Which of the following is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Lapidus procedure
. Proximal crescentic osteotomy alone
. Keller resection arthroplasty
. First metatarsophalangeal (MTP) joint arthrodesis

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The Lapidus procedure (arthrodesis of the first TMT joint) is the procedure of choice for moderate to severe hallux valgus deformities associated with clinical hypermobility of the first ray.

Question 4019

Topic: Midfoot & Hindfoot

A 55-year-old woman with stage IIb adult-acquired flatfoot deformity (posterior tibial tendon dysfunction) presents for surgical evaluation. She has a flexible flatfoot, inability to perform a single heel rise, and >40% uncovering of the talonavicular joint indicating substantial forefoot abduction. Which of the following is the most appropriate combination of surgical procedures?

. Flexor digitorum longus (FDL) transfer alone
. FDL transfer with a medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and a lateral column lengthening
. Triple arthrodesis
. Isolated subtalar arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer alone

Explanation

Stage IIb posterior tibial tendon dysfunction features significant forefoot abduction (talonavicular uncoverage). Optimal correction requires an FDL transfer, a medializing calcaneal osteotomy (for hindfoot valgus), and a lateral column lengthening to correct the forefoot abduction.

Question 4020

Topic: 8. Foot and Ankle

A 40-year-old construction worker falls from a ladder and sustains an isolated tongue-type calcaneus fracture. Clinical examination reveals severe posterior skin tenting and blanching with impending tissue necrosis.

What is the most urgent step in management?

. Application of a strict non-weight-bearing short leg cast
. Urgent percutaneous reduction and screw fixation
. Delayed open reduction via an extensile lateral approach
. Immediate CT scan and strict limb elevation
. Primary subtalar arthrodesis

Correct Answer & Explanation

. Application of a strict non-weight-bearing short leg cast

Explanation

Tongue-type calcaneus fractures can exert direct pressure on the thin posterior skin, rapidly leading to full-thickness necrosis. Urgent reduction and percutaneous fixation are required to relieve tension on the soft tissues.

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