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8. Foot and Ankle MCQs

Practice Set 203 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 4041

Topic: 8. Foot and Ankle

A 22-year-old man with Charcot-Marie-Tooth disease presents with a rigid cavovarus foot deformity. A Coleman block test demonstrates that the hindfoot varus corrects to neutral when the first ray is allowed to drop off the block. Which of the following describes the primary deforming force in this condition?

. Overactivity of the tibialis anterior relative to the peroneus longus
. Overactivity of the peroneus longus relative to the tibialis anterior
. Overactivity of the extensor digitorum longus
. Weakness of the posterior tibial tendon
. Contracture of the Achilles tendon alone

Correct Answer & Explanation

. Overactivity of the tibialis anterior relative to the peroneus longus

Explanation

In Charcot-Marie-Tooth disease, the cavovarus deformity is primarily driven by the peroneus longus overpowering a weak tibialis anterior, causing plantarflexion of the first ray and secondary hindfoot varus.

Question 4042

Topic: 8. Foot and Ankle

A 28-year-old man presents with deep ankle pain after an inversion injury. MRI reveals a cup-shaped osteochondral lesion on the posteromedial aspect of the talar dome. What is the classic mechanism of injury that produces this specific lesion?

. Dorsiflexion and inversion
. Plantarflexion and inversion
. Dorsiflexion and eversion
. Plantarflexion and eversion
. Direct axial loading in neutral

Correct Answer & Explanation

. Dorsiflexion and inversion

Explanation

Posteromedial osteochondral defects of the talus are classically deep, cup-shaped, and caused by inversion and plantarflexion forces. Anterolateral lesions are shallow and caused by inversion and dorsiflexion.

Question 4043

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a severely swollen, erythematous, and warm foot with no history of trauma. Radiographs reveal periarticular debris, joint subluxation, and fragmentation of the midfoot. Which of the following is the most appropriate initial management?

. Immediate surgical arthrodesis of the midfoot
. Intravenous antibiotics and surgical debridement
. Total contact casting and non-weight bearing
. Custom orthotic shoe insert
. Corticosteroid injection into the affected joints

Correct Answer & Explanation

. Immediate surgical arthrodesis of the midfoot

Explanation

This patient has acute Eichenholtz Stage I Charcot arthropathy. The gold standard initial treatment to prevent further deformity while the acute inflammatory phase resolves is total contact casting.

Question 4044

Topic: 8. Foot and Ankle

Which of the following is considered an absolute contraindication for a total ankle arthroplasty in a patient with end-stage ankle osteoarthritis?

. Age older than 70 years
. History of a prior medial malleolus fracture
. Charcot neuroarthropathy of the ankle
. Concomitant subtalar arthritis
. Mild anterior ankle impingement

Correct Answer & Explanation

. Age older than 70 years

Explanation

Charcot neuroarthropathy, active infection, severe avascular necrosis of the talus, and profound peripheral neuropathy are absolute contraindications for total ankle arthroplasty due to high failure rates.

Question 4045

Topic: 8. Foot and Ankle

A 26-year-old runner complains of posterolateral ankle pain and a snapping sensation behind the lateral malleolus. Physical exam demonstrates subluxation of the peroneal tendons with resisted eversion. This condition is most directly associated with incompetence of which of the following structures?

. Inferior extensor retinaculum
. Superior peroneal retinaculum
. Calcaneofibular ligament
. Posterior talofibular ligament
. Anterior inferior tibiofibular ligament

Correct Answer & Explanation

. Inferior extensor retinaculum

Explanation

Peroneal tendon subluxation is caused by an injury or incompetence of the superior peroneal retinaculum (SPR), often requiring surgical deepening of the fibular groove and SPR repair.

Question 4046

Topic: Ankle Trauma & Sports

A 13-year-old boy sustains a Salter-Harris III fracture of the anterolateral distal tibia. The avulsion of this fragment is caused by the pull of which of the following ligaments?

. Anterior talofibular ligament (ATFL)
. Calcaneofibular ligament (CFL)
. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Deltoid ligament

Correct Answer & Explanation

. Anterior talofibular ligament (ATFL)

Explanation

This describes a juvenile Tillaux fracture. It occurs because the anterolateral distal tibial physis is the last to close, and the fragment is avulsed by the anterior inferior tibiofibular ligament (AITFL).

Question 4047

Topic: 8. Foot and Ankle

During a percutaneous repair of an acute Achilles tendon rupture, the surgeon must be particularly careful to avoid injury to the sural nerve. At approximately what distance proximal to the calcaneal insertion does the sural nerve cross the lateral border of the Achilles tendon?

. 2.5 cm
. 5.0 cm
. 9.8 cm
. 15.2 cm
. 20.0 cm

Correct Answer & Explanation

. 2.5 cm

Explanation

The sural nerve crosses from the midline to the lateral aspect of the Achilles tendon at an average of 9.8 cm (roughly 10 cm) proximal to the calcaneal insertion, making it highly vulnerable during percutaneous repairs.

Question 4048

Topic: 8. Foot and Ankle

A 14-year-old girl presents with pain over the dorsal aspect of her forefoot. Radiographs show flattening, sclerosis, and fragmentation of the second metatarsal head. Which of the following is the most likely diagnosis?

. Kohler disease
. Sever disease
. Freiberg infraction
. Iselin disease
. Treves disease

Correct Answer & Explanation

. Kohler disease

Explanation

Freiberg infraction is an avascular necrosis of the metatarsal head, most commonly affecting the second metatarsal in adolescent females.

Question 4049

Topic: 8. Foot and Ankle

A 35-year-old woman complains of burning pain in her forefoot that radiates into her toes, particularly when wearing tight shoes. Examination reveals a palpable click when compressing the metatarsal heads together. Which intermetatarsal space is most commonly affected in this condition?

. First intermetatarsal space
. Second intermetatarsal space
. Third intermetatarsal space
. Fourth intermetatarsal space
. Fifth intermetatarsal space

Correct Answer & Explanation

. First intermetatarsal space

Explanation

This patient has a Morton neuroma, which is a perineural fibrosis of the common digital nerve. It most frequently occurs in the third intermetatarsal space.

Question 4050

Topic: 8. Foot and Ankle

A patient with refractory plantar fasciitis receives multiple local corticosteroid injections. Six weeks later, he experiences a sudden 'pop' in the arch of his foot followed by flattening of the longitudinal arch. What complication has most likely occurred?

. Posterior tibial tendon rupture
. Spring ligament rupture
. Plantar fascia rupture
. Achilles tendon rupture
. Flexor hallucis longus rupture

Correct Answer & Explanation

. Posterior tibial tendon rupture

Explanation

Repeated corticosteroid injections for plantar fasciitis carry a significant risk of plantar fascia rupture, which can present acutely with a 'pop' and subsequent medial arch flattening.

Question 4051

Topic: 8. Foot and Ankle

In evaluating a patient with a suspected syndesmotic injury of the ankle, the 'Cotton test' is performed intraoperatively. Which of the following best describes this test?

. Dorsiflexion and external rotation of the foot
. Lateral translation force applied to the fibula using a bone hook
. Squeezing the proximal fibula and tibia together
. Anterior drawer test in plantarflexion
. Direct visualization of the deltoid ligament

Correct Answer & Explanation

. Dorsiflexion and external rotation of the foot

Explanation

The Cotton test is an intraoperative stress test where a bone hook is used to apply a lateral pull to the fibula to evaluate the integrity of the tibiofibular syndesmosis.

Question 4052

Topic: 8. Foot and Ankle

A 22-year-old collegiate football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs demonstrate widening of the 1st and 2nd metatarsal bases without fracture. MRI confirms a purely ligamentous Lisfranc injury. What is the most appropriate definitive management?

. Non-weight bearing in a short leg cast for 6 weeks
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Suture button suspensionplasty alone

Correct Answer & Explanation

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

Explanation

Purely ligamentous Lisfranc injuries have a high failure rate with ORIF alone. Primary arthrodesis of the medial columns (1st-3rd TMT joints) is associated with better functional outcomes and lower reoperation rates in pure ligamentous injuries compared to ORIF.

Question 4053

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. Examination reveals a "too many toes" sign laterally, and she is unable to perform a single-leg heel rise. Her hindfoot valgus deformity is passively correctable. What is the most appropriate surgical treatment?

. Flexor digitorum longus transfer and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Isolated subtalar arthrodesis
. Gastrocnemius recession and anterior tibial tendon transfer
. Primary repair of the posterior tibial tendon

Correct Answer & Explanation

. Flexor digitorum longus transfer and medial displacement calcaneal osteotomy

Explanation

The patient has a Stage II adult acquired flatfoot deformity (flexible). The gold standard surgical management includes a joint-sparing procedure such as flexor digitorum longus (FDL) transfer to the navicular combined with a medial displacement calcaneal osteotomy.

Question 4054

Topic: 8. Foot and Ankle

A 28-year-old man with a family history of neuropathy presents with a progressive cavovarus foot deformity. A Coleman block test demonstrates that his hindfoot varus corrects to neutral when the first ray drops off the block. Which of the following is the primary deforming force driving the forefoot deformity?

. Overpull of the anterior tibialis relative to the peroneus longus
. Overpull of the peroneus longus relative to the anterior tibialis
. Weakness of the posterior tibialis
. Contracture of the Achilles tendon
. Overpull of the extensor digitorum longus

Correct Answer & Explanation

. Overpull of the anterior tibialis relative to the peroneus longus

Explanation

In Charcot-Marie-Tooth disease, the typical muscle imbalance involves a strong peroneus longus outpulling a weak anterior tibialis, causing a rigidly plantarflexed first ray. The Coleman block test showing correction confirms the hindfoot varus is flexible and driven entirely by this forefoot deformity.

Question 4055

Topic: 8. Foot and Ankle

During an open reduction and internal fixation of a Weber C fibula fracture, the surgeon performs a Cotton test to assess the syndesmosis. Which of the following accurately describes this intraoperative assessment?

. External rotation of the foot while stabilizing the tibia
. Direct lateral pull on the fibula using a bone hook
. Anterior translation of the talus within the mortise
. Squeezing the tibia and fibula together at the mid-calf
. Dorsiflexion of the ankle past neutral

Correct Answer & Explanation

. External rotation of the foot while stabilizing the tibia

Explanation

The Cotton test involves applying a direct lateral pull to the fibula using a bone hook under fluoroscopy to evaluate for syndesmotic instability. Widening of the tibiofibular clear space indicates a syndesmotic injury requiring fixation.

Question 4056

Topic: 8. Foot and Ankle

A 48-year-old recreational runner complains of chronic, severe posterior heel pain located directly at the insertion of the Achilles tendon. Radiographs show a prominent Haglund deformity and intratendinous calcification. Conservative measures have failed. Surgical management should include:

. Excision of the paratenon only
. Gastrocnemius recession without tendon debridement
. Endoscopic removal of the retrocalcaneal bursa
. Debridement of the Achilles insertion, ostectomy of the calcaneal prominence, and tendon reattachment
. Percutaneous longitudinal tenotomies

Correct Answer & Explanation

. Excision of the paratenon only

Explanation

Insertional Achilles tendinopathy with a Haglund deformity and calcification often requires aggressive open management if conservative care fails. This includes debridement of the diseased tendon, excision of the prominent posteriosuperior calcaneal tuberosity (Haglund excision), and reattachment of the tendon using suture anchors.

Question 4057

Topic: 8. Foot and Ankle

A 21-year-old track athlete presents with insidious onset, vague midfoot pain that worsens with sprinting. Exam reveals tenderness localized over the dorsal aspect of the navicular (N-spot). Radiographs are negative. MRI shows a linear signal abnormality in the central third of the navicular.

Why is this region particularly prone to nonunion?

. Excessive shear forces from the posterior tibial tendon
. An inherent avascular zone in the central third
. Inadequate cortical bone density
. Compression by the medial cuneiform
. Lack of robust periosteum

Correct Answer & Explanation

. Excessive shear forces from the posterior tibial tendon

Explanation

The central third of the tarsal navicular has a precarious blood supply and is considered an avascular zone. This watershed area makes stress fractures at high risk for delayed union or nonunion.

Question 4058

Topic: 8. Foot and Ankle

A 25-year-old snowboarder sustains an inversion injury to the ankle. He complains of pain and a snapping sensation over the lateral malleolus. Examination reveals swelling behind the lateral malleolus and subluxation of the peroneal tendons with resisted dorsiflexion and eversion. What is the primary anatomical structure injured in this condition?

. Anterior talofibular ligament
. Calcaneofibular ligament
. Superior peroneal retinaculum
. Inferior peroneal retinaculum
. Peroneus brevis tendon sheath

Correct Answer & Explanation

. Anterior talofibular ligament

Explanation

Peroneal tendon subluxation or dislocation is typically caused by a rupture, avulsion, or attenuation of the superior peroneal retinaculum (SPR). Snowboarding is a classic mechanism due to forced dorsiflexion and forceful inversion.

Question 4059

Topic: Forefoot

A 52-year-old woman presents with a painful bunion. Weight-bearing radiographs show a hallux valgus angle of 45 degrees, an intermetatarsal angle of 18 degrees, and hypermobility at the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate?

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

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

A modified Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA > 15 degrees) especially when accompanied by first TMT joint hypermobility. A distal chevron osteotomy would be inadequate for this severe deformity.

Question 4060

Topic: 8. Foot and Ankle

Which of the following patients with end-stage tibiotalar osteoarthritis is considered the most ideal candidate for a Total Ankle Arthroplasty (TAA)?

. A 65-year-old sedentary male with a well-aligned hindfoot
. A 40-year-old manual laborer with avascular necrosis of the talus
. A 55-year-old female with Charcot neuroarthropathy
. A 30-year-old professional athlete with post-traumatic arthritis
. A 50-year-old male with an active deep soft-tissue infection

Correct Answer & Explanation

. A 65-year-old sedentary male with a well-aligned hindfoot

Explanation

The ideal candidate for a total ankle arthroplasty is an older, relatively sedentary patient with low physical demands, a well-aligned ankle/hindfoot, and no significant bone loss or neuropathy. Charcot arthropathy, substantial AVN, active infection, and high physical demands are strong contraindications.

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