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8. Foot and Ankle MCQs

Practice Set 206 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 4101

Topic: 8. Foot and Ankle

A 22-year-old collegiate athlete sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs demonstrate a 3 mm diastasis between the medial cuneiform and the base of the second metatarsal. What is the most appropriate definitive management?

. Non-weight-bearing in a short leg cast for 6 weeks
. Use of a rigid carbon-fiber shoe insert with immediate weight-bearing
. Operative stabilization with open reduction and internal fixation or primary arthrodesis
. Closed reduction and percutaneous K-wire pinning
. Corticosteroid injection into the tarsometatarsal joints

Correct Answer & Explanation

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

Explanation

Lisfranc injuries exhibiting instability, defined as greater than 2 mm of diastasis on weight-bearing radiographs, require operative stabilization. This is achieved via open reduction and internal fixation (ORIF) or primary arthrodesis, depending on the extent of ligamentous disruption and articular damage.

Question 4102

Topic: 8. Foot and Ankle

A surgeon utilizes the standard extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture. Which nerve is at greatest risk of iatrogenic injury during the creation of the full-thickness soft tissue flap?

. Deep peroneal nerve
. Tibial nerve
. Medial plantar nerve
. Sural nerve
. Saphenous nerve

Correct Answer & Explanation

. Deep peroneal nerve

Explanation

The sural nerve crosses the lateral border of the hindfoot and is at high risk of injury or entrapment during the extensile lateral approach to the calcaneus.

Question 4103

Topic: 8. Foot and Ankle

A 20-year-old football player sustains a midfoot injury. Weight-bearing radiographs show widening of the interval between the first and second metatarsal bases. The primary stabilizing ligament of this articulation (the Lisfranc ligament) connects which two osseous structures?

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

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

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

Question 4104

Topic: 8. Foot and Ankle

When comparing operative versus non-operative management of acute complete Achilles tendon ruptures using functional rehabilitation protocols, current literature indicates which of the following regarding complication rates?

. Operative treatment has a higher re-rupture rate but lower wound complications
. Operative treatment has a lower re-rupture rate but a higher rate of soft tissue/wound complications
. Non-operative treatment has a higher rate of deep vein thrombosis but equal re-rupture rates
. Non-operative treatment provides superior final plantar flexion strength
. There is no difference in either re-rupture rates or soft tissue complications between the two groups

Correct Answer & Explanation

. Operative treatment has a higher re-rupture rate but lower wound complications

Explanation

Recent high-quality evidence shows that operative management slightly decreases the risk of re-rupture compared to traditional non-operative care, but carries a significantly higher risk of complications such as infection, sural nerve injury, and wound breakdown.

Question 4105

Topic: Midfoot & Hindfoot

A 32-year-old male sustains a Hawkins Type III talar neck fracture following a motor vehicle collision. What is the approximate rate of avascular necrosis (AVN) of the talar body expected in this injury pattern?

. 0 to 10 percent
. 20 to 30 percent
. 40 to 50 percent
. 70 to 100 percent
. Always 100 percent

Correct Answer & Explanation

. 0 to 10 percent

Explanation

Hawkins Type III talar neck fractures involve displacement of the talar neck with subluxation or dislocation of both the subtalar and tibiotalar joints. This severe injury disrupts all three major blood supplies to the talar body, leading to an AVN rate approaching 70 to 100 percent.

Question 4106

Topic: Midfoot & Hindfoot

A 28-year-old man sustains a Hawkins type III fracture of the talar neck. Which joints are subluxated or dislocated in this injury pattern?

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

Correct Answer & Explanation

. Subtalar joint only

Explanation

A Hawkins type III talar neck fracture involves displacement of the talar neck with dislocation of both the subtalar and tibiotalar (ankle) joints. This pattern carries nearly a 100% risk of avascular necrosis of the talar body.

Question 4107

Topic: 8. Foot and Ankle

A 24-year-old athlete reports midfoot pain after a forced plantar flexion injury. Weight-bearing radiographs show 2 mm of diastasis between the base of the first and second metatarsals. What is the most appropriate surgical treatment?

. Non-weight-bearing cast for 6 weeks
. Closed reduction and percutaneous K-wire fixation
. Open reduction and rigid internal fixation
. Primary arthrodesis of the transverse tarsal joint
. Tarsometatarsal joint aspiration and steroid injection

Correct Answer & Explanation

. Non-weight-bearing cast for 6 weeks

Explanation

Ligamentous Lisfranc injuries with diastasis (>2 mm) are inherently unstable. Open reduction and rigid internal fixation (ORIF) or primary arthrodesis of the medial column is required to restore anatomic alignment.

Question 4108

Topic: 8. Foot and Ankle

A 40-year-old construction worker falls from a roof and sustains a closed, displaced intra-articular calcaneus fracture. On the lateral radiograph, Bohler's angle is measured at 5 degrees (normal 20-40 degrees). What does a decreased Bohler's angle primarily indicate in this injury?

. Collapse of the posterior facet and loss of calcaneal height
. Varus malalignment of the calcaneal tuberosity
. Lateral wall blowout with sural nerve entrapment
. Subluxation of the calcaneocuboid joint
. Avulsion of the Achilles tendon insertion

Correct Answer & Explanation

. Collapse of the posterior facet and loss of calcaneal height

Explanation

Bohler's angle evaluates the height of the calcaneus. A flattening or decrease of this angle primarily indicates the depression and collapse of the weight-bearing posterior facet and the overall loss of calcaneal height.

Question 4109

Topic: 8. Foot and Ankle

A 20-year-old collegiate football player presents with severe midfoot pain after another player fell on his heel while his foot was plantarflexed. Initial non-weight-bearing radiographs of the foot appear normal. Given the high clinical suspicion for a Lisfranc injury, what is the most appropriate next diagnostic step?

. Discharge with a rigid boot and physical therapy
. Bone scintigraphy (bone scan) of the foot
. Weight-bearing (stress) radiographs of the foot
. Ultrasound of the plantar midfoot
. Electromyography of the deep peroneal nerve

Correct Answer & Explanation

. Discharge with a rigid boot and physical therapy

Explanation

Weight-bearing (stress) radiographs are essential for diagnosing subtle, dynamic Lisfranc instabilities that may spontaneously reduce and appear completely normal on standard non-weight-bearing films. They can reveal widening between the 1st and 2nd metatarsal bases.

Question 4110

Topic: 8. Foot and Ankle

A 24-year-old football player sustains a traumatic anterior knee dislocation, which is urgently reduced in the emergency department. Post-reduction, he has palpable dorsalis pedis and posterior tibial pulses. His Ankle-Brachial Index (ABI) is calculated to be 0.82. What is the most appropriate next step in management?

. Discharge with an immobilizer and follow-up in 1 week
. Perform a computed tomography angiography (CTA) of the lower extremity
. Immediate transport to the operating room for vascular exploration
. Observe closely with serial clinical examinations every 4 hours
. Apply a spanning external fixator immediately

Correct Answer & Explanation

. Discharge with an immobilizer and follow-up in 1 week

Explanation

An ABI less than 0.9 in the setting of a knee dislocation is highly suspicious for a popliteal artery injury, even if distal pulses are palpable. A CT angiogram is indicated to definitively rule out a vascular lesion such as an intimal tear.

Question 4111

Topic: Midfoot & Hindfoot

A 29-year-old snowboarder sustains a Hawkins type III talar neck fracture. Which of the following joint dislocations is characteristic of this specific injury pattern?

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

Correct Answer & Explanation

. Subtalar joint only

Explanation

A Hawkins type III fracture is defined as a talar neck fracture with dislocation of the subtalar, tibiotalar (ankle), and talonavicular joints. This pattern carries an extremely high rate of avascular necrosis due to the disruption of all three major blood supplies to the talar body.

Question 4112

Topic: 8. Foot and Ankle

A 29-year-old rugby player sustains an external rotation ankle injury with a high fibula fracture. Intraoperatively, the syndesmosis remains unstable after fibula length is restored. Which of the following is true regarding syndesmotic screw fixation?

. The screw should be placed parallel to the joint line and angled 30 degrees anteriorly
. The screw must cross four cortices to be effective
. The screw should be placed exactly at the level of the joint line
. Routine removal of the screw at 6 weeks is mandatory
. Suture button constructs have shown higher rates of malreduction compared to static screws

Correct Answer & Explanation

. The screw should be placed parallel to the joint line and angled 30 degrees anteriorly

Explanation

Syndesmotic screws should be placed 2-3 cm above the ankle joint, parallel to the joint line, and angled roughly 20-30 degrees anteriorly to match the anatomic axis. Routine removal is no longer considered mandatory.

Question 4113

Topic: 8. Foot and Ankle

An 18-year-old man sustains a gunshot wound to the distal medial thigh. He presents with an expanding, pulsatile hematoma and absent distal dorsalis pedis and posterior tibial pulses. What is the most appropriate next step in management?

. CT angiography of the lower extremity
. Ankle-Brachial Index (ABI) measurement
. Immediate surgical exploration in the operating room
. Local wound exploration in the Emergency Department
. Duplex ultrasound mapping

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

Hard signs of vascular injury, such as a pulsatile or expanding hematoma, absent distal pulses, or active arterial hemorrhage, mandate immediate surgical exploration. Delaying for advanced imaging in the presence of hard signs increases the risk of limb loss.

Question 4114

Topic: 8. Foot and Ankle

The primary blood supply to the talar body, which is frequently disrupted in Hawkins type III talar neck fractures leading to high rates of avascular necrosis, is provided by which of the following vessels?

. Artery of the tarsal sinus
. Artery of the tarsal canal
. Deltoid artery
. Dorsalis pedis branches
. Peroneal artery branches

Correct Answer & Explanation

. Artery of the tarsal sinus

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, is the dominant blood supply to the talar body. Its disruption, along with other capsular vessels, drives the high avascular necrosis rate seen in severe talar neck fractures.

Question 4115

Topic: 8. Foot and Ankle

A 34-year-old man suffers a crush injury to his foot. Weight-bearing radiographs demonstrate a 3mm widening between the medial cuneiform and the base of the second metatarsal. Which crucial ligamentous structure is primarily injured?

. Dorsal tarsometatarsal ligament
. Plantar aponeurosis
. Interosseous ligament between the 1st and 2nd metatarsal bases
. Interosseous ligament between the medial cuneiform and 2nd metatarsal base
. Plantar calcaneonavicular (spring) ligament

Correct Answer & Explanation

. Dorsal tarsometatarsal ligament

Explanation

The Lisfranc ligament is an interosseous ligament connecting the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is the primary stabilizer of the tarsometatarsal joint complex and its disruption results in diastasis.

Question 4116

Topic: 8. Foot and Ankle

A 45-year-old man develops severe right leg pain radiating to the dorsum of his foot. On examination, he has 3/5 weakness in the extensor hallucis longus and decreased sensation over the first dorsal web space. His patellar and Achilles reflexes are intact. Which of the following disc herniations is most likely responsible?

. L3-L4 paracentral herniation
. L4-L5 paracentral herniation
. L4-L5 far lateral herniation
. L5-S1 paracentral herniation
. L5-S1 far lateral herniation

Correct Answer & Explanation

. L3-L4 paracentral herniation

Explanation

An L4-L5 paracentral disc herniation compresses the traversing L5 nerve root. This presents clinically with extensor hallucis longus weakness and sensory deficits over the dorsal aspect of the foot.

Question 4117

Topic: 8. Foot and Ankle

A 55-year-old man presents with a right foot drop following an acute episode of back pain. Which physical examination finding would best differentiate an L5 radiculopathy from a common peroneal nerve entrapment at the fibular head?

. Weakness in ankle dorsiflexion
. Weakness in ankle inversion
. Weakness in great toe extension
. Numbness over the first dorsal web space
. Positive straight leg raise test

Correct Answer & Explanation

. Weakness in ankle dorsiflexion

Explanation

The tibialis posterior muscle (ankle inversion) is innervated by the tibial nerve (L4, L5) and is unaffected in a common peroneal nerve palsy. Weakness in ankle inversion alongside a foot drop indicates a more proximal lesion, such as an L5 radiculopathy.

Question 4118

Topic: 8. Foot and Ankle

A 65-year-old male presents with severe right leg pain. MRI demonstrates a far lateral (extra-foraminal) disc herniation at the L4-L5 level on the right. Which nerve root is most likely compressed, and what corresponding physical examination finding is expected?

. L4 nerve root; decreased patellar reflex and weakness in ankle dorsiflexion
. L5 nerve root; decreased Achilles reflex and weakness in ankle plantarflexion
. L4 nerve root; decreased Achilles reflex and weakness in extensor hallucis longus
. L5 nerve root; decreased patellar reflex and weakness in ankle inversion
. L3 nerve root; weakness in hip flexion and knee extension

Correct Answer & Explanation

. L4 nerve root; decreased patellar reflex and weakness in ankle dorsiflexion

Explanation

A far lateral (extra-foraminal) disc herniation at L4-L5 compresses the exiting L4 nerve root. This results in L4 radiculopathy, characterized by weakness in quadriceps (affecting knee extension) and anterior tibialis (ankle dorsiflexion), along with a diminished patellar reflex.

Question 4119

Topic: 8. Foot and Ankle

A 35-year-old male sustains a purely ligamentous Lisfranc injury after a fall from a horse. Radiographs reveal diastasis between the medial and middle cuneiforms with proximal migration of the second metatarsal.

What is the most appropriate surgical management for this specific injury pattern to minimize the need for revision surgery?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with transarticular screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Dorsal bridge plating of the first tarsometatarsal joint only
. Flexible suture-button fixation across the medial cuneiform and second metatarsal base

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

Primary arthrodesis of the medial 2 or 3 rays is the treatment of choice for purely ligamentous Lisfranc injuries. Studies demonstrate improved functional outcomes and lower revision rates compared to ORIF for purely ligamentous variants.

Question 4120

Topic: Forefoot

A 40-year-old female presents with a painful bunion. Clinical examination reveals hypermobility of the first tarsometatarsal (TMT) joint. Radiographs show a hallux valgus angle of 38 degrees and an intermetatarsal angle (IMA) of 18 degrees. What is the most appropriate surgical intervention?

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

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

A Lapidus procedure (1st TMT arthrodesis) is indicated for moderate-to-severe hallux valgus (IMA > 15 degrees) combined with first ray hypermobility. It corrects the deformity at the apex and stabilizes the medial column.

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