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8. Foot and Ankle MCQs

Practice Set 207 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 4121

Topic: 8. Foot and Ankle

A 31-year-old recreational basketball player presents with an acute mid-substance Achilles tendon rupture. After discussing operative and non-operative management, he elects for non-operative treatment. Which of the following rehabilitation protocols provides re-rupture rates most comparable to surgical repair?

. Casting in equinus for 8 weeks followed by weight-bearing
. Early functional mobilization and weight-bearing in a functional brace
. Strict non-weight-bearing cast for 12 weeks
. Immediate full weight-bearing in regular footwear with a heel lift
. Immobilization in dorsiflexion for 6 weeks

Correct Answer & Explanation

. Casting in equinus for 8 weeks followed by weight-bearing

Explanation

Recent high-level evidence shows that non-operative management with early functional mobilization and weight-bearing protocols yields re-rupture rates equivalent to surgical repair, while avoiding surgical wound complications.

Question 4122

Topic: 8. Foot and Ankle
A 55-year-old female presents with worsening medial ankle pain and a progressively flattening arch. On examination, she is unable to perform a single-leg heel rise. Weight-bearing radiographs demonstrate >50% talonavicular uncoverage and an abnormal talo-first metatarsal angle. Which surgical strategy is most appropriate?
. Isolated flexor digitorum longus (FDL) transfer to the navicular
. Gastrocnemius recession alone
. Medial displacement calcaneal osteotomy with FDL transfer
. Lateral column lengthening (Evans), medial calcaneal osteotomy, and FDL transfer
. Triple arthrodesis

Correct Answer & Explanation

. Lateral column lengthening (Evans), medial calcaneal osteotomy, and FDL transfer

Explanation

This is a Stage IIb adult acquired flatfoot deformity (flexible, >50% talonavicular uncoverage). Management typically requires a FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening to correct the severe forefoot abduction.

Question 4123

Topic: 8. Foot and Ankle

A 60-year-old diabetic male presents with a red, hot, and swollen right foot. He has bounding pedal pulses and a loss of protective sensation. Laboratory tests show normal WBC and a mildly elevated ESR. Radiographs show fragmentation of the midfoot joints. What is the most appropriate initial management?

. Incision and drainage
. Intravenous antibiotics
. Total contact casting and strict non-weight-bearing
. Primary midfoot arthrodesis
. Below-knee amputation

Correct Answer & Explanation

. Incision and drainage

Explanation

The clinical presentation is classic for acute Charcot neuroarthropathy (Eichenholtz stage I). The standard initial treatment is offloading via total contact casting to prevent further deformity until the acute inflammatory phase resolves.

Question 4124

Topic: 8. Foot and Ankle

A 22-year-old track athlete complains of vague, chronic dorsal midfoot pain that worsens with sprinting. Plain radiographs are negative, but an MRI reveals a high T2 signal and an incomplete fracture line in the central third of the navicular. What is the recommended initial management?

. Symptomatic management in a stiff-soled shoe
. Cortisone injection into the talonavicular joint
. Non-weight-bearing cast immobilization for 6 to 8 weeks
. Open reduction and internal fixation with a compression screw
. Primary talonavicular fusion

Correct Answer & Explanation

. Symptomatic management in a stiff-soled shoe

Explanation

Tarsal navicular stress fractures carry a high risk of nonunion due to a relatively avascular central third. Initial conservative management for incomplete fractures requires strict non-weight-bearing in a cast for 6 to 8 weeks.

Question 4125

Topic: 8. Foot and Ankle

A 48-year-old man presents with chronic insertional Achilles tendinopathy and a large Haglund deformity. Non-operative management has failed. During surgery, aggressive debridement of the calcific tendinosis requires removal of 60% of the Achilles tendon insertion. What additional procedure is indicated?

. Primary end-to-end repair
. V-Y advancement flap
. Flexor hallucis longus (FHL) tendon transfer
. Peroneus brevis tendon transfer
. Gastrocnemius recession only

Correct Answer & Explanation

. Primary end-to-end repair

Explanation

When >50% of the Achilles tendon insertion is debrided during surgery for insertional Achilles tendinopathy, an FHL tendon transfer is indicated to augment plantarflexion strength and revascularize the repair site.

Question 4126

Topic: 8. Foot and Ankle

A patient with Charcot-Marie-Tooth disease presents with a symptomatic cavovarus foot. A Coleman block test is performed by placing the patient's heel and lateral forefoot on a block while allowing the first metatarsal to drop. The hindfoot varus corrects to neutral. What does this test signify?

. The hindfoot deformity is fixed, requiring a triple arthrodesis.
. The deformity is driven by a plantarflexed first ray, requiring a dorsiflexion osteotomy of the first metatarsal.
. The Achilles tendon is contracted, requiring a percutaneous lengthening.
. The subtalar joint has arthritic changes, requiring a subtalar fusion.
. The tibialis posterior tendon is ruptured, requiring an FDL transfer.

Correct Answer & Explanation

. The hindfoot deformity is fixed, requiring a triple arthrodesis.

Explanation

The Coleman block test distinguishes between fixed and flexible hindfoot varus. If the varus corrects when the first metatarsal is allowed to drop, the deformity is forefoot-driven (flexible hindfoot), and a dorsiflexion osteotomy of the 1st metatarsal is indicated.

Question 4127

Topic: 8. Foot and Ankle

A 62-year-old male is considering surgical options for end-stage ankle osteoarthritis. Which of the following is an absolute contraindication to a total ankle arthroplasty (TAA)?

. Age greater than 60 years
. Concomitant subtalar joint arthritis
. Body mass index of 32 kg/m2
. Severe Charcot neuroarthropathy of the ankle
. Previous open reduction and internal fixation of a bimalleolar fracture

Correct Answer & Explanation

. Age greater than 60 years

Explanation

Absolute contraindications to total ankle arthroplasty include active infection, severe peripheral neuropathy/Charcot neuroarthropathy, absent limb sensation, and avascular necrosis of >50% of the talar body.

Question 4128

Topic: Forefoot

A 50-year-old female presents with dorsal midfoot pain localized to the first metatarsophalangeal (MTP) joint. Radiographs show mild to moderate joint space narrowing with a large dorsal osteophyte, consistent with Grade 2 hallux rigidus. She has failed conservative management. What is the most appropriate surgical treatment?

. Dorsal cheilectomy
. First MTP joint arthrodesis
. Keller resection arthroplasty
. Total first MTP joint arthroplasty
. Lapidus procedure

Correct Answer & Explanation

. Dorsal cheilectomy

Explanation

For early to moderate hallux rigidus (Coughlin and Shurnas Grades 1 and 2) with dorsal impingement and preserved plantar cartilage, dorsal cheilectomy is the surgical treatment of choice and preserves joint motion.

Question 4129

Topic: 8. Foot and Ankle

A 25-year-old skier presents with lateral ankle pain and swelling after catching an edge, forcibly dorsiflexing and everting the foot. He reports a snapping sensation posterior to the lateral malleolus. Radiographs reveal a small cortical avulsion fracture off the posterolateral margin of the distal fibula. What is the most likely diagnosis?

. Anterior talofibular ligament tear
. Superior peroneal retinaculum tear with peroneal tendon dislocation
. Calcaneofibular ligament tear
. Achilles tendon subluxation
. Fifth metatarsal base avulsion fracture

Correct Answer & Explanation

. Anterior talofibular ligament tear

Explanation

The 'fleck sign' (avulsion fracture off the posterolateral fibula) is pathognomonic for a superior peroneal retinaculum injury, resulting in subluxation or dislocation of the peroneal tendons.

Question 4130

Topic: 8. Foot and Ankle

A 45-year-old female presents with burning pain and numbness on the plantar aspect of her foot. Symptoms are worse with prolonged standing. She has a positive Tinel's sign posterior to the medial malleolus. What imaging modality is most useful to identify the etiology in this patient?

. Weight-bearing AP and lateral radiographs
. Computed tomography (CT) of the hindfoot
. Magnetic Resonance Imaging (MRI) of the ankle
. Diagnostic ultrasound of the plantar fascia
. Bone scan

Correct Answer & Explanation

. Weight-bearing AP and lateral radiographs

Explanation

The patient has tarsal tunnel syndrome. Because up to 80% of tarsal tunnel syndrome cases are caused by a space-occupying lesion (e.g., ganglion cyst, lipoma, or varicosities), an MRI is the most useful imaging modality.

Question 4131

Topic: 8. Foot and Ankle

A 55-year-old female presents with a 6-month history of a 'pebble in my shoe' sensation and burning pain in her 3rd web space. Compression of the forefoot produces a palpable click and exacerbates the pain. She has not improved after shoe modifications and corticosteroid injections. If surgery is performed, which of the following is critical to prevent recurrence?

. Releasing only the deep transverse metatarsal ligament
. Excising the nerve distal to the bifurcation
. Performing a dorsal cheilectomy of the adjacent metatarsal heads
. Excising the nerve well proximal to the deep transverse metatarsal ligament
. Transposing the nerve dorsal to the interosseous muscles without excision

Correct Answer & Explanation

. Releasing only the deep transverse metatarsal ligament

Explanation

For a Morton's neuroma that fails conservative care, operative excision is indicated. It is critical to resect the nerve well proximal to the deep transverse metatarsal ligament to ensure the cut nerve stump retracts into soft muscle tissue, avoiding a painful stump neuroma.

Question 4132

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. She is able to perform a single heel rise, though it is painful and weak. On examination, she has a positive too-many-toes sign and flexible hindfoot valgus. Forefoot abduction is present and uncovers >40% of the talar head. What is the most appropriate surgical management?
. FDL transfer to the navicular and medial displacement calcaneal osteotomy
. FDL transfer to the navicular, medial displacement calcaneal osteotomy, and lateral column lengthening
. Subtalar arthrodesis
. Triple arthrodesis
. Spring ligament repair alone

Correct Answer & Explanation

. FDL transfer to the navicular, medial displacement calcaneal osteotomy, and lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction (PTTD) is characterized by a flexible deformity with significant forefoot abduction (>40% talonavicular uncoverage). This requires a lateral column lengthening in addition to FDL transfer and medial displacement calcaneal osteotomy.

Question 4133

Topic: 8. Foot and Ankle

A 45-year-old roofer sustained a closed, displaced intra-articular calcaneus fracture treated with ORIF via an extensile lateral approach 1 year ago. He complains of lateral ankle pain with walking. Examination reveals tenderness inferior to the lateral malleolus and pain with resisted foot eversion. Subtalar motion is well-preserved and painless. What is the most likely cause of his current symptoms?

. Subtalar post-traumatic arthritis
. Sural nerve entrapment
. Peroneal tendon impingement
. Complex regional pain syndrome
. Tibiotalar arthritis

Correct Answer & Explanation

. Subtalar post-traumatic arthritis

Explanation

Lateral wall blowout or prominent hardware post-calcaneus fracture ORIF can cause subfibular impingement of the peroneal tendons. This typically presents with lateral ankle pain and pain on resisted eversion, while painless subtalar motion rules against subtalar arthritis.

Question 4134

Topic: Midfoot & Hindfoot

A 24-year-old collegiate football player sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial and middle cuneiforms.

What is the most appropriate surgical management?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Primary arthrodesis of all five tarsometatarsal joints
. Dorsal bridge plating without joint preparation

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

Purely ligamentous Lisfranc injuries have a high rate of hardware failure and loss of reduction with ORIF. Primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) is preferred for athletes to ensure a more reliable return to play and prevent post-traumatic arthritis.

Question 4135

Topic: 8. Foot and Ankle

Which of the following is true regarding the operative versus nonoperative management of acute Achilles tendon ruptures according to high-level clinical evidence?

. Operative management always has a higher re-rupture rate.
. Nonoperative management has a significantly higher re-rupture rate even with early functional rehabilitation.
. Early functional rehabilitation makes the re-rupture rates equivalent between the two groups.
. Operative management has a lower risk of sural nerve injury.
. Nonoperative management has a higher rate of deep tissue infection.

Correct Answer & Explanation

. Operative management always has a higher re-rupture rate.

Explanation

Recent level 1 evidence shows no significant difference in re-rupture rates between operative and nonoperative treatment when a strict early functional rehabilitation protocol is employed. Operative treatment carries a slightly higher risk of soft-tissue complications and nerve injury.

Question 4136

Topic: 8. Foot and Ankle

A 22-year-old collegiate football player sustains a pure ligamentous Lisfranc injury. Weight-bearing radiographs show 3 mm of widening between the medial cuneiform and the base of the second metatarsal. What is the most appropriate surgical management for this athlete?

. Closed reduction and casting
. Primary arthrodesis of the 1st, 2nd, and 3rd tarsometatarsal joints
. Open reduction and internal fixation with transarticular screws
. Primary arthrodesis of the 4th and 5th tarsometatarsal joints
. Percutaneous K-wire fixation

Correct Answer & Explanation

. Closed reduction and casting

Explanation

Primary arthrodesis is the preferred surgical treatment over ORIF for purely ligamentous Lisfranc injuries, particularly in athletes. Arthrodesis yields better mid- to long-term functional outcomes and significantly lowers the rates of hardware failure and revision surgery.

Question 4137

Topic: 8. Foot and Ankle

A 55-year-old man presents with dorsal midfoot pain during gait. Examination shows a painful block at 20 degrees of passive first MTP dorsiflexion, but preserved and painless plantarflexion.

Radiographs reveal dorsal osteophytes with joint space narrowing limited to the dorsal half of the joint. What is the most appropriate surgical treatment?

. MTP joint arthrodesis
. Keller resection arthroplasty
. Cheilectomy
. Silicone implant arthroplasty
. First metatarsal plantarflexion osteotomy

Correct Answer & Explanation

. MTP joint arthrodesis

Explanation

The patient has Grade II hallux rigidus characterized by preserved plantarflexion and pain primarily at the extremes of dorsiflexion due to impingement. Cheilectomy (resection of dorsal osteophytes and the dorsal third of the metatarsal head) has a high success rate for this specific stage.

Question 4138

Topic: 8. Foot and Ankle

A 65-year-old female presents with severe, activity-limiting post-traumatic ankle osteoarthritis. Radiographs demonstrate bone-on-bone tibiotalar arthritis and moderate subtalar osteoarthritis. She has a well-aligned hindfoot. What is the primary advantage of total ankle arthroplasty (TAA) over ankle arthrodesis in this specific patient?

. Decreased risk of deep infection
. Preservation of motion to limit progression of adjacent joint arthritis
. Higher rate of successful return to high-impact sports
. Elimination of the need for future revision surgery
. Shorter initial postoperative immobilization period

Correct Answer & Explanation

. Decreased risk of deep infection

Explanation

TAA is favored in patients with adjacent joint arthritis (like subtalar OA) because it preserves tibiotalar motion. This reduces compensatory stresses on already degenerative neighboring joints, whereas arthrodesis accelerates adjacent arthritic progression.

Question 4139

Topic: Forefoot

A 55-year-old male complains of progressive right big toe pain. Examination reveals a rigid first metatarsophalangeal (MTP) joint with less than 10 degrees of dorsiflexion and severe pain in the midrange of motion. Radiographs show joint space obliteration and large dorsal osteophytes (Coughlin and Shurnas Grade 3). What is the most reliable surgical option for long-term pain relief?

. Cheilectomy
. Proximal phalanx extension osteotomy (Moberg)
. First MTP arthrodesis
. Silastic unipolar implant arthroplasty
. Keller resection arthroplasty

Correct Answer & Explanation

. Cheilectomy

Explanation

First MTP arthrodesis is the gold standard for advanced hallux rigidus (Grade 3 and 4) presenting with pain in the midrange of motion. Cheilectomy is indicated for early stages where pain is primarily at terminal dorsiflexion.

Question 4140

Topic: 8. Foot and Ankle

A 48-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. Examination reveals she is unable to perform a single-limb heel rise. Weight-bearing radiographs demonstrate uncovering of the talar head of 45% on the AP view (forefoot abduction) and plantarflexion of the talus on the lateral view. Which of the following surgical strategies is most appropriate for this Stage IIb deformity?

. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and lateral column lengthening
. Isolated subtalar arthrodesis
. Isolated spring ligament repair
. Gastrocnemius recession and conservative shoe wear

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy (MDCO)

Explanation

Stage IIb adult acquired flatfoot deformity includes flexible hindfoot valgus with significant forefoot abduction (>30% talonavicular uncoverage). This requires a lateral column lengthening (e.g., Evans osteotomy) in addition to FDL transfer and MDCO.

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