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8. Foot and Ankle MCQs

Practice Set 21 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 401

Topic: 8. Foot and Ankle

A 52-year-old man presents for treatment of acute pain in the forefoot. He notes that the onset of pain started 24 hours ago, and he is unable to walk. Examination of the hallux (Slide) is uncomfortable. The recommended treatment for this condition is:

. Bed rest and intravenous antibiotic therapy
. Drainage of the hallux metatarsophalangeal joint, cultures, and initiation of a broad spectrum antibiotic
. Immobilization of the foot in a short leg walking cast
. A wide comfortable shoe or sandal until the joint inflammation settles down
. Intra-articular steroid injection

Correct Answer & Explanation

. Intra-articular steroid injection

Explanation

This patient presents with a classic acute gout attack. Although the hallux is in severe valgus, it is unlikely that this is the cause of the joint pain. Note the swelling of the hallux and the shiny skin from the acute inflammation. These clinical findings are typical of gout. Intra-articular injection of steroids is effective treatment and can be combined with oral anti-inflammatory agents.

Question 402

Topic: 8. Foot and Ankle

A 43-year-old patient presents for treatment of a chronically painful ankle. He notes pain with ambulation, is unable to exercise, and has had marked swelling of the ankle for the last 6 months. When walking, he notes continued instability of the ankle. Examination of the ankle is unremarkable with the exception of swelling. A plain radiograph and intraoperative photograph are shown (Slide 1 and Slide 2). The most likely cause for this condition is:

. Recurrent ankle sprain with proliferative synovitis
. Hemorrhagic synovitis
. Early onset rheumatoid arthritis
. Pigmented villonodular synovitis
. Synovitis associated with pseudogout

Correct Answer & Explanation

. Pigmented villonodular synovitis

Explanation

The appearance of the synovium is typical of pigmented villonodular synovitis. Staining of the synovium is characteristic. It is unlikely that a 43- year-old man will present with rheumatoid arthritis, although synovitis may appear similar. Recurrent ankle sprains cause a nonspecific synovitis that is not pigmented.

Question 403

Topic: 8. Foot and Ankle

A 61-year-old woman presents for treatment of a painful ankle. She reports that 4 years ago, she sustained a fracture of her ankle that was treated with cast immobilization. She has experienced progressively worsening pain over the past 2 years. On examination, she has good range of motion of the ankle with crepitus and pain. Radiographs are presented (Slide 1 and Slide 2). All of the following are acceptable forms of surgical correction except:

. Supramalleolar osteotomy of the tibia
. Ankle arthroscopy
. Ankle arthrodesis
. Total ankle replacement
. Distraction lengthening osteotomy of the fibula

Correct Answer & Explanation

. Supramalleolar osteotomy of the tibia

Explanation

Each of the alternatives presented is reasonable except for ankle arthroscopy because it has a limited role in the management of posttraumatic arthritis of the ankle. In this patient, there is a possibility to salvage the ankle before arthrodesis or joint replacement with an osteotomy of the tibia and or the fibula. Both have a definite role in management of ankle deformity and arthritis. A closing wedge osteotomy of the tibia was performed in this patient, and she remains asymptomatic 4 years later (Slide 3 and Slide 4).

Question 404

Topic: 8. Foot and Ankle

This patient developed a peripheral neuropathy of uncertain etiology. She has a partial peroneal nerve palsy with lack of extensor function of the hallux. She repeatedly stubs and catches the hallux when walking. Upon examination, she has good strength of the extensor digitorum longus tendon, as well as the anterior tibial tendon. Flexor strength of the foot is intact. All of the following are acceptable surgical alternatives except:

. Arthrodesis of the hallux metatarsophalangeal (MP) joint
. Tenodesis of the extensor hallucis longus tendon to the extensor digitorum longus tendon
. Tenodesis of the extensor hallucis longus tendon to the anterior tibial tendon
. Transfer of the peroneus tertius tendon to the extensor hallucis longus tendon
. Transfer of a portion of the extensor digitorum longus tendon to the extensor hallucis longus tendon

Correct Answer & Explanation

. Arthrodesis of the hallux metatarsophalangeal (MP) joint

Explanation

When arthrodesis of the hallux MP joint is performed, it stabilizes the MP joint and continued flexion of the hallux with recurrent deformity occurs because the hallux interphalangel joint is not controlled with MP arthrodesis. All of the other procedures are satisfactory alternatives.

Question 405

Topic: 8. Foot and Ankle
A 28-year-old professional athlete presents for treatment of foot pain following an inversion injury to her ankle. She has been immobilized in a short leg walker boot for 1 month with minimal relief of symptoms. On examination, pain is present in the sinus tarsi. The patient's ankle is not painful or unstable. Radiographs demonstrate a calcaneonavicular coalition. Recommended treatment includes:
. Corticosteroid and lidocaine injection into the sinus tarsi
. Continued immobilization in a boot for an additional month
. Physical therapy treatments aimed at mobilizing the subtalar joint
. Subtalar arthrodesis
. Excision of the tarsal coalition

Correct Answer & Explanation

. Excision of the tarsal coalition

Explanation

When a tarsal coalition becomes symptomatic in an adult, surgery becomes necessary. Initial immobilization may be attempted, although prolonged immobilization in an athlete is not ideal. Manipulation of the foot will exacerbate the pain, and therapy is not indicated. If arthrodesis of the hindfoot is performed for treatment of a calcaneonavicular coalition, then a triple arthrodesis is performed. Excision of the adult calcaneonavicular coalition is the preferred treatment.

Question 406

Topic: 8. Foot and Ankle

A 43-year-old woman presents for treatment of pain in her forefoot that has been present for 1 year. The pain is localized to the second toe and radiates out to the tip of the toe with activities. When the patient wears high heel shoes, the pain is associated with numbness and burning of the toe. Your initial treatment consists of:

. Excision of a third web space neuroma
. Excision of a second web space neuroma
. Transfer of the flexor tendon to stabilize the metatarsophalangeal joint
. Oblique metatarsal head osteotomy
. None of the above

Correct Answer & Explanation

. None of the above

Explanation

This patient has typical symptoms of an interdigital neuroma, most likely involving the second web space. The likelihood of resolution of pain with nonsurgical treatment is good despite the duration of symptoms. Treatment can be initiated with a wide shoe, an orthotic arch support, or an injection of corticosteroid into the affected web space.

Question 407

Topic: 8. Foot and Ankle
A 62-year-old man presents for treatment of ankle pain. He suffered a fibular fracture 7 months ago while hiking in the mountains. He was treated with a short leg walking cast. On examination, he has pain on range of motion of the ankle, pain over the distal fibula, and no instability or crepitus to range of motion of the ankle. Pain is present on external rotation of the foot under the leg. Radiographs of the ankle demonstrate a healed fibular fracture with 7 mm of shortening and slight external rotation. There is a 7° valgus tilt of the tibiotalar joint and a widening of the medial clear space. The joint space laterally appears slightly narrowed. Recommended treatment includes:
. Total ankle replacement
. Ankle arthrodesis
. Lengthening osteotomy of the fibula
. Deltoid ligament reconstruction
. Ankle arthroscopy

Correct Answer & Explanation

. Lengthening osteotomy of the fibula

Explanation

This patient has a malunion of the fibula that does not appear to be associated with ankle arthritis, despite the radiographic changes. The valgus tilt of the ankle joint is common with shortening of the fibula and does not imply arthritis. Therefore, arthrodesis and ankle replacement are not indicated. Lengthening osteotomy of the fibula combined with excision of the medial joint scar is ideal to realign the tibiotalar joint. Although ankle arthroscopy may be performed in conjunction with the fibular osteotomy, it is not sufficient treatment.

Question 408

Topic: 8. Foot and Ankle

The most common complication following operative treatment of an acute rupture of the Achilles tendon is:

. Wound infection
. Sural neuritis
. Re-rupture
. Excessive dorsiflexion of the foot
. Thickening of the tendon

Correct Answer & Explanation

. Re-rupture

Explanation

Although all of the above complications may occur following repair of an acute Achilles rupture, improper tensioning of the repair and stretching of the repair occur most commonly. This is due to a number of factors including the position of the foot during the repair, incorrect tensioning of the repair, and premature unprotected dorsiflexion of the foot following surgery. When suturing the tendon ends, the sutures must be inserted correctly and not into the frayed tendon ends, which will lead to incorrect tension on the repair. It is preferable to position the foot in slight equinus during the repair.

Question 409

Topic: 8. Foot and Ankle

A 67-year-old obese patient presents for treatment of ankle pain. Twenty- five years ago, he underwent a total ankle replacement. He was asymptomatic for 15 years, and his symptoms have become intolerable. He has limited ankle motion, associated with pain in the ankle. His radiograph is presented (Slide). Which of the following is the preferred surgical procedure:

. Revision total ankle replacement with graft and a larger prosthesis
. Ankle arthrodesis
. Tibiotalocalcaneal arthrodesis
. Pantalar arthrodesis
. Removal of the implant

Correct Answer & Explanation

. Ankle arthrodesis

Explanation

Removal of the implant is necessary but will not be sufficient to alleviate pain from arthritis. In this obese patient, an arthrodesis is necessary. An extended hindfoot arthrodesis is only necessary when pain and arthritis are present in joints adjacent to the ankle. An ankle arthrodesis with interposition graft is sufficient.

Question 410

Topic: 8. Foot and Ankle

A patient presents for treatment of a dislocated second metatarsophalangeal joint. Radiographs demonstrate the dislocation. In addition to soft tissue balancing, you perform an oblique shortening osteotomy of the second metatarsal head (Weil). The most common complication following this osteotomy is:

. Recurrent dislocation
. Avascular necrosis of the metatarsal head
. Arthritis of the second metatarsophalangeal joint
. Elevation of the second toe
. C law toe deformity

Correct Answer & Explanation

. Elevation of the second toe

Explanation

The Weil osteotomy is a good procedure to correct deformity about the lesser metatarsophalangeal joint but is associated with potential complications, the most common of which is elevation of the second toe. As a result of shortening and plantar shifting of the metatarsal, the intrinsic muscles shift dorsally and can function as a dorsiflexor of the metatarsophalangeal joint.

Question 411

Topic: 8. Foot and Ankle

A 26-year-old professional football player presents for evaluation of ankle pain. He was playing in a match 2 days ago and felt a pop in his ankle. On examination, the peroneal tendon is felt to subluxate anterior to the fibula. Magnetic resonance imaging confirms a tear of the superior peroneal retinaculum. Recommended treatment includes:

. Immobilization in a short leg walking cast
. Immobilization in a hinged range of motion walker boot
. Repair of the superior peroneal retinaculum
. Deepening of the fibular groove
. Periosteal-tendon flap repair of the subluxated tendon

Correct Answer & Explanation

. Repair of the superior peroneal retinaculum

Explanation

An acute dislocation of the peroneal tendon must be repaired. The results of immobilization are not predictable and, in a professional athlete, the added potential for failure with nonoperative treatment must be considered. With a rupture of the superior peroneal retinaculum likely to be the cause of the dislocation, the peroneal tendon should be repaired. When repair of an acute dislocation is performed, it should not be necessary to deepen the fibular groove.

Question 412

Topic: 8. Foot and Ankle

This patient is a 17-year-old athlete who presents for treatment of a feeling of giving way of the ankle. The inversion clinical stress is demonstrated below (Slide). Which statement concerning the image presented below is correct:

. Ankle instability is present.
. Subtalar instability is present.
. Ankle and subtalar instability are present.
. Generalized ligamentous laxity is present.
. No determination of instability can be made from this picture.

Correct Answer & Explanation

. No determination of instability can be made from this picture.

Explanation

Although some laxity may be present in this patient, it is impossible to determine whether this is present in the ankle or the subtalar joint based upon this clinical test. Simple inversion stress without simultaneously palpating the lateral shoulder of the talus cannot indicate the presence or the type of instability. An anterior drawer that is positive and, in particular, is associated with a vacuum phenomenon in the anterolateral ankle is more diagnostic of ankle instability.

Question 413

Topic: 8. Foot and Ankle

What structure is held in between the forceps in this photograph (Slide):

. Anterior talofibular ligament
. Peroneus tertius tendon
. C alcaneofibular ligament
. Extensor retinaculum
. Interosseous ligament

Correct Answer & Explanation

. Extensor retinaculum

Explanation

The extensor retinaculum is an important structure in maintaining and possibly augmenting the stability of the lateral ankle and subtalar joint. The inferior root of the extensor retinaculum inserts in the floor of the sinus tarsi, improving stability of the subtalar joint. This structure can be used to augment a repair of ankle instability.

Question 414

Topic: 8. Foot and Ankle

A 37-year-old woman injured her ankle 17 weeks ago when stepping off a sidewalk. She has experienced pain in the ankle since that time, and no treatment has yet been initiated. Presented is a view of the ankle performed with external rotation stress (Slide). The recommended treatment at this time is:

. Repair of the deltoid ligament
. Repair of the deltoid ligament and open reduction of the syndesmosis
. Screw fixation of the syndesmosis
. Open reduction internal fixation of a high fibular fracture
. Open reduction internal fixation of a high fibular fracture and repair of the deltoid ligament

Correct Answer & Explanation

. Screw fixation of the syndesmosis

Explanation

This unstable ankle is associated with a complete disruption of the syndesmosis. With the information available, it is not likely that a high fibular fracture is present. One has to assume that the injury is limited to the syndesmosis. Although the deltoid ligament may be torn, one cannot determine this until the time of surgery. At surgery, if the mortise reduces well following insertion of screw(s), then the deltoid is left alone. If the talus does not reduce, then there may be deltoid tissue that needs to be removed before the reduction can be accomplished.

Question 415

Topic: 8. Foot and Ankle

A 42-year-old male patient presents with a history of repeated giving way of his ankle. He notes that this has been present for 1 year. He does not experience any pain, even with the episodic bouts of the ankle buckling. On examination, the ankle range of motion is normal, no pain is elicited, and there is no crepitus. A stress radiograph (Slide 1) and a lateral weight- bearing radiograph (Slide 2) are presented. The patient does not want to undergo surgery, but he needs to know the possibility of problems with his ankle in the future. The patient should be advised that:

. A high incidence of subsequent ankle arthritis is likely.
. The episodes of ankle instability will decrease over time.
. He is likely to develop an osteochondral injury of the talus.
. His ankle may dislocate with a future inversion injury.
. He is not likely to experience any problem other than intermittent giving way of the ankle in the future.

Correct Answer & Explanation

. A high incidence of subsequent ankle arthritis is likely.

Explanation

Ankle arthritis is rarely idiopathic. In the United States, the most common source of ankle arthritis is following trauma, usually of a major nature. Repetitive ankle injury, particularly when associated with recurrent instability and a varus or cavus foot, will likely lead to the development of ankle arthritis. Patients should be counseled that recurrent instability of the ankle, particularly when osteophytes are already present, frequently leads to arthritis.

Question 416

Topic: 8. Foot and Ankle
A 73-year-old woman states that she has been tripping over her right foot for the past year. She walks with a limp, and she states that her foot "slaps" the ground. On examination, weakness in which muscle is likely present:
. Gastrocnemius
. Anterior tibial
. Posterior tibial
. Flexor hallucis longus
. Peroneus longus and brevis

Correct Answer & Explanation

. Anterior tibial

Explanation

This patient presents with a typical rupture of the anterior tibial tendon. She reports a drop foot, commonly perceived by the patient as a slapping sensation of the foot when attempting to lift the foot up as the heel contacts the ground. Note the slight extension of the hallux, indicating chronic overuse in an attempt to provide accessory dorsiflexion of the ankle.

Question 417

Topic: 8. Foot and Ankle
A 76-year-old man has experienced aching in the anterior aspect of his ankle for 6 months. He felt a sudden onset of soreness 6 months ago. Since then, he has noted weakness of the foot. He walks with a limp, and the foot hits the ground during the heel contact phase of gait. On examination there is a mobile subcutaneous mass in the anterior ankle. The patient's magnetic resonance image (MRI) is presented. Which of the following is the most accurate diagnosis:
. A ganglion of the anterior ankle
. Synovial sarcoma
. Pigmented villonodular synovitis
. A rupture of the anterior tibial tendon
. An accessory extensor hallucis longus

Correct Answer & Explanation

. A rupture of the anterior tibial tendon

Explanation

This MRI presents the typical appearance of an anterior tibial tendon rupture. There is no continuity of the tendon distally, and the retracted tendon end has formed a scar palpable as a subcutaneous mass. The clinical history of the weakness associated with a drop foot gait is characteristic of the tendon rupture.

Question 418

Topic: 8. Foot and Ankle

A 23-year-old carpenter fell off a roof 4 weeks ago. He has pain in the ankle and a deformity. The lateral radiograph is presented (Slide). Which of the following treatments is most likely to return this patient to work with a functioning foot and ankle:

. Open reduction internal fixation of the calcaneus fracture
. Short leg cast, no weight bearing for 8 weeks, followed by physical therapy
. Immediate vigorous physical therapy emphasizing range of motion
. Open reduction internal fixation of the calcaneus fracture with primary subtalar arthrodesis
. Physical therapy, followed by subtalar arthrodesis at 6 months

Correct Answer & Explanation

. Open reduction internal fixation of the calcaneus fracture with primary subtalar arthrodesis

Explanation

The calcaneus fracture is associated with subluxation of the subtalar joint, giving the appearance of injury to the talus and calcaneus. The true extent of the injury cannot be determined without a computed tomography scan; however, the question is not as to the outcome of treatment, but the ability to return this patient to his occupation. At 4 weeks following injury, while open reduction internal fixation of the fracture is possible, anatomic reduction may be difficult. The most likely means of returning this patient to work iswith early arthrodesis, which should be combined with an open reduction internal fixation of the calcaneus.

Question 419

Topic: Forefoot

A patient underwent an arthrodesis of the hallux metatarsophalangeal joint for correction of painful arthritis (Slide 1 and Slide 2). She remains symptomatic and cannot walk without pain. The most likely cause for her pain is:

. Fusion of the hallux in too much plantarflexion
. Fusion of the hallux in too much dorsiflexion
. Fusion of the hallux in too much varus
. Removal of too much bone in the metatarsophalangeal joint during fusion, leading to claw hallux
. Removal of too much bone in the metatarsophalangeal joint during fusion, leading to lesser toe metatarsalgia

Correct Answer & Explanation

. Fusion of the hallux in too much varus

Explanation

The ideal position for arthrodesis of the hallux metatarsophalangeal joint is in 5° of valgus, 10° of dorsiflexion relative to the ground, and neutral rotation. Although the hallux is short and may be associated with painful metatarsalgia, the most likely cause of pain is abutment of the hallux against the shoe because it was fused in varus.

Question 420

Topic: 8. Foot and Ankle

A 53-year-old woman presents for treatment of painful toe and metatarsal deformities (Slide). She underwent surgery to the hallux 2 years ago for correction of arthritis of the hallux metatarsophalangeal joint. Pain in the joint persists. She has no systemic disease, and the opposite foot is normal. What is the ideal surgical correction for her forefoot:

. C apsulotomy of the lesser toe metatarsophalangeal joints and extensor tendon lengthening with temporary K-wire fixation
. Resection of the lesser metatarsal heads
. Arthrodesis of the hallux metatarsophalangeal joint with interposition bone block graft
. Shortening osteotomies of the lesser toe metatarsals and arthrodesis of the hallux metatarsophalangeal joint
. Revision resection arthroplasty of the hallux and resection of the lesser metatarsal heads

Correct Answer & Explanation

. Shortening osteotomies of the lesser toe metatarsals and arthrodesis of the hallux metatarsophalangeal joint

Explanation

Resection of the lesser metatarsal heads is an operation that is commonly performed for patients with rheumatoid arthritis; however, this may also be performed for patients with debilitating metatarsalgia in the absence of systemic disease. Capsulotomy and tendon lengthening will not correct the alignment of the lesser toes or address the metatarsalgia. Revision of the resection arthroplasty will not address the metatarsalgia, and recurrent deformity of the hallux is likely. Shortening osteotomies of the metatarsal will decompress the joint, realign the toes, and decrease the metatarsalgia, particularly if performed in conjunction with metatarsophalangeal arthrodesis. A lengthening bone block fusion is not necessary.

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