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8. Foot and Ankle MCQs

Practice Set 212 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 4221

Topic: Forefoot

A 55-year-old man reports chronic dorsal midfoot pain at the first metatarsophalangeal (MTP) joint, worst during toe-off. Radiographs display moderate dorsal osteophytes but preservation of the plantar joint space (Coughlin/Shurnas Grade 2). Conservative measures have failed. Which surgical option is most indicated?

. First MTP arthrodesis
. Cheilectomy
. Keller resection arthroplasty
. Total joint arthroplasty
. Lapidus procedure

Correct Answer & Explanation

. First MTP arthrodesis

Explanation

Cheilectomy (excision of the dorsal osteophytes and the dorsal third of the metatarsal head) is highly effective for Grade 1 and 2 hallux rigidus where plantar cartilage is preserved. Arthrodesis is generally reserved for end-stage (Grade 3 or 4) disease.

Question 4222

Topic: 8. Foot and Ankle

A 28-year-old man sustains a high-energy motor vehicle collision and presents with a closed Hawkins Type II talar neck fracture. Which of the following best represents the approximate rate of avascular necrosis (AVN) of the talar body associated with this specific injury pattern?

. 0 to 10%
. 20 to 50%
. 60 to 80%
. 90 to 100%
. AVN does not occur with this fracture pattern

Correct Answer & Explanation

. 0 to 10%

Explanation

Hawkins Type II talar neck fractures involve subtalar subluxation or dislocation and disrupt two of the three major blood supplies to the talus. This results in an avascular necrosis (AVN) rate of approximately 20% to 50%.

Question 4223

Topic: Forefoot

A 45-year-old woman presents with severe bunion pain. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and clinical examination demonstrates gross hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue release
. First tarsometatarsal joint arthrodesis (Lapidus procedure)
. First metatarsophalangeal joint arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

First tarsometatarsal (TMT) arthrodesis, or the Lapidus procedure, is indicated for moderate to severe hallux valgus (IMA > 15 degrees) associated with first ray hypermobility. Distal osteotomies are insufficient for high intermetatarsal angles and do not address the TMT instability.

Question 4224

Topic: Midfoot & Hindfoot

A 55-year-old woman reports medial ankle pain and a progressively collapsing arch over the past year. Examination reveals a flexible flatfoot deformity and an inability to perform a single-leg heel rise on the affected side. Radiographs show no degenerative joint disease. What is the most appropriate surgical management if conservative care fails?

. Gastrocnemius recession alone
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Subtalar arthrodesis
. Anterior tibial tendon transfer

Correct Answer & Explanation

. Gastrocnemius recession alone

Explanation

Stage II posterior tibial tendon dysfunction presents with a flexible flatfoot and inability to perform a single-leg heel rise. The standard surgical treatment involves an FDL transfer to replace the diseased posterior tibial tendon, combined with a medial displacement calcaneal osteotomy to restore the mechanical axis.

Question 4225

Topic: 8. Foot and Ankle

A 14-year-old boy presents with a rigid flatfoot and recurrent ankle sprains. Radiographs demonstrate a continuous bony bridge between the calcaneus and the navicular. He has failed 6 months of non-operative management including orthotics and casting. There is no evidence of subtalar arthritis. What is the best surgical option?

. Resection of the coalition with fat pad or muscle interposition
. Subtalar arthrodesis
. Triple arthrodesis
. Lateral column lengthening
. Achilles tendon lengthening alone

Correct Answer & Explanation

. Resection of the coalition with fat pad or muscle interposition

Explanation

Calcaneonavicular coalitions typically present in adolescents. If conservative management fails and there is no significant degenerative arthritis, surgical resection with interposition (fat pad or extensor digitorum brevis) is the gold standard procedure.

Question 4226

Topic: 8. Foot and Ankle

A 60-year-old man requires surgical intervention for chronic insertional Achilles tendinopathy. Intraoperatively, after resecting the Haglund deformity and debriding the degenerative tendinosis, it is noted that 60% of the Achilles tendon insertion has been removed. What is the most appropriate adjunctive procedure?

. Flexor digitorum longus (FDL) transfer
. Flexor hallucis longus (FHL) transfer
. Peroneus brevis transfer
. Gastrocnemius recession
. Primary end-to-end repair using non-absorbable suture

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer

Explanation

When more than 50% of the Achilles tendon insertion must be detached or debrided for insertional tendinopathy, the remaining tendon is at high risk for rupture. Augmentation with a flexor hallucis longus (FHL) transfer is the standard choice due to its strength, line of pull, and proximity.

Question 4227

Topic: Forefoot

A 50-year-old man presents with a painful, stiff great toe. Examination reveals 15 degrees of dorsiflexion with pain at the extremes of motion. Radiographs demonstrate a dorsal osteophyte but well-preserved plantar joint space (Coughlin Grade 2 hallux rigidus). Which of the following is the most appropriate surgical treatment?

. Cheilectomy
. First metatarsophalangeal (MTP) joint arthrodesis
. First MTP joint silicone arthroplasty
. Keller resection arthroplasty
. First tarsometatarsal (TMT) arthrodesis

Correct Answer & Explanation

. Cheilectomy

Explanation

Cheilectomy, which involves removal of the dorsal osteophyte and the dorsal third of the metatarsal head, is indicated for early to moderate hallux rigidus (Grades 1 and 2) where the plantar cartilage is preserved. MTP arthrodesis is typically reserved for end-stage (Grade 3 or 4) arthritis.

Question 4228

Topic: Forefoot

A 45-year-old female presents with a severe bunion deformity. Examination reveals hypermobility of the 1st tarsometatarsal (TMT) joint. Radiographs show a Hallux Valgus Angle of 45 degrees and an Intermetatarsal Angle of 18 degrees.

What is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. 1st TMT arthrodesis (Lapidus)
. 1st MTP arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The Lapidus procedure (1st TMT arthrodesis) is indicated for severe hallux valgus with an IMA >15 degrees, especially in the presence of 1st TMT hypermobility. Distal osteotomies are insufficient for this degree of deformity.

Question 4229

Topic: Midfoot & Hindfoot

A 28-year-old competitive runner sustains a subtle midfoot injury. Weight-bearing radiographs demonstrate 3 mm of diastasis between the medial and middle cuneiforms with no associated fractures. According to recent literature, what is the most appropriate definitive management for this purely ligamentous injury?

. Non-weight-bearing short leg cast for 6 weeks
. Open reduction and internal fixation with screws
. Primary arthrodesis of the affected tarsometatarsal joints
. Closed reduction and percutaneous pinning

Correct Answer & Explanation

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

Explanation

Purely ligamentous Lisfranc injuries have a higher rate of failure with ORIF compared to primary arthrodesis. Arthrodesis restores stability and has been shown to yield better long-term functional outcomes in pure ligamentous disruptions.

Question 4230

Topic: 8. Foot and Ankle

A 55-year-old woman presents with a flexible flatfoot deformity, medial ankle pain, and inability to perform a single heel raise. The hindfoot valgus completely corrects when the patient sits. Which surgical intervention is most appropriate after failure of nonoperative management?

. Triple arthrodesis
. Talonavicular arthrodesis
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Gastrocnemius recession and Achilles tendon lengthening

Correct Answer & Explanation

. Triple arthrodesis

Explanation

Stage II adult acquired flatfoot deformity is characterized by a flexible deformity and posterior tibial tendon dysfunction. An FDL transfer replaces the dysfunctional tendon, while a medializing calcaneal osteotomy corrects the hindfoot valgus.

Question 4231

Topic: Forefoot

A 45-year-old man presents with dorsal midfoot pain and limited dorsiflexion of his first metatarsophalangeal (MTP) joint. Radiographs show a dorsal osteophyte and joint space narrowing isolated to the dorsal half of the 1st MTP joint. Which procedure is most appropriate?

. 1st MTP joint arthrodesis
. Cheilectomy
. Keller resection arthroplasty
. Silastic implant arthroplasty

Correct Answer & Explanation

. 1st MTP joint arthrodesis

Explanation

Coughlin Grade 2 hallux rigidus presents with dorsal osteophytes and preserved plantar joint cartilage. Cheilectomy removes the dorsal impingement, providing excellent pain relief and improved dorsiflexion.

Question 4232

Topic: 8. Foot and Ankle

A 45-year-old man has severe insertional Achilles tendinopathy with a Haglund deformity. MRI shows tendinosis affecting 60% of the Achilles tendon insertion. What is the recommended surgical procedure after failed conservative therapy?

. Percutaneous Achilles tendon lengthening
. Gastrocnemius recession alone
. Endoscopic calcaneoplasty
. Retrocalcaneal bursectomy, exostectomy, and Achilles debridement with FHL transfer

Correct Answer & Explanation

. Percutaneous Achilles tendon lengthening

Explanation

When surgical debridement compromises more than 50% of the Achilles tendon insertion, a flexor hallucis longus (FHL) tendon transfer is indicated to provide vascularity and structural strength.

Question 4233

Topic: 8. Foot and Ankle

Which of the following patient factors is considered an absolute or strong relative contraindication to a total ankle arthroplasty (TAA)?

. Age greater than 70 years
. Body mass index (BMI) of 28
. Significant loss of protective sensation (neuropathy)
. Contralateral subtalar arthritis

Correct Answer & Explanation

. Age greater than 70 years

Explanation

Neuropathy with loss of protective sensation (e.g., Charcot arthropathy risk) is a major contraindication for total ankle arthroplasty due to unacceptably high rates of implant failure and complications.

Question 4234

Topic: Midfoot & Hindfoot

A 62-year-old man with poorly controlled diabetes presents with an acutely swollen, erythematous, and warm right foot without ulcers. Radiographs reveal fragmentation of the midfoot. WBC count is normal. What is the most appropriate initial management?

. Urgent surgical debridement and external fixation
. Intravenous antibiotics
. Total contact casting and non-weight-bearing
. Midfoot arthrodesis with robust internal fixation

Correct Answer & Explanation

. Urgent surgical debridement and external fixation

Explanation

This is a classic presentation of acute Eichenholtz stage 0 or I Charcot arthropathy. Total contact casting and strict non-weight-bearing are the gold standard treatments to halt progressive bone destruction.

Question 4235

Topic: 8. Foot and Ankle
A 30-year-old sustains a Hawkins Type III talar neck fracture. Which of the following best describes the disruption of the blood supply associated with this injury pattern?
. Only the artery of the sinus tarsi is disrupted
. Only the deltoid branches are disrupted
. Artery of the tarsal canal and sinus tarsi are disrupted, but deltoid branches remain intact
. Artery of the tarsal canal, artery of the sinus tarsi, and deltoid branches are all disrupted

Correct Answer & Explanation

. Artery of the tarsal canal, artery of the sinus tarsi, and deltoid branches are all disrupted

Explanation

A Hawkins III fracture involves dislocation of the tibiotalar and subtalar joints. This disrupts all three major sources of talar blood supply, leading to a high risk of avascular necrosis.

Question 4236

Topic: 8. Foot and Ankle
A 35-year-old male sustains a high-energy motor vehicle collision resulting in a Hawkins Type III talar neck fracture. Despite urgent reduction, the patient is counseled on the high risk of avascular necrosis. Which of the following arterial structures provides the primary blood supply to the talar body that is disrupted in this injury pattern?
. Artery of the tarsal sinus
. Artery of the tarsal canal
. Deltoid branch of the posterior tibial artery
. Dorsalis pedis artery
. Perforating peroneal artery

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The primary blood supply to the talar body is the artery of the tarsal canal, a branch of the posterior tibial artery. It enters the talar neck plantarly and anastomoses with the artery of the tarsal sinus to form a vascular sling. Disruption of this network, especially in displaced Hawkins III fractures, leads to a high rate of avascular necrosis.

Question 4237

Topic: 8. Foot and Ankle

A 24-year-old professional football player sustains an axial load to a plantarflexed foot. Clinical evaluation and the radiograph shown indicate a midfoot injury.

Which of the following ligaments represents the primary stabilizer disrupted in this classic injury pattern?

. Dorsal tarsometatarsal ligament
. Plantar calcaneocuboid ligament
. Interosseous ligament between the medial cuneiform and second metatarsal base
. Spring ligament
. Bifurcate ligament

Correct Answer & Explanation

. Dorsal tarsometatarsal ligament

Explanation

The clinical scenario and radiograph imply a Lisfranc injury, which requires disruption of the Lisfranc ligament complex. The thickest, strongest, and most critical component is the interosseous ligament passing from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. Rupture leads to diastasis and midfoot instability.

Question 4238

Topic: Forefoot

A 45-year-old female presents with severe pain over the medial eminence of her left foot. Weight-bearing radiographs reveal a hallux valgus angle of 45 degrees, an intermetatarsal angle of 21 degrees, and marked hypermobility of the first tarsometatarsal joint. Which of the following procedures is most appropriate to achieve durable correction?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue release
. First tarsometatarsal arthrodesis (Lapidus procedure)
. Keller resection arthroplasty
. Akin osteotomy alone

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

A first tarsometatarsal arthrodesis (Lapidus procedure) is the procedure of choice for severe hallux valgus associated with first ray hypermobility or an intermetatarsal angle greater than 20 degrees. It addresses the apex of the deformity, stabilizes the medial column, and provides multiplanar correction.

Question 4239

Topic: Midfoot & Hindfoot

A 55-year-old female presents with progressive flattening of her left foot. On examination, she is unable to perform a single-leg heel rise, and her hindfoot is in valgus but passively correctable. AP radiographs show 45% talonavicular uncoverage. What is the most appropriate surgical intervention?

. Medializing calcaneal osteotomy and flexor digitorum longus (FDL) transfer
. Lateral column lengthening (Evans), medializing calcaneal osteotomy, and FDL transfer
. Subtalar arthrodesis
. Triple arthrodesis
. Gastrocnemius recession alone

Correct Answer & Explanation

. Medializing calcaneal osteotomy and flexor digitorum longus (FDL) transfer

Explanation

The patient has Stage IIB adult acquired flatfoot deformity (flexible, >30-40% talonavicular uncoverage indicating severe forefoot abduction). A lateral column lengthening (Evans osteotomy) is required to correct the significant transverse plane deformity. This is combined with a medializing calcaneal osteotomy and FDL transfer to restore medial column function.

Question 4240

Topic: 8. Foot and Ankle

A 30-year-old male sustains an acute, closed mid-substance Achilles tendon rupture. He elects for non-operative management. To achieve functional outcomes and rerupture rates most comparable to operative repair, what is the most critical element of his non-operative protocol?

. Six weeks of non-weight-bearing in a long leg cast
. Corticosteroid injection into the retrocalcaneal bursa
. Early functional rehabilitation with protected weight-bearing in a brace
. Immediate full weight-bearing without orthosis
. Serial casting in maximal dorsiflexion for four weeks

Correct Answer & Explanation

. Six weeks of non-weight-bearing in a long leg cast

Explanation

Recent evidence demonstrates that early functional rehabilitation with protected, accelerated weight-bearing in a functional brace yields rerupture rates equivalent to operative management. Prolonged non-weight-bearing cast immobilization is obsolete as it increases rates of stiffness, muscle atrophy, and rerupture.

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