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8. Foot and Ankle MCQs

Practice Set 214 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 4261

Topic: 8. Foot and Ankle

A 55-year-old man presents with chronic posterior heel pain that has failed 6 months of physical therapy, heel lifts, and shoe modifications. Examination reveals swelling and point tenderness directly over the central Achilles tendon insertion. A lateral radiograph reveals a prominent posterosuperior calcaneal exostosis.

Intraoperatively, extensive degenerative tearing and intrasubstance calcification are noted, necessitating debridement and detachment of 60% of the Achilles tendon from its insertion. Along with reattachment of the remaining tendon using suture anchors and calcaneal exostectomy, what is the most appropriate additional step in management?

. V-Y tendon advancement
. Flexor hallucis longus (FHL) tendon transfer
. Flexor digitorum longus (FDL) tendon transfer
. Peroneus brevis tendon transfer
. Gastrocnemius recession

Correct Answer & Explanation

. V-Y tendon advancement

Explanation

When surgical debridement for insertional Achilles tendinopathy dictates detachment of more than 50% of the tendon, augmentation is required to restore plantarflexion strength and minimize the risk of rupture. The flexor hallucis longus (FHL) is the ideal transfer due to its high tensile strength, anatomical proximity, and in-phase firing during the gait cycle.

Question 4262

Topic: 8. Foot and Ankle

A 28-year-old professional soccer player sustains an external rotation ankle injury. Radiographs show a widening of the medial clear space and tibiofibular clear space. Intraoperative stress testing confirms syndesmotic instability. Which of the following statements regarding syndesmotic fixation is most accurate?

. Suture button fixation results in significantly higher rates of malreduction compared to screw fixation.
. Removal of syndesmotic screws is routinely required before weight-bearing to prevent breakage.
. Suture button fixation allows for physiologic motion and demonstrates comparable or improved clinical outcomes relative to static screw fixation.
. Rigid fixation with two 4.5mm quadricortical screws is strictly indicated for all high fibular fractures.
. Syndesmosis screws must always be placed parallel to the ankle joint line and perpendicular to the fibula in the sagittal plane.

Correct Answer & Explanation

. Suture button fixation results in significantly higher rates of malreduction compared to screw fixation.

Explanation

Suture button fixation (flexible fixation) for syndesmotic injuries allows for physiologic motion at the distal tibiofibular joint. Multiple studies and meta-analyses have shown that flexible fixation results in comparable, if not slightly improved, clinical outcomes and lower rates of malreduction compared to static screw fixation. Routine removal of syndesmotic screws is no longer recommended unless they become symptomatic, and screw breakage does not typically correlate with worse clinical outcomes.

Question 4263

Topic: 8. Foot and Ankle

A 34-year-old male sustains a purely ligamentous Lisfranc injury of the left foot after falling off a horse with his foot caught in the stirrup. Weight-bearing radiographs demonstrate 3 mm of widening between the base of the first and second metatarsals. He is healthy and highly active. 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
. Midfoot amputation

Correct Answer & Explanation

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

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the medial column (first, second, and third tarsometatarsal joints) has been shown in prospective randomized trials (e.g., Ly and Coetzee) to yield better functional outcomes and a lower rate of revision surgery compared to open reduction and internal fixation (ORIF). ORIF is generally preferred for bony Lisfranc fracture-dislocations.

Question 4264

Topic: 8. Foot and Ankle

A 42-year-old recreational basketball player experiences a sudden 'pop' in his posterior heel. Clinical examination demonstrates a positive Thompson test. He opts for non-operative management with a functional rehabilitation protocol. Compared to acute surgical repair, which of the following is true regarding his chosen management?

. It has a significantly higher rate of deep infection.
. It carries a similar rate of re-rupture when utilizing an early functional mobilization protocol.
. It results in a significantly greater loss of plantarflexion strength.
. It has a higher rate of sural nerve injury.
. It is contraindicated in patients older than 40 years.

Correct Answer & Explanation

. It has a significantly higher rate of deep infection.

Explanation

Recent high-quality level 1 evidence demonstrates that non-operative management of acute Achilles tendon ruptures using an early functional rehabilitation protocol (incorporating early weight-bearing and mobilization) yields re-rupture rates that are comparable to those of surgical repair. Surgical repair carries a higher risk of complications such as wound healing issues, deep infection, and sural nerve injury, while non-operative management avoids these surgical risks without significantly compromising functional strength.

Question 4265

Topic: 8. Foot and Ankle
A 55-year-old woman presents with progressive flattening of her right foot and medial ankle pain. Examination reveals a flexible pes planovalgus deformity, inability to perform a single-leg heel rise, and tenderness along the course of the posterior tibial tendon. The hindfoot valgus corrects to neutral when standing on her toes. Which surgical intervention is most appropriate if non-operative management fails?
. Flexor digitorum longus (FDL) transfer to the navicular and medializing calcaneal osteotomy
. Subtalar arthrodesis alone
. Triple arthrodesis
. Ankle arthrodesis
. Tibialis anterior tendon transfer

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer to the navicular and medializing calcaneal osteotomy

Explanation

The patient presents with Stage II adult acquired flatfoot deformity (posterior tibial tendon dysfunction), characterized by a flexible deformity and an inability to perform a single-leg heel rise. The standard operative management for a flexible Stage II deformity involves joint-sparing procedures, typically a flexor digitorum longus (FDL) tendon transfer to replace the dysfunctional posterior tibial tendon, combined with a medializing calcaneal osteotomy (MCO) to correct the hindfoot valgus and restore the biomechanical axis. Arthrodesis is reserved for fixed deformities or joint degeneration (Stage III).

Question 4266

Topic: 8. Foot and Ankle

A 24-year-old male with Charcot-Marie-Tooth disease presents with bilateral cavovarus foot deformities. A Coleman block test is performed. When the patient's heel and lateral border of the foot are placed on a 1-inch block while the first metatarsal hangs freely off the block, the hindfoot varus corrects to a neutral position. What does this physical examination finding indicate?

. The hindfoot deformity is rigid and requires a triple arthrodesis.
. The hindfoot varus is flexible and driven by a plantarflexed first metatarsal.
. The subtalar joint is ankylosed.
. The tibialis anterior is overactive.
. The Achilles tendon is excessively lengthened.

Correct Answer & Explanation

. The hindfoot deformity is rigid and requires a triple arthrodesis.

Explanation

The Coleman block test is used to evaluate a cavovarus foot to determine if the hindfoot varus is flexible and driven by a forefoot deformity (specifically a rigid, plantarflexed first metatarsal) or if it is a rigid hindfoot deformity. If the hindfoot varus corrects to neutral when the first metatarsal is allowed to drop off the block, the hindfoot deformity is flexible and forefoot-driven. Surgical management would therefore include a dorsiflexion osteotomy of the first metatarsal rather than an initial primary hindfoot arthrodesis.

Question 4267

Topic: Forefoot

A 45-year-old woman presents with severe bunion pain. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 20 degrees. Clinical examination reveals profound hypermobility at the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate?

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

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The patient has a severe hallux valgus deformity (HVA > 40 degrees, IMA > 13-15 degrees) accompanied by first tarsometatarsal (TMT) joint hypermobility. A first TMT arthrodesis (Lapidus procedure) is the surgical treatment of choice in this scenario. It provides powerful correction of the intermetatarsal angle and addresses the underlying hypermobility at the TMT joint, reducing the risk of recurrence. Distal osteotomies are insufficient for severe deformities with joint hypermobility.

Question 4268

Topic: 8. Foot and Ankle

A 58-year-old male with poorly controlled type 2 diabetes presents with a red, hot, swollen right foot. He denies recent trauma. Radiographs reveal fragmentation, periarticular debris, and subluxation of the midfoot joints. Laboratory results show a normal WBC count and mildly elevated CRP. What is the most appropriate initial management for this condition?

. Immediate open reduction and internal fixation
. Midfoot amputation
. Total contact casting
. Intravenous antibiotics for 6 weeks
. Incision and drainage

Correct Answer & Explanation

. Immediate open reduction and internal fixation

Explanation

The clinical presentation and radiographic findings (fragmentation, debris, subluxation) are classic for acute Charcot neuroarthropathy (Eichenholtz stage I - development/fragmentation). The initial management for acute Charcot foot is strict immobilization and offloading, most effectively achieved with a total contact cast (TCC), to prevent further progression of the deformity until the acute inflammatory phase subsides. Surgery in the acute phase is generally contraindicated due to unacceptably high complication rates, and the normal WBC mitigates the likelihood of acute deep space infection requiring immediate drainage.

Question 4269

Topic: 8. Foot and Ankle

A 40-year-old roofer falls from a ladder and sustains a displaced intra-articular calcaneus fracture (Sanders type II). He is a current smoker (1 pack per day). Open reduction and internal fixation via an extensile lateral approach is planned. Which of the following is the most critical factor regarding the timing and approach to minimize soft tissue complications in this patient?

. Proceeding with surgery within 24 hours of injury to reduce swelling
. Delaying surgery until the 'wrinkle sign' is present, typically 10-14 days
. Using a medial approach to avoid the devitalized lateral skin
. Performing an immediate primary subtalar arthrodesis
. Prescribing prophylactic anticoagulation for 6 months

Correct Answer & Explanation

. Proceeding with surgery within 24 hours of injury to reduce swelling

Explanation

Wound healing complications are a major concern with the extensile lateral approach for calcaneus fractures, especially in high-risk patients such as smokers. To minimize these risks, surgery must be delayed until the soft tissue swelling has subsided, indicated by the return of skin wrinkles (the 'wrinkle sign'). This typically takes 10 to 14 days, and sometimes longer. Operating through severely swollen soft tissues significantly increases the risk of wound dehiscence, flap necrosis, and deep infection.

Question 4270

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with a progressive flatfoot deformity. She reports pain localized medially along the posterior tibial tendon and laterally within the sinus tarsi. On examination, she is completely unable to perform a single-leg heel rise on the affected side. Weight-bearing radiographs demonstrate 45% uncovering of the talar head on the AP view and severe talonavicular sag on the lateral view. What is the most appropriate surgical management for this patient?

. Posterior tibial tendon debridement and tenosynovectomy
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO)
. Flexor digitorum longus (FDL) transfer, MDCO, and lateral column lengthening
. Isolated subtalar arthrodesis
. First tarsometatarsal (Lapidus) arthrodesis

Correct Answer & Explanation

. Posterior tibial tendon debridement and tenosynovectomy

Explanation

This patient presents with a Stage IIb adult-acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage II denotes a flexible deformity where the patient is unable to perform a single-leg heel rise. Stage IIb specifically involves significant forefoot abduction, radiographically indicated by >40% uncovering of the talar head on the AP view. Treatment for Stage IIb requires addressing both the medial column failure and the lateral column shortening. The standard surgical treatment includes an FDL transfer, a medial displacement calcaneal osteotomy (MDCO) to correct hindfoot valgus, and a lateral column lengthening (e.g., Evans osteotomy or calcaneocuboid distraction arthrodesis) to correct the severe forefoot abduction.

Question 4271

Topic: 8. Foot and Ankle

A 24-year-old professional football player sustains an axial load injury to a plantarflexed foot. Weight-bearing radiographs show 3 mm of widening between the base of the first and second metatarsals without any obvious fracture fragments, consistent with a purely ligamentous Lisfranc injury. Based on recent outcome studies, which of the following treatments provides the lowest rate of hardware removal and the highest functional outcome score at 2 years for this specific injury pattern?

. Non-weight-bearing cast for 6 weeks
. Open reduction and internal fixation (ORIF) with transarticular screws
. Primary arthrodesis of the 1st, 2nd, and 3rd tarsometatarsal joints
. Open reduction and internal fixation with dorsal spanning plates
. Suture button fixation across the medial cuneiform and 2nd metatarsal base

Correct Answer & Explanation

. Non-weight-bearing cast for 6 weeks

Explanation

Purely ligamentous Lisfranc injuries have poor healing potential compared to bony avulsion fractures. Level I evidence (e.g., Ly and Coetzee, JBJS Am) has shown that primary arthrodesis of the medial 2 or 3 tarsometatarsal joints for purely ligamentous Lisfranc injuries results in superior functional outcomes, lower rates of subsequent surgeries (hardware removal), and fewer persistent symptoms compared to open reduction and internal fixation (ORIF).

Question 4272

Topic: 8. Foot and Ankle

A 62-year-old man presents with severe, end-stage post-traumatic ankle osteoarthritis and is inquiring about total ankle arthroplasty (TAA). Which of the following conditions is considered an absolute contraindication to performing a total ankle arthroplasty?

. Patient age over 60 years
. Coronal plane deformity of 10 degrees
. Charcot neuroarthropathy of the ankle
. Body mass index of 32 kg/m2
. A history of prior lateral ankle ligament reconstruction

Correct Answer & Explanation

. Patient age over 60 years

Explanation

Absolute contraindications to total ankle arthroplasty (TAA) include active or recent ankle infection, severe peripheral vascular disease, inadequate soft tissue coverage, absent lower extremity sensation, Charcot neuroarthropathy, and extensive avascular necrosis of the talus (>50%). Age, moderate BMI, mild to moderate coronal deformities (which can be corrected concurrently), and previous ligamentous surgeries are relative contraindications or factors requiring careful planning, but are not absolute contraindications.

Question 4273

Topic: 8. Foot and Ankle
A 31-year-old man falls from a height of 15 feet and sustains a Hawkins type III talar neck fracture. Which of the following correctly describes the joint dislocations associated with this specific injury grade, and what is the primary blood supply to the talar body that is at greatest risk of disruption?
. Subtalar joint only; artery of the sinus tarsi
. Subtalar and tibiotalar joints; artery of the tarsal canal
. Subtalar, tibiotalar, and talonavicular joints; deltoid artery branches
. Tibiotalar joint only; artery of the sinus tarsi
. Subtalar and tibiotalar joints; dorsal branches of the dorsalis pedis

Correct Answer & Explanation

. Subtalar and tibiotalar joints; artery of the tarsal canal

Explanation

The Hawkins classification of talar neck fractures is predictive of the risk of avascular necrosis (AVN). Type I is non-displaced. Type II involves subtalar subluxation/dislocation. Type III involves both subtalar and tibiotalar (ankle) dislocation. Type IV (added by Canale) includes talonavicular dislocation. The talar body's most significant blood supply is the artery of the tarsal canal (a branch of the posterior tibial artery), which supplies the majority of the talar body. In a type III fracture, the artery of the tarsal canal, the artery of the sinus tarsi, and the dorsal network are typically all disrupted, leading to a very high risk of AVN.

Question 4274

Topic: 8. Foot and Ankle

A 58-year-old man with a 15-year history of poorly controlled type 2 diabetes presents with a swollen, warm, and erythematous right foot. He denies any recent trauma, systemic illness, or fever. Radiographs show fragmentation, periarticular debris, and early subluxation of the midfoot joints, but no signs of ulceration, gas, or focal osteomyelitis. Laboratory tests show a normal white blood cell count and a slightly elevated CRP.

What is the most appropriate initial management?

. Immediate open reduction and internal fixation of the midfoot
. Excisional debridement and empiric intravenous antibiotics
. Immobilization and offloading in a total contact cast
. Prescription of custom orthoses and accommodative wide shoe wear
. Primary arthrodesis of the midfoot joints

Correct Answer & Explanation

. Immediate open reduction and internal fixation of the midfoot

Explanation

This patient is presenting with acute Charcot neuroarthropathy (Eichenholtz stage I: development/fragmentation stage). The clinical picture often mimics infection, but the lack of an open ulcer, systemic signs of infection, and normal WBC point to an acute Charcot event. The gold standard for initial treatment is offloading the extremity to arrest the progression of the deformity and allow the inflammatory process to resolve. This is most effectively accomplished with a total contact cast (TCC), which is changed frequently as the edema subsides. Surgical intervention during the acute, hyperemic stage is generally contraindicated due to poor bone quality and high risk of failure.

Question 4275

Topic: Forefoot

A 45-year-old woman complains of progressive pain and deformity of her left great toe that limits her ability to wear closed-toe shoes. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. Clinical examination demonstrates significant hypermobility of the first tarsometatarsal (TMT) joint with dorsal elevation of the first ray. There is no evidence of metatarsophalangeal (MTP) joint arthritis. Which of the following surgical procedures is most appropriate to provide a durable correction?

. Distal chevron osteotomy
. First metatarsophalangeal (MTP) arthrodesis
. Proximal crescentic osteotomy without TMT arthrodesis
. First tarsometatarsal (Lapidus) arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

This patient has a severe hallux valgus deformity (HVA > 40 degrees, IMA > 15 degrees) combined with clinical hypermobility of the first tarsometatarsal (TMT) joint. A Lapidus procedure (first TMT arthrodesis) is the procedure of choice in this scenario. It provides powerful correction of large intermetatarsal angles and definitively addresses the underlying instability at the TMT joint, preventing recurrence. Distal osteotomies are insufficient for this degree of deformity, and proximal osteotomies without fusion do not address the TMT hypermobility. MTP arthrodesis is typically reserved for severe deformity with concomitant MTP arthritis.

Question 4276

Topic: 8. Foot and Ankle

During the operative treatment of a displaced, intra-articular calcaneus fracture via an extensile lateral approach, the surgeon must reduce the lateral tuberosity and posterior facet fragments to the 'constant' fragment. Which anatomical structure maintains the position of this 'constant' fragment relative to the talus?

. Calcaneofibular ligament
. Spring (plantar calcaneonavicular) ligament
. Deltoid ligament and interosseous talocalcaneal ligament
. Anterior talofibular ligament
. Bifurcate ligament

Correct Answer & Explanation

. Calcaneofibular ligament

Explanation

The 'constant' fragment in a calcaneus fracture refers to the anteromedial fragment, which includes the sustentaculum tali. Despite severe comminution of the rest of the calcaneus, this fragment consistently remains anatomically aligned with the talus. This stability is maintained by the strong medial talocalcaneal ligament, the interosseous talocalcaneal ligament, and the superficial fibers of the deltoid ligament. During open reduction, this fragment serves as the foundational cornerstone to which the rest of the calcaneus is reduced.

Question 4277

Topic: 8. Foot and Ankle

A 52-year-old woman presents with burning pain in her forefoot that is exacerbated by wearing tight, high-heeled shoes. She describes a sensation of 'walking on a bunched-up sock.' Examination reveals a palpable click and radiating pain when compressing the medial and lateral aspects of the forefoot while simultaneously applying pressure to the plantar aspect of the third web space (Mulder's sign). If surgical excision of the lesion is eventually performed, what is the expected primary histologic finding of the excised tissue?

. Proliferation of atypical Schwann cells
. Perineural fibrosis and nerve degeneration
. Granulomatous inflammation with multinucleated giant cells
. Synovial hyperplasia with hemosiderin deposition
. Demyelination with sparing of the axonal cylinders

Correct Answer & Explanation

. Proliferation of atypical Schwann cells

Explanation

The patient's presentation is classic for a Morton's neuroma, most commonly occurring in the third intermetatarsal space. Despite the name, a Morton's neuroma is not a true neoplasm or a true neuroma (which would show Schwann cell proliferation). Instead, it is a compressive/entrapment neuropathy resulting from mechanical irritation of the common digital nerve under the transverse metatarsal ligament. Histologically, it is characterized by extensive perineural fibrosis, local vascular proliferation, edema, and subsequent axonal degeneration.

Question 4278

Topic: 8. Foot and Ankle

A 35-year-old recreational basketball player sustains an acute, closed Achilles tendon rupture. He is active but prefers to avoid surgery if possible. After discussing treatment options, he elects to undergo non-operative management with an early functional rehabilitation protocol. Compared to traditional open operative repair, what is the most statistically expected outcome of his chosen management?

. Significantly higher re-rupture rate with equivalent functional outcomes
. Lower re-rupture rate with higher risk of sural nerve injury
. Similar re-rupture rate with a lower overall complication rate
. Significantly decreased terminal plantarflexion strength at 2 years
. Increased rate of deep vein thrombosis due to prolonged immobilization

Correct Answer & Explanation

. Significantly higher re-rupture rate with equivalent functional outcomes

Explanation

Recent high-quality level I evidence and meta-analyses have demonstrated that non-operative management of acute Achilles tendon ruptures utilizing an early functional rehabilitation protocol (involving early weight-bearing in an orthosis) results in re-rupture rates that are statistically similar to operative repair. Non-operative management also avoids surgical complications such as deep infection, wound breakdown, and iatrogenic sural nerve injury, leading to a lower overall complication rate.

Question 4279

Topic: 8. Foot and Ankle

A 62-year-old woman with a BMI of 28 presents with severe, end-stage post-traumatic osteoarthritis of the right ankle. Radiographs demonstrate bone-on-bone tibiotalar joint space narrowing with a 5-degree varus deformity. She is evaluating the options of total ankle arthroplasty (TAA) versus ankle arthrodesis. When counseling the patient, which of the following is considered a well-documented advantage of TAA compared to arthrodesis?

. Decreased risk of developing adjacent hindfoot joint osteoarthritis over time
. Superior long-term pain relief at 15 years
. Decreased rate of reoperation and hardware-related complications
. Better suitability and outcomes for severe (>15 degrees) coronal plane deformities
. Higher likelihood of returning to high-impact sports like running

Correct Answer & Explanation

. Decreased risk of developing adjacent hindfoot joint osteoarthritis over time

Explanation

Total Ankle Arthroplasty (TAA) preserves tibiotalar motion, which alters the biomechanical stresses on adjacent joints. Studies have shown that TAA is associated with a decreased risk, or delayed progression, of adjacent joint osteoarthritis (such as the subtalar and talonavicular joints) compared to ankle arthrodesis. However, TAA generally has a higher reoperation rate and is not recommended for patients desiring a return to high-impact sports, or those with severe, uncorrectable coronal plane deformities.

Question 4280

Topic: Midfoot & Hindfoot
A 55-year-old female presents with medial foot pain, difficulty standing on her toes, and a progressively flattening arch over the past year. Examination reveals a positive 'too-many-toes' sign and a flexible hindfoot that corrects to neutral on heel rise. Standing AP radiograph shows greater than 40% uncoverage of the talonavicular joint. Based on the Johnson and Strom classification (modified by Myerson), what is the most appropriate surgical management?
. Flexor digitorum longus (FDL) transfer, medial calcaneal displacement osteotomy, and lateral column lengthening
. Isolated FDL transfer to the navicular
. Triple arthrodesis
. Isolated subtalar arthrodesis
. Gastrocnemius recession and FHL transfer

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer, medial calcaneal displacement osteotomy, and lateral column lengthening

Explanation

The patient has Stage IIb posterior tibial tendon dysfunction (adult-acquired flatfoot deformity), characterized by a flexible hindfoot but significant forefoot abduction (defined as >40% talonavicular uncoverage). Appropriate surgical management includes FDL transfer to replace the diseased posterior tibial tendon, medial calcaneal displacement osteotomy (to correct hindfoot valgus), and lateral column lengthening (Evans osteotomy) to correct the severe forefoot abduction. Stage IIa (<40% uncoverage) can often be treated without the lateral column lengthening. Stage III (rigid deformity) requires arthrodesis.

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