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8. Foot and Ankle MCQs

Practice Set 216 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 4301

Topic: 8. Foot and Ankle

A 55-year-old woman complains of medial ankle pain and progressive flattening of her left foot. Examination reveals an inability to perform a single-leg heel raise and a flexible planovalgus deformity (Stage II Adult Acquired Flatfoot Deformity). She undergoes a flexor digitorum longus (FDL) transfer and a medializing calcaneal osteotomy. Which of the following best describes the primary biomechanical rationale of the calcaneal osteotomy in this setting?

. It lengthens the lateral column to correct forefoot abduction.
. It shifts the mechanical axis, converting the Achilles tendon into an invertor.
. It plantarflexes the first ray to restore the medial longitudinal arch.
. It recreates the tension and function of the spring ligament.
. It provides a rigid medial strut to support the talonavicular joint.

Correct Answer & Explanation

. It lengthens the lateral column to correct forefoot abduction.

Explanation

Adult acquired flatfoot deformity (AAFD) Stage II is characterized by a flexible planovalgus foot. By translating the posterior calcaneal tuberosity medially, the medializing calcaneal osteotomy (MCO) shifts the mechanical axis of the hindfoot. This converts the pull of the Achilles tendon from an evertor (which exacerbates the valgus deformity) into an invertor, thereby decreasing the stress on the medial soft tissue reconstructions, such as the FDL transfer.

Question 4302

Topic: 8. Foot and Ankle

A 65-year-old man presents with end-stage post-traumatic ankle osteoarthritis and is evaluating surgical options between ankle arthrodesis and total ankle arthroplasty (TAA). Which of the following is considered a primary indication favoring TAA over ankle arthrodesis?

. Severe coronal plane deformity greater than 25 degrees
. Severe neuroarthropathy of the midfoot and hindfoot
. Advanced ipsilateral subtalar and talonavicular arthritis
. Significant avascular necrosis of the talar body
. History of a prior deep infection in the ankle joint

Correct Answer & Explanation

. Severe coronal plane deformity greater than 25 degrees

Explanation

Total ankle arthroplasty (TAA) is indicated for end-stage ankle arthritis. Because ankle arthrodesis alters foot biomechanics and significantly increases stress on adjacent joints, pre-existing advanced arthritis of the ipsilateral subtalar or talonavicular joints is a primary indication for TAA over arthrodesis. Absolute contraindications for TAA include active or prior deep infection, severe peripheral neuropathy (Charcot), significant talar body avascular necrosis, and severe, uncorrectable malalignment.

Question 4303

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs show a hallux valgus angle of 35 degrees and an intermetatarsal angle (IMA) of 17 degrees. Clinical examination of the first tarsometatarsal (TMT) joint demonstrates significant hypermobility in the sagittal plane. What is the most appropriate surgical intervention?

. Distal soft tissue reconstruction with proximal phalanx osteotomy (Akin)
. Distal metatarsal chevron osteotomy
. First tarsometatarsal joint arthrodesis (Lapidus procedure)
. First metatarsophalangeal joint arthrodesis
. Diaphyseal scarf osteotomy

Correct Answer & Explanation

. Distal soft tissue reconstruction with proximal phalanx osteotomy (Akin)

Explanation

Hallux valgus associated with first tarsometatarsal (TMT) joint hypermobility and a significant intermetatarsal angle (IMA > 15 degrees) is best treated with a first TMT arthrodesis, also known as the Lapidus procedure. This provides powerful correction of the IMA and stabilizes the medial column, addressing the primary deforming force and reducing the risk of recurrence. Distal osteotomies are indicated for mild deformities without hypermobility.

Question 4304

Topic: 8. Foot and Ankle

A 58-year-old male with poorly controlled diabetes mellitus presents with a swollen, erythematous, warm, and painless right foot. Radiographs demonstrate periarticular fragmentation, debris, and subluxation of the tarsometatarsal joints. According to the modified Eichenholtz classification, what is the appropriate stage of this disease process, and what is the most appropriate initial management?

. Stage 0; Intramedullary beaming
. Stage I; Total contact casting
. Stage II; Surgical arthrodesis
. Stage III; Custom accommodative orthoses
. Stage I; Primary partial foot amputation

Correct Answer & Explanation

. Stage 0; Intramedullary beaming

Explanation

Charcot neuroarthropathy in the acute phase presents with a warm, erythematous, and swollen foot. According to the modified Eichenholtz classification, Stage I (Development/Fragmentation) is characterized by joint subluxation, periarticular fragmentation, and debris. The gold standard for initial management of Stage I is strict offloading and immobilization, most effectively achieved with a total contact cast (TCC), to prevent progressive deformity while the bones coalesce (Stage II) and consolidate (Stage III).

Question 4305

Topic: 8. Foot and Ankle

A 54-year-old female presents with medial ankle pain and progressive flattening of her left foot arch. On examination, she has a flexible hindfoot valgus, flexible forefoot varus, and is unable to perform a single-leg heel raise. Weight-bearing radiographs reveal a talonavicular coverage angle of 45 degrees. A trial of custom orthotics and physical therapy has failed to provide relief. What is the most appropriate surgical intervention?

. Flexor digitorum longus transfer and medializing calcaneal osteotomy
. Flexor digitorum longus transfer, medializing calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis
. Isolated subtalar arthrodesis
. Isolated flexor digitorum longus transfer

Correct Answer & Explanation

. Flexor digitorum longus transfer and medializing calcaneal osteotomy

Explanation

The patient presents with Stage IIb adult acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage IIb is characterized by a flexible hindfoot valgus and significant forefoot abduction (typically indicated by a talonavicular coverage angle > 30-40 degrees). In addition to a flexor digitorum longus (FDL) transfer and a medializing calcaneal osteotomy to correct the hindfoot valgus, a lateral column lengthening (e.g., Evans osteotomy or calcaneocuboid distraction arthrodesis) is required to correct the forefoot abduction. A triple arthrodesis is reserved for Stage III (rigid deformity).

Question 4306

Topic: Forefoot

A 65-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 42 degrees and an intermetatarsal angle (IMA) of 16 degrees. There is evidence of hypermobility at the first tarsometatarsal (TMT) joint, but no degenerative changes are noted at the first metatarsophalangeal (MTP) joint. Which of the following surgical procedures is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue reconstruction
. First tarsometatarsal joint arthrodesis (Lapidus procedure) with distal soft tissue reconstruction
. First metatarsophalangeal joint arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

This patient presents with a severe hallux valgus deformity (HVA > 40 degrees, IMA > 13 degrees) combined with first tarsometatarsal (TMT) joint hypermobility. A first TMT joint arthrodesis (Lapidus procedure) provides correction of the severe deformity and stabilizes the hypermobile medial column, preventing recurrence. Distal osteotomies (like a chevron osteotomy) are inadequate for severe deformities and do not address TMT hypermobility. First MTP arthrodesis is typically reserved for severe hallux valgus associated with MTP joint degenerative changes.

Question 4307

Topic: 8. Foot and Ankle

A 35-year-old roofer falls from a height and sustains a closed, displaced intra-articular calcaneus fracture. He undergoes open reduction and internal fixation via an extensile lateral approach. Which of the following structures is at greatest risk of injury when reflecting the full-thickness fasciocutaneous flap?

. Sural nerve
. Superficial peroneal nerve
. Tibial nerve
. Deep peroneal nerve
. Lateral plantar nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The extensile lateral approach to the calcaneus involves creating a full-thickness fasciocutaneous flap to preserve the precarious vascular supply. The sural nerve travels behind the lateral malleolus and along the lateral aspect of the foot. It crosses both the vertical and horizontal limbs of the standard extensile lateral incision and is at significant risk of injury (either direct transection or traction neuritis) during flap elevation and retraction. Strict adherence to subperiosteal dissection and a 'no-touch' technique for the apex of the flap minimize this risk.

Question 4308

Topic: 8. Foot and Ankle

Which of the following patient presentations represents an absolute contraindication to a primary total ankle arthroplasty (TAA) for end-stage ankle osteoarthritis?

. A 65-year-old patient with prior open reduction and internal fixation of a bimalleolar ankle fracture
. A 58-year-old patient with a body mass index (BMI) of 32 kg/m2
. A 62-year-old patient with a history of Charcot neuroarthropathy of the midfoot
. A 70-year-old patient with adjacent-joint subtalar osteoarthritis
. A 55-year-old patient with a 10-degree varus coronal plane deformity

Correct Answer & Explanation

. A 65-year-old patient with prior open reduction and internal fixation of a bimalleolar ankle fracture

Explanation

Active or a history of significant Charcot neuroarthropathy (loss of protective sensation and severe dysvascular or neuropathic states) is generally considered an absolute contraindication to total ankle arthroplasty due to an unacceptably high risk of implant loosening, subsidence, and catastrophic failure. Relative contraindications include significant malalignment (>15 degrees), severe obesity, younger age with high physical demand, and avascular necrosis of the talus. Prior trauma and adjacent joint arthritis (which may actually favor TAA over fusion to preserve motion) are not contraindications.

Question 4309

Topic: 8. Foot and Ankle

A 42-year-old recreational basketball player sustains an acute closed Achilles tendon rupture. He opts for percutaneous surgical repair. During the procedure, the surgeon places sutures blindly through the proximal stump of the Achilles tendon. Which of the following anatomical structures is most susceptible to iatrogenic injury during this specific step?

. Plantaris tendon
. Sural nerve
. Tibial nerve
. Posterior tibial artery
. Flexor hallucis longus tendon

Correct Answer & Explanation

. Plantaris tendon

Explanation

During percutaneous or minimally invasive repair of the Achilles tendon, blind or semi-blind suture passage through the proximal tendon stump places the sural nerve at significant risk. The sural nerve crosses from medial to lateral, crossing the lateral border of the Achilles tendon approximately 10 cm proximal to the calcaneal insertion, and travels distally. Passing sutures from lateral to medial in the proximal stump must be done with extreme caution, often requiring small stab incisions to spread down to the tendon, to avoid entrapping or transecting the nerve.

Question 4310

Topic: 8. Foot and Ankle

A 24-year-old collegiate football lineman presents with midfoot pain after his foot was axially loaded while plantarflexed. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the first and second metatarsals. An MRI confirms a complete tear of the Lisfranc ligament. He undergoes open reduction and internal fixation. Which of the following fixation constructs is considered the biomechanical gold standard to restore the primary stabilizing function of the Lisfranc complex?

. A transarticular screw traversing the first tarsometatarsal joint
. A screw directed from the medial cuneiform to the base of the second metatarsal
. A dorsal spanning plate over the second tarsometatarsal joint alone
. A screw directed from the medial cuneiform to the medial aspect of the first metatarsal
. A screw from the navicular to the medial cuneiform

Correct Answer & Explanation

. A transarticular screw traversing the first tarsometatarsal joint

Explanation

The Lisfranc ligament connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal, representing the primary structural tie between the medial and middle columns of the foot. The biomechanical 'home run' screw mimics this anatomical trajectory, crossing from the medial cuneiform to the base of the second metatarsal to effectively reduce and stabilize the diastasis, acting as a surrogate for the torn interosseous ligament.

Question 4311

Topic: 8. Foot and Ankle

A 58-year-old man with poorly controlled diabetes mellitus presents with a unilateral swollen, warm, and erythematous left foot. He denies trauma, fever, or chills, and there are no cutaneous ulcers. Radiographs reveal soft tissue swelling without obvious bony fragmentation. You suspect acute Charcot neuroarthropathy but wish to rule out an infectious etiology. Which of the following clinical bedside tests is most helpful in differentiating early acute Charcot neuroarthropathy from infection?

. Tinel's sign at the tarsal tunnel
. The Silfverskiöld test
. Assessing for loss of protective sensation with a 10g monofilament
. Elevating the affected extremity for 5 to 10 minutes
. The Coleman block test

Correct Answer & Explanation

. Tinel's sign at the tarsal tunnel

Explanation

The clinical presentation of acute Charcot neuroarthropathy mimics infection (cellulitis or early osteomyelitis) with a red, hot, swollen foot. A classic bedside test to differentiate the two is elevating the affected leg for 5 to 10 minutes. In a patient with acute Charcot neuroarthropathy, the erythema is primarily due to autonomic neuropathy and resultant arteriovenous shunting (hyperemia), which typically resolves or significantly diminishes with elevation. In contrast, erythema secondary to an infectious process will persist despite limb elevation.

Question 4312

Topic: 8. Foot and Ankle

A 14-year-old boy presents with frequent ankle sprains and a rigid, painful flatfoot. On examination, he has decreased subtalar motion and peroneal muscle spasm. Radiographs reveal a 'C-sign' on the lateral view. A CT scan confirms a middle facet talocalcaneal coalition involving approximately 60% of the joint surface. There are secondary degenerative changes noted in the posterior facet. What is the most appropriate definitive surgical management?

. Resection of the coalition with extensor digitorum brevis interposition
. Subtalar arthrodesis
. Calcaneonavicular coalition resection
. Evans lateral column lengthening
. Gastrocnemius recession and custom orthotics

Correct Answer & Explanation

. Resection of the coalition with extensor digitorum brevis interposition

Explanation

The patient has a symptomatic talocalcaneal coalition, supported by the radiographic 'C-sign'. The standard surgical treatment for symptomatic talocalcaneal coalitions that fail conservative management is resection, provided the coalition involves less than 50% of the joint surface area and there are no significant degenerative changes. In this scenario, the coalition involves 60% of the middle facet joint surface and there are secondary degenerative changes in the posterior facet. Therefore, resection is contraindicated due to a high rate of failure and persistent pain, making a subtalar (or triple) arthrodesis the most appropriate definitive management to relieve pain and stabilize the hindfoot.

Question 4313

Topic: Ankle Trauma & Sports

A 26-year-old male sustains a pronation-external rotation ankle injury. Radiographs show a high fibular fracture (Maisonneuve). During surgical fixation, a syndesmotic injury is confirmed. The surgeon elects to use a flexible, suture-button construct rather than static syndesmotic screws. According to recent literature, what is the primary biomechanical and clinical advantage of using a suture-button construct for syndesmotic fixation?

. Complete rigid immobilization of the distal tibiofibular joint
. Decreased risk of superficial peroneal nerve injury during placement
. Elimination of the need for routine hardware removal and allowance for physiologic joint micromotion
. Increased resistance to anterior translation of the fibula compared to four-cortical screws
. Lower cost of the implant construct compared to standard screws

Correct Answer & Explanation

. Complete rigid immobilization of the distal tibiofibular joint

Explanation

Flexible suture-button constructs have become popular for syndesmotic fixation. Their primary advantages include allowing for physiologic micromotion at the syndesmosis (dynamic stabilization), which more closely replicates native kinematics and may lead to earlier functional recovery. Additionally, it avoids the need for routine hardware removal, which is a common requirement or secondary procedure when using traditional rigid metal screws, as rigid screws can loosen, back out, or break upon weight-bearing.

Question 4314

Topic: 8. Foot and Ankle

A 28-year-old male sustains an axial load injury to his plantarflexed foot while playing football. Non-weight-bearing radiographs are unremarkable. However, weight-bearing radiographs demonstrate a 3 mm diastasis between the base of the first and second metatarsals. MRI confirms a complete rupture of the primary stabilizing ligament of this joint without associated fractures. Which of the following statements regarding the definitive surgical management of this injury is most strongly supported by current literature?

. Primary arthrodesis is associated with a higher rate of hardware removal compared to open reduction and internal fixation (ORIF).
. Primary arthrodesis results in fewer unplanned reoperations and superior mid-term functional outcomes compared to ORIF for purely ligamentous injuries.
. ORIF with transarticular screws is biomechanically superior to primary arthrodesis for purely ligamentous variants.
. ORIF with dorsal bridge plating eliminates the risk of post-traumatic midfoot osteoarthritis.
. Percutaneous clamp reduction and Kirschner wire fixation is the preferred initial management for this injury pattern.

Correct Answer & Explanation

. Primary arthrodesis is associated with a higher rate of hardware removal compared to open reduction and internal fixation (ORIF).

Explanation

Purely ligamentous Lisfranc injuries are prone to poor outcomes with ORIF due to the lack of primary bone healing, leading to high rates of hardware failure, hardware removal, and post-traumatic arthritis. Multiple randomized controlled trials and long-term follow-up studies have demonstrated that primary arthrodesis for purely ligamentous Lisfranc injuries results in superior functional outcomes, fewer unplanned reoperations (such as isolated hardware removal), and a faster return to pre-injury activity levels compared to ORIF.

Question 4315

Topic: Midfoot & Hindfoot

A 52-year-old woman presents with progressive medial ankle pain and flattening of her left foot arch over the past year. On examination, she is unable to perform a single-leg heel rise on the left. Weight-bearing radiographs reveal a talonavicular uncoverage of 45%, a Meary's angle of 15 degrees apex plantar, and no subtalar or talonavicular arthrosis. Which of the following surgical combinations is most appropriate for her condition?

. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy (MDCO) alone.
. FDL transfer to the navicular, MDCO, and lateral column lengthening (e.g., Evans osteotomy).
. Subtalar and talonavicular (double) arthrodesis.
. Triple arthrodesis.
. Tibialis anterior tendon transfer (STATT) and spring ligament repair.

Correct Answer & Explanation

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

Explanation

The patient has Stage IIb adult-acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage II is characterized by a flexible deformity. Stage IIb specifically involves significant forefoot abduction (defined as > 40% talonavicular uncoverage on an AP radiograph). The appropriate surgical management for Stage IIb requires addressing both the medial column weakness and the lateral column shortening. An FDL transfer restores the dynamic medial longitudinal arch stabilizer, while a medial displacement calcaneal osteotomy (MDCO) realigns the hindfoot valgus. Due to the significant forefoot abduction, a lateral column lengthening is also mandatory to correct the deformity. Joint-sparing procedures are preferred over arthrodesis in flexible, non-arthritic deformities.

Question 4316

Topic: 8. Foot and Ankle

Tendons transmit high tensile forces from muscle to bone, but specific anatomical regions are predisposed to degeneration and spontaneous rupture due to relative hypovascularity. Where is the classic 'watershed area' of the Achilles tendon located?

. Myotendinous junction
. Mid-substance, approximately 2 to 6 cm proximal to the calcaneal insertion
. Osteotendinous junction (enthesis)
. The epitenon
. The endotenon

Correct Answer & Explanation

. Myotendinous junction

Explanation

The Achilles tendon has a relative zone of hypovascularity, often referred to as a 'watershed area,' located approximately 2 to 6 cm proximal to its insertion on the calcaneus. This region relies heavily on diffusion for nutrition and is the most common site for degenerative tendinopathy and acute ruptures. The myotendinous and osteotendinous junctions generally possess a more robust local blood supply derived from the adjacent muscle belly and bony attachments, respectively.

Question 4317

Topic: 8. Foot and Ankle

Following an acute traumatic rupture of the Achilles tendon, a cascade of biological events is initiated to promote tissue repair. Which of the following cell types represents the earliest cellular infiltrate to predominate during the initial inflammatory phase of tendon healing?

. Macrophages
. Fibroblasts
. Neutrophils
. Lymphocytes
. Tenocytes

Correct Answer & Explanation

. Macrophages

Explanation

Tendon healing proceeds through three distinct phases: inflammation, proliferation, and remodeling. During the immediate inflammatory phase, neutrophils are the first leukocytes to migrate to the site of injury, typically peaking within the first 24 to 48 hours. Macrophages subsequently arrive and peak after a few days to clear necrotic debris and release cytokines. Fibroblasts become the predominant cell type later, during the proliferative phase, to synthesize new extracellular matrix.

Question 4318

Topic: Ankle Trauma & Sports

A football player sustains a high ankle sprain. This injury typically involves damage to which of the following ligamentous complexes?

. Anterior talofibular ligament (ATFL)
. Calcaneofibular ligament (CFL)
. Posterior talofibular ligament (PTFL)
. Deltoid ligament complex
. Anterior inferior tibiofibular ligament (AITFL)

Correct Answer & Explanation

. Anterior talofibular ligament (ATFL)

Explanation

A 'high ankle sprain' refers to an injury of the tibiofibular syndesmosis. The primary ligaments composing the syndesmosis are the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), the transverse tibiofibular ligament (deep part of PITFL), and the interosseous membrane/ligament. Among the given options, the AITFL is the most commonly injured component in a high ankle sprain. The ATFL, CFL, and PTFL are components of the lateral ankle collateral ligament complex, involved in 'low' ankle sprains (inversion injuries). The deltoid ligament is the medial collateral ligament complex of the ankle.

Question 4319

Topic: 8. Foot and Ankle

A patient presents with burning pain, numbness, and tingling along the plantar aspect of the foot, exacerbated by activity and relieved by rest. Tapping posterior to the medial malleolus elicits symptoms (positive Tinel's sign). Which of the following anatomical structures passes most superiorly through the tarsal tunnel?

. Tibial nerve
. Posterior tibial artery
. Flexor digitorum longus tendon
. Flexor hallucis longus tendon
. Tibialis posterior tendon

Correct Answer & Explanation

. Tibial nerve

Explanation

The tarsal tunnel contains structures that pass from the posterior compartment of the leg into the foot, typically listed in order from anterior (most superior, immediately posterior to the medial malleolus) to posterior (most inferior, closer to the calcaneus). The mnemonic 'Tom, Dick, And Nervous Harry' helps recall this order: Tibialis posterior tendon, Flexor digitorum longus tendon, posterior tibial Artery, Tibial Nerve, Flexor Hallucis Longus tendon. Therefore, the Tibialis posterior tendon passes most superiorly (anteriorly) through the tarsal tunnel.

Question 4320

Topic: Ankle Trauma & Sports

A patient sustains an inversion ankle injury with associated avulsion fracture of the anterior aspect of the distal fibula. Which ligament is not considered part of the lateral collateral ligament complex of the ankle?

. Anterior talofibular ligament (ATFL)
. Posterior talofibular ligament (PTFL)
. Calcaneofibular ligament (CFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Accessory lateral ligament (meniscoid body)

Correct Answer & Explanation

. Anterior talofibular ligament (ATFL)

Explanation

The lateral collateral ligament complex of the ankle primarily consists of the anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). These ligaments resist inversion. The posterior inferior tibiofibular ligament (PITFL) is a component of the tibiofibular syndesmosis, which stabilizes the distal tibiofibular joint, and is injured in 'high ankle sprains' (eversion and dorsiflexion injuries). The accessory lateral ligament is an anatomical variant sometimes found. Therefore, PITFL is the correct answer as it is not part of the lateral collateral ligament complex.

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