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 4361
Topic: 8. Foot and Ankle
A patient is evaluated for foot drop following a traumatic knee dislocation. An MRI reveals an intact common peroneal nerve that is compressed by a fibular head hematoma. In this anatomical region, the nerve wraps around the fibular neck deep to the origin of which muscle?
Correct Answer & Explanation
. Peroneus longus
Explanation
The common peroneal nerve wraps around the neck of the fibula deep to the origin of the peroneus longus muscle. It is highly susceptible to injury at this location due to direct trauma, traction, or compression.
Question 4362
Topic: 8. Foot and Ankle
A surgeon performs an extensile lateral approach to the calcaneus for an intra-articular fracture. Which nerve is most at risk during the initial skin incision and elevation of the full-thickness flap?
Correct Answer & Explanation
. Sural nerve
Explanation
The sural nerve runs posterior to the lateral malleolus and along the lateral border of the hindfoot. It is highly vulnerable to iatrogenic injury during the standard extensile lateral approach to the calcaneus.
Question 4363
Topic: 8. Foot and Ankle
The Lisfranc ligament is essential for the stability of the midfoot and is often implicated in high-energy tarsometatarsal fracture-dislocations. Which of the following best describes its exact true anatomical attachments?
Correct Answer & Explanation
. Medial cuneiform to the base of the second metatarsal
Explanation
The Lisfranc ligament is a stout, interosseous ligament that originates on the lateral aspect of the medial cuneiform and inserts onto the medial aspect of the base of the second metatarsal. There is notably no direct ligamentous connection between the bases of the first and second metatarsals.
Question 4364
Topic: 8. Foot and Ankle
Tarsal tunnel syndrome involves entrapment of the tibial nerve. In relation to the other structures located posterior to the medial malleolus, where does the main neurovascular bundle lie within the tarsal tunnel?
Correct Answer & Explanation
. Between the flexor digitorum longus and flexor hallucis longus tendons
Explanation
From anterior to posterior, the structures are the Tibialis posterior, Flexor Digitorum Longus, Artery, Vein, Nerve, and Flexor Hallucis Longus (Tom, Dick, And Very Nervous Harry). Therefore, the neurovascular bundle lies safely sandwiched between the FDL and FHL tendons.
Question 4365
Topic: 8. Foot and Ankle
When evaluating the non-operative management of acute Achilles tendon ruptures utilizing an early functional rehabilitation protocol compared to surgical repair, current high-level evidence demonstrates:
Correct Answer & Explanation
. Similar rates of re-rupture and significantly lower rates of soft tissue complications in the non-operative group
Explanation
Recent high-quality randomized controlled trials and meta-analyses comparing functional bracing/rehabilitation to surgical repair for acute Achilles tendon ruptures have shown similar re-rupture rates between the two groups. However, non-operative management avoids surgical complications such as wound breakdown, nerve injury, and deep infection.
Question 4366
Topic: 8. Foot and Ankle
A 35-year-old recreational basketball player sustains an acute Achilles tendon rupture. He elects to undergo a minimally invasive percutaneous repair to minimize wound complications. During the procedure, the surgeon places sutures through the proximal stump of the tendon. Which of the following structures is at the highest risk of iatrogenic injury during this specific step?
Correct Answer & Explanation
. Sural nerve
Explanation
The sural nerve is at significant risk of entrapment or laceration during percutaneous or minimally invasive Achilles tendon repair, particularly when placing sutures in the proximal stump. The nerve courses distally along the posterior calf, migrating laterally to run closely adjacent to the lateral border of the Achilles tendon in the middle and distal thirds of the leg.
Question 4367
Topic: 8. Foot and Ankle
When comparing the outcomes of acute Achilles tendon ruptures treated with operative repair versus non-operative management utilizing early functional bracing and mobilization, non-operative management is associated with which of the following?
Correct Answer & Explanation
. Similar re-rupture rates and elimination of surgical site infection risk
Explanation
High-quality randomized controlled trials (such as Willits et al.) have demonstrated that when non-operative treatment of acute Achilles tendon ruptures is paired with an early functional rehabilitation protocol, the re-rupture rates are statistically similar to those of operative repair. Non-operative management eliminates the risks associated with surgery, most notably surgical site infections, wound healing complications, and iatrogenic sural nerve injury. Plantar flexion strength and return to work times are generally comparable between the two groups.
Question 4368
Topic: 8. Foot and Ankle
A 31-year-old male sustains a knee dislocation (Schenck KD-IIIL) after a high-speed motorcycle accident. On initial presentation, he has an absent dorsalis pedis pulse with an ABI of 0.6, and a profound 'foot drop' with absent sensation in the first web space. Following a successful vascular bypass, orthopedic ligamentous reconstruction is planned. Which of the following statements regarding his neurologic deficit is most accurate?
Correct Answer & Explanation
. Meaningful functional recovery of ankle dorsiflexion following common peroneal nerve palsy in the setting of a multiligament knee injury occurs in less than 40% of patients.
Explanation
Common peroneal nerve palsy is a devastating complication of knee dislocations, especially those involving the posterolateral corner (KD-IIIL or KD-IV). The injury is typically a high-energy stretch/traction injury over a long segment, making primary end-to-end repair nearly impossible without grafting. The prognosis for spontaneous functional recovery (useful motor function for dorsiflexion) is historically poor, occurring in less than 30-40% of cases. Consequently, tendon transfers (such as a posterior tibial tendon transfer) or an ankle-foot orthosis (AFO) are frequently required for long-term functional management.
Question 4369
Topic: 8. Foot and Ankle
A 35-year-old recreational tennis player presents with acute posterior ankle pain after lunging for a drop shot. He has a positive Thompson test. An MRI of the ankle is shown in Figure 7.
He elects to undergo minimally invasive surgical repair of the Achilles tendon. During percutaneous suture passage in the proximal stump, which nerve is at the greatest risk of iatrogenic injury?
Correct Answer & Explanation
. Sural nerve
Explanation
The sural nerve courses distally along the posterolateral aspect of the calf, crossing the lateral border of the Achilles tendon roughly 10 cm proximal to its insertion. During percutaneous or minimally invasive Achilles tendon repair, the sural nerve is at significant risk of being captured, tethered, or injured during the blind passage of sutures in the proximal tendon stump. Surgeons must carefully map or protect the nerve laterally when passing sutures.
Question 4370
Topic: 8. Foot and Ankle
A 24-year-old professional hockey player sustains an external rotation injury to his right ankle.
Examination reveals tenderness over the anterior inferior tibiofibular ligament (AITFL) and a positive squeeze test. Gravity stress radiographs show an increased medial clear space. According to the Lauge-Hansen classification for a typical pronation-external rotation (PER) injury, which of the following describes the correct order of ligamentous/bony failure?
In a Lauge-Hansen Pronation-External Rotation (PER) injury, the foot is pronated (tensioning medial structures) and an external rotation force is applied. The sequence of injury is: 1) Deltoid ligament rupture or medial malleolus avulsion, 2) Anterior inferior tibiofibular ligament (AITFL) tear, 3) High fibular fracture (or interosseous membrane tear up to the level of the fracture), and 4) Posterior inferior tibiofibular ligament (PITFL) tear or posterior malleolus fracture.
Question 4371
Topic: 8. Foot and Ankle
A 35-year-old recreational basketball player suffers an acute, closed mid-substance Achilles tendon rupture. He is treated nonoperatively utilizing a modern functional rehabilitation protocol that incorporates early weight-bearing in a functional brace. Based on current high-level evidence, how do his long-term clinical outcomes compare to a similar patient treated with acute surgical repair?
Correct Answer & Explanation
. Nonoperative management has equivalent re-rupture rates and functional outcomes, with a significantly lower rate of overall complications.
Explanation
Recent high-level evidence, including large randomized controlled trials and meta-analyses, has demonstrated that when acute Achilles tendon ruptures are treated with a modern functional rehabilitation protocol (involving early functional bracing and early weight-bearing), the re-rupture rates and long-term functional outcomes are equivalent to those of operative repair. However, surgical repair carries a significantly higher risk of complications, such as surgical site infections, delayed wound healing, and sural nerve injury.
Question 4372
Topic: 8. Foot and Ankle
A 31-year-old male sustains a multiligamentous knee injury (MLKI) following a tackle in soccer. The knee is grossly deformed but is reduced in the emergency department. Post-reduction, the pedal pulses are palpable and symmetric. However, the ankle-brachial index (ABI) is measured at 0.8. What is the most appropriate next step in management?
Correct Answer & Explanation
. CT angiography of the affected lower extremity
Explanation
A knee dislocation is associated with a high risk of popliteal artery injury. Even in the presence of palpable pedal pulses, an ABI < 0.9 is highly suspicious for a vascular injury (e.g., an intimal tear). The gold standard for evaluating this finding is a CT angiogram, which guides further vascular intervention. Serial examinations alone are inadequate given the low ABI.
Question 4373
Topic: 8. Foot and Ankle
A 25-year-old professional hockey player sustains an external rotation injury to his ankle. He exhibits localized tenderness over the anterior inferior tibiofibular ligament (AITFL) and a positive squeeze test. Stress radiographs show a normal medial clear space and no tibiofibular diastasis. MRI confirms an isolated tear of the AITFL with an intact deltoid ligament. What is the most appropriate treatment?
Correct Answer & Explanation
. Controlled functional rehabilitation in a walking boot
Explanation
Isolated syndesmotic injuries without radiographic diastasis and without deltoid ligament compromise are classified as stable (Grade I or II). The standard of care for stable syndesmosis sprains is nonoperative management with a brief period of immobilization in a walking boot, followed by early weight-bearing as tolerated and progressive functional rehabilitation.
Question 4374
Topic: 8. Foot and Ankle
A 24-year-old male is brought to the emergency department after a high-velocity motorcycle accident. Examination reveals a multiligamentous knee injury (Schenck KD III). The foot is warm, but the Ankle-Brachial Index (ABI) on the injured extremity is 0.8. Which of the following is the most appropriate next step in management?
Correct Answer & Explanation
. CT angiography of the lower extremity
Explanation
In the setting of a knee dislocation, vascular status must be carefully assessed. An ABI < 0.9 is highly suspicious for an occult vascular injury and warrants advanced imaging, primarily CT angiography, to evaluate the popliteal artery. Immediate surgical exploration is indicated for 'hard signs' of arterial ischemia, such as absent pulses, an expanding or pulsatile hematoma, or active pulsatile bleeding.
Question 4375
Topic: 8. Foot and Ankle
A 25-year-old football player sustains a knee dislocation after a violent tackle. The knee is reduced on the field. In the emergency department, his Ankle-Brachial Index (ABI) is calculated to be 0.8. He has palpable distal pulses, no expanding hematoma, and no active bleeding. What is the most appropriate next step in management?
Correct Answer & Explanation
. CT angiography of the lower extremity
Explanation
In the setting of a knee dislocation, vascular status must be carefully assessed. An ABI of less than 0.9 strongly indicates abnormal arterial flow and mandates advanced vascular imaging; CT angiography is the current gold standard. Immediate surgical exploration is reserved for patients presenting with 'hard signs' of ischemia (absent pulses, expanding/pulsatile hematoma, active hemorrhage, or overt distal ischemia). Observation alone is inappropriate given the abnormal ABI.
Question 4376
Topic: 8. Foot and Ankle
A 32-year-old male sustains a high-energy knee dislocation in a motor vehicle collision. The knee is reduced in the emergency department. The pedal pulses are palpable, but the ankle-brachial index (ABI) is measured at 0.85. What is the most appropriate next step in management?
Correct Answer & Explanation
. CT angiography of the lower extremity
Explanation
In the setting of a knee dislocation, vascular injury (especially the popliteal artery) must be meticulously excluded. An ABI less than 0.9 is a highly sensitive indicator of an arterial injury, even in the presence of palpable pulses, because collateral circulation can preserve distal pulses. The appropriate next step is advanced vascular imaging, most commonly a CT angiogram, to definitively diagnose and localize the injury. Immediate surgical exploration is indicated only for 'hard signs' of ischemia (absent pulses, expanding hematoma, pulsatile bleeding).
Question 4377
Topic: 8. Foot and Ankle
A 28-year-old male sustains a high-energy traumatic knee dislocation (KD-III) in a motorcycle collision. The knee is grossly reduced in the emergency department. Upon initial assessment, pedal pulses are palpable but slightly asymmetric compared to the uninjured limb. The ankle-brachial index (ABI) is measured at 0.85.
What is the most appropriate next step in management?
Correct Answer & Explanation
. Perform a CT angiogram of the lower extremity
Explanation
In the setting of a knee dislocation, an ABI of less than 0.90 is highly concerning for a vascular injury to the popliteal artery. According to modern trauma algorithms, an ABI < 0.90 or asymmetric pulses mandates further advanced vascular imaging, most commonly a CT angiogram, to identify intimal tears or partial occlusions. Immediate OR exploration is reserved for 'hard' signs of ischemia (e.g., absent pulses, active pulsatile hemorrhage, expanding hematoma). Serial checks alone are inadequate for an abnormal ABI < 0.90.
Question 4378
Topic: 8. Foot and Ankle
A 35-year-old recreational basketball player sustains an acute, complete, mid-substance rupture of his Achilles tendon. He opts for nonoperative management. Based on recent Level I evidence, which of the following rehabilitation protocols provides re-rupture rates most comparable to operative treatment?
Correct Answer & Explanation
. Early functional rehabilitation with protected, early weight-bearing in a functional equinus orthosis
Explanation
Recent high-quality Level I evidence (including randomized controlled trials) has demonstrated that when an acute Achilles tendon rupture is treated nonoperatively using an early functional rehabilitation protocol (which includes early protected weight-bearing and active plantarflexion in a functional orthosis), the re-rupture rates are statistically similar to operative repair. Traditional strict casting (prolonged immobilization) has historically higher re-rupture rates and greater functional deficits.
Question 4379
Topic: 8. Foot and Ankle
A 31-year-old male is evaluated in the emergency department after a motorcycle accident. He has a grossly unstable knee diagnosed as a KD-III-M injury (ACL, PCL, and MCL tears). His pedal pulses are palpable, symmetric, and an ABI is 1.0. However, he demonstrates a complete foot drop and sensory loss over the dorsum of his foot. Assuming vascular stability, if the patient's neurologic deficit persists without signs of recovery, what is the most appropriate management regarding the injured nerve?
Correct Answer & Explanation
. Observation for 3 months followed by EMG; if no recovery, consider surgical options
Explanation
Peroneal nerve palsy associated with knee dislocations is most often a stretch injury in continuity (neuropraxia or axonotmesis). The standard of care is observation for approximately 3 months, often accompanied by serial clinical exams and EMG/NCS. If there is no evidence of reinnervation at 3-6 months, surgical options such as nerve exploration/decompression, nerve grafting, or tendon transfer (e.g., posterior tibial tendon transfer) should be considered.
Question 4380
Topic: 8. Foot and Ankle
A 35-year-old recreational basketball player sustains an acute Achilles tendon rupture. After an extensive discussion of the risks and benefits of all treatment options, he elects for nonoperative management. What rehabilitation protocol has been shown in recent literature to reduce the re-rupture rate in nonoperatively managed Achilles tendon ruptures to a level comparable to surgical repair?
Correct Answer & Explanation
. Early functional rehabilitation with controlled weight-bearing and early ankle range of motion in a functional brace
Explanation
Recent high-quality, randomized controlled trials demonstrate that early functional rehabilitation protocols—involving early protected range of motion and controlled weight-bearing in a functional brace—for nonoperatively treated Achilles tendon ruptures yield functional outcomes and re-rupture rates that are comparable to operative treatment. Traditional prolonged rigid immobilization is associated with higher re-rupture rates and poorer functional recovery.
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