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8. Foot and Ankle MCQs

Practice Set 225 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 4481

Topic: 8. Foot and Ankle

The extensile lateral approach to the calcaneus for fracture fixation is associated with a high rate of wound complications. A full-thickness "no-touch" subperiosteal flap must be created to protect the primary blood supply to this flap. Which artery provides this primary blood supply?

. Sural artery
. Lateral calcaneal artery
. Peroneal artery
. Anterior tibial artery
. Dorsalis pedis artery

Correct Answer & Explanation

. Lateral calcaneal artery

Explanation

The lateral calcaneal artery, a branch of the peroneal artery, supplies the lateral skin flap. A full-thickness subperiosteal flap is crucial to preserve this vessel and minimize wound edge necrosis.

Question 4482

Topic: 8. Foot and Ankle

In a classic Lisfranc injury, which of the following describes the precise anatomical attachment of the primary interosseous Lisfranc ligament?

. Medial cuneiform to the base of the first metatarsal
. Intermediate cuneiform to the base of the second metatarsal
. Medial aspect of the intermediate cuneiform to the medial second metatarsal
. Lateral aspect of the medial cuneiform to the medial aspect of the second metatarsal base
. Cuboid to the lateral aspect of the third metatarsal base

Correct Answer & Explanation

. Lateral aspect of the medial cuneiform to the medial aspect of the second metatarsal base

Explanation

The Lisfranc ligament is a stout intra-articular interosseous ligament that runs from the lateral surface of the medial cuneiform to the medial base of the second metatarsal, stabilizing the midfoot.

Question 4483

Topic: Forefoot

A 22-year-old collegiate football player sustains a grade 3 turf toe injury. MRI confirms a complete tear of the plantar plate with proximal retraction of the sesamoids. What is the most appropriate management?

. Taping, stiff-soled shoe, and immediate return to play
. Immobilization in a walking boot for 6 weeks
. Primary surgical repair of the plantar plate
. Surgical excision of the tibial sesamoid only
. Arthrodesis of the first metatarsophalangeal joint

Correct Answer & Explanation

. Primary surgical repair of the plantar plate

Explanation

Grade 3 turf toe injuries involving a complete tear of the plantar plate and sesamoid retraction generally require primary surgical repair to restore push-off strength and prevent chronic instability or hallux rigidus.

Question 4484

Topic: 8. Foot and Ankle

A 55-year-old man presents with painful, limited dorsiflexion of his first MTP joint. Radiographs reveal dorsal osteophytes but preserved joint space on the plantar aspect (Coughlin and Shurnas Grade 2). After failing conservative treatment, what is the preferred surgical intervention?

. Cheilectomy
. First MTP joint arthrodesis
. First MTP total joint arthroplasty
. Keller resection arthroplasty
. Weil osteotomy

Correct Answer & Explanation

. Cheilectomy

Explanation

Cheilectomy (excision of the dorsal osteophytes and the dorsal one-third of the metatarsal head) is the procedure of choice for Grade 1 and 2 hallux rigidus where the plantar articular cartilage is still well preserved.

Question 4485

Topic: 8. Foot and Ankle

A 45-year-old woman presents with burning forefoot pain radiating to the third and fourth toes, exacerbated by tight shoes. A Mulder's click is present. If conservative measures fail, what is the most definitive surgical treatment?

. Percutaneous plantar fascia release
. Tarsal tunnel decompression
. Distal metatarsal shortening osteotomy
. Excision of the interdigital nerve
. Transposition of the intermetatarsal bursa

Correct Answer & Explanation

. Excision of the interdigital nerve

Explanation

Morton's neuroma is a compressive neuropathy of the interdigital nerve. Surgical excision of the affected nerve, typically via a dorsal approach, is the definitive and most successful treatment after failed nonoperative care.

Question 4486

Topic: 8. Foot and Ankle

In a patient presenting with asymmetric varus ankle osteoarthritis, which of the following is an absolute prerequisite for performing a joint-preserving supramalleolar osteotomy instead of an arthrodesis?

. Age greater than 65 years
. Complete loss of both medial and lateral tibiotalar cartilage
. Fixed subtalar arthritis
. Preservation of at least the lateral half of the tibiotalar articular cartilage
. Pre-existing hindfoot valgus deformity greater than 15 degrees

Correct Answer & Explanation

. Preservation of at least the lateral half of the tibiotalar articular cartilage

Explanation

A supramalleolar osteotomy corrects the mechanical axis to shift weight-bearing loads away from the diseased area. In varus ankle OA, the lateral joint space must be well preserved to safely bear the shifted load.

Question 4487

Topic: Midfoot & Hindfoot

A 50-year-old woman presents with a flexible, adult-acquired flatfoot deformity (Stage II posterior tibial tendon dysfunction) that has not responded to custom orthotics. What is the gold standard surgical reconstruction?

. Isolated subtalar arthrodesis
. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer combined with a medial displacement calcaneal osteotomy
. Tibialis anterior tendon transfer to the navicular
. Isolated talonavicular arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer combined with a medial displacement calcaneal osteotomy

Explanation

Stage II posterior tibial tendon dysfunction is characterized by a flexible deformity. The standard joint-sparing reconstruction consists of an FDL tendon transfer to substitute for the torn posterior tibial tendon, paired with a medial displacement calcaneal osteotomy to correct the mechanical axis.

Question 4488

Topic: Midfoot & Hindfoot

A 45-year-old runner has severe inferior heel pain for 12 months, refractory to stretching, orthotics, and corticosteroid injections. If surgical intervention is pursued, which structure is typically released?

. The entire plantar fascia
. The medial one-third to one-half of the plantar fascia
. The lateral band of the plantar fascia
. The abductor digiti minimi fascia
. The flexor digitorum brevis origin

Correct Answer & Explanation

. The medial one-third to one-half of the plantar fascia

Explanation

Surgical treatment for recalcitrant plantar fasciitis involves a partial release of the medial one-third to one-half of the plantar fascia. Releasing the entire fascia risks severe arch destabilization and lateral column overload.

Question 4489

Topic: 8. Foot and Ankle

When performing an isolated ankle arthrodesis, what is the optimal position for fusing the tibiotalar joint?

. 5 degrees of plantarflexion, neutral valgus, and internal rotation
. Neutral dorsiflexion, 0 to 5 degrees of valgus, and 5 to 10 degrees of external rotation
. 10 degrees of dorsiflexion, 5 degrees of varus, and neutral rotation
. Neutral dorsiflexion, neutral coronal alignment, and 20 degrees of internal rotation
. 5 degrees of plantarflexion, 5 degrees of valgus, and 10 degrees of external rotation

Correct Answer & Explanation

. Neutral dorsiflexion, 0 to 5 degrees of valgus, and 5 to 10 degrees of external rotation

Explanation

The optimal position for an ankle arthrodesis to maximize gait efficiency and prevent adjacent joint arthritis is neutral dorsiflexion, 0 to 5 degrees of valgus, and external rotation matching the contralateral limb (typically 5-10 degrees).

Question 4490

Topic: 8. Foot and Ankle

Tarsal tunnel syndrome is a compressive neuropathy of the posterior tibial nerve or its branches. Which anatomic structure forms the primary roof of the tarsal tunnel?

. Flexor retinaculum
. Inferior extensor retinaculum
. Plantar aponeurosis
. Deep fascia of the abductor hallucis
. Spring ligament

Correct Answer & Explanation

. Flexor retinaculum

Explanation

The roof of the tarsal tunnel is formed by the flexor retinaculum (also known as the laciniate ligament). The tunnel's floor consists of the medial talus, calcaneus, and deltoid ligament.

Question 4491

Topic: 8. Foot and Ankle

Recent meta-analyses comparing functional rehabilitation with surgical repair for acute Achilles tendon ruptures show what primary difference in clinical outcomes?

. Higher deep infection rate with nonoperative management.
. Improved plantarflexion strength with nonoperative management.
. Equal re-rupture rates when using early functional rehab, but higher wound complications with surgery.
. Significantly faster return to sport with surgery.
. Lower re-rupture rate with surgery regardless of rehab protocol.

Correct Answer & Explanation

. Equal re-rupture rates when using early functional rehab, but higher wound complications with surgery.

Explanation

Recent level 1 evidence shows that with early functional rehabilitation, nonoperative and operative treatments have similar re-rupture rates. However, surgical intervention is associated with a higher risk of soft-tissue and wound complications.

Question 4492

Topic: Midfoot & Hindfoot

In a 45-year-old active male with a purely ligamentous Lisfranc injury involving the 1st, 2nd, and 3rd tarsometatarsal joints, which treatment has been shown to have lower rates of hardware removal and higher functional scores at medium-term follow-up compared to ORIF?

. Closed reduction and percutaneous pinning.
. Non-weight bearing cast for 8 weeks.
. Dorsal bridge plating.
. Suture-button fixation of the Lisfranc ligament.
. Primary arthrodesis of the medial three rays.

Correct Answer & Explanation

. Primary arthrodesis of the medial three rays.

Explanation

Primary arthrodesis for purely ligamentous Lisfranc injuries reduces the need for hardware removal and avoids the late midfoot arthrosis commonly associated with ORIF. Studies show comparable or superior functional outcomes in these patients.

Question 4493

Topic: 8. Foot and Ankle

A 55-year-old diabetic patient presents with a swollen, erythematous foot without ulceration. Radiographs show periarticular fragmentation and subluxation at the midfoot. What is the most appropriate initial management?

. Immediate open reduction and internal fixation.
. Total contact casting and strict non-weight bearing.
. Intravenous antibiotics and irrigation & debridement.
. Charcot Restraint Orthotic Walker (CROW) boot with weight-bearing as tolerated.
. Primary midfoot arthrodesis.

Correct Answer & Explanation

. Total contact casting and strict non-weight bearing.

Explanation

In acute Eichenholtz stage I Charcot neuroarthropathy, the standard of care is immediate immobilization in a total contact cast and strict non-weight bearing. This prevents further deformity and joint destruction until the acute inflammatory phase resolves.

Question 4494

Topic: 8. Foot and Ankle

During ORIF of a Weber C ankle fracture, the syndesmosis is fixed with two metallic screws. Regarding syndesmotic screw removal, current evidence suggests:

. Routine removal is necessary at 6 weeks to restore ankle dorsiflexion.
. Screws should be removed before full weight-bearing to prevent distal tibiofibular synostosis.
. Routine removal is not indicated unless the patient is symptomatic, as broken screws do not worsen clinical outcomes.
. Screw removal decreases the risk of post-traumatic arthritis.
. Flexible fixation has identical reoperation rates to metallic screws.

Correct Answer & Explanation

. Routine removal is not indicated unless the patient is symptomatic, as broken screws do not worsen clinical outcomes.

Explanation

Routine removal of syndesmotic screws is not supported by current literature. Retained or broken screws do not negatively affect functional outcomes, whereas routine removal exposes patients to unnecessary surgical risks.

Question 4495

Topic: Forefoot

A 60-year-old female presents with severe hallux valgus (HVA 45 degrees, IMA 18 degrees) and hypermobility of the first tarsometatarsal (TMT) joint. Which surgical procedure is most appropriate?

. First TMT arthrodesis (Lapidus procedure).
. Proximal crescentic osteotomy.
. Distal chevron osteotomy.
. First MTP arthrodesis.
. Akin osteotomy.

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure).

Explanation

A Lapidus procedure (first TMT arthrodesis) is specifically indicated for severe hallux valgus with an increased intermetatarsal angle and first ray hypermobility. It provides triplanar correction and restores medial column stability.

Question 4496

Topic: Midfoot & Hindfoot
A 50-year-old woman has flexible flatfoot, is unable to perform a single-leg heel raise, and has significant forefoot abduction (>40% talonavicular uncoverage). Which surgical combination is most appropriate for this Stage IIb posterior tibial tendon dysfunction?
. FDL transfer and medial displacement calcaneal osteotomy (MDCO).
. Triple arthrodesis.
. FDL transfer, MDCO, and lateral column lengthening.
. Isolated subtalar arthrodesis.
. Spring ligament repair alone.

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening.

Explanation

Stage IIb PTTD involves a flexible deformity with significant forefoot abduction. This is best addressed with FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening (e.g., Evans osteotomy) to specifically correct the abduction.

Question 4497

Topic: 8. Foot and Ankle

A 35-year-old male smoker sustains a displaced intra-articular calcaneus fracture. The surgeon elects to proceed with ORIF via an extensile lateral approach. Which complication is most uniquely associated with this specific approach?

. Medial plantar nerve entrapment.
. Tibial artery pseudoaneurysm.
. Achilles tendon rupture.
. Sural nerve injury and tip necrosis of the lateral flap.
. Deep peroneal nerve palsy.

Correct Answer & Explanation

. Sural nerve injury and tip necrosis of the lateral flap.

Explanation

The extensile lateral approach to the calcaneus carries a significant risk of wound healing complications, particularly at the flap apex. It also risks iatrogenic injury to the sural nerve, with risks compounded by smoking.

Question 4498

Topic: Forefoot

A 45-year-old male runner presents with dorsal midfoot pain and limited MTP dorsiflexion. Radiographs reveal dorsal osteophytes at the 1st MTP joint with preserved plantar joint space (Coughlin/Shurnas Grade 2). He failed nonoperative management. What is the best surgical option?

. 1st MTP arthrodesis.
. Cheilectomy.
. Keller arthroplasty.
. Silicone joint replacement.
. Lapidus procedure.

Correct Answer & Explanation

. Cheilectomy.

Explanation

Cheilectomy (removal of dorsal osteophytes and the dorsal one-third of the metatarsal head) is highly effective for Grade 1 and 2 hallux rigidus. It relieves impingement pain while preserving joint motion required for running.

Question 4499

Topic: 8. Foot and Ankle
A 26-year-old skier presents with lateral ankle pain and snapping behind the lateral malleolus upon resisted eversion. Conservative management has failed. Which of the following is the most appropriate surgical treatment?
. Brostrรถm-Gould procedure.
. Peroneus brevis to longus tenodesis.
. Achilles tendon lengthening.
. Excision of the os peroneum.
. Superior peroneal retinaculum (SPR) repair and fibular groove deepening.

Correct Answer & Explanation

. Superior peroneal retinaculum (SPR) repair and fibular groove deepening.

Explanation

Symptomatic chronic peroneal tendon subluxation is best treated with repair or reconstruction of the superior peroneal retinaculum. This is frequently combined with deepening of the retromalleolar fibular groove to prevent recurrence.

Question 4500

Topic: 8. Foot and Ankle

A 35-year-old woman complains of burning pain in her 3rd web space radiating to her toes, worsening in narrow shoes. A palpable click is noted with lateral compression of the metatarsal heads. If surgical excision is planned, what is the primary advantage of a dorsal approach over a plantar approach?

. Better visualization of the plantar plate.
. Quicker return of toe sensation.
. Lower risk of recurrence (stump neuroma).
. Avoidance of a painful plantar scar.
. Easier access to the medial plantar nerve.

Correct Answer & Explanation

. Avoidance of a painful plantar scar.

Explanation

The dorsal approach for Morton's neuroma excision avoids the creation of a potentially painful plantar scar in a weight-bearing area. This allows for earlier weight-bearing and limits postoperative morbidity.

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