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8. Foot and Ankle MCQs

Practice Set 227 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 4521

Topic: 8. Foot and Ankle

A 55-year-old female presents with a 2-year history of progressive medial foot pain and flattening of her arch. Examination reveals a flexible hindfoot valgus, a positive 'too many toes' sign, and inability to perform a single-leg heel rise. Weight-bearing radiographs demonstrate uncovering of the talonavicular joint of 40%. Which of the following surgical combinations is most appropriate for this patient?

. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO)
. Triple arthrodesis
. FDL transfer, MDCO, and lateral column lengthening
. Subtalar arthrodesis and Achilles tendon lengthening
. First TMT arthrodesis and FDL transfer

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible flatfoot, inability to perform a single heel rise, and significant forefoot abduction (talonavicular uncovering > 30%). While Stage IIa (minimal forefoot abduction) can be treated with an FDL transfer and MDCO, Stage IIb requires the addition of a lateral column lengthening (such as an Evans calcaneal osteotomy or calcaneocuboid distraction arthrodesis) to correct the severe forefoot abduction and restore the lateral column length.

Question 4522

Topic: 8. Foot and Ankle
A 30-year-old male sustains a high-energy motor vehicle collision resulting in a Hawkins Type III talar neck fracture. During the surgical approach for reduction and internal fixation, the surgeon must be meticulous to preserve the remaining blood supply to the talar body. In this specific fracture pattern, which of the following vessels is most likely providing the sole remaining blood supply to the extruded talar body?
. Artery of the tarsal canal
. Artery of the sinus tarsi
. Superior neck branches of the dorsalis pedis
. Deltoid branches of the posterior tibial artery
. Medial plantar artery branches

Correct Answer & Explanation

. Deltoid branches of the posterior tibial artery

Explanation

In a Hawkins Type III fracture, there is a fracture of the talar neck with dislocation of both the subtalar and tibiotalar joints. This displacement systematically disrupts the artery of the tarsal canal, the artery of the sinus tarsi, and the superior neck vessels. The only remaining blood supply to the talar body is often through the deltoid branches of the posterior tibial artery, which enter the medial aspect of the talar body. Preserving the intact medial soft tissues (deltoid ligament) is critical during surgical intervention.

Question 4523

Topic: 8. Foot and Ankle

A 62-year-old man presents to the clinic to discuss surgical options for end-stage ankle arthritis. He has a complicated medical history and is weighing the risks and benefits of total ankle arthroplasty (TAA) versus ankle arthrodesis. Which of the following conditions is considered an absolute contraindication to total ankle arthroplasty?

. Age less than 50 years
. History of a successfully treated ankle joint infection 10 years ago
. Charcot neuroarthropathy with severe talar bone loss
. Body Mass Index (BMI) of 32
. Contralateral ankle arthrodesis

Correct Answer & Explanation

. Charcot neuroarthropathy with severe talar bone loss

Explanation

Absolute contraindications to total ankle arthroplasty (TAA) include active infection, severe peripheral vascular disease, Charcot neuroarthropathy (especially with bone loss), avascular necrosis of the talus affecting > 50% of the talar body, and absent lower extremity sensation. Age < 50, well-controlled prior infection, elevated BMI, and contralateral fusions are considered relative contraindications or factors that require careful patient selection, but not absolute contraindications.

Question 4524

Topic: 8. Foot and Ankle

When managing a displaced intra-articular calcaneus fracture, surgeons often debate between an extensile lateral approach and a limited sinus tarsi approach. Which of the following is the primary advantage of utilizing the sinus tarsi approach compared to the traditional extensile lateral approach?

. Improved visualization of the medial calcaneal wall
. Lower incidence of post-operative wound complications
. Higher rate of anatomic reduction of the posterior facet
. Ability to place a standard lateral perimeter plate
. Decreased incidence of post-traumatic subtalar arthritis

Correct Answer & Explanation

. Lower incidence of post-operative wound complications

Explanation

The primary advantage of the limited sinus tarsi approach is a significantly lower rate of post-operative wound complications and infections compared to the extensile lateral approach. The extensile lateral approach requires a large full-thickness flap that has a known high risk of wound edge necrosis and dehiscence. Studies have shown comparable clinical outcomes and reduction quality for appropriate fracture patterns between the two approaches, but the sinus tarsi approach excels in minimizing soft tissue morbidity.

Question 4525

Topic: Midfoot & Hindfoot

A 35-year-old male sustains a purely ligamentous Lisfranc injury. After nonoperative management fails to provide a stable arch, surgical intervention is discussed. Compared to primary open reduction and internal fixation (ORIF), recent literature suggests that primary arthrodesis for purely ligamentous Lisfranc injuries provides which of the following advantages?

. A significantly shorter period of non-weight bearing
. Decreased rates of subsequent and revision surgeries
. Superior restoration of the longitudinal arch height
. Lower risk of nonunion in the medial column
. Preservation of normal midfoot kinematics

Correct Answer & Explanation

. Decreased rates of subsequent and revision surgeries

Explanation

Multiple prospective, randomized studies (e.g., Ly and Coetzee) have demonstrated that primary arthrodesis for purely ligamentous Lisfranc injuries results in fewer subsequent surgeries. Patients undergoing ORIF frequently require a second procedure for hardware removal and have a higher rate of secondary surgeries for post-traumatic midfoot arthritis. Functional outcomes in the primary arthrodesis group are generally equivalent to or better than those in the ORIF group for purely ligamentous injuries.

Question 4526

Topic: 8. Foot and Ankle

A 42-year-old recreational athlete presents with an acute, closed Achilles tendon rupture. He is evaluating the pros and cons of nonoperative management with a functional rehabilitation protocol versus primary surgical repair. Based on current Level I evidence, what is the most accurate statement regarding the comparison of these two treatment strategies?

. Nonoperative management has a significantly higher rerupture rate regardless of the rehabilitation protocol used.
. Surgical repair yields significantly greater peak plantar flexion strength at 2-year follow-up.
. Functional rehabilitation protocols result in rerupture rates comparable to surgical repair, while avoiding surgical wound complications.
. Surgical repair enables immediate full weight-bearing, which is contraindicated in nonoperative functional protocols.
. Nonoperative management increases the risk of deep vein thrombosis compared to surgical repair.

Correct Answer & Explanation

. Functional rehabilitation protocols result in rerupture rates comparable to surgical repair, while avoiding surgical wound complications.

Explanation

Historically, nonoperative treatment of Achilles tendon ruptures using prolonged rigid immobilization was associated with higher rerupture rates. However, modern Level I evidence (such as the study by Willits et al.) has shown that when an early functional rehabilitation protocol (early weight-bearing and early ROM in a brace) is utilized, the rerupture rates are statistically similar to those of surgical repair. Nonoperative management avoids the risks of surgical complications, particularly wound breakdown and infection, which are notable concerns in Achilles surgery.

Question 4527

Topic: 8. Foot and Ankle

A 58-year-old male with long-standing, poorly controlled type 2 diabetes presents with a unilaterally swollen, warm, and erythematous right foot and ankle. He denies any recent trauma or systemic symptoms such as fever. Pedal pulses are bounding. Plain radiographs show no fractures, dislocations, or destructive bone changes. Upon elevating the foot for 10 minutes, the erythema resolves completely. What is the most appropriate initial management?

. Urgent MRI to rule out osteomyelitis
. Empiric intravenous antibiotics and admission
. Total contact casting and strict non-weight bearing
. Arterial duplex ultrasound to assess for venous thrombosis
. Immediate operative debridement of the midfoot joints

Correct Answer & Explanation

. Total contact casting and strict non-weight bearing

Explanation

This patient presents with a classic Stage 0 (acute inflammatory) Charcot neuroarthropathy. The key clinical finding is a warm, red, swollen foot with normal plain radiographs, and erythema that resolves upon elevation. This elevation test distinguishes Charcot arthropathy from acute infection (cellulitis/osteomyelitis), where erythema typically persists despite elevation. The gold standard for initial management of acute Charcot is immediate offloading with total contact casting (TCC) and non-weight bearing to prevent progression to fragmentation and deformity (Stage 1).

Question 4528

Topic: 8. Foot and Ankle

A 60-year-old man undergoes surgical debridement of severe non-insertional Achilles tendinosis. Because more than 50% of the tendon requires excision, an augmentation using a flexor hallucis longus (FHL) tendon transfer is performed. Which of the following is a key biomechanical advantage of using the FHL for Achilles augmentation?

. Its line of pull exactly replicates the function of the tibialis posterior.
. It is an in-phase plantar flexor that fires simultaneously with the triceps surae.
. It has a larger physiological cross-sectional area than the soleus muscle.
. Harvesting the FHL causes no measurable decrease in hallux plantar flexion strength.
. It originates from the distal fibula, providing a shorter, more direct transfer vector.

Correct Answer & Explanation

. It is an in-phase plantar flexor that fires simultaneously with the triceps surae.

Explanation

The flexor hallucis longus (FHL) is the preferred tendon transfer for augmenting a compromised Achilles tendon because it is an 'in-phase' muscle, meaning it naturally fires during the same phase of the gait cycle (plantar flexion at push-off) as the triceps surae complex. It is also the second strongest plantar flexor of the foot (behind the triceps surae) and its axis of pull closely mimics that of the Achilles tendon. Although harvest does cause some measurable decrease in hallux push-off strength, the clinical deficit is usually well-tolerated.

Question 4529

Topic: 8. Foot and Ankle

A 24-year-old female presents with a rigid cavovarus foot deformity. Neurological workup confirms Charcot-Marie-Tooth disease. Which of the following muscle imbalances is the primary driver of the plantarflexed first ray in this patient's condition?

. Peroneus brevis overdriving peroneus longus
. Peroneus longus overdriving tibialis anterior
. Tibialis posterior overdriving peroneus brevis
. Extensor hallucis longus overdriving flexor hallucis longus
. Tibialis anterior overdriving Achilles tendon

Correct Answer & Explanation

. Tibialis posterior overdriving peroneus brevis

Explanation

In Charcot-Marie-Tooth (CMT) disease, the characteristic cavovarus deformity is driven by specific muscle imbalances. The tibialis anterior weakens early, while the peroneus longus is relatively spared. The strong peroneus longus pulls the first metatarsal into plantarflexion, creating a forefoot-driven cavus. Concurrently, the tibialis posterior overpowers the weakened peroneus brevis, leading to varus deformity of the hindfoot.

Question 4530

Topic: 8. Foot and Ankle

A 55-year-old male presents with progressive pain and stiffness in his right great toe. Examination reveals pain at the extremes of dorsiflexion, which is limited to 20 degrees. Radiographs demonstrate dorsal osteophytes and mild joint space narrowing (Coughlin and Shurnas Grade 2). Conservative measures, including rigid Morton extensions and NSAIDs, have failed. What is the most appropriate surgical intervention?

. First MTP arthrodesis
. Cheilectomy
. Silastic implant arthroplasty
. Keller arthroplasty
. First metatarsal osteotomy

Correct Answer & Explanation

. Cheilectomy

Explanation

For Coughlin and Shurnas Grade 1 and 2 hallux rigidus (mild to moderate joint space narrowing, dorsal osteophytes, and pain mainly at extremes of motion), cheilectomy is the surgical treatment of choice. Grade 3 (severe narrowing) and Grade 4 (pain in mid-range of motion) are best treated with arthrodesis.

Question 4531

Topic: Midfoot & Hindfoot
A 52-year-old female presents with a progressive flatfoot deformity. Examination shows a flexible hindfoot valgus and inability to perform a single-leg heel raise. Additionally, there is uncovering of the talonavicular joint (more than 40%) on AP weight-bearing radiographs, indicative of severe forefoot abduction. She has failed prolonged brace management. What combination of procedures is most appropriate?
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and lateral column lengthening
. Subtalar arthrodesis
. Triple arthrodesis
. Tibialis anterior transfer and medial cuneiform osteotomy

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible deformity with severe forefoot abduction (talonavicular uncoverage > 30-40%). Management typically involves a soft tissue transfer (FDL to navicular) to replace the diseased posterior tibial tendon, a medial displacement calcaneal osteotomy (MDCO) to correct hindfoot valgus, and a lateral column lengthening (e.g., Evans osteotomy) to correct the severe forefoot abduction. Stage IIa (minimal abduction) can often be treated with FDL transfer and MDCO alone. Rigid deformities (Stage III) require arthrodesis.

Question 4532

Topic: 8. Foot and Ankle

A 21-year-old collegiate basketball player undergoes intramedullary screw fixation for an acute Zone 2 fifth metatarsal base fracture (Jones fracture) to expedite return to play. Postoperatively, he complains of numbness along the lateral aspect of his foot. Which of the following anatomical structures was most likely injured during the surgical approach?

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

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve provides sensory innervation to the lateral aspect of the foot. Its lateral dorsal cutaneous branch is at significant risk during the approach for intramedullary screw fixation of the fifth metatarsal. Care must be taken to identify and protect this nerve when establishing the starting point for the guide wire and screw at the base of the fifth metatarsal.

Question 4533

Topic: 8. Foot and Ankle

A 30-year-old male sustains an ankle fracture-dislocation. Intraoperative stress testing after fixation of the fibula confirms syndesmotic instability. The surgeon opts for dynamic (suture-button) fixation rather than rigid screw fixation. According to current literature, what is the primary advantage of dynamic fixation over static screw fixation for syndesmotic injuries?

. Decreased risk of hardware-related complications and reoperation
. Improved immediate postoperative rigid stability
. Lower cost of implants
. Elimination of the need for concurrent fibular fracture fixation
. Increased incidence of spontaneous tibiofibular synostosis

Correct Answer & Explanation

. Decreased risk of hardware-related complications and reoperation

Explanation

Suture-button (dynamic) fixation allows for physiologic motion at the syndesmosis while maintaining reduction. Studies have shown it reduces hardware-related complications (such as screw breakage or loosening) and significantly lowers the need for routine hardware removal procedures compared to static screw fixation.

Question 4534

Topic: 8. Foot and Ankle

A 60-year-old diabetic patient presents with a warm, swollen, and erythematous right foot. He has a plantar ulcer under the first metatarsal head. Which of the following imaging modalities is the most sensitive and specific for differentiating acute Charcot neuroarthropathy from pedal osteomyelitis?

. Three-phase Technetium-99m bone scan
. Gallium-67 scan
. Indium-111 labeled leukocyte scan combined with Technetium-99m sulfur colloid marrow scan
. Non-contrast MRI of the foot
. Positron emission tomography (PET) scan

Correct Answer & Explanation

. Indium-111 labeled leukocyte scan combined with Technetium-99m sulfur colloid marrow scan

Explanation

Differentiating acute Charcot neuroarthropathy from osteomyelitis is clinically and radiographically challenging. While MRI is highly sensitive, its specificity is reduced in acute Charcot due to widespread marrow edema. A combined leukocyte-marrow scan (Indium-111 WBC combined with Tc-99m sulfur colloid marrow scan) is highly accurate. Osteomyelitis shows increased uptake on the WBC scan with corresponding decreased or normal uptake on the marrow scan (discordant). Charcot arthropathy shows congruent increased uptake on both scans (concordant).

Question 4535

Topic: 8. Foot and Ankle

A 45-year-old female runner complains of burning pain and tingling in the plantar aspect of her right foot that worsens with activity and at night. Examination reveals a positive Tinel's sign posterior to the medial malleolus. Compression of which of the following nerves within the fibro-osseous tunnel is responsible for her symptoms?

. Deep peroneal nerve
. Sural nerve
. Posterior tibial nerve
. Medial plantar nerve only
. Lateral plantar nerve only

Correct Answer & Explanation

. Posterior tibial nerve

Explanation

Tarsal tunnel syndrome is a compressive neuropathy of the posterior tibial nerve as it passes through the tarsal tunnel behind the medial malleolus, deep to the flexor retinaculum. The tunnel contains the tibialis posterior tendon, flexor digitorum longus tendon, posterior tibial artery and vein, posterior tibial nerve, and flexor hallucis longus tendon. Compression leads to sensory symptoms along the plantar foot in the distribution of the medial and lateral plantar nerves and calcaneal branches.

Question 4536

Topic: 8. Foot and Ankle

A 22-year-old female presents with a progressive, bilateral cavovarus foot deformity. She reports frequent ankle sprains and difficulty finding comfortable footwear. Neurological examination suggests a diagnosis of Charcot-Marie-Tooth disease. A Coleman block test is performed, and the hindfoot varus corrects to neutral when the first ray is allowed to drop off the block. Which of the following best describes the primary muscular imbalance responsible for the initial development of this deformity?

. Overactivity of the tibialis anterior relative to the peroneus longus
. Overactivity of the peroneus longus relative to the tibialis anterior
. Overactivity of the peroneus brevis relative to the tibialis posterior
. Overactivity of the gastrocnemius relative to the soleus
. Weakness of the flexor hallucis longus relative to the extensor hallucis longus

Correct Answer & Explanation

. Overactivity of the peroneus longus relative to the tibialis anterior

Explanation

In Charcot-Marie-Tooth (CMT) disease, the characteristic cavovarus deformity is primarily driven by muscle imbalances. The earliest and most prominent imbalance is the preservation or overactivity of the peroneus longus relative to a weakening tibialis anterior. The strong peroneus longus intensely plantarflexes the first ray, creating a rigid forefoot valgus. During stance, this plantarflexed first ray forces the hindfoot into a compensatory varus alignment (a forefoot-driven hindfoot varus). The Coleman block test demonstrates that the hindfoot is still flexible and corrects when the first ray's deforming force is eliminated. Other common imbalances in CMT include a strong tibialis posterior overpowering a weak peroneus brevis.

Question 4537

Topic: 8. Foot and Ankle

A 68-year-old male presents with severe, end-stage post-traumatic osteoarthritis of the right ankle. He is interested in joint preservation and inquires about a Total Ankle Arthroplasty (TAA) instead of an ankle arthrodesis. Which of the following conditions is considered an absolute contraindication to performing a primary Total Ankle Arthroplasty in this patient?

. Patient age greater than 65 years
. Body Mass Index (BMI) of 32 kg/m2
. Avascular necrosis involving 60% of the talar body
. Concomitant subtalar osteoarthritis
. Previous open reduction and internal fixation of a bimalleolar ankle fracture

Correct Answer & Explanation

. Avascular necrosis involving 60% of the talar body

Explanation

Total ankle arthroplasty (TAA) has specific indications and contraindications. Absolute contraindications include active infection, severe neuroarthropathy (Charcot), absent lower extremity sensation, inadequate soft-tissue envelope, severe peripheral vascular disease, and extensive avascular necrosis (AVN) of the talus (>50% of the talar body), as the talar component will lack sufficient viable bone for ingrowth and support, leading to early catastrophic failure. Age over 65 is actually an ideal indication for TAA over arthrodesis. Obesity (BMI >30), prior trauma, and adjacent joint arthritis (subtalar arthritis is actually a relative indication for TAA to preserve remaining hindfoot motion) are not absolute contraindications.

Question 4538

Topic: 8. Foot and Ankle

A 55-year-old woman returns to the clinic 8 months after undergoing a distal chevron osteotomy with a lateral soft-tissue release for a moderate hallux valgus deformity. She now complains of worsening medial forefoot pain and difficulty wearing enclosed shoes. Clinical examination reveals a first metatarsophalangeal (MTP) joint that is deviated medially, and she is unable to actively flex the MTP joint. Which of the following intraoperative technical errors is the most common cause of this specific postoperative complication?

. Inadequate lateral soft-tissue release
. Over-resection of the medial eminence combined with fibular sesamoidectomy
. Failure to perform an Akin osteotomy
. Plantar translation of the capital fragment
. Nonunion of the distal metatarsal osteotomy

Correct Answer & Explanation

. Over-resection of the medial eminence combined with fibular sesamoidectomy

Explanation

The patient has developed iatrogenic hallux varus, a dreaded complication of hallux valgus surgery characterized by medial deviation of the great toe. The most common cause is over-resection of the medial eminence (staking the metatarsal head), which removes the bony buttress for the proximal phalanx. This is frequently exacerbated by excessive lateral release, specifically the excision of the fibular sesamoid, or over-plication of the medial capsule. Inadequate lateral release would result in undercorrection or recurrence of hallux valgus, not hallux varus. Plantar translation or nonunion does not typically drive a coronal plane varus deformity.

Question 4539

Topic: 8. Foot and Ankle

A 25-year-old professional soccer player sustains an inversion and internal rotation injury to his ankle while pivoting. He has pain over the anterior aspect of the distal tibiofibular syndesmosis. Weight-bearing radiographs of the ankle reveal a normal mortise with no widening of the medial clear space. An MRI demonstrates a complete rupture of the anterior inferior tibiofibular ligament (AITFL) extending 4 cm proximally into the interosseous membrane. The deltoid ligament complex is intact. What is the most appropriate management for this player?

. Immediate operative stabilization with a flexible suture-button device
. Operative stabilization with two trans-syndesmotic cortical screws
. Non-weight-bearing in a short leg cast for 6 weeks
. Functional bracing with progressive weight-bearing as tolerated and physical therapy
. Open repair of the AITFL and interosseous membrane

Correct Answer & Explanation

. Functional bracing with progressive weight-bearing as tolerated and physical therapy

Explanation

This patient has an isolated, stable syndesmotic injury (high ankle sprain) without diastasis. The key finding is the intact deltoid ligament and normal weight-bearing radiographs. Isolated AITFL and interosseous membrane tears, without deep deltoid disruption or dynamic mortise widening, are biomechanically stable. The standard of care is non-operative management consisting of a short period of immobilization or functional bracing, progressive weight-bearing as tolerated, and aggressive physical therapy. Operative fixation is reserved for syndesmotic injuries with associated unstable fractures or frank diastasis (unstable syndesmosis, typically involving deltoid rupture or equivalent).

Question 4540

Topic: Midfoot & Hindfoot
A 60-year-old female presents with a progressive, painful flatfoot deformity. Clinical examination demonstrates a positive 'too many toes' sign, an inability to perform a single-limb heel rise, and a flexible hindfoot that corrects to neutral passively. Radiographs show significant collapse of the medial longitudinal arch and 45% lateral uncovering of the talonavicular joint on the AP view. What is the most appropriate surgical intervention for this specific stage of adult-acquired flatfoot deformity?
. Flexor digitorum longus (FDL) transfer to the navicular and gastrocnemius recession
. Medializing calcaneal osteotomy, lateral column lengthening, FDL transfer, and Achilles lengthening
. Triple arthrodesis
. Isolated talonavicular arthrodesis
. Subtalar arthrodesis and Spring ligament repair

Correct Answer & Explanation

. Medializing calcaneal osteotomy, lateral column lengthening, FDL transfer, and Achilles lengthening

Explanation

This patient presents with Stage IIb adult-acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage II signifies a flexible hindfoot deformity. Stage II is further subdivided: IIa has minimal forefoot abduction, while IIb has significant forefoot abduction (typically >30-40% talonavicular uncovering on AP radiographs). For Stage IIa, an FDL transfer + medializing calcaneal osteotomy (MCO) is often sufficient. For Stage IIb, the significant forefoot abduction requires addressing the lateral column; therefore, a lateral column lengthening (e.g., Evans osteotomy) is indicated in addition to the MCO, FDL transfer, and heel cord lengthening. Triple arthrodesis (Option C) is reserved for Stage III (rigid deformity).

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