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8. Foot and Ankle MCQs

Practice Set 229 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 4561

Topic: 8. Foot and Ankle

A 48-year-old warehouse worker sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs reveal a 4 mm diastasis between the first and second metatarsal bases without evidence of fracture. MRI confirms a complete tear of the Lisfranc ligament complex. Based on prospective randomized studies comparing operative treatments for purely ligamentous Lisfranc injuries, which of the following is the most significant advantage of primary arthrodesis over open reduction and internal fixation (ORIF)?

. Decreased rate of postoperative infection
. Lower rate of planned hardware removal and secondary revision procedures
. Greater preservation of midfoot motion during the gait cycle
. Shorter time to full weight-bearing
. Reduced risk of adjacent joint arthritis

Correct Answer & Explanation

. Lower rate of planned hardware removal and secondary revision procedures

Explanation

For purely ligamentous Lisfranc injuries, evidence (such as the landmark prospective trial by Ly and Coetzee) has demonstrated that primary arthrodesis yields superior functional outcomes and a lower rate of subsequent surgeries. ORIF typically mandates a second procedure for hardware removal and has a higher incidence of secondary post-traumatic arthritis requiring salvage arthrodesis compared to primary fusion.

Question 4562

Topic: 8. Foot and Ankle

A 55-year-old woman undergoes surgical reconstruction for Stage IIB adult acquired flatfoot deformity. The procedure includes a medializing calcaneal osteotomy, lateral column lengthening, flexor digitorum longus (FDL) transfer, and spring ligament repair. Following fixation of the hindfoot, intraoperative assessment using a simulated weight-bearing view reveals a residual forefoot varus with a clinically elevated first ray. Which of the following is the most appropriate next surgical step to achieve a plantigrade foot?

. Strayer procedure
. Calcaneocuboid joint arthrodesis
. Dorsal opening wedge medial cuneiform osteotomy (Cotton osteotomy)
. First metatarsophalangeal joint arthrodesis
. Proximal medial opening wedge first metatarsal osteotomy

Correct Answer & Explanation

. Dorsal opening wedge medial cuneiform osteotomy (Cotton osteotomy)

Explanation

In chronic adult acquired flatfoot deformity, the forefoot undergoes compensatory supinatus (varus) to maintain ground contact as the hindfoot falls into valgus. When the hindfoot valgus is surgically corrected, this forefoot deformity often persists as a fixed elevation of the first ray. A Cotton osteotomy (dorsal opening wedge of the medial cuneiform) plantarflexes the medial column, restoring the tripod effect and ensuring a plantigrade foot.

Question 4563

Topic: 8. Foot and Ankle

A 62-year-old man presents with debilitating end-stage ankle osteoarthritis. He has exhausted all non-operative management options and is inquiring about a total ankle arthroplasty (TAA). Which of the following patient factors is considered an absolute contraindication to TAA?

. Concomitant severe subtalar osteoarthritis
. Isolated anterior talofibular ligament insufficiency
. Body mass index of 32 kg/m2
. Charcot neuroarthropathy with loss of protective sensation
. A history of an open medial malleolus fracture treated 20 years ago without current signs of infection

Correct Answer & Explanation

. Charcot neuroarthropathy with loss of protective sensation

Explanation

Charcot neuroarthropathy with absent protective sensation is considered an absolute contraindication to total ankle arthroplasty due to poor bone stock and a prohibitively high risk of catastrophic implant failure, subsidence, and ulceration. Conversely, concomitant subtalar or transverse tarsal arthritis is widely considered an indication for TAA to preserve the remaining motion in the hindfoot.

Question 4564

Topic: 8. Foot and Ankle

A 32-year-old male sustains an acute, closed Achilles tendon rupture while playing tennis. He elects non-operative management. He is placed in a functional rehabilitation protocol incorporating early weight-bearing in a brace. According to current evidence-based literature, how do the outcomes of early functional rehabilitation compare to surgical repair for acute Achilles tendon ruptures?

. Surgical repair demonstrates a significantly lower re-rupture rate, but higher complication rates.
. Early functional rehabilitation results in identical strength profiles but a higher re-rupture rate.
. Early functional rehabilitation yields similar re-rupture rates to surgical repair, with a lower rate of soft-tissue complications.
. Surgical repair provides an earlier return to work but worse long-term functional scores.
. Early functional rehabilitation is associated with a higher incidence of deep vein thrombosis compared to surgical repair.

Correct Answer & Explanation

. Early functional rehabilitation yields similar re-rupture rates to surgical repair, with a lower rate of soft-tissue complications.

Explanation

Multiple high-level randomized controlled trials (such as Willits et al.) have demonstrated that non-operative treatment of acute Achilles tendon ruptures using an early functional rehabilitation protocol (incorporating early weight-bearing) achieves functional outcomes and re-rupture rates statistically equivalent to those of surgical repair. Furthermore, the non-operative group entirely avoids surgical complications, such as wound breakdown and sural nerve injury.

Question 4565

Topic: 8. Foot and Ankle

A 24-year-old male presents with bilateral cavovarus foot deformity and reports frequent ankle sprains. Examination shows a plantarflected first ray and weakness in certain muscle groups. In the pathogenesis of a cavovarus foot deformity in Charcot-Marie-Tooth disease, which muscle typically retains its strength and drives the initial plantar flexion of the first ray?

. Tibialis anterior
. Peroneus brevis
. Peroneus longus
. Extensor digitorum brevis
. Tibialis posterior

Correct Answer & Explanation

. Tibialis anterior

Explanation

In Charcot-Marie-Tooth (CMT) disease, there is a characteristic pattern of muscle weakness. The tibialis anterior and peroneus brevis typically weaken early. The peroneus longus and tibialis posterior maintain their strength longer. The relatively strong peroneus longus unopposed by the weak tibialis anterior leads to plantarflexion of the first ray, causing a forefoot-driven cavovarus deformity.

Question 4566

Topic: 8. Foot and Ankle

A 25-year-old athlete sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs show a 3 mm diastasis between the base of the first and second metatarsals. He is diagnosed with a purely ligamentous Lisfranc injury. Which of the following surgical interventions has been shown to result in better functional outcomes and lower rates of hardware removal for a purely ligamentous Lisfranc injury?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation (ORIF) with transarticular screws
. Open reduction and internal fixation (ORIF) with dorsal bridge plating
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Rigid cast immobilization for 8 weeks

Correct Answer & Explanation

. Primary arthrodesis of the first, second, and third tarsometatarsal joints

Explanation

Studies (such as those by Ly and Coetzee) have shown that for purely ligamentous Lisfranc injuries, primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) results in superior functional outcomes, less need for subsequent hardware removal, and a lower rate of secondary procedures compared to ORIF.

Question 4567

Topic: Forefoot

A 55-year-old female presents with severe pain and stiffness in her first metatarsophalangeal (MTP) joint. Radiographs demonstrate marked dorsal osteophytes, total loss of joint space, and subchondral sclerosis consistent with Coughlin and Shurnas Grade 3 hallux rigidus. Conservative measures have failed. Which of the following surgical procedures is considered the gold standard for long-term pain relief and functional improvement?

. Cheilectomy
. First MTP joint arthrodesis
. First MTP joint total arthroplasty
. Keller resection arthroplasty
. Proximal phalanx osteotomy (Moberg)

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

For advanced hallux rigidus (Coughlin and Shurnas Grade 3 or 4), arthrodesis of the first MTP joint remains the gold standard. It provides excellent long-term pain relief, functional stability, and high patient satisfaction rates. Cheilectomy is generally reserved for Grades 1 and 2 where the joint space is relatively preserved.

Question 4568

Topic: 8. Foot and Ankle

A 45-year-old avid runner presents with posterior heel pain. MRI shows insertional Achilles tendinosis with retrocalcaneal bursitis and a Haglund's deformity. She has failed 6 months of nonoperative management. If surgical intervention is planned, what percentage of the Achilles tendon insertion can typically be detached without requiring augmentation?

. Up to 10%
. Up to 25%
. Up to 50%
. Up to 75%
. 100%

Correct Answer & Explanation

. Up to 50%

Explanation

During surgical debridement of insertional Achilles tendinopathy and excision of a Haglund's deformity, it is often necessary to detach a portion of the Achilles tendon. Biomechanical studies have shown that up to 50% of the tendon's insertion can be detached without a significant risk of avulsion or need for primary augmentation. Detachment greater than 50% generally warrants suture anchor repair or FHL transfer.

Question 4569

Topic: Midfoot & Hindfoot
A 30-year-old male is involved in a high-speed motor vehicle collision and sustains a talar neck fracture with subluxation of the subtalar joint and complete dislocation of the tibiotalar joint. The talonavicular joint remains anatomically reduced. According to the Hawkins classification, what type of fracture is this, and what is the approximate risk of avascular necrosis (AVN) of the talar body?
. Type I; 0-10% risk of AVN
. Type II; 20-50% risk of AVN
. Type III; >75% risk of AVN
. Type IV; 100% risk of AVN
. Type II; >75% risk of AVN

Correct Answer & Explanation

. Type II; 20-50% risk of AVN

Explanation

The Hawkins classification describes talar neck fractures: Type I is non-displaced (0-10% AVN risk). Type II is a talar neck fracture with subtalar dislocation or subluxation (20-50% AVN risk). Type III involves subtalar and tibiotalar dislocation (>75% AVN risk, sometimes quoted as 75-90% in modern series). Type IV involves subtalar, tibiotalar, and talonavicular dislocation.

Question 4570

Topic: 8. Foot and Ankle

A 42-year-old construction worker falls from a ladder, sustaining a joint-depressed, intra-articular calcaneus fracture. During an extensile lateral approach for open reduction and internal fixation (ORIF), the surgeon must carefully plan the incision to avoid a nerve that crosses the lateral hindfoot. Which of the following structures is most at risk during flap elevation?

. Tibial nerve
. Sural nerve
. Superficial peroneal nerve
. Posterior tibial artery
. Medial calcaneal nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The extensile lateral approach for calcaneus ORIF involves creating a full-thickness subperiosteal flap. The sural nerve crosses the lateral aspect of the hindfoot and is at significant risk of transection or stretch injury during the incision and retraction. The vertical limb is placed just anterior to the Achilles tendon and the horizontal limb in the transition zone between the plantar and lateral skin to safely mobilize the sural nerve within the flap.

Question 4571

Topic: 8. Foot and Ankle

A 24-year-old male presents with a long-standing history of frequent ankle sprains and progressive foot deformity. Clinical examination reveals a cavovarus foot posture with a positive "peek-a-boo" heel sign. During the Coleman block test, the hindfoot varus corrects completely to neutral. Based on this physical examination finding, which of the following surgical interventions is most appropriate?

. Triple arthrodesis
. Dwyer calcaneal osteotomy and lateralizing calcaneal osteotomy
. Dorsiflexion osteotomy of the first metatarsal and peroneus longus to peroneus brevis transfer
. Tibiotalocalcaneal arthrodesis
. Medial displacement calcaneal osteotomy and flexor digitorum longus transfer

Correct Answer & Explanation

. Dorsiflexion osteotomy of the first metatarsal and peroneus longus to peroneus brevis transfer

Explanation

The Coleman block test is utilized to evaluate hindfoot flexibility in a cavovarus foot deformity. If the hindfoot varus corrects when the first ray is dropped off a block (neutralizing the plantarflexed first ray), the deformity is forefoot-driven, and the hindfoot is flexible. Therefore, joint-sparing, forefoot-correcting procedures (e.g., 1st metatarsal dorsiflexion osteotomy) and tendon transfers (peroneus longus to peroneus brevis to decrease plantarflexion force on the 1st ray) are appropriate. If the hindfoot does not correct, the deformity is rigid, necessitating a calcaneal osteotomy or arthrodesis.

Question 4572

Topic: 8. Foot and Ankle

A 45-year-old female undergoes a modified Lapidus procedure (first tarsometatarsal arthrodesis) for a severe hallux valgus deformity. Three months postoperatively, she returns complaining of a new, severe plantar foot pain directly beneath the second metatarsal head. Which of the following technical errors during the index procedure is the most likely cause of her new symptom?

. Dorsal elevation of the first metatarsal
. Excessive plantarflexion of the first metatarsal
. Over-tightening of the medial capsulorrhaphy
. Inadequate lateral soft tissue release
. Over-lengthening of the first metatarsal

Correct Answer & Explanation

. Dorsal elevation of the first metatarsal

Explanation

Transfer metatarsalgia following a Lapidus procedure is most commonly caused by dorsal elevation (malunion) or excessive shortening of the first metatarsal. Dorsal elevation unloads the first ray during the stance phase of gait, transferring disproportionate weight-bearing stress to the lesser metatarsals, typically the second metatarsal head. Excessive plantarflexion would instead lead to primary sesamoiditis or an intractable plantar keratosis under the first metatarsal head.

Question 4573

Topic: 8. Foot and Ankle
A 32-year-old male sustains a closed talar neck fracture following a motor vehicle collision. Radiographs demonstrate a displaced fracture of the talar neck with posterior displacement of the talar body, which is extruded from both the subtalar and tibiotalar joints. The talonavicular joint remains reduced. Which of the following vessels provides the primary blood supply to the talar body and is at highest risk of catastrophic disruption in this specific fracture pattern?
. Artery of the tarsal sinus
. Artery of the tarsal canal
. Dorsalis pedis artery
. Deltoid branches of the posterior tibial artery
. Perforating peroneal artery

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

This patient has a Hawkins Type III talar neck fracture (subtalar and tibiotalar dislocation). The primary blood supply to the talar body is the artery of the tarsal canal, which is a branch of the posterior tibial artery. While the artery of the tarsal sinus supplies the head and neck, and deltoid branches supply the medial body, the artery of the tarsal canal is the most critical source for the body. A Hawkins III fracture disrupts nearly all vascular sources, most importantly the artery of the tarsal canal, leading to an avascular necrosis (AVN) rate traditionally reported to approach 75-100%.

Question 4574

Topic: 8. Foot and Ankle
A 55-year-old female presents with medial ankle pain and a progressive flatfoot deformity. Examination demonstrates a flexible hindfoot valgus and inability to perform a single-leg heel raise. Weight-bearing radiographs reveal greater than 40% talonavicular uncoverage and significant forefoot abduction. In addition to a flexor digitorum longus (FDL) to navicular transfer and medializing calcaneal osteotomy, which of the following procedures is indicated to adequately correct her deformity?
. Evans calcaneal osteotomy
. Naviculocuneiform arthrodesis
. Triple arthrodesis
. Kidner procedure
. First metatarsocuneiform arthrodesis

Correct Answer & Explanation

. Evans calcaneal osteotomy

Explanation

The patient presents with Stage IIb adult-acquired flatfoot deformity (flexible deformity with significant forefoot abduction characterized by >40% talonavicular uncoverage). Surgical reconstruction for Stage IIb requires restoring the medial column (FDL transfer) and correcting the hindfoot/midfoot deformity. A medializing calcaneal osteotomy corrects hindfoot valgus, but a lateral column lengthening (Evans calcaneal osteotomy or calcaneocuboid distraction arthrodesis) is specifically indicated to correct the substantial forefoot abduction. A triple arthrodesis is a joint-sacrificing procedure generally reserved for Stage III (rigid) deformities.

Question 4575

Topic: 8. Foot and Ankle

A 22-year-old collegiate football player sustains an axial loading injury to his plantarflexed foot. Weight-bearing radiographs demonstrate subtle widening of the interval between the first and second metatarsal bases, and a "fleck sign" is noted in this space. The ligament represented by this bony avulsion normally originates from which of the following bony structures?

. Base of the first metatarsal
. Medial cuneiform
. Intermediate cuneiform
. Lateral cuneiform
. Base of the second metatarsal

Correct Answer & Explanation

. Base of the second metatarsal

Explanation

The "fleck sign" is highly specific for a Lisfranc injury and represents a bony avulsion of the Lisfranc ligament. The Lisfranc ligament is an oblique, stout ligament that originates from the lateral aspect of the medial cuneiform and inserts onto the medial base of the second metatarsal. It acts as the primary stabilizer between the first and second rays, given the absence of a direct transverse intermetatarsal ligament between the bases of the first and second metatarsals.

Question 4576

Topic: 8. Foot and Ankle

A 60-year-old male with long-standing, poorly controlled type 2 diabetes presents with a red, hot, swollen right foot. He denies any recent trauma, fever, or open ulcerations. Laboratory studies reveal a normal white blood cell count and a mildly elevated CRP. Radiographs show extensive periarticular fragmentation, subluxation of the tarsometatarsal joints, and bony debris, without definitive signs of osteomyelitis. What is the most appropriate initial management for this condition?

. Intravenous antibiotics and emergent surgical debridement
. Total contact casting and strict non-weight-bearing
. Midfoot arthrodesis with rigid internal fixation
. Accommodative shoe wear and custom orthotics
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The patient is presenting with acute Charcot neuroarthropathy, specifically Eichenholtz Stage I (Developmental/Fragmentation phase), which is characterized by a red, hot, swollen foot and radiographically by bone fragmentation, joint subluxation, and debris. In the absence of an open ulcer, this is an inflammatory rather than an infectious process. The gold standard for initial treatment is immobilization with a total contact cast (TCC) and strict non-weight-bearing to arrest the acute inflammatory phase, prevent further progressive deformity, and allow progression to the coalescence phase.

Question 4577

Topic: 8. Foot and Ankle

A 40-year-old roofer falls from a ladder and sustains a displaced intra-articular Sanders Type IIB calcaneus fracture. He is indicated for open reduction and internal fixation via an extensile lateral approach. Which of the following neurovascular structures is at the highest risk of iatrogenic injury during the creation of the full-thickness soft tissue flap, particularly at the superior and anterior aspect of the vertical limb?

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

Correct Answer & Explanation

. Sural nerve

Explanation

The extensile lateral approach to the calcaneus requires elevating a full-thickness subperiosteal "no-touch" flap to minimize the risk of wound necrosis. The sural nerve courses posterior and inferior to the lateral malleolus and provides sensation to the lateral border of the foot. It is highly susceptible to injury or retraction neuropraxia during the vertical limb and corner creation of the extensile lateral incision. The primary vascular supply to this flap is the lateral calcaneal artery.

Question 4578

Topic: 8. Foot and Ankle

A 38-year-old recreational athlete sustains an acute, closed mid-substance Achilles tendon rupture. After discussing treatment options with his orthopedic surgeon, he elects for non-operative management utilizing an early functional rehabilitation protocol. Compared to open surgical repair, which of the following clinical outcomes is most strongly supported by current Level I evidence for this patient?

. Significantly higher risk of deep vein thrombosis (DVT)
. Significantly higher Achilles tendon rerupture rate
. Equivalent rerupture rate but higher risk of sural nerve injury
. Equivalent rerupture rate and decreased risk of soft tissue complications
. Superior plantarflexion strength at 1-year follow-up

Correct Answer & Explanation

. Equivalent rerupture rate and decreased risk of soft tissue complications

Explanation

Multiple Level I studies, including the landmark randomized controlled trial by Willits et al., have demonstrated that when an early functional rehabilitation protocol (weight-bearing and early ROM in a controlled brace) is strictly utilized for acute Achilles tendon ruptures, the rerupture rates between non-operative and operative management are not statistically different. However, non-operative management avoids the inherent surgical risks, thereby demonstrating a significantly decreased rate of soft-tissue complications, infections, and sural nerve injuries.

Question 4579

Topic: 8. Foot and Ankle

A 26-year-old female presents with an external rotation injury to her right ankle. Weight-bearing radiographs show no fracture, but there is an isolated widening of the medial clear space to 6 mm. An MRI confirms an acute syndesmotic rupture. On a standard radiographic ankle series, which of the following parameters is considered the most reliable indicator of a normal distal tibiofibular syndesmosis?

. Tibiofibular clear space < 6 mm measured 1 cm proximal to the plafond on both AP and mortise views
. Tibiofibular overlap > 10 mm on the mortise view
. Medial clear space equal to the superior clear space on the AP view
. Tibiofibular overlap > 1 mm on the AP view
. Shenton's line of the ankle remaining intact on the mortise view

Correct Answer & Explanation

. Tibiofibular clear space < 6 mm measured 1 cm proximal to the plafond on both AP and mortise views

Explanation

The tibiofibular clear space is the most reliable radiographic parameter for evaluating the syndesmosis because it is the least affected by the rotational position of the foot during the radiograph. It is measured 1 cm proximal to the tibial plafond and should be less than 6 mm on both the AP and mortise views. Tibiofibular overlap is highly dependent on rotation and thus less reliable. While medial clear space widening indicates deltoid insufficiency and lateral talar shift (often seen in syndesmotic injuries), the tibiofibular clear space is the direct measure of syndesmotic integrity.

Question 4580

Topic: Midfoot & Hindfoot
A 55-year-old female presents with medial foot pain and a progressive flatfoot deformity. Examination shows a flexible hindfoot valgus and inability to perform a single-leg heel raise. Weight-bearing radiographs demonstrate >40% uncovering of the talonavicular joint. If conservative management fails, which of the following surgical interventions is most appropriate?
. Flexor digitorum longus (FDL) transfer to the navicular alone
. FDL transfer, medial displacement calcaneal osteotomy (MDCO), and lateral column lengthening
. Primary triple arthrodesis
. Isolated subtalar arthrodesis
. Gastrocnemius recession alone

Correct Answer & Explanation

. FDL transfer, medial displacement calcaneal osteotomy (MDCO), and lateral column lengthening

Explanation

The patient has Stage IIb adult acquired flatfoot deformity (posterior tibial tendon dysfunction), characterized by a flexible hindfoot valgus and forefoot abduction (>40% talonavicular uncoverage). Surgical correction requires addressing both the medial column weakness and the biomechanical deformity. An FDL transfer addresses the tendon deficiency, an MDCO corrects the hindfoot valgus, and a lateral column lengthening corrects the severe forefoot abduction.

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