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8. Foot and Ankle MCQs

Practice Set 232 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 4621

Topic: 8. Foot and Ankle

A 24-year-old rugby player sustains an axial load injury to a plantarflexed foot. Weight-bearing radiographs reveal 2.5 mm of diastasis between the bases of the first and second metatarsals. What is the precise anatomic origin and insertion of the primary ligamentous structure disrupted in this injury?

. Medial cuneiform to the base of the first metatarsal
. Intermediate cuneiform to the base of the second metatarsal
. Medial cuneiform to the base of the second metatarsal
. Lateral cuneiform to the base of the third metatarsal
. Navicular to the base of the second metatarsal

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is the largest and most important of the interosseous ligaments stabilizing the tarsometatarsal joint complex. It originates from the lateral aspect of the medial cuneiform and inserts onto the medial aspect of the base of the second metatarsal. This ligament provides crucial stability to the midfoot arch, and its disruption leads to diastasis between the first and second rays, hallmark findings of a Lisfranc injury.

Question 4622

Topic: 8. Foot and Ankle

During a reconstructive procedure for a flexible stage II adult acquired flatfoot deformity (posterior tibial tendon dysfunction), the surgeon evaluates the primary static stabilizer of the talonavicular joint. Attenuation of this structure is a major contributor to the classic 'too many toes' sign. What is the most critical anatomical component of this stabilizing complex?

. Plantar fascia
. Superomedial calcaneonavicular ligament
. Bifurcate ligament
. Inferior extensor retinaculum
. Long plantar ligament

Correct Answer & Explanation

. Superomedial calcaneonavicular ligament

Explanation

The spring ligament complex, specifically the superomedial calcaneonavicular ligament, is the primary static stabilizer of the talonavicular joint and provides crucial support to the medial longitudinal arch. In adult acquired flatfoot deformity, failure of the posterior tibial tendon places increased stress on the spring ligament complex, leading to its attenuation and eventual failure. This results in talonavicular subluxation, plantarflexion of the talus, and the abductoplanovalgus deformity clinically recognized by the 'too many toes' sign.

Question 4623

Topic: 8. Foot and Ankle
A 55-year-old female presents with medial ankle pain and progressive flattening of the foot. On examination, she is unable to perform a single heel raise on the affected side. Her hindfoot is in valgus but is passively correctable. Radiographs demonstrate uncovering of the talonavicular joint (30%) but no arthritic changes. Which of the following is the most appropriate surgical management if conservative treatment fails?
. Isolated subtalar arthrodesis
. Talonavicular arthrodesis
. Flexor digitorum longus (FDL) transfer to the navicular with a medial displacement calcaneal osteotomy
. Triple arthrodesis
. Spring ligament reconstruction alone

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer to the navicular with a medial displacement calcaneal osteotomy

Explanation

This patient has Stage II posterior tibial tendon dysfunction (flexible flatfoot, inability to perform a single heel raise, correctable deformity, and no arthritis). The gold standard surgical management for Stage II involves a joint-sparing procedure such as an FDL transfer (tendon substitution) and a medial displacement calcaneal osteotomy (bony realignment). Triple arthrodesis is reserved for Stage III (rigid/fixed deformity) or when clinically significant arthritis is present.

Question 4624

Topic: 8. Foot and Ankle
A 32-year-old male sustains a high-impact motor vehicle accident and presents with a Hawkins Type III talar neck fracture. Which of the following best describes the disruption of the blood supply to the talus and the associated expected rate of avascular necrosis (AVN)?
. Disruption of the artery of the tarsal canal only; 10-20% AVN risk
. Disruption of the artery of the tarsal canal and branches of the dorsalis pedis; 30-50% AVN risk
. Disruption of the artery of the tarsal canal, artery of the tarsal sinus, and deltoid branches; approaching 100% AVN risk
. Disruption of the anterior tibial artery branches only; 20-30% AVN risk
. Disruption of the peroneal artery branches; approaching 100% AVN risk

Correct Answer & Explanation

. Disruption of the artery of the tarsal canal, artery of the tarsal sinus, and deltoid branches; approaching 100% AVN risk

Explanation

A Hawkins Type III talar neck fracture involves displacement of the talar body from both the subtalar and tibiotalar joints. This results in the disruption of all three major sources of blood supply to the talar body: the artery of the tarsal canal (from the posterior tibial artery), the artery of the tarsal sinus (from branches of the anterior tibial and peroneal arteries), and the deltoid branches. The risk of avascular necrosis (AVN) is historically reported to be extremely high, approaching 100%.

Question 4625

Topic: Forefoot

A 45-year-old female undergoes a proximal crescentic osteotomy and distal soft tissue realignment for severe hallux valgus. Six months postoperatively, she complains of medial forefoot pain and difficulty wearing shoes. Examination reveals the great toe is deviated medially, and weight-bearing radiographs show a negative hallux valgus angle. Which of the following intraoperative maneuvers most likely contributed to this complication?

. Excessive lateral translation of the capital fragment
. Inadequate release of the adductor hallucis
. Over-tightening of the medial capsule and excessive resection of the medial eminence
. Under-correction of the intermetatarsal angle
. Failure to perform an Akin osteotomy

Correct Answer & Explanation

. Over-tightening of the medial capsule and excessive resection of the medial eminence

Explanation

The complication described is iatrogenic hallux varus (medial deviation of the great toe following hallux valgus surgery). The most common intraoperative causes include excessive resection of the medial eminence ('staking the metatarsal head'), over-tightening of the medial joint capsule, and excessive release of the lateral structures (lateral collateral ligament and adductor hallucis) combined with over-correction of the intermetatarsal angle.

Question 4626

Topic: 8. Foot and Ankle

A 35-year-old construction worker sustains an axial load to a plantarflexed foot. Weight-bearing radiographs show a 4mm gap between the 1st and 2nd metatarsal bases with no associated fractures. When comparing open reduction and internal fixation (ORIF) to primary arthrodesis for this specific injury pattern, primary arthrodesis is associated with:

. A higher rate of hardware-related complications
. A lower rate of unplanned secondary surgeries
. A significant decrease in functional AOFAS scores
. A higher nonunion rate
. A faster return to high-impact activities

Correct Answer & Explanation

. A lower rate of unplanned secondary surgeries

Explanation

This is a purely ligamentous Lisfranc injury. Prospective randomized trials (e.g., Ly and Coetzee, JBJS 2006) have demonstrated that for purely ligamentous Lisfranc injuries, primary arthrodesis yields superior functional outcomes and a significantly lower rate of unplanned secondary surgeries (such as hardware removal and salvage arthrodesis for post-traumatic arthritis) compared to standard ORIF.

Question 4627

Topic: 8. Foot and Ankle

A 42-year-old male presents with a palpable gap in his Achilles tendon 4 cm proximal to its insertion after feeling a 'pop' while playing basketball. He opts for non-operative management. Which of the following rehabilitation protocols has been shown to produce functional outcomes and re-rupture rates most comparable to operative management?

. Serial casting in equinus for 12 weeks with strict non-weight bearing
. Early functional rehabilitation with immediate weight-bearing in a functional orthosis
. Immobilization in a neutral position for 6 weeks followed by physical therapy
. Non-weight bearing in a boot for 8 weeks followed by eccentric stretching
. Cast immobilization in maximum dorsiflexion to approximate the tendon ends

Correct Answer & Explanation

. Early functional rehabilitation with immediate weight-bearing in a functional orthosis

Explanation

Recent high-level evidence has demonstrated that non-operative management with an early functional rehabilitation protocol (early weight-bearing in a functional orthosis/boot with heel lifts and early range of motion) results in clinical outcomes and re-rupture rates that are not significantly different from operative management. This approach avoids surgical complications such as wound breakdown and nerve injury.

Question 4628

Topic: 8. Foot and Ankle
A 58-year-old male with poorly controlled type 2 diabetes presents with a swollen, warm, erythematous, and painless left foot. He has no fevers. Radiographs show fragmentation of the midfoot with subluxation of the tarsometatarsal joints, but no distinct osteomyelitis. In this acute phase (Eichenholtz stage I), what is the most appropriate initial management?
. Urgent surgical debridement and internal fixation
. Total contact casting and strict offloading
. Primary midfoot arthrodesis
. Intravenous antibiotics for 6 weeks
. Custom accommodating shoe wear

Correct Answer & Explanation

. Total contact casting and strict offloading

Explanation

The patient presents with acute Charcot neuroarthropathy (Eichenholtz Stage I: fragmentation phase characterized by erythema, edema, heat, joint subluxation, and bony fragmentation). The mainstay of treatment in the acute phase is strict immobilization and offloading, most effectively achieved with a total contact cast (TCC), to prevent further deformity while the bones coalesce (Stage II) and consolidate (Stage III). Surgery in the acute phase is generally contraindicated due to the high risk of hardware failure in hyperemic, osteopenic bone.

Question 4629

Topic: 8. Foot and Ankle

A 38-year-old roofer falls 15 feet, sustaining a closed, displaced, intra-articular calcaneus fracture (Sanders type II). He is scheduled for open reduction and internal fixation via an extensile lateral approach. To minimize the risk of wound healing complications and skin flap necrosis, which of the following principles should be strictly adhered to during the surgical approach?

. Developing a full-thickness subperiosteal flap without utilizing a 'no-touch' retractor technique
. Incorporating the sural nerve within the flap to maintain its vascular supply
. Performing the surgery within the first 24 hours regardless of soft tissue swelling
. Creating a full-thickness subperiosteal flap incorporating the peroneal tendons and utilizing K-wires for 'no-touch' retraction
. Using multiple small superficial retractors on the skin edges to maximize visualization

Correct Answer & Explanation

. Creating a full-thickness subperiosteal flap incorporating the peroneal tendons and utilizing K-wires for 'no-touch' retraction

Explanation

The extensile lateral approach to the calcaneus carries a significant risk of wound complications. To minimize this risk, the flap must be elevated as a single, full-thickness subperiosteal layer containing the sural nerve, peroneal tendons, and calcaneofibular ligament. 'No-touch' retraction should be employed, typically by placing K-wires into the talus and cuboid to hold the flap open, avoiding the use of hand-held or self-retaining retractors on the skin edges which cause pressure necrosis.

Question 4630

Topic: Midfoot & Hindfoot
A 55-year-old female presents with progressive medial foot pain and a flatfoot deformity. Clinical examination reveals a flexible pes planovalgus deformity, an inability to perform a single heel rise, and tenderness directly along the course of the posterior tibial tendon. Radiographs show a talonavicular uncoverage angle of 20 degrees. Following a failed 6-month trial of conservative management with customized orthotics and physical therapy, which of the following is the most appropriate surgical intervention?
. Flexor digitorum longus (FDL) transfer to the navicular, medial displacement calcaneal osteotomy, and gastrocnemius recession
. Subtalar arthrodesis with isolated posterior tibial tendon debridement
. Triple arthrodesis (subtalar, talonavicular, and calcaneocuboid)
. Isolated naviculocuneiform arthrodesis
. Tenodesis of the posterior tibial tendon to the flexor hallucis longus (FHL) tendon

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer to the navicular, medial displacement calcaneal osteotomy, and gastrocnemius recession

Explanation

This patient presents with Stage II posterior tibial tendon dysfunction (PTTD), characterized by a flexible flatfoot deformity and the inability to perform a single heel rise. When conservative management fails, joint-sparing flatfoot reconstruction is indicated. The standard of care includes soft tissue reconstruction (FDL transfer to the navicular to replace the incompetent PTT) combined with bony procedures to correct the deformity (medial displacement calcaneal osteotomy) and addressing equinus contracture (gastrocnemius recession or Achilles tendon lengthening). Triple arthrodesis is reserved for rigid deformities (Stage III) or significant arthritic changes.

Question 4631

Topic: 8. Foot and Ankle

A 42-year-old man undergoes minimally invasive, percutaneous repair of an acute midsubstance Achilles tendon rupture. Postoperatively, he complains of new-onset numbness and tingling over the lateral aspect of his heel and the lateral border of his foot. Iatrogenic injury to which of the following anatomic structures is the most likely cause of his symptoms?

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

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve provides sensation to the lateral aspect of the heel and the lateral border of the foot. It typically courses from midline to lateral, crossing lateral to the Achilles tendon in the distal third of the leg. The nerve is at significant risk of iatrogenic injury or entrapment during percutaneous or minimally invasive Achilles tendon repairs, particularly during the passage of lateral sutures. The saphenous nerve supplies the medial aspect of the leg and ankle. The superficial peroneal nerve supplies the dorsum of the foot. The medial calcaneal nerve supplies the medial heel.

Question 4632

Topic: 8. Foot and Ankle

A 25-year-old professional rugby player sustains an axial load to a plantarflexed foot. Weight-bearing radiographs and a subsequent MRI confirm an isolated, complete rupture of the primary stabilizing ligament of the Lisfranc complex without associated fractures. This primary stabilizing interosseous ligament anatomically connects which of the following two osseous structures?

. Medial aspect of the medial cuneiform and the base of the first metatarsal
. Lateral aspect of the medial cuneiform and the medial aspect of the base of the second metatarsal
. Medial aspect of the middle cuneiform and the medial aspect of the base of the second metatarsal
. Lateral aspect of the lateral cuneiform and the medial aspect of the base of the third metatarsal
. Anterior aspect of the cuboid and the base of the fourth metatarsal

Correct Answer & Explanation

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

Explanation

The Lisfranc ligament is an oblique interosseous ligament that originates from the lateral aspect of the medial cuneiform and inserts onto the medial aspect of the base of the second metatarsal. It is the strongest and most critical ligament for maintaining the stability of the tarsometatarsal (Lisfranc) complex. Note that there is no intermetatarsal ligament connecting the bases of the first and second metatarsals, making this articulation highly dependent on the Lisfranc ligament.

Question 4633

Topic: Midfoot & Hindfoot
A 30-year-old male is brought to the trauma bay following a high-speed motorcycle collision. Plain radiographs reveal a displaced fracture of the talar neck with complete dislocation of both the subtalar and tibiotalar joints. According to the Hawkins classification, what is the grade of this injury and its historically associated risk of avascular necrosis (AVN) of the talar body?
. Hawkins Type I; 0-10% risk of AVN
. Hawkins Type II; 20-50% risk of AVN
. Hawkins Type III; near 100% risk of AVN
. Hawkins Type IV; 20-50% risk of AVN
. Hawkins Type I; near 100% risk of AVN

Correct Answer & Explanation

. Hawkins Type III; near 100% risk of AVN

Explanation

The Hawkins classification is used for talar neck fractures and predicts the risk of avascular necrosis (AVN). Type I is non-displaced (0-10% AVN). Type II involves subtalar subluxation or dislocation (20-50% AVN). Type III involves dislocation of both the subtalar and tibiotalar joints, historically carrying an AVN rate approaching 100%, though modern fixation techniques have slightly reduced this. Type IV (added by Canale and Kelly) includes subtalar, tibiotalar, and talonavicular dislocation.

Question 4634

Topic: Forefoot

A 60-year-old female presents with a painful bunion that restricts her shoe wear. Clinical examination reveals hypermobility of the first tarsometatarsal (TMT) joint. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 42 degrees and an intermetatarsal angle (IMA) of 18 degrees. Based on these findings, which of the following surgical procedures is most indicated to minimize the risk of recurrence?

. Distal soft tissue reconstruction (modified McBride procedure)
. Distal metatarsal chevron osteotomy
. Proximal metatarsal opening wedge osteotomy without TMT arthrodesis
. First tarsometatarsal joint arthrodesis (Lapidus procedure)
. First metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. First tarsometatarsal joint arthrodesis (Lapidus procedure)

Explanation

The patient has a severe hallux valgus deformity (HVA > 40 degrees, IMA > 13 degrees) complicated by clinically demonstrable hypermobility of the first ray (first TMT joint). The Lapidus procedure (first TMT joint arthrodesis) is the most appropriate procedure as it provides powerful correction for large intermetatarsal angles and inherently addresses the hypermobility of the first ray, significantly lowering the risk of recurrence. Distal or proximal osteotomies alone do not stabilize the hypermobile first TMT joint.

Question 4635

Topic: 8. Foot and Ankle
A 45-year-old construction worker falls from a ladder and sustains a displaced, intra-articular calcaneal fracture (Sanders Type III). The surgeon plans for an open reduction and internal fixation via an extensile lateral approach. To critically minimize the risk of wound edge necrosis and postoperative wound complications, which of the following techniques must be employed during the surgical exposure?
. Placing the vertical limb of the incision directly posterior to the Achilles tendon
. Elevating the soft tissue as a full-thickness, subperiosteal 'no-touch' flap
. Dissecting sharply through the subcutaneous fat to identify and retract the sural nerve outside the flap
. Elevating the peroneal tendons independently from the cutaneous flap
. Delaying surgery until 6 weeks post-injury to ensure complete resolution of edema

Correct Answer & Explanation

. Elevating the soft tissue as a full-thickness, subperiosteal 'no-touch' flap

Explanation

The extensile lateral approach to the calcaneus is notorious for high rates of wound breakdown and infection. To mitigate this risk, the surgeon must create a full-thickness, subperiosteal flap that includes the periosteum, peroneal tendons, and sural nerve within the flap. This 'no-touch' technique preserves the delicate microvascular supply to the corner of the L-shaped flap, primarily fed by the lateral calcaneal artery. Dissecting through subcutaneous tissue or separating the tendons/nerve compromises this blood supply.

Question 4636

Topic: 8. Foot and Ankle

During the operative fixation of an unstable pronation-external rotation (PER) ankle fracture, the surgeon completes rigid fixation of the medial and lateral malleoli. Suspecting an associated syndesmotic injury, the surgeon performs the intraoperative 'Cotton test'. Which of the following best describes the execution of this test?

. Applying an external rotation force to the foot while monitoring the deltoid ligament tension
. Applying a lateral and posterior traction force to the fibula using a bone hook while observing the tibiofibular clear space under fluoroscopy
. Applying an anterior translation force to the talus to assess the competence of the anterior talofibular ligament
. Squeezing the proximal calf to observe for passive plantarflexion of the ankle
. Dorsiflexing the ankle to 10 degrees to lock the talus in the mortise prior to placing a syndesmotic screw

Correct Answer & Explanation

. Applying a lateral and posterior traction force to the fibula using a bone hook while observing the tibiofibular clear space under fluoroscopy

Explanation

The Cotton test is an intraoperative maneuver used to evaluate the integrity of the distal tibiofibular syndesmosis after malleolar fixation. It is performed by placing a bone hook or clamp around the fibula and applying a strong lateral (and slightly posterior) pulling force. The surgeon simultaneously views the ankle under AP or mortise fluoroscopy; widening of the tibiofibular clear space indicates syndesmotic instability requiring fixation. Squeezing the calf is the Thompson test for the Achilles tendon.

Question 4637

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs show a hallux valgus angle (HVA) of 35 degrees and an intermetatarsal angle (IMA) of 16 degrees. Clinical examination reveals no hypermobility at the first tarsometatarsal joint. What is the most appropriate surgical management?

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

Correct Answer & Explanation

. Proximal metatarsal osteotomy with distal soft tissue reconstruction

Explanation

For a moderate to severe hallux valgus deformity (IMA 14-20 degrees, HVA < 40 degrees) without first tarsometatarsal (TMT) joint hypermobility or arthritis, a proximal metatarsal osteotomy (e.g., crescentic, Ludloff) combined with a distal soft-tissue procedure is indicated. A distal chevron osteotomy is reserved for mild deformities (IMA < 13 degrees). The Lapidus procedure is indicated if there is TMT hypermobility. MTP arthrodesis is preferred for severe deformity with arthritis or in patients with rheumatoid arthritis. A Keller arthroplasty is reserved for older, low-demand patients.

Question 4638

Topic: 8. Foot and Ankle

A 35-year-old male sustains an acute Achilles tendon rupture while playing tennis. He opts for non-operative management with a functional rehabilitation protocol. Compared to operative treatment, which of the following is true regarding non-operative management utilizing early functional rehabilitation?

. Higher rate of deep infection
. Significantly higher rate of rerupture
. Similar rate of rerupture
. Markedly decreased plantar flexion strength at 2 years
. Higher rate of sural nerve injury

Correct Answer & Explanation

. Similar rate of rerupture

Explanation

High-level evidence demonstrates that non-operative management of acute Achilles tendon ruptures utilizing an early functional rehabilitation protocol results in similar rerupture rates compared to operative management. Operative treatment is associated with higher risks of soft tissue complications, infection, and iatrogenic sural nerve injury. Long-term functional outcomes and strength are comparable between the two groups.

Question 4639

Topic: 8. Foot and Ankle

A 24-year-old football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the first and second metatarsals. What is the primary stabilizing structure of the Lisfranc joint complex that is most likely injured?

. The dorsal ligament between the first and second metatarsals
. The plantar ligament from the medial cuneiform to the second metatarsal base
. The interosseous ligament from the medial cuneiform to the second metatarsal base
. The peroneus longus tendon
. The plantar fascia

Correct Answer & Explanation

. The interosseous ligament from the medial cuneiform to the second metatarsal base

Explanation

The Lisfranc ligament is a strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the thickest, strongest, and primary stabilizer of the Lisfranc complex. Notably, there is no direct ligamentous connection between the first and second metatarsals.

Question 4640

Topic: Midfoot & Hindfoot
A 55-year-old female presents with progressive flattening of her left foot, medial-sided pain, and an inability to perform a single-leg heel raise. Clinical examination demonstrates a flexible hindfoot valgus and forefoot abduction. Which of the following is the most appropriate surgical treatment?
. Posterior tibial tendon debridement and tenosynovectomy
. Flexor digitorum longus (FDL) transfer with a medial displacement calcaneal osteotomy
. Subtalar arthrodesis
. Triple arthrodesis
. Tibiotalocalcaneal fusion

Correct Answer & Explanation

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

Explanation

This patient has Stage II posterior tibial tendon dysfunction, characterized by a flexible deformity and an inability to perform a single-leg heel raise. The gold standard surgical management for Stage II is a soft tissue transfer (FDL to navicular or medial cuneiform) combined with a bony procedure to correct the deformity, most commonly a medial displacement calcaneal osteotomy (MDCO). Stage I is treated with conservative care or tenosynovectomy. Stage III involves a rigid deformity requiring triple or isolated hindfoot arthrodesis.

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